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Based on observations during tour of the facility, it was determined that the hospital failed to maintain fire protection and occupancy features necessary to minimize danger to patients from smoke and fire gases, should a fire occur. The hospital failed to provide smoke doors to limit the transfer of smoke and fire gases should a fire occur. This condition could allow smoke and fire gases to quickly spread, in the event of a fire, endangering building occupants.


The findings include:


On 1/9/15, while on tour of the hospital with hospital representatives at all corridor smoke compartment doors, field applied weatherstripping was applied at the meeting edges of the doors. At the doors leading to the Intensive Care Unit, the rubber insert in the weatherstrip was observed to be pulled from the aluminum track leaving a gap between the doors. All of the doors were part of a 1 hour fire rated assembly. The hospital failed to provide documentation for the fire resistance or listing information for the applied weatherstrips or their use as a substitute for an astragal or split astragal. According to NFPA 101 (2000 edition) 18.3.7.8; "Rabbets, bevels, or astragals shall be required at the meeting edges, and stops shall be required at the head and sides of door frames in smoke barriers. Positive latching hardware shall not be required. Center mullions shall be prohibited."

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Based on records review and observations made during the tour of the hospital, it was determined that the hospital failed to utilize hazardous area enclosures where situations would require, and that the areas are properly equipped to protect from the specific hazards utilized. The storage of combustible materials in quantities that could be deemed hazardous could result in an increased fire fuel load accelerating the spread of the fire.


The findings include:


On 1/9/15 at 9:36 a.m., while on tour of the hospital with hospital representatives in room 1209A, a 12" diameter hole was observed in the wall. Review of the hospital construction drawings indicated that this wall was part of a 1 hour fire rated assembly.

On 1/9/15 at 10:02 a.m., while on tour of the hospital with hospital representatives in room 1549, the door to the room did not have a fire listing label and did not have a self-closing device. Review of the hospital construction drawings indicated that this door was part of a 1 hour fire rated assembly.

On 1/9/15 at 11:07 a.m., while on tour of the hospital with hospital representatives in room 1503 and 1504A, the doors to the rooms did not have a fire listing label. Review of the hospital construction drawings indicated that this door was part of a 1 hour fire rated assembly.

According to NFPA 101 (2000 edition) 8.4.1.3; "Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.", and 18.3.2.1; "Any hazardous area shall be protected in accordance with Section 8.4. The areas described in Table 18.3.2.1 shall be protected as indicated." Per Table 18.3.2.1; "Storage rooms larger than 100 ft2
(9.3 m2) storing combustible material, 1 hour separation/protection."

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Based on observations, the hospital failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.


The findings include:


On 1/8/15 at 3:00 p.m., while conducting records review of the hospital, the hospital failed to provide evidence of quarterly fire sprinkler inspections. The hospital provided the acceptance documents dated 8/8/14. There was no record of inspections subsequent to the acceptance of the system. According to NFPA 25 (1998 edition) 1-9.2; "Inspection and periodic testing determine what, if any, maintenance actions are required to maintain the operability of a water-based fire protection system. The standard establishes minimum inspection/testing frequencies, responsibilities, test routines, and reporting procedures but does not define precise limits of anomalies where maintenance actions are required." The frequency of inspections, testing and maintenance shall comply with Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance.