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Based on interview and record review, the facility failed to ensure the elevator equipment in 2 of 2 elevator equipment rooms was provided with a shunt trip. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon or prior to the application of water from the sprinkler located in the elevator machine room. The elevator equipment rooms were located in the basement and could affect any number of staff in the hospital.

Findings include:

Based on interview with the Manager Support Services on 04/30/13 at 12:03 p.m., a shunt trip, which is designed to automatically disconnect power to the affected elevator, had not been installed on the elevator equipment in the two basement elevator equipment rooms. Based on record review with the Manager Support Services and the Quality Accreditation Specialist at 12:15 p.m., the waiver request documentation submitted by the facility included the comment "This quote does not include the additional cost of electrician labor needed to install shunt trips prior to activation." Based on an interview with the Manager Support Services at the time of record review, he said the facilities sprinkler contractor company, Shambaugh and Sons, stated a shunt trip was not required per code but he was unable to provide documentation from Shambaugh and Sons to confirm that statement.