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Tag No.: K0025
NFPA 101 Life Safety Code 2000 Edition
Chapter 19 EXISTING HEALTH CARE OCCUPANCIES
19.3 Protection
19.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Chapter 8 FEATURES OF FIRE PROTECTION
8.3 Smoke Barriers
8.3.2
To ensure that a smoke barrier is continuous, it is necessary to seal completely all openings where the smoke barrier abuts other smoke barriers, fire barriers, exterior walls, the floor below, and the floor or ceiling above.
It is not the intent to prohibit a smoke barrier from stopping at a fire barrier if the fire barrier meets the requirements of a smoke barrier (that is, the fire barrier is a combination smoke barrier/fire barrier).
This Standard is not met as evidenced by:
Based on observation and staff interview, it was determined the facility failed to maintain smoke barrier walls to provide at least one half hour fire resistance rating. Facility census is twenty (20).
Findings include:
1. On 02/11/14 at approximately 1:15 p.m., an inspection of the smoke barrier wall above the drop ceiling near nurse station D was conducted. At this time, there was a opening approximately six (6) inches by twelve (12) inches with a two and one quarter copper line, not sealed around through the smoke barrier wall.
2. On 02/11/14 at approximately 1:19 p.m., an inspection of the smoke barrier wall above the drop ceiling at the fire doors, near the entrance to the special care area was observed to have two (2) inch sleeves and one two (2) inch cable bundle that were not sealed around and sleeves were not sealed inside through the smoke barrier wall.
3. On 02/11/14 at approximately 1:25 p.m., an inspection of smoke barrier wall above the drop ceiling at the smoke doors near the lobby was conducted. At this time, there were two (2) inch sleeves and one two (2) inch cable bundle that were not sealed around and sleeves were not sealed inside through the smoke barrier wall.
4. These findings were discussed with the hospital maintenance director and maintenance supervisor on 02/11/1 at approximately 1:25 p.m. and they agreed there were openings in the smoke barrier walls.