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Based on observation and interview, the facility failed to maintain the integrity of the fire-resistance rated construction of its smoke barrier walls as evidenced by an unsealed penetration. This penetration could result in a reduction in the facility's staff ability to protect in place and increase the risk of injury to the the patients due to smoke and/or fire. This affected one of ten buildings.

NFPA 101, Life Safety Code, 2000 Edition
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.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, CHFM, and Engineering Staff 1 on 6/10/15, the smoke barrier walls were observed and a staff person was interviewed.

Rideout Hospital
6/10/15
1. At 1:40 p.m., there was an approximately 2 feet by 4 inch section of the drywall in the south smoke barrier wall near the Emergency Department and expansion wall.

At 1:42 p.m., the CHFM said that he was not aware that the section of drywall that was missing. A staff person was called to repair the missing section.

Based on observation and interview, the facility failed to ensure that the fire alarm system was installed to cover all areas and properly maintained. This was evidenced by a strobe that failed to illuminate and the absence of automatic notification devices located on one section of two floors in the Fremont Building. This had the potential for occupants to not be notified of smoke or fire in the building, increasing the risk for injury. This affected one of ten buildings.
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NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protective's
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Findings:

During a tour of the facility with the Life Safety Officer, Engineer Staff 2, Emergency Preparedness Staff 1, and CHFM on 6/8/15 to 6/12/15, the fire alarm system was tested and observed, and staff were interviewed.

Rideout Hospital
6/10/15
1. At 8:56 a.m., the strobe near the Locker Room in the Pharmacy did not illuminate when tested.

Based on observation, the facility failed to maintain all fire extinguishers as evidenced by two fire extinguishers that were obscured from view. This could result in a delay in extinguishing a fire during a fire emergency. This affected two of ten buildings.
NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

1.5.7 Portable fire extinguishers other than wheeled extinguisher shall be installed securely on the hanger, or in the bracket supplied by the extinguisher manufacturer, or in a listed bracket approved for such purpose, or placed in cabinets or wall recesses. Wheeled fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with facility with the Life Safety Officer, Emergency Preparedness Staff 1, Engineering Staff 1, and CHFM on 6/9/15, the fire extinguishers were observed.

Cancer Center
6/9/15
1. At 10:13 a.m., inside the Wellness Center, the fire extinguisher was mounted in a recessed cabinet. There was no sign designating the location of the fire extinguisher. Further, there was no sign on the corridor door designating the location of the fire extinguisher inside the room.

2. At 10:15 a.m., inside the Staff Lounge near the Wellness Center, there was no sign on the corridor door designating the location of the fire extinguisher inside the room.



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Rideout
6/9/15
4. At 2:21 p.m., the fire extinguisher in the Radiology Electrical Room was not mounted securely. The fire extinguisher was hanging on the bracket by the back portion of the handle.

Based on observation, the facility failed to maintain its smoke barrier walls as evidenced by an unsealed pipe traveling through a wall. This affected one of ten buildings, and could result in the spread of smoke or fire to other portions of the building.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, and CHFM on 6/9/15, the facility's smoke barrier walls were observed.

Rideout Hospital
6/9/15
1. At 2:48 p.m., there was an approximately one inch orange conduit pipe that was unsealed traveling through the west wall of the IDF Room.