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Based on observation, and document review, it was determined that the facility failed to ensure interior finishes comply with the National Fire Protection's (NFPA) Life Safety Code (101), 2012 edition.

Findings include:

Reference #1: NFPA 101:10.2.1.4: "Fixed or movable walls and partitions, paneling, wall pads, and crash pads applied structurally or for decoration, acoustical correction, surface insulation, or other purposes shall be considered interior finish and shall not be considered decorations or furnishings."

Reference #2: NFPA 101:10.2.4.7 "Polypropylene (PP) and High-Density Polyethylene (HDPE). Polypropylene and High-Density Polyethylene materials shall not be permitted as interior wall or ceiling finish unless the material complies with the requirements of 10.2.3.7.2. The tests shall be performed on the finished assembly and on the maximum thickness intended for use."

Reference #3: NFPA 101:10.2.3.7.2 "The interior finish shall comply with all of the following when tested using the test protocol of NFPA 286, Standard Methods of Fire Tests For Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth: (1) During the 40 kW exposure, flames shall not spread to the ceiling. (2) The flame shall not spread to the outer extremities of the samples on the 8 foot by 12 foot walls. (3) Flashover, as described in NFPA 286, shall not occur. (4) For new installations, the total smoke released throughout the test shall not exceed 1,000 meters squared."

Reference #4: NFPA 101:10.2.4.3 "Cellular or Foamed Plastics, Cellular or foamed plastic materials shall not be used as interior and ceiling finish unless specifically permitted by 10.2.4.3.1 or 10.2.4.3.2. The requirements of 10.2.4.3 through 10.2.4.3.2 shall apply both to exposed foamed plastics and to foamed plastics used in conjunction with a textile or vinyl facing or cover."

Reference #5: NFPA 101:10.2.4.3.1 "Cellular or foamed plastic materials shall be permitted where subjected to large-scale fire tests that substantiate their combustibility and smoke release characteristics for the use intended under actual fire conditions. The tests shall be performed on the finished foamed plastic assembly related to the actual end-use configuration, including any cover or facing, and at the maximum thickness intended fore use. Suitable large-scale fire tests shall include those shown in 10.2.4.3.1.1."

1. On 12/10/19 at 1:20 PM, in the presence of Staff #54, #93, #94, and #95, all patient bathroom doors within the "Larch" building were removed and replaced with a movable partition constructed with a foamed material. These movable partitions were constructed with polypropylene foam and wrapped in a vinyl covering. These movable partitions are held in place by magnets that allow the partition to swing like a door. Refer to Reference #1 and Reference #2.

a. During an interview with Staff #54 on 12/11/19 at 1:30 PM, no evidence could be provided to demonstrate that the Kennon, Soft Suicide Prevention Doors and Artwork were tested utilizing a large-scale test. Refer to Reference #3, Reference #4 and Reference #5.

b. During a review of the manufacture specifications for Kennon, Soft Suicide Prevention Doors and Artwork, lacked any information related to testing in accordance with NFPA 286, Standard Methods of Fire Tests For Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth. Refer to Reference #3, Reference #4 and Reference #5.