HospitalInspections.org
Bringing transparency to federal inspections
WESTFIELD MEMORIAL HOSPITAL, INC
Sprinkler System - Installation
Tag No.: K0351
Based on observation and interview, the facility failed to ensure that sprinkler heads (component of the automatic fire sprinkler system activated in response to heat) of the same thermal sensitivity (ability to distinguish between temperatures) were installed in the same corridor compartment.
Findings Include:
Observation on 04/23/25 at 11:21 AM in the corridor of the Radiology Suite, revealed there were pendent type quick response sprinkler heads (thin red tube-react faster than standard response sprinkler heads) mixed with standard response pendent type sprinkler heads with a fusible link (two small pieces of metal that are held together with solder, and when heated the solder melts and the metal detaches and water flows from the head), in the same compartment. National Fire Protection Agency 13, 2010 edition, Section 8.3.3.2 indicates where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted by 8.3.3.3.
Interview on 04/24/25 at 10:30 AM with Staff (AA), Facility Manager, verified these findings and indicated there was a renovation of approximately half of the suite. The pendent quick response sprinkler heads were installed as part of the renovation. The existing standard response sprinkler heads with a fusible link, remained in the unrenovated portion of the corridor.
Corridor - Doors
Tag No.: K0363
Based on observation, document review, and interview, the facility failed to ensure that two of three sets of corridor doors, that are part of a two-hour fire rated barrier (a barrier designed to resist a fire for at least two hours), close completely and latch.
Findings Include:
Observation on 04/24/25 at 09:45 AM with Staff (AA), Facilities Manager, revealed the corridor doors on the second floor by the elevator, were equipped with latching mechanism, but both leaves (main panel of a door that opens and closes) did not close and latch. On the first floor by stairwell "C," one of two corridor door leaves equipped with a latching mechanism, did not close and latch.
Review of the "Life Safety Plan- 1st and 2nd Floor Plans LS-01," indicated both sets of corridor doors had 1 1/2-hour rating and were located in a two-hour firewall.
Interview on 04/24/25 at 09:50 AM with Staff (AA), Facilities Manager, verified these findings.