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12-3.11, NFPA 99, HEALTH CARE FACILITIES
Hospitals shall comply with the provisions of Chapter 11 for disaster planning, as appropriate.

11-1, NFPA 99, HEALTH CARE FACILITIES
This chapter establishes minimum criteria for health care facility emergency preparedness management in the development of a program for effective disaster preparedness, mitigation, response, and recovery.

11-2, NFPA 99, HEALTH CARE FACILITIES
The purpose of this chapter is to provide those with the responsibility for disaster management planning in health care facilities with a framework to assess, mitigate, prepare for, respond to, and recover from, disasters. This chapter is intended to aid in meeting requirements for having an emergency preparedness management plan.

11-5.3.9, NFPA 99, HEALTH CARE FACILITIES
Drills: Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

3.1.3, NFPA 101, LIFE SAFETY CODE
Where terms are not defined in this chapter or within an occupancy chapter, they shall be defined using their ordinarily accepted meanings within the context in which they are used. Webster ' s Third New International Dictionary of the English Language, Unabridged, shall be a source for ordinarily accepted meaning.

Websters Dictionary, 3rd edition
Drill:
1. a : to fix something in the mind or habit pattern of by repetitive instruction... b : to impart or communicate by repetition... c : to train or exercise in military drill

Based on record review and interview the facility failed to ensure that at least two disaster drills have been conducted within the past 12 months.

Findings include:

Record review of disaster drills during tour on 10/17/11 between 12:45 p.m. and 1:45 p.m. revealed that the most recent disaster drill was conducted on 11/29/10.

Interview during tour on 10/17/11 between 1:45 p.m. and 5:30 p.m. with Staff B (Area Director of Facilities) and Staff C (Maintenance Supervisor) confirmed the findings.

19.3.5.1, NFPA 101, LIFE SAFETY CODE
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1, NFPA 101, LIFE SAFETY CODE
Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

9.7.5, NFPA 101, LIFE SAFETY CODE
Maintenance and Testing: All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

5-1.1, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

5-5.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: A minimum distance shall be maintained between sprinklers to prevent operating sprinklers from wetting adjacent sprinklers and to prevent skipping of sprinklers. The minimum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

5-6.3.4, NFPA 13, INSTALLATION OF SPRINKLER SYSTEMS
Minimum Distance Between Sprinklers: Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

5-6.5.1.2 Sprinklers shall be arranged to comply with... Table 5-6.5.1.2
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP):

Distance from Sprinklers to Side of Obstruction: Less than 1 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 0

Distance from Sprinklers to Side of Obstruction: 1 ft to less than 1 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 2-1/2

Distance from Sprinklers to Side of Obstruction: 1 ft 6 in. to less than 2 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 3-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft to less than 2 ft 6 in.

Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 5-1/2

Distance from Sprinklers to Side of Obstruction: 2 ft 6 in. to less than 3 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 7-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft to less than 3 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 9-1/2

Distance from Sprinklers to Side of Obstruction: 3 ft 6 in. to less than 4 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 12

Distance from Sprinklers to Side of Obstruction: 4 ft to less than 4 ft 6 in.
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 14

Distance from Sprinklers to Side of Obstruction: 4 ft 6 in. to less than 5 ft
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 16-1/2

Distance from Sprinklers to Side of Obstruction: 5 ft and greater
Maximum Allowable Distance of Deflector above Bottom of Obstruction (in.): 18

2-2.1.1, NFPA 25, WATER-BASED FIRE PROTECTION SYSTEMS
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Based on observation and interview the facility failed to ensure that the sprinkler system is properly installed and/or maintained.

Findings include:

Observation during tour on 10/17/11 between 2:45 p.m. and 4:15 p.m. with Staff B (Area Director of Facilities) and Staff C (Maintenance Supervisor) revealed the following:

1. The Human Resources Directors office has two sprinkler heads approximately 4 feet in distance from each other.

2. The spray pattern of at least one sprinkler head on the second floor of the south stairwell is obstructed by a ceiling mounted light fixture. The deflector of the sprinkler head is approximately 1 inch from the ceiling, the side of the ceiling mounted light fixture is approximately 4-1/2 inches in width from the ceiling, and the distance is approximately 9 inches from the centerline of the sprinkler head to the nearest side of the light fixture.

Interview during tour on 10/17/11 with Staff B and Staff C at the time of discovery confirmed the findings.