HospitalInspections.org

Based on observation, testing, and interview, the provider failed to maintain the fire-resistive design for one of two building separation walls (Northern two-hour wall separating the hospital and the clinic). Findings include:

1. Observation and testing on 8/13/24 at 1:12 p.m. revealed the ninety-minute fire-rated doors in the separation wall between the hospital and the clinic (door # 1547 near the conference room) did not latch into the frame. The east leaf of that pair of doors had a latch that was malfunctioning and did not latch into the frame for three of three attempts.

Interview with the maintenance technician at the same time confirmed that finding.

2. Observation on 8/13/24 at 2:52 p.m. revealed the two-hour fire-rated separation wall between the hospital and the clinic (above door #1007 outside of the lab) had four layers of 5/8 inch gypsum board on the wall above the lay-in ceiling. The gypsum board had unsealed openings above a conduit in the middle of the corridor.
Those openings were not sealed or provided with any approved material to maintain the fire rating of the wall.

Interview with the maintenance technician at the same time confirmed that finding. He stated that conduit had been added to provide power from the back-up generator to the reverse osmosis filtration system in the dialysis clinic.
These deficiencies could affect 100% of the occupants of either of the smoke compartments.