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Based on observation and interview, the two smoke compartments located on the ground floor were not fully divided with a smoke barrier as required by NFPA 101, section 19.3.7.1.

Observed on 1/14/15 at 12:40 PM: Medical gas lines are penetrating the smoke barrier wall above the drop ceiling in the main corridor on the ground floor, near the cashier station. The penetration was not sealed. Penetrations of this type will negate the smoke and fire resistance of the material in which they occur. Findings were verified with Director of Engineering and Vice President & Administrator at time of observation.

Facility staff reported later that day that the penetration in the smoke barrier had been appropriately sealed after observation.

Based on observation and interview, the West Stairway shaft was not fully enclosed with construction having a fire resistance rating of at least 1 hour as required by NFPA 101, section 19.3.1.1.

Observed on 1/14/15 at 11:50 AM: The West Stairway contains a sprinkler pipe which serves the 2nd floor. Above the drop ceiling in the corridor of the 2nd floor, outside the stairwell, the sprinkler pipe penetration through the stairwell enclosure is not sealed. Penetrations of this type will negate the fire resistance of the material in which they occur. Findings were verified with Director of Engineering and Vice President & Administrator at time of observation.

Based on staff interview, and document review the hospital did not ensure that the fire alarm system initiating devices (smoke and duct detectors, and pull stations) are maintained in accordance with NFPA 72 National Fire Alarm Code.

Findings include: Review of Red Hawk Fire and Security quarterly inspection and testing forms on 1/15/15 indicate that 15 smoke detectors, 20 duct detectors, and 1 pull station were not tested annually in accordance with NFPA 72 (1999 ed.) Sec.7-3.2.

The detectors not tested were:

Smoke Detectors:
1-34, 1-35, 1-36, 1-46, 1-48, 1-50, 1-51, 1-52, 5-22, 7-27, 8-11, 8-12, 9-31, 9-32, 11-30

Duct Detectors:
3-25, 3-34, 3-36, 3-37, 3-38, 3-39, 3-40, 3-41, 3-44, 3-45, 3-46, 3-47, 3-48, 3-49 , 6-09, 8-29, 8-30, 8-31, 8-32, 8-53

Pull Station: 5-06

Interview with the Director of Engineering on 1/15/15 at 2PM, revealed that some of these detectors may have been placed out of service. Documentation was requested regarding the detectors that have been taken out of service. As of 01/21/2015 this documentation had not been received.

Based on observation and interview, the two smoke compartments located on the ground floor were not fully divided with a smoke barrier as required by NFPA 101, section 19.3.7.1.

Observed on 1/14/15 at 12:40 PM: Medical gas lines are penetrating the smoke barrier wall above the drop ceiling in the main corridor on the ground floor, near the cashier station. The penetration was not sealed. Penetrations of this type will negate the smoke and fire resistance of the material in which they occur. Findings were verified with Director of Engineering and Vice President & Administrator at time of observation.

Facility staff reported later that day that the penetration in the smoke barrier had been appropriately sealed after observation.

Based on observation and interview, the West Stairway shaft was not fully enclosed with construction having a fire resistance rating of at least 1 hour as required by NFPA 101, section 19.3.1.1.

Observed on 1/14/15 at 11:50 AM: The West Stairway contains a sprinkler pipe which serves the 2nd floor. Above the drop ceiling in the corridor of the 2nd floor, outside the stairwell, the sprinkler pipe penetration through the stairwell enclosure is not sealed. Penetrations of this type will negate the fire resistance of the material in which they occur. Findings were verified with Director of Engineering and Vice President & Administrator at time of observation.

Based on staff interview, and document review the hospital did not ensure that the fire alarm system initiating devices (smoke and duct detectors, and pull stations) are maintained in accordance with NFPA 72 National Fire Alarm Code.

Findings include: Review of Red Hawk Fire and Security quarterly inspection and testing forms on 1/15/15 indicate that 15 smoke detectors, 20 duct detectors, and 1 pull station were not tested annually in accordance with NFPA 72 (1999 ed.) Sec.7-3.2.

The detectors not tested were:

Smoke Detectors:
1-34, 1-35, 1-36, 1-46, 1-48, 1-50, 1-51, 1-52, 5-22, 7-27, 8-11, 8-12, 9-31, 9-32, 11-30

Duct Detectors:
3-25, 3-34, 3-36, 3-37, 3-38, 3-39, 3-40, 3-41, 3-44, 3-45, 3-46, 3-47, 3-48, 3-49 , 6-09, 8-29, 8-30, 8-31, 8-32, 8-53

Pull Station: 5-06

Interview with the Director of Engineering on 1/15/15 at 2PM, revealed that some of these detectors may have been placed out of service. Documentation was requested regarding the detectors that have been taken out of service. As of 01/21/2015 this documentation had not been received.