HospitalInspections.org
Bringing transparency to federal inspections
ST LUKE'S HOSPITAL
No Description Available
Tag No.: K0062
The facility failed to ensure the automatic sprinkler system was continuously maintained in a reliable operating condition as required by NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-based Fire Protection Systems.
1) Observation determined:
a) The two sprinklers in the X-ray Storage Room were obstructed by surface mounted light fixtures.
b) One of the sprinklers in the Tub Room was obstructed by a privacy curtain.
2) Heat from a fire stratifies to the ceiling and travels along the ceiling to activate the sprinkler. When ceilings are removed, it delays the activation of the automatic fire sprinkler system. Observation determined three suspended ceiling tiles were missing in Data/IT Room.
3) Sprinkler record review could not verify the newly installed sprinkler system was tested for compliance with NFPA 25.