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Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in three (above the fire-rated doors south of the public elevators, second floor, above the fire-rated doors north of the public elevators second floor, and above the fire-rated doors in the smoke barrier on the first floor) of seven areas observed by protecting penetrations in the barrier with a system or material capable of restricting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility on 01/25/2017 at 1020, it was observed cables penetrating the smoke barrier above the fire-rated doors north of the public elevators were not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. While touring the facility on 01/25/2017 at 1020, it was observed a 3 inch electrical conduit penetrating the smoke barrier above the fire-rated doors south of the public elevators was not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
C. While touring the facility on 01/25/2017 at 1030, it was observed cables penetrating the smoke and fire barrier above the fire-rated doors in the smoke barrier on the first floor were not sealed with a material capable of limiting the transfer of smoke from one side of the barrier to the other.
D. During the tour, the Plant Operations Manager verified the penetrations were not sealed with a material capable of restricting the transfer of smoke from one side of the barriers to the other.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1