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NFPA 80 Standard for Fire Doors and Other Opening Protectives
4.2.1 Listed items shall be identified by a label.
4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly.
4.2.3 The label or listing shall be considered evidence that sampling of such devices or materials have been evaluated by tests and that such devices or materials are produced under an in-plant, follow-up inspection programs.
5.2 Inspections
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.4 Swinging Doors with Builders Hardware of Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of the door assembly.
5.2.4.2 As a minimum, the following items shall be verified.
(1) No open holes or breaks exist in the surface of the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7.
(6) The self closing device is operational: that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before the active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observations and interview, it was determined the facility failed to ensure one 45-minute fire-rated door assembly failed to automatically close to a full latched position.

Findings include:

Observations during tour on 8/24/23 between 11:00 a.m. and 11:45 a.m. with Staff A (Maintenance Supervisor) and Staff B (Environmental Services Director) revealed the 45-minute fire-rated door assembly, located outside the Dartmouth Orthopedics Department, failed to automatically close to a full latched position when released from the magnetic hold-open device. The right-hand door panel failed to engage the top locking rod to secure the door in the closed position.

Interview on 8/24/23 with Staff A and Staff B confirmed the above findings, existing conditions, and location.

Based on observations and interview, it was determined the facility failed to ensure four Alcohol Based Hand Sanitizer (ABHS) dispensers were not placed above an electrical ignition source.

Findings include:

Observations during tour on 8/24/23 between 10:00 a.m. and 1:15 p.m. with Staff A (Maintenance Supervisor) and Staff B (Environmental Services Director) revealed the following four ABHS dispenser locations above an ignition source:
1. The Respitory/Cardiology office (above an outlet).
2. The Stress Echo Lab (above an electrical outlet).
3. The Procedure Room D 120 (above an electrical outlet).
4. The Infusion Room (above an electrical outlet).

Interview on 8/24/23 with Staff A and Staff B confirmed the above findings, locations, and existing conditions.

NFPA 25 (2011 edition) Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems

Chapter 14 Obstruction Investigation
14.2 Internal Inspection of Piping.

14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC).
14.2.1.3 If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in section 14.3.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.
14.2.1.5 In dry pipe systems and pre-action systems, the sprinkler removed shall be from the most remote branch line from the source of water that is not equipped with the inspector's test valve.

Based on record review and interview, it was determined the facility failed to ensure two separate (wet type) sprinkler systems received an internal obstruction investigation every 5 years.

Findings include:

Record review during tour on 8/23/23 between 8:45 a.m. and 1:30 p.m. with Staff B (Environmental Services Director) revealed sprinkler vendor documents stating the previous Clough Center sprinkler system obstruction test and the Emergency Department sprinkler system obstruction test were both conducted on 11/30/17 and due to be completed again on 11/30/22 (5-year interval). The obstruction testing was recently scheduled but at this time is 9 months overdue on each system.

Interview on 8/24/23 with Staff A (Maintenance Supervisor) and Staff B confirmed the above findings and available documentation.

NFPA 10 Standard for Portable Fire Extinguishers (2010 edition)

7.1.1 Responsibility. The owner or designated agent or occupant of a property in which fire extinguishers are located shall be responsible for inspection, maintenance, and recharging.
7.1.2.3 Persons performing 30-day inspections shall not be required to be certified.
7.2.1.2 Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a maximum of 30-day intervals.

Based on record review, observations, and interview, it was determined that the facility failed to ensure documentation of the monthly (30 day) fire extinguisher inspections included the actual date of the inspections.

Findings include:

Record review during tour on 8/23/23 between 8:45 a.m. and 1:00 p.m. with Staff B (Environmental Services Director) revealed the monthly fire extinguisher location list, used to track the complete count/location, only had the month and year recorded. All of the inspection documents only contain the month and year. The physical inspection card affixed to each fire extinguisher only included the initials of the personnel conducting the monthly inspections.

Interview on 8/24/23 with Staff A (Maintenance Supervisor) and Staff B confirmed the above findings and available documentation.

NFPA 101 Life Safety Code (2012 edition)
8.5 Smoke Barriers
8.5.2.1 Smoke barriers required by this code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
8.5.6.2 Penetrations for Cables. Cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall floor, or floor/ceiling assembly constructed as a smoke barrier, or a through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

Based on observations and interview, it was determined the facility failed to ensure one smoke/fire barrier wall was maintained to resist the passage of smoke or the effects of fire.

Findings include:

Observations during tour on 8/24/23 between 1:00 p.m. and 2:30 p.m. with Staff A (Maintenance Supervisor) and Staff B (Environmental Services Director) revealed multiple unprotected penetrations, above the suspended ceiling, over the 90-minute fire-rated corridor door assembly, next to the Radiology Services Suite. The 2-hour smoke/fire barrier had multiple mixed fire-stopping materials and multiple open/unsealed penetrations through the drywall.

Interview on 8/24/23 with Staff A and Staff B confirmed the above findings, existing conditions, and location.