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Based on observation and interview, it was determined the facility failed to maintain the sprinkler system according to NFPA standards. The deficiency had the potential to affect each of the two (2) smoke compartments on the seventh and ninth floors of the hospital, all patients, staff and visitors.


The findings include:

Observations, on 09/22/11 between 9:00 AM and 10:30 AM, with the Director of Engineering revealed items stored within 18" of a sprinkler head in two (2) storage rooms; one (1) located on the ninth floor, South, and the other on the seventh floor, East. Also observed on the seventh floor, in the soiled utility room, was a sprinkler head missing an escutcheon plate (trim piece) at the ceiling line.

Interviews, on 09/22/11 between 9:00 AM and 10:30 AM, with the Director of Engineering revealed he was not aware of the items being stored with 18" of a sprinkler head in the storage rooms, and the escutcheon plate (trim piece) missing on the sprinkler head located in the soiled utility room.



Reference:

NFPA 13 (1999 Edition)

5-5.5.2* Obstructions to Sprinkler Discharge
Pattern Development.
5-5.5.2.1 Continuous or noncontiguous
obstructions less Than or equal to 18 in.
(457 mm) below the sprinkler deflector
That prevent the pattern from fully developing
shall comply With 5-5.5.2.

NFPA 25 (1998 Edition)

1-11.1 Maintenance shall be performed to keep the system
equipment operable or to make repairs. As-built system installation
drawings, original acceptance test records, and device
manufacturer ' s maintenance bulletins shall be retained to
assist in the proper care of the system and its components.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained according to NFPA standards. The deficiency had the potential to affect each of the two (2) smoke compartments located on the seventh floor, patients, staff, and visitors.


The findings include:

Observations, on 09/22/11 between 10:00 AM and 10:30 AM, with the Director of Engineering revealed an open electrical junction box, without a cover plate, located in both the Electrical Room and the Communications Room, located on the seventh floor, East.

Interviews, on 09/22/11 between 10:00 AM and 10:30 AM, with the Director of Engineering revealed he was unaware of the open electrical junction boxes.



Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system according to NFPA standards. The deficiency had the potential to affect each of the two (2) smoke compartments on the seventh and ninth floors of the hospital, all patients, staff and visitors.


The findings include:

Observations, on 09/22/11 between 9:00 AM and 10:30 AM, with the Director of Engineering revealed items stored within 18" of a sprinkler head in two (2) storage rooms; one (1) located on the ninth floor, South, and the other on the seventh floor, East. Also observed on the seventh floor, in the soiled utility room, was a sprinkler head missing an escutcheon plate (trim piece) at the ceiling line.

Interviews, on 09/22/11 between 9:00 AM and 10:30 AM, with the Director of Engineering revealed he was not aware of the items being stored with 18" of a sprinkler head in the storage rooms, and the escutcheon plate (trim piece) missing on the sprinkler head located in the soiled utility room.



Reference:

NFPA 13 (1999 Edition)

5-5.5.2* Obstructions to Sprinkler Discharge
Pattern Development.
5-5.5.2.1 Continuous or noncontiguous
obstructions less Than or equal to 18 in.
(457 mm) below the sprinkler deflector
That prevent the pattern from fully developing
shall comply With 5-5.5.2.

NFPA 25 (1998 Edition)

1-11.1 Maintenance shall be performed to keep the system
equipment operable or to make repairs. As-built system installation
drawings, original acceptance test records, and device
manufacturer ' s maintenance bulletins shall be retained to
assist in the proper care of the system and its components.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained according to NFPA standards. The deficiency had the potential to affect each of the two (2) smoke compartments located on the seventh floor, patients, staff, and visitors.


The findings include:

Observations, on 09/22/11 between 10:00 AM and 10:30 AM, with the Director of Engineering revealed an open electrical junction box, without a cover plate, located in both the Electrical Room and the Communications Room, located on the seventh floor, East.

Interviews, on 09/22/11 between 10:00 AM and 10:30 AM, with the Director of Engineering revealed he was unaware of the open electrical junction boxes.



Reference: NFPA 70 (1999 edition)

370.28(c) Covers.

All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where metal covers are used, they shall comply with the grounding requirements of Section 250-110. An extension from the cover of an exposed box shall comply with Section 370-22, Exception.