HospitalInspections.org

Based upon observation and staff interview, the facility fails to assure that spaces between penetrating items and smoke barriers are filled with a material that is capable of maintaining the smoke resistance of the smoke barrier. The deficient practice would not prevent the passage of smoke to other areas of the building, affecting 3 of 8 smoke zones. The facility has a capacity of 25 with a census of 5 at the time of the survey.

Findings include:

During the tour conducted on 3/26/2012 it is observed:

--1. At 3:15 p.m., the smoke barrier wall located near the central supply has unsealed gaps around wires and cables.

--2. At 3:20 p.m., the smoke barrier wall located near the director of nursing office has unsealed gaps around conduit and wires.

Maintenance Staff A and Administrative Staff A were present and acknowledged the unsealed gaps around the wires, cables and conduit. Maintenance Staff A indicated that he would would seal the gaps with approved materials.

NFPA Standard: Smoke barriers shall be continuous from an outside wall to an outside wall. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces per NFPA 101, 8.3.2. When pipes, conduits, cables, wires, air ducts and similar building service equipment pass through smoke barriers, the space between the penetrating item and the smoke barrier shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier or protected by an approved device that is designed for the specific purpose per 2000 NFPA 101, 8.3.6.1