HospitalInspections.org

Based on observations, the automatic sprinkler system is not installed and maintained in accordance with NFPA 13 the Standard for the Installation of Sprinkler Systems 2010 edition. The failure to maintain the sprinkler system in compliance with NFPA 13 (10) could allow system being place out of service causing a decrease in the fire protection system capability in the event of an emergency that could affect patients, as well as an undetermined number of staff, and visitors.


Findings include:

On facility tour between 10:00 a.m. to 3:00 p.m. on 01/24/2017, observations reveled that the fire sprinkler spare heads that is located in the kitchen refrigerator and freezer had a frangible glass bulb that had no color and it could not be accurately ascertained that there is any fluid within the bulb.


This deficient practice was confirmed by the Maintenance Supervisor.