HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction. This was evidenced by unsealed penetrations in the facility walls. This could result in the spread of smoke or fire to other locations in the facility. This affected 2 of 3 smoke compartments

NFPA 101, Life Safety Code, 2000 Edition
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a tour of the facility with the Fire Fighter, the ERS I, the Residence Manager, the Nurse Instructor, and the Standard Compliance Coordinator on 11/26/14, the building construction was observed.

1. At 8:48 a.m. there was a four plug outlet box (no wires inside) that was uncovered with an approximately 3/4 inch unsealed penetration in the west wall of Room 4016, bedroom.

2. At 9:06 a.m., there was an approximately 1 inch unsealed penetration in the south wall of Room 4021, Electrical Room. There were two black wires hanging out of the hole.

Based on observation, the facility failed to maintain corridor doors. This was evidenced by a corridor door that was missing components. This could result in a delay to contain smoke or fire to a room. This affected 1 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
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 13/4-in. (4.4-cm) 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. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.4. All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a tour of the facility with the Fire Fighter and the Standard Compliance Coordinator on 11/26/14, the doors in the facility were observed.

At 9:17 a.m., the door frame to the oxygen room 4109 was missing a striker plate. The door was not completely latching when tested.

Based on observation, the facility failed to maintain their automatic closing fire doors. This was evidenced by fire doors that failed to release from the magnetic hold open device and close. This could allow the spread of smoke or flames in the event of a fire. The wing was unoccupied. This affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Fire Fighter and the Standard Compliance Coordinator on 11/26/14, the doors held open by magnetic hold-open devices were observed and tested.

1. At 9:42 a.m., the fire door 4111 was not releasing from the magnetic hold-open device, and closing when tested.

2. At 9:44 a.m., the fire door 4113 was not releasing from the magnetic hold-open device, and closing when tested.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by an unsealed penetration in the smoke barrier wall. This could result in the spread of smoke or fire to other smoke compartments. This affected 2 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
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.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Fire Fighter, the ERS I, and the Standard Compliance Coordinator on 11/26/14, the smoke barrier walls were observed.

At 9:53 a.m., there was an approximately 6 inch by 8 inch unsealed penetration in the smoke barrier wall near Room 4110.

Based on observation, the facility failed to maintain the smoke barrier doors. This was evidenced by a smoke barrier door that was impeded from closing. This could fail to contain smoke in the event of a fire. This affected 2 of 3 smoke compartments. The wing was unoccupied.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Fire Fighter, ERS I, and Standard Compliance Coordinator on 11/26/14 the facility smoke barrier doors were observed.

At 9:38 a.m., the smoke barrier door near Room 4110 was impeded from closing with an unattended ladder leaning against the door frame.