HospitalInspections.org

Based on observation and interview, the facility failed to ensure safety to patients, visitors and staff of the facility due to either lack of required ? hr corridor wall separation of one office space from corridor, or unsealed pipe and cable penetrations in corridor wall above ceiling in accordance with NFPA 101 19.3.6.1. This deficient practice affected 3 of 23 smoke compartments in the facility.

Findings include

During a tour of the facility with Staff A (president and chief executive officer), Staff D (plant operations director), Staff E (safety officer), Staff F (plant operations mechanic), and Staff H (plant operations mechanic) 8/23/2010, Surveyor 12316 observed in the following 3 locations that the corridor wall had either unsealed penetrations or did not provide ?-hr fire resistance rating.

1. On 8/23/2010 at 1:45 pm, the sliding glass window of approximately 4 ' x 3 ' -6 " high in the corridor wall of the Cashier ' s Office on the Ground Floor did not provide a ? hr fire resistance rating in accordance with the NFPA 101 19.3.6.2.1 requirement. The windows in the corridor wall were not fixed fire window assemblies in accordance with NFPA 101 8.2.3.2.2, nor was the Cashier ' s office and the adjacent corridor protected with an electrically supervised automatic smoke detection system in accordance with the NFPA 101 19.3.6.1 Exception No. 6(a) to consider the office as a space open to corridor.

2. On 8/23/2010 at 1:55 pm, the annular gap of one pipe penetration above the double doors in corridor wall of the Vending Machine room was not sealed to provide a ? hr fire resistance rating of the wall. The vending machine room is located adjacent to the Electrical Room with automatic transfer switches on the Ground Floor.

3. On 8/23/2010 at 4 pm, one sprinkler pipe and two cable penetrations of corridor wall above ceiling were not sealed to provide a ? hr fire resistance rating of the wall. The corridor wall was located adjacent to the Patient Accounting Office and across the Physical Therapy on the Ground Floor.

The above deficiency was acknowledged by the plant operations director, safety officer and plant operations mechanics at the time of discovery, and confirmed with Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.


During the verification visit of the Door County Memorial Hospital on 10/08/2010, Surveyor 12316 found that Item 2 of the above deficiency was not corrected. The other two items were verified to have been corrected.

Based on observation and interview, the facility failed to ensure safety to patients, staff and visitors of the facility due to (i) lack of isolation smoke dampers to isolate one air-handling unit, and (ii) lack of duct smoke detector in the supply side of the air-handling unit AC#2 in accordance with NFPA 90A 2-3.9.2 and 4-4.2. This affected some areas of the Ground Floor and 1st Floor.

Findings include

Item 1. During a tour of the facility with Staff D (plant operations director), Staff F (plant operations mechanic), and Staff G (plant operations mechanic) on 8/24/2010, Surveyor 12316 observed at 2:55 pm that the air-handling unit AHU#1 of a 21500 cfm (cubic feet per minute) capacity did not have isolation smoke dampers on the supply and return sides. This unit is located in the Mechanical Room on the Ground Floor adjacent to the Medical Record Storage, and serves the Ground Floor and 1st Floor of the 1990 building.

Item 2. Based on interview with Staff D (plant operations director) and Staff G (plant operations mechanic) on 8/25/2010 at 3 pm, it was revealed that the air-handling unit AHU#2 of 4000 cfm capacity did not have a duct smoke detector on the supply side of the unit to shut down the fan upon detection of smoke. This unit is located in the Mechanical Room on the Ground Floor adjacent to the Male Locker Room on the Ground Floor, and serves the 2nd Floor above.

The above deficiency was confirmed with the plant operations director, Staff B (vice president) and Staff C (chief quality officer) at the exit conference on 8/25/2010 at 4:30 pm.

During the verification visit of the Door County Memorial Hospital on 10/08/2010, Surveyor 12316 determined that the facility has made a satisfactory progress toward correcting the above deficiency. The approved completion date is January 1, 2011.