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Based on observation and staff interview, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 19.3 and Section 8.3. This was evidenced by the following:

Smoke barrier walls were not constructed as a one-hour rated wall assembly, as required. (Reference facility Life Safety Plans Pages LS 3 and 4.)
The one-hour rated smoke barrier wall (between the third floor electric room and equipment supply room) had the following deficiencies:

a) The wall assembly was not continuous to the roof deck, as required. The electric room side of the one-hour wall (above the gypsum board ceiling), did not have fire rated gypsum board installed on the steel studs.

b) Joints and screw heads were not finished with tape and joint compound, as required. Wall seams appeared to be finished with a red colored fire stop sealant. The gypsum board wall joints (seams) are required to be finished in accordance with the Gypsum Association Fire Resistance Design Manual, GA-600. Facility records included a document titled: "Engineering Judgment Firestop Detail" from Hilit, Inc. The document addresses the use of Hilti CP 606 Flexible Firestop Sealant for application on gypsum wallboard joints in a one-hour fire rated wall assembly. The Engineering Judgment states: "This Engineering Judgment represents a firestop system that would be expected to pass the stated ratings if tested." The Gypsum Association Fire Resistance Design Manual, GA-600 states: "Fire-resistance ratings, STCs, FSTCs, and IICs are the results of tests conducted on systems composed of specific materials put together in a specified manner. Substitution of other materials or deviation from the specified construction could adversely affect performance." The manual specifies that face layers of all systems shall have joints taped (minimum of Level 1 as specified in GA-214 -Recommended Levels of Gypsum Board Finish) and fastener heads treated. Level 1: All joints and interior angles shall have tape set in joint compound.

The Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ? hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with the Life Safety Code Section 19.3.2.1. This was evidenced by the following:

The third floor soiled holding room (core area) was not separated by smoke resistive construction, as required. The soiled room was not separated from the adjacent radio closet by smoke resistive construction. The radio closet was not enclosed with smoke resistive construction due to the absence of enclosure walls extending to structure and the absence of a complete and intact suspended ceiling. Engineering staff acknowledged the absence of a smoke resistive enclosure during a tour of the third floor. The Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting partitions and doors.

Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 19.7.1.2 and 4.7. This was evidenced by the following:

Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records documented the following drill times:

Evening Shift:

05/11/10 @ 3:46 p.m.
02/23/10 @ 3:20 p.m.
11/19/09 @ 3:39 p.m.
08/28/09 @ 4:30 p.m.

The Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on observation, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:

Sprinkler heads were not maintained to be free of obstructions to discharge, as required.

Closet sprinkler heads were observed to be obstructed by full depth shelves in room 334.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

Based on observation and staff interview it was determined that the facility failed to install curtains that were flame retardant in accordance with the provisions of the Life Safety Code Section 10.3.1. This was evidenced by the following:

Window valances could not be documented as being flame retardant, as required. The blue and beige colored valances, installed in C wing rooms #354, #355, #356 and #358, did not have tags attached that documented the material as flame retardant. Engineering staff were not aware of any separate flame retardant documentation on file at the facility.

The Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Based on observation and staff interview during the survey, it was determined that the facility failed to install alcohol based hand rub dispensers in accordance with Life Safety Code Section 19.3.2.7 (as amended by NFPA Technical Interim Amendment TIA 00-1 (101)). This was evidenced by the following:

Alcohol Based Hand Rub dispensers were not installed with adequate separation from an ignition source, as required. A corridor wall mounted dispenser was installed directly above a duplex electric receptacle near room #324. The Plant Services Director acknowledged the dispenser location during a tour of the facility.

Life Safety Code Section 19.3.2.7 states, in part, that alcohol based hand rub dispensers shall not be installed over or adjacent to an ignition source.

Based on observation and staff interview, it was determined that the facility failed to maintain the fire resistance rating of smoke barrier walls in accordance with the Life Safety Code Section 19.3 and Section 8.3. This was evidenced by the following:

Smoke barrier walls were not constructed as a one-hour rated wall assembly, as required. (Reference facility Life Safety Plans Pages LS 3 and 4.)
The one-hour rated smoke barrier wall (between the third floor electric room and equipment supply room) had the following deficiencies:

a) The wall assembly was not continuous to the roof deck, as required. The electric room side of the one-hour wall (above the gypsum board ceiling), did not have fire rated gypsum board installed on the steel studs.

b) Joints and screw heads were not finished with tape and joint compound, as required. Wall seams appeared to be finished with a red colored fire stop sealant. The gypsum board wall joints (seams) are required to be finished in accordance with the Gypsum Association Fire Resistance Design Manual, GA-600. Facility records included a document titled: "Engineering Judgment Firestop Detail" from Hilit, Inc. The document addresses the use of Hilti CP 606 Flexible Firestop Sealant for application on gypsum wallboard joints in a one-hour fire rated wall assembly. The Engineering Judgment states: "This Engineering Judgment represents a firestop system that would be expected to pass the stated ratings if tested." The Gypsum Association Fire Resistance Design Manual, GA-600 states: "Fire-resistance ratings, STCs, FSTCs, and IICs are the results of tests conducted on systems composed of specific materials put together in a specified manner. Substitution of other materials or deviation from the specified construction could adversely affect performance." The manual specifies that face layers of all systems shall have joints taped (minimum of Level 1 as specified in GA-214 -Recommended Levels of Gypsum Board Finish) and fastener heads treated. Level 1: All joints and interior angles shall have tape set in joint compound.

The Life Safety Code Section 19.3.7.3 requires that the smoke barrier wall be constructed in accordance with Section 8.3, and shall have a fire resistance rating of not less than ? hour. Section 8.3.2 requires that the barrier be continuous through concealed spaces.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain sprinkler protected hazardous areas in accordance with the Life Safety Code Section 19.3.2.1. This was evidenced by the following:

The third floor soiled holding room (core area) was not separated by smoke resistive construction, as required. The soiled room was not separated from the adjacent radio closet by smoke resistive construction. The radio closet was not enclosed with smoke resistive construction due to the absence of enclosure walls extending to structure and the absence of a complete and intact suspended ceiling. Engineering staff acknowledged the absence of a smoke resistive enclosure during a tour of the third floor. The Life Safety Code Section 19.3.2.1 requires that sprinkler protected hazardous areas be separated from other spaces by smoke-resisting partitions and doors.

Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with Life Safety Code Sections 19.7.1.2 and 4.7. This was evidenced by the following:

Fire drills were not conducted at unexpected times and under varying conditions, as required. A review of fire drill records documented the following drill times:

Evening Shift:

05/11/10 @ 3:46 p.m.
02/23/10 @ 3:20 p.m.
11/19/09 @ 3:39 p.m.
08/28/09 @ 4:30 p.m.

The Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held at unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Based on observation, it was determined that the facility failed to maintain the automatic fire sprinkler system in accordance with National Fire Protection Association (NFPA) Standard 13 and Standard 25. This was evidenced by the following:

Sprinkler heads were not maintained to be free of obstructions to discharge, as required.

Closet sprinkler heads were observed to be obstructed by full depth shelves in room 334.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, Section 2-2.1.2 states "Unacceptable obstructions to spray patterns shall be corrected."

Based on observation and staff interview it was determined that the facility failed to install curtains that were flame retardant in accordance with the provisions of the Life Safety Code Section 10.3.1. This was evidenced by the following:

Window valances could not be documented as being flame retardant, as required. The blue and beige colored valances, installed in C wing rooms #354, #355, #356 and #358, did not have tags attached that documented the material as flame retardant. Engineering staff were not aware of any separate flame retardant documentation on file at the facility.

The Life Safety Code Section 19.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.