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Based upon observation and interview hospital staff failed to ensure that a vertical opening was enclosed with material to maintain the required fire resistance rating.

FINDING

On 1/04/12 at 1500 hours during a tour of the hospital with physical plant management, a penetration in the 1st floor computer server room ceiling was observed. This penetration was not filled with material to maintain the fire resistance rating of the room.

This finding was confirmed during interview 1/04/12 at 1500 hours with the manager of facilities.

Based upon observation and interview, hospital staff failed to maintain the automatic sprinkler system in reliable working condition.

FINDING:

On 1/04/12 at 1615 hours during a tour of the hospital laundry with physical plant management, sprinkler heads in the area above the dryers were observed to be covered in lint.

This finding was confirmed with the manager of facilities during interview on 1/04/12 at 1615 hours.

Based upon observation and interview hospital staff failed to maintain the smoke resistance rating of a smoke compartment.

FINDING:

On 1/04/12 at 1515 hours during a tour of the hospital with physical plant management, a penetration of the smoke compartment was observed in a wall of the first floor janitors closet. This penetration was not filled with material to maintain the smoke and fire resistance of the smoke compartment.

On 1/05/12 at 0830 hours during a tour of the hospital with physical plant management, a penetration of a wall of the smoke compartment was observed in the area of the dental clinic registration desk. This penetration was not filled with material to maintain the smoke and fire resistance of the smoke compartment.

These findings were confirmed with the manager of facilities during interviews on 1/04/12 at 1515 hours and on 1/05/12 at 0830 hours.