HospitalInspections.org

Based on documentation review and interview it was determined the facility failed to properly maintain and inspect the automatic sprinkler system affecting two of two smoke compartments in this component.

Findings include:

A. Review of sprinkler system testing and inspection documentation on April 20, 2011 at 8:35 AM, revealed the facility did not have documentation available to support conducting a required 5-year inspection of the internal portion of the 60,000 gallon bulk water storage tank which supplies water for the sprinkler system in accordance with NFPA 25, 1998 edition, Chapter 6-2.4

Interview with maintenance representative #1 on April 20, 2011 at 8:35 AM, confirmed that documentation for the required internal 5-year inspection 60,000 gallon bulk water storage tank, that supplies water for the sprinkler system, was not available.

At the time of the Revisit, the following was found:

1. Documentation was not provided to support the water storage tank was inspected in accordance with NFPA 25, 1998 edition. Documentation provided indicated the water storage tank was inspected in accordance with NFPA 22, 2008 edition.

2. Documentation provided did not clearly delineate between "recommendations" and "deficiencies" found at the time of the inspection.

3. There was no documentation provided to support the "recommendations/deficiencies" were corrected.