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Based on record review, and interview with the Facilities Director, the facility failed to maintain the automatic fire sprinkler system (AFSS). Failure to maintain the system could lead to an AFSS failure.

Findings included:

During the facility tour with the Facilities Director on 05/29/2019 through 5/30/2019 between 9:15a.m. and 4:45p.m., it was found that:
1) 5th floor
a) 1/4 sprinklers located in clean utility room #OB506 were loaded
b) 1/2 sprinklers located in OBOR nurses station were loaded
c) 1/6 sprinklers located in recovery room #548 were loaded
d) 3/8 sprinklers located in the labor and delivery corridor were loaded
e) 3/10 sprinklers located in the nursery were loaded
2) 3rd floor
a) 3/4 sprinklers located in the staff lounge were loaded
b) 1/3 sprinklers located in room #307 were loaded and the sprinkler located in the bathroom was loaded
c) The sprinkler located in the M22 med storage room was loaded
d) The sprinkler located in the dictation room was loaded
e) 1/2 sprinklers located in clean utility room #IP0399 were loaded
3) 2nd floor
a) The sprinkler located in MT1 main med room was loaded
b) 2/2 sprinklers located in ICU room #2 were loaded
4) 1st floor
a) The sprinker located in ED room #23 was loaded
b) 1/11 sprinklers located in the OR clean work room were loaded
c) 2/2 sprinklers located in the OR staff lounge were loaded

The facility shall perform an inspection of and document ALL sprinklers installed throughout the facility for evidence of loading, painted, and corrosion and make repairs as required by NFPA 25.

An interview was conducted with the facilities director concurrent with the observations and confirmed the findings.

Per NFPA 101 (2012 Edition) 19.3.5, 9.7
Per NFPA 25 (2011 Edition) 5.2.1.1.1, 5.2.1.1.2