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FHN MEMORIAL HOSPITAL
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Tag No.: K0020
A) Based on direct observation on December 11, 2012, with the Hospital Operation Manager and the Executive VP of Quality, also observing and based upon a review of the Construction Documents for the building dated January 2009, the surveyor finds that the Main Lobby of this facility has a three story open stair that connects to the Lower Level, 1st and 2nd Floors. This stair is open to most of the spaces on the 1st and 2nd Floor and it is open to all 1st and 2nd Floor exit access corridors. The stair is shown on drawings with a one hour separation at the Lower Level. This three story open space does not comply with Section 8.2.5 and more specifically it does not comply with with 8.2.5.5, 8.2.5.6, 8.2.5.7 or 8.2.5.8.
Findings include:
1) The stair is open to the 1st Floor, the large lobby space and waiting areas of the 1st Floor and all of the exit access corridors of the 1st Floor which includes at least two means of egress for the 1st Floor PT/OT space.
2) The stair is open to most spaces on the 2nd Floor including all of the exit access corridors. Exit paths to other enclosed exit stairs must travel through spaces exposed to the open stair.
3) No atrium smoke control system was found
4) Although the Lower Level is identified on plans with a one hour fire barrier separation the fire barrier is incomplete and not installed in accordance with 8.2.5 (fire barriers for vertical openings):
a) Corrected 4/11/13.
b) Corrected 09/11/13.
c) Corrected 4/11/13.
d) Corrected 4/11/13.
e) Corrected 4/11/13.
f) See also K021
5) Even with 4 "a" through "f" corrected the open stair will still not comply with 8.2.5. Failure to install and maintain vertical opening protection will allow fire to spread throughout multiple floors and multiple spaces in a fire emergency.
NEW 09/11/13 regarding Items A.1. through A.5. above: Surveyor 14290 notes that the remaining corrective action to be completed is the isntallation of a series of draft curtains around the perimeter of the communicating opening at the First Floor.