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NFPA 101, 8.3.6.1 (1). Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.
- Fire Barriers: (NFPA 101, 8.3.5.1)Smoke Barriers: (NFPA 101, 8.3.6.1)Smoke partitions: (NFPA 101, 8.2.4.4.1)
Based on observation and interview, the facility failed to ensure fire/smoke barrier's one (1) hour fire rated construction is maintained. (NFPA 101, 8.2.3.2.4.2.)
The findings include:
Observation and interview with the Maintenance Director, on 9/19/2016 at 10:53 AM confirmed an air conditioning duct chase in the wall between a corridor and endoscopy procedure room. No damper was in the duct on the room side resulting in the corridor smoke barrier wall not being capable of resisting the passage of smoke.
This finding was verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on 9/19/2016.