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Based on observation, not all enclosures for hazardous areas are constructed and maintained as required. This deficient practice could affect patients, staff, and visitors if smoke and fire could pass from the hazardous areas to the remainder of the building in the event of a fire event.

Findings include:

On 10/23/2019 at 11:05am while accompanied by CEO and FD, it was determined that a hazardous area is not safe guarded by a fire barrier having a 1-hour fire resistance rating to comply with 19.3.2.1. Locations and conditions observed:

1. First floor level, East end corridor of 1914 building leading to the MOB is undergoing construction. This entire area is missing ceiling tile, contains capped off smoke detectors, and contains openings to unprotected areas of the building addition. This part of the means of egress corridor is part of a construction zone and lacks adequate separation from the occupied part of the hospital.

2. Basement level, East end corridor of 1914 building is used for storage. This entire area contains multiple containers along with capped off smoke detection and openings to unprotected areas of the building addition. This part of the means of egress corridor is part of a construction zone and lacks adequate separation from the occupied part of the hospital.

Based on review of record documentation of door inspections, doors are not being maintained in fully functional condition to afford the protection they are intended to provide. Failure to maintain doors can compromise adjacent spaces during a fire condition.

The finding is:

On 10/23/2019 at 11:45am while in the company of the CEO and FD, documentation for fire rated doors was reviewed. Documents were not maintained for inspection by the AHJ to comply with NFPA 80 5.2.1. Documents provided were incomplete and did not comply with NFPA 80 2010, 5.2.4.2 (1) - (11).