HospitalInspections.org

Based on observation and interview, it was determined the fire rated construction separating the hospital from the adjacent ambulatory health care occupancy did not meet the minimum two hour rating. The failed practice had the potential to affect all patients, staff, and visitors because they were not protected from fire and smoke originating from the adjacent ambulatory surgery center for a minimum of 2 hours as required by NFPA 101, Section 19.1.2.3 (2000 edition). The facility had a census of 15 patients on 03/25/13. The findings follow:

A. On a tour of the hospital with the Facilities and Engineering Lead Technician and Administrative Director on 03/27/13 at 0950, observation above the ceiling at the entrance to the adjacent ambulatory surgery center revealed the wall consisted of a single layer of gypsum board installed on one side of the metal studs. A single layer of gypsum board provides 30 minutes of fire protection (Reference NFPA 101, Section 8.2.3 and NFPA 251).
B. The Facilities and Engineering Administrative Director verified the wall did not meet the criteria for a 2 hour rated construction in an interview conducted on 03/27/13 at 0955.