HospitalInspections.org

Based on observation and interview, it was determined the facility failed to ensure the automatic sprinkler system was maintained, according to National Fire Protection Association (NFPA) standards.

The findings include:

Observation on 10/25/16 at 1:27 PM, with the Director of Quality Management, revealed data wires attached to the automatic sprinkler system piping in both smoke barriers. Interview, with the Director of Quality Management, revealed the facility was not aware data wires were attached to the automatic sprinkler system piping.

The findings were acknowledged by the Administrator.

Reference: NFPA 25 (1998 Edition)
2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Based on observation and interview, it was determined the facility failed to ensure portable space heaters were not used, according to National Fire Protection Association (NFPA) standards.


The findings include:


Observation on 10/25/16 at 1:40 PM, with the Director of Quality Management, revealed two (2) space heaters in a communication closet. Interview, with the Director of Quality Management at the time of observation, revealed the heaters were used sometimes in offices when the buildings heating system was not working properly. The Director of Quality Management was not aware if the heating element exceeded 212 degrees Fahrenheit or if the heaters had been inspected.


Interview on 10/25/16 at 2:53 PM, with the Director of Quality Management, revealed the facility had a policy for space heater use. The policy, with a revision date of 07/01/2015 stated space heaters used in the facility would be inspected to ensure the heating element would not exceed 212 degrees Fahrenheit.


The findings were acknowledged by the Administrator.


Reference: NFPA 101 (2000 Edition)

19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).