Smoke Barrier Wall Deficiencies Identified
Penalty
Summary
The facility failed to maintain smoke barrier walls in two specific locations, impacting four out of twenty-seven smoke compartments. During an observation on December 17, 2024, it was noted that there was an unsealed penetration in the smoke wall of the Level 6300 Elevator Room. Additionally, there was a previously sealed penetration above the double doors next to Data Room 2400.22, where the fire sealant had either been removed or had fallen out. These deficiencies were confirmed through an interview with the TCU Unit Director, Facility Staff, and the Safety Manager on the same day.
Plan Of Correction
The penetration in the Elevator Room will be sealed to prevent the passage of smoke. The penetration above the double doors next to room 2400.22 will be sealed to prevent the passage of smoke. This will be reported to the hospital safety committee and included in the hospital quality assurance program. Door maintenance is monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities and environmental services.