HospitalInspections.org

NFPA 25,13.2.1 An investigation of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of investigating for the presence of foreign organic and inorganic material.
Based on observation and interview, the facility failed to assure the sprinkler system had a 5-year obstruction investigation performed.
The findings include:
Record review and interview with the Maintenance Director, on May 14, 2012 at 9:40 a.m. confirmed the sprinkler company ' s quarterly reports dated 4-11-12 and 1-11-12 indicated the 5-year maintenance was past due. No documentation was provided to indicate when the last 5-year maintenance was completed.
Based on observation and interview, the facility failed to assure all areas were sprinkled.
The findings include:
Observation and interview with the Maintenance Director, on May 14, 2012 at 2:40 p.m. confirmed the 1st floor IT closet was not provided with sprinkler protection.
NFPA 13 - 5-3.1.5.2 states: When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
Observation and interview with the Maintenance Director, on May 14, 2012 at 1:30 p.m. confirmed the x-ray file storage room has 4 quick response heads and 2 standard response heads.
These finding were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on May 14, 2012.

Based on observation and interview, the facility failed to assure GFCI outlets were located in all wet areas.
The findings include:
Observation and interview with the Maintenance Director, on May 14, 2012 at 1:45 p.m. confirmed the janitor's closet next to room 305 had a quad emergency power receptacle was located 3-feet next to the sink and was not GFCI protected. (NFPA 70, 517-20).
This finding was verified by the Maintenance Director and acknowledged by the Administrator during the exit conference on May 14, 2012.

NFPA 25,13.2.1 An investigation of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of investigating for the presence of foreign organic and inorganic material.
Based on observation and interview, the facility failed to assure the sprinkler system had a 5-year obstruction investigation performed.
The findings include:
Record review and interview with the Maintenance Director, on May 14, 2012 at 9:40 a.m. confirmed the sprinkler company ' s quarterly reports dated 4-11-12 and 1-11-12 indicated the 5-year maintenance was past due. No documentation was provided to indicate when the last 5-year maintenance was completed.
Based on observation and interview, the facility failed to assure all areas were sprinkled.
The findings include:
Observation and interview with the Maintenance Director, on May 14, 2012 at 2:40 p.m. confirmed the 1st floor IT closet was not provided with sprinkler protection.
NFPA 13 - 5-3.1.5.2 states: When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
Observation and interview with the Maintenance Director, on May 14, 2012 at 1:30 p.m. confirmed the x-ray file storage room has 4 quick response heads and 2 standard response heads.
These finding were verified by the Maintenance Supervisor and acknowledged by the Administrator during the exit conference on May 14, 2012.

Based on observation and interview, the facility failed to assure GFCI outlets were located in all wet areas.
The findings include:
Observation and interview with the Maintenance Director, on May 14, 2012 at 1:45 p.m. confirmed the janitor's closet next to room 305 had a quad emergency power receptacle was located 3-feet next to the sink and was not GFCI protected. (NFPA 70, 517-20).
This finding was verified by the Maintenance Director and acknowledged by the Administrator during the exit conference on May 14, 2012.