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NFPA 72 (1999 Edition)

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for purpose.
(4) Smoke detector/control unit arrangement whereby the detector caused a signal at the control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Based on record review and interview, the facility failed to ensure Sensitivity Testing of smoke detection devices was conducted on a two (2) year cycle. Not testing detection devices for sensitivity every two years could result in a undetected fire which presents a risk of potential harm by fire to patients within the hospital. The findings are:

A. Record review of Fire Alarm System, no documentation was provided to indicate detection devices had been sensitivity tested within the last 2 years.

B. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they were unaware of the requirement, acknowledging the finding.

NFPA 25 (1998 Edition)

Chapter 10 Obstruction Investigation
10-2.1 To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:

(a) defective intake for fire pumps taking suction from open bodies of water.
(b) The discharge of obstructive material during routine water tests.
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves.
(d) Foreign material in water during drain tests or plugging of inspector's test connections.
(e) Plugged piping in sprinkler systems dismantled during building alterations.
(f) A record of broken public mains in the vicinity.
(g) Abnormally frequent false tripping of a dry pipe valve(s).
(h) A system that is returned to service after an extended shutdown (greater than 1 year).
(i) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper systems.
(j) A system has been supplied with raw water via the fire department connection.

10-2.2 Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior or a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review and interview of fire Sprinkler System, facility failed to ensure Sprinkler System had a five (5) obstruction test. Not conducting obstruction test every 5 years could result in the Sprinkler System not functioning as required, which presents a risk of potential harm by fire to all patients in the hospital. The findings are:

A. Record review of the fire sprinkler system, no documentation was provided to indicate the Obstruction test had been conducted within the last 5 years.

B. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they were unaware the obstruction test was required, acknowledging the finding.

Based on observation and interview, the facility failed to ensure mechanical ventilation was operating in the Medical Surgical (Soiled Utility Room), and Emergency Room (Janitorial Closet). Not having properly working exhaust ventilation could result in noxious odors being accumulated and spread throughout adjacent areas, which could result in a potential health hazard to all patients in the hospital. The findings are:


A. On 04/20/16, at 11:00 am, observation of Exhaust Ventilation located in Medical Surgical (Soiled Utility Room), not operating when tested.

B. On 04/20/16, at 11:15 am, observation of Exhaust Ventilation located in Emergency Room (Janitorial Closet), not operating when tested.

C. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they were unaware the exhaust ventilation was not operating, and should periodically be checked for constant operation of exhaust ventilation in areas such as these.

NFPA 110

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing specific gravity when applicable or warranted.

Based on record review and interview, the facility failed to ensure the Emergency Generator batteries had specific gravity readings taken within the last twelve months. Not conducting specific gravity readings on the batteries could result in the failure of the Emergency Generator starting in the event of a main power outage, which presents a risk of potential harm to all patients within the hospital. The findings are:

A. Record review of the Emergency Generator log book revealed no documentation was provided to indicate specific gravity readings had been taken for the last twelve (12) months.

B. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they had been following the maintenance schedule which was in place, and the form did not indicate specific gravity readings to be checked.

NFPA 72 (1999 Edition)

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for purpose.
(4) Smoke detector/control unit arrangement whereby the detector caused a signal at the control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Based on record review and interview, the facility failed to ensure Sensitivity Testing of smoke detection devices was conducted on a two (2) year cycle. Not testing detection devices for sensitivity every two years could result in a undetected fire which presents a risk of potential harm by fire to patients within the hospital. The findings are:

A. Record review of Fire Alarm System, no documentation was provided to indicate detection devices had been sensitivity tested within the last 2 years.

B. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they were unaware of the requirement, acknowledging the finding.

NFPA 25 (1998 Edition)

Chapter 10 Obstruction Investigation
10-2.1 To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:

(a) defective intake for fire pumps taking suction from open bodies of water.
(b) The discharge of obstructive material during routine water tests.
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves.
(d) Foreign material in water during drain tests or plugging of inspector's test connections.
(e) Plugged piping in sprinkler systems dismantled during building alterations.
(f) A record of broken public mains in the vicinity.
(g) Abnormally frequent false tripping of a dry pipe valve(s).
(h) A system that is returned to service after an extended shutdown (greater than 1 year).
(i) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper systems.
(j) A system has been supplied with raw water via the fire department connection.

10-2.2 Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior or a dry valve or preaction valve and by removing two cross main flushing connections.

Based on record review and interview of fire Sprinkler System, facility failed to ensure Sprinkler System had a five (5) obstruction test. Not conducting obstruction test every 5 years could result in the Sprinkler System not functioning as required, which presents a risk of potential harm by fire to all patients in the hospital. The findings are:

A. Record review of the fire sprinkler system, no documentation was provided to indicate the Obstruction test had been conducted within the last 5 years.

B. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they were unaware the obstruction test was required, acknowledging the finding.

Based on observation and interview, the facility failed to ensure mechanical ventilation was operating in the Medical Surgical (Soiled Utility Room), and Emergency Room (Janitorial Closet). Not having properly working exhaust ventilation could result in noxious odors being accumulated and spread throughout adjacent areas, which could result in a potential health hazard to all patients in the hospital. The findings are:


A. On 04/20/16, at 11:00 am, observation of Exhaust Ventilation located in Medical Surgical (Soiled Utility Room), not operating when tested.

B. On 04/20/16, at 11:15 am, observation of Exhaust Ventilation located in Emergency Room (Janitorial Closet), not operating when tested.

C. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they were unaware the exhaust ventilation was not operating, and should periodically be checked for constant operation of exhaust ventilation in areas such as these.

NFPA 110

8.3.7 Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer's specifications.

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing specific gravity when applicable or warranted.

Based on record review and interview, the facility failed to ensure the Emergency Generator batteries had specific gravity readings taken within the last twelve months. Not conducting specific gravity readings on the batteries could result in the failure of the Emergency Generator starting in the event of a main power outage, which presents a risk of potential harm to all patients within the hospital. The findings are:

A. Record review of the Emergency Generator log book revealed no documentation was provided to indicate specific gravity readings had been taken for the last twelve (12) months.

B. On 04/20/16, at 1:00 pm, during interview, Director of Plant Operations and Safety Officer stated they had been following the maintenance schedule which was in place, and the form did not indicate specific gravity readings to be checked.