HospitalInspections.org

Based on observation and staff interview, the facility does not assure that dampers are in accordance with NFPA 72 and 2012 NFPA 101, 8.4.6.2. This deficient practice could affect persons who may need to use areas as a safe zone in the event of an emergency, affecting all residents, patients, visitors and staff in 6 of 6 smoke zones. The facility has a capacity of 20 with a census of 3 at the time of this survey.

Findings include:

During the tour conducted on 01/17/18, at 9:30 a.m., during a review of records, it is observed:

-- 1. No documented testing and maintenance of fire dampers within the last 6 years.

-- 2. No policy in place to assure that smoke dampers are tested, inspected and maintained.

Safety Coordinator and Maintenance Director affirmed the results of the records review. Safety Coordinator and Maintenance Director acknowledged that the facility has fire dampers and that there is no available documentation indicating completion of maintenance and testing.

NFPA Standard: The operability of controlled mechanical equipment (e.g., smoke and fire dampers, elevator recall arrangements, and door holders) should be verified by periodic testing. Failure to test and properly maintain controlled mechanical equipment can result in operational failure during an emergency, with potential consequences up to and including loss of life.

NFPA Standard: An approved damper designed to resist the passage of smoke shall be provided for each air transfer opening or duct penetration of a required smoke barrier per NFPA 101, 8.3.5.1. Required smoke dampers in air transfer openings shall close upon detection of smoke by approved smoke detectors in accordance with 2010 NFPA 72 and 2012 NFPA 101, 8.3.5.3

NFPA Standard: Air-transfer openings in smoke partitions shall be provided with approved smoke dampers designed and tested in accordance with the requirements of ANSI/UL 555S, Standard for Smoke Dampers, to limit the transfer of smoke. 2012 NFPA 101 8.4.6.2

NFPA Standard: Each damper shall be tested and inspected 1 year after installation; the test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years; all tests shall be completed in a safe manner by personnel wearing personal protective equipment; full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required; if the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in place if so equipped; the operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts; the damper frame shall not be penetrated by any foreign objects that would affect fire damper operations; the damper shall not be blocked from closure in any way; the fusible link shall be reinstalled after testing is complete; if the link is damaged or painted, it shall be replaced with a link of the same size, temperature, and load rating; all inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered; the documentation shall have a space to indicate when and how the deficiencies were corrected; all documentation shall be maintained and made available for review by the AHJ; periodic inspections and testing of a combination fire/smoke damper shall also meet the inspection and testing requirements contained in Chapter 6 of NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80, 19.4

NFPA Standard: Reports of changes in airflow or noise from the duct system shall be investigated to verify that they are not related to damper operation; all exposed moving parts of the damper shall be dry lubricated as required by the manufacturer; if the damper is not operable, repairs shall begin without delay; following any repairs, the damper shall be tested for operation in accordance with Section 19.4; all maintenance shall be documented in accordance with 19.4.9 and 19.4.10; maintenance of a combination fire/smoke damper shall also meet the maintenance requirements contained in Chapter 6 of NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 80, 19.5