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Based on observation, staff interview and review of maintenance records between 8/23 and 8/25/2010, the facility failed to construct, install and maintain the building systems to ensure life safety to patients due to (i) one cable and one conduit penetration of fire-rated floor not fire-stopped; (ii) one office space with sliding glass windows not properly separated from corridor, and unsealed pipe and cable penetrations in corridor walls above ceiling; (iii) fire-rated doors of two hazardous areas held open with a rope, and not maintained to automatically or self-close; (iv) one penetration with multiple cables through a smoke barrier not fire-stopped; (v) one pair of smoke doors not properly maintained to fully close; (vi) failure to maintain one sprinkler system branch pipe free of external load application; (vii) lack of isolation smoke dampers on each side of one air-handling unit, and lack of a duct smoke detector in the main supply duct of one air-handling unit to shut down the fan; (viii) medical gas and vacuum system as required by NFPA 99 due to lack of a 2nd master alarm panel; (ix) objects stored in front of electrical panel and equipment and not maintaining a clear working space; (x) lack of positive latching hardware on one pair of corridor doors; (xi) more than 1/8 inch allowable gap at the meeting edge of a pair of fire-rated corridor doors of one hazardous area; (xii) trash and soiled linen receptacles of more than 32 gal capacity not stored in a room protected as a hazardous area; and (xiii) two dirty spaces improperly ventilated.

The cumulative effects of these environmental problems resulted in the hospital's inability to ensure a safe environment for the patients.

On the verification visit of the Door County Memorial Hospital on 10/8/2010, Surveyor 12316 determined that the hospital has made a satisfactory progress toward correcting the Items (ii) and (vii) listed above. All other 11 items have been verified to be corrected.

Refer to the following tags for details:
Building 01: K-17 and K-67; and C-231

Based on observation, staff interview and review of maintenance records, the facility failed to ensure 'life safety from fire' to patients.

Findings include

Building 01

1. Failed to protect the life safety of patients from fire due to one unsealed cable and one conduit penetration of 2-hr fire-rated floor construction;

2. Failed to protect the life safety of patients from fire due to failure to separate corridor from the one office space, and fire-stop pipe and cable penetrations in corridor wall above ceiling in accordance with NFPA 101 19.3.6.1;

3. Failed to protect the life safety of patients from fire due to fire-rated doors of two hazardous areas held open with a rope, and not maintained to automatically or self-close in accordance with NFPA 101 19.3.2.1, 8.4.1.3;

4. Failed to protect the life safety of patients from fire due to one penetration with multiple cables through a smoke barrier not fire-stopped to provide ? hr fire resistance rating of the smoke barrier;

5. Failed to protect the life safety of patients from fire due to failure of one pair of smoke doors to fully close;

6. Failed to protect the life safety of patients from fire due to failure to maintain one sprinkler system branch pipe free of external load application;

7. Failed to protect the life safety of patients from fire due to (i) lack of isolation smoke dampers on each side of one air-handling unit, and (ii) lack of duct smoke detector in the supply side of the air-handling unit AC#2;

8. Failed to protect the life safety of patients from fire due to lack of a 2nd master alarm panel in the medical gas and vacuum system as required by NFPA 99;

9. Failed to protect the life safety of patients from fire due to failure to maintain clear working space in front of electrical panel and equipment in two mechanical rooms in accordance with NFPA 70 110-26.

Building 03

10. Failed to protect the life safety of patients from fire due to lack of positive latching hardware on one pair of corridor doors;

11. Failed to protect the life safety of patients from fire due to more than allowable gap at the meeting edge of one pair of fire-rated corridor doors of one hazardous area; and

12. Failed to protect the life safety of patients from fire due to trash and soiled linen receptacles of more than 32 gal capacity not stored in a room protected as a hazardous area.

This had a potential of affecting patients, staff and the public on the Ground Floor, 1st, 2nd and 3rd Floors of the hospital building.


On the verification visit of the Door County Memorial Hospital on 10/8/2010, Surveyor 12316 determined that the hospital has made a satisfactory progress toward correcting the Items 2 and 7 listed above. All other 10 items have been verified to be corrected.

Refer to the following tags for details:

Building 01: K-17 and K-67