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Based on observation and interview it was determined one of six smoke barrier walls observed was incomplete due to a domestic water line, installed in such a manner as to comprise the upper portion of the smoke barrier wall, which was not an approved assembly for a smoke barrier wall to provide a one-half hour fire rating. The failed practice had the potential to affect all patients, staff, and visitors due to the potential spread of fire from one side of the smoke barrier to the other. The facility had 54 inpatients and 6 observation patients on 01/04/12. The findings follow:

A. On a tour of the facility on 01/05/12 at 0905 with the Engineering Supervisor, inspection above the ceiling of the smoke barrier located near the Educational Office on the first floor revealed an insulated domestic water pipe comprised the upper portion of the smoke barrier wall at this location. The pipe was installed directly on top of the lower portion of the wall, so that the smoke barrier wall stopped at the bottom of the pipe. The remainder of the smoke barrier wall extending to the floor deck above consisted of the water pipe. The assembly did not qualify as an approved one-half hour fire rated assembly at this location.

B. The Director of Engineering/Construction visually inspected the smoke barrier on 01/05/12 at 1400 and verified in an interview at that time the smoke barrier did not meet the requirements for a one-half hour rated wall assembly.

Based on observation and interview it was determined the door for two of four medical records rooms were not self-closing as required for hazardous areas. The failed practice had the potential to affect all patients, staff, and visitors due to the potential spread of fire and smoke to other parts of the facility from these rooms. The facility had 54 inpatients and 6 observation patients on 01/04/12. The findings follow:

A. On a tour of the Medical Records department on 01/09/12 at 0905 with the Engineering Supervisor, the doors to Medical Records Room 3 and Medical Records Room 4 were observed without self-closing devices. Without these devices, the doors would not automatically close when they were opened.

B. In an interview on 01/06/12 at 0930 the Engineering Supervisor verified the doors did not have self closing devices.

Based on observation and interview it was determined one of six smoke barrier walls observed was incomplete due to a domestic water line, installed in such a manner as to comprise the upper portion of the smoke barrier wall, which was not an approved assembly for a smoke barrier wall to provide a one-half hour fire rating. The failed practice had the potential to affect all patients, staff, and visitors due to the potential spread of fire from one side of the smoke barrier to the other. The facility had 54 inpatients and 6 observation patients on 01/04/12. The findings follow:

A. On a tour of the facility on 01/05/12 at 0905 with the Engineering Supervisor, inspection above the ceiling of the smoke barrier located near the Educational Office on the first floor revealed an insulated domestic water pipe comprised the upper portion of the smoke barrier wall at this location. The pipe was installed directly on top of the lower portion of the wall, so that the smoke barrier wall stopped at the bottom of the pipe. The remainder of the smoke barrier wall extending to the floor deck above consisted of the water pipe. The assembly did not qualify as an approved one-half hour fire rated assembly at this location.

B. The Director of Engineering/Construction visually inspected the smoke barrier on 01/05/12 at 1400 and verified in an interview at that time the smoke barrier did not meet the requirements for a one-half hour rated wall assembly.

Based on observation and interview it was determined the door for two of four medical records rooms were not self-closing as required for hazardous areas. The failed practice had the potential to affect all patients, staff, and visitors due to the potential spread of fire and smoke to other parts of the facility from these rooms. The facility had 54 inpatients and 6 observation patients on 01/04/12. The findings follow:

A. On a tour of the Medical Records department on 01/09/12 at 0905 with the Engineering Supervisor, the doors to Medical Records Room 3 and Medical Records Room 4 were observed without self-closing devices. Without these devices, the doors would not automatically close when they were opened.

B. In an interview on 01/06/12 at 0930 the Engineering Supervisor verified the doors did not have self closing devices.