Means of Egress - General
Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
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Observations:
Name: MAIN BUILDING THOMPSON - Component: 01 - Tag: 0211
Based on observation and interview, it was determined the facility failed to maintain special locking arrangements and lacked delayed egress signage, in seven of ten smoke zones within the component.
Findings include:
1. Observation on August 21, 2025, between 12:45 PM and 1:30 PM, revealed the exit discharge doors lacked delayed egress signage, at the following locations:
a. 12:45 PM, 1st floor, 1 West exit door;
b. 12:49 PM, 1st floor, 1 Center Hall exit door;
c. 12:58 PM, 1st floor, 1 East, exit door;
d. 1:05 PM, 2nd floor, 2 East exit door;
e. 1:15 PM, 2nd floor, 2 Center Hall exit door;
f. 1:20 PM, 2nd floor, 2 CA East exit door;
g. 1:30 PM, 2nd floor, 2 West exit door.
Interview at the time of the exit conference with the President and CEO, Administrator of Healthcare Services and Director of Facilities Services on August 21, 2025, at 2:00 PM,
confirmed exit doors lacked delayed egress signage.
| | Plan of Correction - To be completed: 10/20/2025
Updated compliant signage was placed on the following doors: 1 West exit door, 1 Center Hall exit door, 1 East exit door, 2 East exit door, 2 Center Hall exit door, 2 CA East exit door, and 2 West exit door.
These are the only doors in the facility that are subject to this requirement.
The Director of Maintenance was re-educated by the Vice President of Facility Services on the requirements of this regulation
The signage will be audited weekly for two weeks and semi-annually thereafter to ensure compliance with this regulation
This audit will be reviewed by the Facility Quality Assurance / Process Improvement team for further recommendations.
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