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Based on observation and interview, it was determined the facility failed to maintain the fire and smoke rated barrier in 4 (above the fire-rated doors labeled #4 central corridor of Building 01, #5 south corridor Building 01, #6 in the north corridor near the lobby Building 01, and #16 in the west corridor of Building 02) of 10 areas observed by protecting penetrations in the barrier with a system or material capable of limiting the transfer of smoke. The failed practice had the potential to affect all patients, visitors, and staff because it could not be assured that smoke would not spread from one side of the barrier to the other in the event of a fire and smoke event. Findings follow:

A. While touring the facility with the Director of Maintenance and Engineering on 11/14/17 at 12:50 to 1:30 PM, observation showed:
1) Fire alarm cables in one penetration in the fire-rated barrier above the fire-rated doors labeled #5. The penetration was not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
2) A black pipe in one penetration in the fire-rated barrier above the fire-rated doors labeled #4. The penetration was not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
3) A black pipe in one penetration in the fire-rated barrier above the fire-rated doors in the north corridor labeled #6. The penetration was not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
4) Three electrical conduits in three penetrations of the fire-rated barrier above the fire-rated doors labeled #16. The penetrations were not sealed with a system or material capable of limiting the transfer of smoke from one side of the barrier to the other.
B. During the tour, the Director of Maintenance and Engineering verified the penetrations were not sealed with a material capable of limiting the transfer of smoke from one side of the barriers to the other.
C. See K300.

Referenced code: NFPA 101; 2012 edition, Section 8.4.4.1

Based on record review and interview, the facility failed to provide evidence of an inventory of all source systems, control valves, alarms systems, manufactured assemblies, and outlets in order to perform a risk assessment and develop a maintenance program for gas and vacuum piped systems for medical gas, vacuum, Waste Anesthesia Gas Disposal (WAGD), or support gas systems as required by NFPA 99, Section: 5.1.14.2. Failure to develop and implement a program for the periodic inspection and maintenance of the facility's medical gas and vacuum piped systems had the potential to affect all patients requiring medical gas, vacuum, and support gas systems because it could not be assured the systems would have operated correctly to serve the patients' needs. Findings follow:

A. Review of policies and procedures and preventative maintenance records on 11/13/17 at 12:30 PM showed that there was no evidence of an inventory of the facility's source systems, control valves, alarm systems, manufactured assemblies, and outlets to perform a risk assessment in order to develop a maintenance program for their medical gas, vacuum, WAGD, or support gas systems.
B. During an interview on 11/13/17 at 12:30 PM, the Director of Maintenance and Engineering stated that the facility had not developed a maintenance program for their nitrogen, vacuum, WAGD, and support gas systems.