HospitalInspections.org

Based on observation and interview, it was determined that the facility failed to ensure that buildings classified as fully sprinklered have sprinkler protection in all required areas in two of twelve smoke zones within this component.

Findings:

1. Observations made on July 8, 2015, between 9:25 am and 10:00 am, revealed that the third floor mechanical space area lacked sprinkler protection in the following locations:

a. Generator room.
b. ATS room.
c. Electrical room.
d. Both exhaust shafts that vent the generator radiators.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed the above named areas lack sprinkler protection.

2. Observation made on July 8, 2015, between 10:20 am and 11:10 am, revealed missing sprinkler heads at the following locations:

a. 10:20 am, ground floor, kitchen, house keeping sink closet.
b. 10:33 am, ground floor, data room.
c. 10:56 am, ground floor, intern suite closet.
d. 11:10 am, ground floor, old physical therapy suite closets.

Interview with the Clinical Associate Executive Director and the Director of Safety and Security on July 8, 2015, at 2:30 pm, confirmed these areas lacked sprinkler coverage.

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Observation made on October 21, 2015, at 11:50 am, during an onsite Revisit survey, revealed the following:

Item 1a,b,c,d - Not Completed. Automatic sprinkler protection in the third floor mechanical space in the areas noted above were not installed at the time of this inspection.

All other deficiencies listed under this citation were corrected.

Interview with the Clinical Associate Executive Director and the Facilities Director on October 21, 2015, at 1:10 pm, confirmed the areas lacked sprinkler coverage.