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Tag No.: K0062
Based upon observation and interview the facility failed to maintain the Automatic Fire Sprinkler System in a reliable operating condition, by allowing ordinary and quick response (QR) sprinkler heads to be intermixed in area or compartment. This deficient practice could prevent or delay the ordinary sprinkler heads from operating.
Findings include:
1) During the facility tour on 2/7/12 observation revealed mixed quick and ordinary response sprinkler heads in the cafeteria two QR heads were installed intermixed with ordinary heads. This was observed by the surveyor and acknowledged by the Director of Facilities Management.
2) During the facility tour on 2/7/12 observation revealed mixed quick and ordinary response sprinkler heads in the Imaging waiting area one QR head was installed intermixed with ordinary heads. This was observed by the surveyor and acknowledged by the Director of Facilities Management.
3) During the facility tour on 2/7/12 observation revealed a missing sprinkler head in the MRI electrical room. This was observed by the surveyor and acknowledged by the Director of Facilities Management.
4) During the facility tour on 2/7/12 observation revealed mixed quick and ordinary response sprinkler heads in the Operating Room Scrub area "C" a single QR head was installed intermixed with ordinary heads. This was observed by the surveyor and acknowledged by the Director of Facilities Management and the Operating Room Manager.
5) During the facility tour on 2/7/12 observation revealed mixed quick and ordinary response sprinkler heads in the Operating Room Recovery area, a single QR head was installed intermixed with ordinary heads. This was observed by the surveyor and acknowledged by the Director of Facilities Management and the Operating Room Manager.
6) During the facility tour on 2/7/12 observation revealed mixed quick and ordinary response sprinkler heads in the Central Sterile Supply Room. Approximately 50% of the heads were QR installed adjacent to the other side of the room with ordinary heads. This was observed by the surveyor and acknowledged by the Director of Facilities Management and the Operating Room Manager.
7) During the facility tour of the Radiation-Oncology Center on 2/8/12 observation revealed mixed quick and ordinary response sprinkler heads in the CT room corridor. Two QR heads were installed intermixed with ordinary heads. This was observed by the surveyor and acknowledged by the Director of Facilities Management.
The above findings were acknowledged by the Director of Facilities Management during the exit conference on February 8, 2012.
Actual NFPA standard:
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-4.1.1*
Replacement sprinklers shall have the proper characteristics for the application intended. These include the following:
(a) Style
(b) Orifice size and K-factor
(c) Temperature rating
(d) Coating, if any
(e) Deflector type (e.g., upright, pendant, sidewall)
(f) Design requirements
Exception No. 1: Spray sprinklers shall be permitted to replace old-style sprinklers.
Exception No. 2: Replacement sprinklers for piers and wharves shall comply with NFPA 307, Standard for the Construction and Fire Protection of Marine Terminals, Piers, and Wharves.
2-4.1.3* Special and Quick-Response Sprinklers.
Special and quick-response sprinklers as defined by NFPA 13, Standard for the Installation of Sprinkler Systems, shall be replaced with sprinklers of the same make, model, orifice, size, temperature range and thermal response characteristics, and K-factor.
Exception: If the special or quick-response sprinkler is no longer manufactured, a special or quick-response sprinkler with comparable performance characteristics shall be installed.
A-2-4.1.3
It is imperative that any replacement sprinkler have the same characteristics as the sprinkler being replaced. If the same temperature range, response characteristics, spacing requirements, flow rates, and K-factors cannot be obtained, a sprinkler with similar characteristics should be used, and the system should be evaluated to verify the sprinkler is appropriate for the intended use. With regard to response characteristics, matching identical Response Time Index (RTI) and conductivity factors is not necessary unless special design considerations are given for those specific values.