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GEORGE E WEEMS MEMORIAL HOSPITAL
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on record review and interview with the Maintenance Director, the facility was unable to provide documentation that the fire alarm system was inspected and tested as required. The facility failed to provide documentation that the fire alarm sensitivity tests had been done. This in the event of fire could delay or deny the fire alarm system to perform as required.
The findings include:
During the Fire and Life Safety document review on 08/03/2022 from 10:30 AM to 2:30 PM, with the Maintenance Director, the facility failed to produce the fire alarm sensitivity test report and Duct Detector differential testing.. . The Maintenance Director verified these findings at the times identified. Sensitivity test shall be checked 1 year after installation. Sensitivity test shall be checked every alternate year. Differential testing on a annual basis.
NFPA 101 (2018) 18.3.4 & 19.3.4. NFPA 72 (2010 edition) 14.4.5.3.1 & 14.4.5.3.2
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on observation and interview with the Maintenance Director, the facility failed to provide inspection, maintenance and testing of the fire sprinkler system in accordance with NFPA 25. Failure to inspect, maintain, and test system components could result in the system failing to perform as designed.
The findings include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 08/03/2022 between 10:30 AM to 2:30 PM. 4 out of 6 sprinkler heads located in the main lobby were corroded and showing signs of chemical damage. Also it was observed that no sprinkler head inventory list was present in the riser room. The Maintenance Director verified these findings at the times observed.
According to NFPA 25 (2011 edition) 5.2.1.1.1; "Sprinklers shall not show signs of leakage, shall be free of corrosion, foreign materials, paint and physical damage; and shall be installed in the correct orientation." and 5.2.1.1.2; "Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of fluid in the glass bulb heat responsive element, (5) Loading, (6) Painting unless painted by the sprinkler manufacturer."
Subdivision of Building Spaces - Smoke Compar
Tag No.: K0371
Based on observation and interview with the Maintenance Director, the facility failed to properly maintain the required Fire/Smoke barrier penetrations, which have not been fire stopped or smoke sealed per the requirements of NFPA 101(2018 edition). This condition could allow Fire/Smoke to travel from one compartment to other compartments, thus endangering occupants of the facility.
The findings include:
During the Fire & Life Safety tour of the facility with the Director of Maintenance on 08/03/2022 between 10:30 AM to 2:30 PM, it was found that penetrations through the wall above the ceiling have not been fire stopped or smoke sealed. The following location was observed to have penetrations - unapproved spray foam above fire doors 1 through 8.
All locations were not properly protected with the required fire caulk.
The Maintenance Director verified these findings at the times observed.
According to NFPA 101(2018 edition) 8.3 and 19.3.7