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Based on observation, the facility failed to ensure that all components of the sprinkler system are installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

The findings are:

During a tour of the Emergency Department on 12/7/2016 at approximately 10:15 AM, it was observed that the sprinkler heads in Exam Room #5 and Exam Room #6 were located so that the centerline of the sprinkler head was less than four inches from the privacy curtain rail, potentially interfering with the spray pattern from the sprinkler heads.

Failure to install sprinkler heads in a manner which prevents them from operating optimally, may result in injury to patients and staff in the event of a fire emergency.

This finding was verified by the Senior Administrative Director at the time of observation.

Based on observation, the facility failed to provide adequate fire protection at three (3) of the emergency power generators.

The findings are:

During a tour of the facility on 12/8/2016 between 1:10 PM and 1:40 PM, it was observed that three (3) of the four (4) of the facility's emergency power generators, which are located separately from the building, lacked a fire extinguisher at the generator housing.

NFPA 37 Standard for the Installation and use of Stationary Combustion Engines and Gas Turbines (referenced in NFPA 110 Standard for Emergency and Standby Power Systems) requires that a fire risk evaluation be performed to determine the level of protection needed based on the type and quantity of combustible materials involved, including engine fuel and lubricating oil.

In the absence of a fire risk evaluation, fire extinguishers shall be present at all generator sites.

Failure to provide adequate fire protection at the generator site may result in failure of the generator, and may also result in injury to personnel in the event of a fire.

These findings were verified by the Senior Administrative Director at the time of observation.

Based on observation and interview, the facility failed to ensure that all elevators comply with the provisions of NFPA 101 Life Safety Code 9.4, and ASME/ANSI A17.3 Safety Code for Existing Elevators and Escalators.

The finding is:

During a tour of the facility on 12/7/2016, it was observed that elevator # 5, a hydraulic elevator, lacked sprinkler protection at the top and near the bottom of the elevator shaft.

Failure to provide adequate protection from fire in the elevator shaft, particularly in a shaft where combustible hydraulic fluids are present, may result in injury from fire to patients and staff.

This finding was verified by the Senior Administrative Director at the time of observation.