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Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in 2 (the electrical room which supplies the new emergency room and above the fire rated doors outside the laboratory entrance) of 17 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 09/12/17 at 1:20 PM, observation showed seven electrical conduits penetrating the smoke and fire barrier wall adjacent to the door to the electrical room which supplied the Emergency Room 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 09/12/17 at 2:00 PM, observation showed a large opening in the fire and smoke barrier above the fire-rated doors near the entrance to the laboratory.
C. During the tour, the Director of Plant Services 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