HospitalInspections.org

Based on record review of documentation received on 10/22/21 the facility failed to have a functioning sprinkler system.


Findings include:

Record review of document 'AA11 Invoice#21FPS William Nash Invoice' included 'Service Report Work Order Replacement of Jockey Pump Housing' dated July 19,2021 revealed statements 'Informed by Staff A, that the cistern needed to be filled before pump can be turned on. Left in the Off position' and 'Suction line has a lot of scale build-up, you may want to replace in the near future'

The pump did not include performance testing, commissioning and certification of the fire pump and piping system.


Record review of document 'Document AA16 Austin Fire Systems (002)' August 5, 2021 revealed a proposal to conduct annual inspection and certification of the hospital and the Cardiac Center sprinkler systems.

There was no documentation submitted or evidence on date of the inspection and certification of the hospital and the Cardiac Center sprinkler systems.

Record review of document 'AA17 Fire Pump Weekly Testing Log File' included 'Fire Pump Weekly Performance Test 2021' revealed the following:

09/02/21 'Inline piping damage in the containment area on 8.31.21. Cistern contents emptied to assessed damaged piping. Couplings and requisite items are being quoted. RPM gauge faulty'

10/14/21 'Water pressure low due to cistern levels that are low to conduct repairs to the
main line'

10/17/21 'Requisite piping on order for the damage piping'

There was no documentation on the corrective actions taken due to functional issues identified with the fire pump and piping system.