HospitalInspections.org

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

1. Observation at 2:30 p.m. on 1/24/17 revealed the two-hour fire-rated separation wall between the hospital and the clinic had an unsealed opening above the lay-in ceiling at the door. The unsealed opening was approximately three inches in diameter and had numerous computer wires, fire alarm wires, and cat. 5 cabling run through it. The opening was not sealed or provided with any approved material to maintain the fire rating of the wall.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment.

Based on observation, testing, and interview, the provider failed to ensure one randomly observed corridor door (old operating room) was equipped with positive latching hardware. Findings include:

1. Observation at 2:15 p.m. on 1/24/17 revealed the slave door for the pair of doors to the old operating room was free-swinging in the metal frame. Testing of the door by pulling it closed and flush with the frame revealed the door was not equipped with positive latching hardware. The other door's striker was designed to latch into the strike plate of the slave door. Further testing of the two doors revealed the doors would push open with minimal force applied.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency could affect 100% of the occupants of the smoke compartment.