HospitalInspections.org

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

1. Observation on 7/27/21 at 10:30 a.m. revealed the two-hour, fire-rated separation wall between the original building and the first addition (in 400 wing near Exam 2) had ninety-minute, fire-rated doors that did not latch on the top latch.

Interview at at 10:30 on 7/27/21 with the maintenance supervisor confirmed that condition. Although repair was attempted immediately, he was not successful.

2. Observation on 7/27/21 at 11:15 a.m. revealed the two-hour, fire-rated separation wall between the original building and the second addition (near Prep Room 2) had ninety-minute, fire-rated doors that did not latch on the top latch.

Interview at at 11:15 a.m. on 7/27/21 with the maintenance supervisor confirmed that condition. Although repair was attempted immediately, he was not successful.


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

Based on observation and interview, the provider failed to ensure proper working space was provided around electrical equipment in four random electrical equipment locations (electrical transfer switches, central supply electrical panel, kitchen storage, emergency power panel in OR corridor). Findings include:

1. Observation on 7/27/21 at 10:00 a.m. revealed the switchgear room adjacent to the generator (exterior) location. That room was currently being used to store multiple items that blocked access to electrical sub panels in that room. A minimum of 36 inches of clearance was required to allow for proper working space. Working access to switchgear is crucial to maintain life safety and critical power in an emergency.

2. Observation on 7/27/21 at 10:30 a.m. in the central supply store room revealed the electrical panel was blocked by shelving. Additional units were purchased for storing COVID supplies and required "reach-in" access. Although the door was able to be opened, there was no space available in front of the panel. A minimum of 36 inches of clearance was required to allow for proper working space.

3. Observation on 7/27/21 at 1:10 p.m. in the kitchen store room revealed all electrical panels were blocked by carts. The entire series of carts would have to be removed to access the electrical panel in the corner. A minimum of 36 inches of clearance was required to allow for proper working space.

4. Observation on 7/27/21 at 2:00 p.m. in the surgical corridor revealed an electrical panel at the corridor end blocked by a surgical cart. A minimum of 36 inches of clearance was required to allow for proper working space.

Interview with the maintenance director at the time of the above observations confirmed that conditions. He indicated the facility was tight on storage space due to influx of equipment and supplies to deal with the current pandemic. He indicated he was aware of the proper working space around electrical equipment.