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Based on record review and staff interview, the facility failed to ensure that they maintained their automatic sprinkler and standpipe systems per the requirements of:


NFPA 101 Life Safety Code (LSC) 2012 edition, Chapters 4.6.1.1, 4.6.12.1, 4.6.12.4, 4.6.12.5, 9.7.1.1, 9.7.5, 9.7.7, 9.7.8
NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 edition, Chapters 3.3.19, 4.1.1.1.1, 4.1.1.2, 5.1.1.1, 5.1.1.2, 5.1.3, 14.2 through 14.2.2.2, 14.3 through 14.3.3, Table 5.1.1.2


This deficiency is an isolated event and has the potential to affect a very small number of patients, staff and visitors located throughout the facility.


Findings include:


Record review (Hampton Regional Medical Center) on 11/28/2018 at approximately 1120 hrs to 1245 hrs revealed no documentation for a five (5) year internal inspection of piping.


The Maintenance Director was present when the deficiency was identified (during record review). Exit interview with the Maintenance Director and CEO (Chief Executive Officer) on 11/28/2018 at approximately 1250 hrs verified knowledge of having no documentation for a five (5) year internal inspection of piping.

Based on observation and staff interview, the facility failed to ensure that they maintained their portable fire extinguishers per the requirements of:


NFPA 101 Life Safety Code (LSC) 2012 edition, Chapters 4.6.1.1, 4.6.12.1, 4.6.12.4, 4.6.12.5, 19.3.5.12
NFPA 10 Standard for Portable Fire Extinguishers 2010 edition, Chapter 7.1.1, 7.2.1 through 7.2.1.3,
7.2.2 through 7.2.2.2, 7.2.4.1 through 7.2.4.6.


This deficiency is a patterned event and has the potential to affect less than 75% of patients, staff and visitors located throughout the facility.


Findings include:


Observation during facility tour (Hampton Regional Medical Center) on 11/28/2018 at approximately 0945 hrs to 1115 hrs revealed all portable fire extinguishers located throughout facility were not manually inspected on a month-to-month basis (fire extinguishers were already marked being inspected for the month of December 2018, but were conducted during the week of survey 11/26/2018 per the Maintenance Director).


The Maintenance Director was present when the deficiency was identified (during walk-through). Exit interview with the Maintenance Director and CEO (Chief Executive Officer) on 11/28/2018 at approximately 1250 hrs verified knowledge of all portable fire extinguishers located throughout facility not being manually inspected on a month-to-month basis