HospitalInspections.org

Based on documentation review for the hospital and staff interview, it was determined that the facility failed to ensure that all fire dampers installed at ventilation duct openings/duct penetrations in connection with the ventilation systems/equipment were functional and in good repair, and in accordance with NFPA 90A, Standard for the installation of Air Conditioning and Ventilating systems.
Findings include:
Review of the Interim Life Safety Measures Evaluation and the fire dampers test revealed that more and about 81 fire dampers were identified as defective or not being accessible.
During an interview with the Vice President of facilities on 8/14/2012, he stated that there were many more fire dampers identified to be defective and that the facility had corrected many of them. The remaining fire dampers required more work that may involve construction to correct them.
However, the facility did not have a detailed plan that include time frames for correcting the rest of the fire and smoke dampers.
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Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include but were not limited to:

Review of the hospital Life Safety Interim Measures revealed that the facility had identified numerous deficiencies that included penetrations of fire rated walls and partitions not enclosed by rated walls and doors according to LSC requirements.


1. At least ninety (90) locations were identified by the facility to have penetrations in the fire rated walls. Smoke partitions across the hospital lacked the proper protection by the fire stops.
2. Many electric closets were observed to have very dirty floors and they were dust laden. Also, some of those electric closets were found to have penetrations in their fire rating walls. Examples included but were not limited to: electric closet by the OR suite, electric closet 2C-3, ground floor of Seton Building GC-4, electrical closet of the ED2.
3. There were penetrations around conduits on the fire rated wall above the fire and smoke doors between the medical ICU and the ambulatory surgical unit.
4. The fire rated wall of the electric closet 1C-5 on the first floor of Seton building was noted to be open to the corridor above the ceiling tiles and was not protected or sealed by the proper fire stops.
Interview with the Hospital Vice President of Facilities and the Safety Officer on the morning of 8/14/2012, revealed that the hospital identified more than 1400 Life safety Deficiencies and that the hospital corrected many of those deficiencies. However, there were more than 250 items that were not yet corrected . Some of those deficiencies required construction work to correct them. The hospital did not have a detailed time line of correcting the identified life safety deficiencies.