HospitalInspections.org

Based on observation and interview, the facility failed to ensure a two hour rated separation between the hospital and the occupancy next door was provided.

Findings included:

1. Observation on 05/31/23 showed a one hour rated door between the hospital and a rural health clinic next door. The door did not close fully and latch.

2. During an interview on 05/31/23 at 10:00 AM, Staff B, Maintenance, stated the construction type of the occupancy next door was unknown as it was not shown on the facility blueprints. Staff B confirmed the door was one hour rated.

Based on record review and interview, the facility failed to document an annual inspection on all fire doors.

Findings included:

1. Review of the document provided by the facility for the fire door inspection showed a single page titled "Fire Door Annual Check" with 10 criteria and a handwritten note that said all doors.

2. During an interview on 05/31/23 at 9:10 AM, Staff B, Maintenance, stated there were seven or eight fire rated doors in the facility and all were inspected but only the one document was completed, and findings for individual doors were not reflected on the document.