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Based upon observation and interview it was determined that the facility did not maintain the integrity of a smoke barrier. Sections of a smoke barrier were not finished on one side of the wall and penetrations were not sealed. 2000 NFPA 101, Life Safety Code, section 19.3.7.3, requires that smoke barriers be constructed with a fire rating of not less than 1/2 hour. Section 8.3.6.1 requires that smoke barriers be continuous through all concealed spaces and penetrations therein be filled with fire-rated materials.

FINDINGS:

During a tour of the facility on 11/14/11 at 1400 hours it was observed that a smoke barrier in the 3rd floor data closet (smoke compartment #2) had two penetrations which were not filled with fire-rated material to maintain the fire rating.

During interview on 11/14/11 at 1400 hours the Director of Plant Operations and the Manager of Plant Operations acknowledged that two penetrations of the smoke barrier had not been repaired to maintain the fire rating.

Based upon staff interview and record review hospital staff failed to conduct at least one drill per shift per quarter.

FINDING:

Record review of fire drills conducted during 2011 revealed that hospital staff failed to conduct a drill during the third staff shift (2300-0700 hours) in the 2nd quarter of 2011.

During interview with the hospital project manager, the Director of Plant Operations and the Manager of Plant Operations on 11/16/11 at 1000 hours it was acknowledged that a fire drill was not conducted as required for the third shift in the 2nd quarter of 2011.