HospitalInspections.org

Based on observation the facility failed to provide doors that did not close, latch, or resist the passage of smoke for 8 of 90 corridor doors in the facility as per NFPA 101 (Life Safety Code). This deficiency affects could affect all patients in the facility.

Note: NFPA 101, 2000 edition
NFPA 101 Chapter 19, " Existing Health Care Occupancy, " 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required.

Findings:

During facility tour on May 10, 2011 between 9:00 a.m. and 4:00 p.m. the following doors did not latch or had no latching device on them. If the doors are not latching then this would allow smoke to transfer between the corridor and the rooms.

1. The Emergency room on the first floor has a sliding door with no positive latching on it.
2. The door to the Emergency room lounge has no positive latching device on it.
3. The three Primary Care units on the first floor have no positive latching device on them.
4. The two set of doors going into the Critical Care unit have no positive latching device on them.

Based on observations the facility failed to provide smoke barriers that were constructed with at least a one-half hour fire resistance rating for 2 of 4 walls in the facility. This deficiency affects 2 of 4 smoke compartments and all patients in the facility.

Note: NFPA 101, 2000 edition:
NFPA 101:19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Findings:

During facility tour on May 10, 2011 between 9:30 a.m. and 4:00 p.m., the integrity of a smoke barrier walls were observed to be compromised in the following area.

1. A one inch conduit is penetrating the smoke barrier wall on the first floor across from air handler AH 1-5 is not sealed.
2. The three med gas line that are penetrating the smoke barrier wall in room 315 is not sealed.