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Based on observations the facility failed to assure smoke barriers that were constructed with at least a one- hour fire resistance rating for 1 of 1 smoke barrier walls. The walls are required to be continuous and properly protected from penetrations and gaps. Unprotected penetrations would permit the movement of smoke and fire from one compartment to the other in the facility. This deficient practice had the potential to affect 2 of 2 smoke compartments and all 26 patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101: 18.3.7.3
Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than one hour.

Findings:

During facility tour on April 22, 2014 between 11:30 a.m. and 3:30 p.m., the integrity of the smoke barrier wall was observed to be compromised in the following area.

1. The smoke barrier wall in the main waiting room by the consult room has metal sleeve that is two inches in diameter with wires going through it that is not sealed.
2. The smoke barrier wall in the front lobby area has two metal conduits that are not sealed. This conduits are above the door to the treatment room.