HospitalInspections.org

Based on observation and staff interview during the revisit, conducted on May 7, 2013, it was determined the facility failed to install the automatic fire sprinkler system in accordance with NFPA 101. This was evidenced by the following:
During the walk through with the Maintenance Supervisor, Facilities Director:
1. The main electric room has two fire sprinkler heads spaced less than the required minimum distance between sprinklers of 6 feet.
2. The material storage and air compressor room has a 1" branch line supplying four sprinkler heads, documentation is required that will support the adequate water demand from the branch line in these locations.
3. The attached canopy's exceed 4 feet and do not have fire sprinkler protecting these areas; ambulance canopy, employee entrance, and loading dock.
4. Sprinkler heads are located closer than 4" from a wall or exceed the maximum listed spacing from walls; this was observed in the following locations: corridors adjacent to room 104 and 107, sun room adjacent to the Dining room, the dietary office, patient care supply room, the maintenance office, the CT scan control room, materials storage area, the garage/maintenance shop, the chapel, in the bathroom of patient room 126, and the janitor' closet by patient room 105.
5. The facility was not fully sprinklered throughout, this was observed in the following locations: corridor adjacent to copy room in front office area, an alcove in the ED administrative area, the vestibule from the ambulance entrance, the x-ray room closet, the IT storage room by a nurse station, the IT office, the bathroom of patient room 100 and above the false fire place in the small conference room.

The maintenance staff acknowledged the above items.

Based on observation during the revisit conducted on May 7, 2013, it was determined the facility failed to provide supervisory devices for automatic sprinkler system components and valves in accordance with NFPA 101. This was evidenced by the following:

During the walk-through with the Maintenance Supervisor, Facilities Director;
Control valve on antifreeze loop located in boiler room did not have a provision to monitor conditions of sprinkler system control valve.

The maintenance staff acknowledged the above item.

Based on observation and staff interview during the course of the revisit conducted on May 7, 2013, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101. This was evidenced by the following:
1. During the review of facility records with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Annual fire sprinkler inspection report dated February 20, 2012 did not indicate any sampling or testing of the antifreeze solution for the loop located in the southwest corner of the boiler room.
b. Documentation was not provided to indicate that any five year internal inspections have been performed on system check valves.
2. During the walk-through of the facility with the Maintenance Supervisor, Facilities Director and Risk Manager:
a. Boiler room has a sprinkler branch line missing a hanger to support the pipe.
b. The spare sprinkler head cabinet did not have a minimum of two sprinkler heads of each type utilized in the facility including a sprinkler wrench for each type.
c. Sprinklers shall be replaced that are painted, corroded, damaged, loaded, or in the improper orientation; in the dining room, patient room 114 and the kitchen area sprinkler heads were loaded with debris and in the materials office there were painted sprinkler heads.
d. A sprinkler head in the drug screening room and small room off ED overflow were missing the escutcheon plate for the sprinkler head.
e. Sprinkler head is obstructed by HVAC duct work in the scope cleaning room.
f. A standard response sprinkler head in the copier room was within 1-foot of the ceiling diffuser; this head shall be of intermediate response.
g. In the Heart Risk Prevention room, patient room 113 and the PA's room the sprinkler head was pushed below the ceiling leaving a gap between the drywall and the sprinkler head.
h. One of the sprinkler heads in patient room 109 appeared to be without fluid in the frangible bulb.

The maintenance staff acknowledged the above items during the survey.

Based on observation and staff interview during the course of the revisit conducted on May 7, 2013, it was determined the facility did not provide commercial cooking equipment in accordance with NFPA 101, 19.3.2.6, 9.2.3 including NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Equipment. The following evidenced this:

During the walk-through with the Maintenance Supervisor, Facilities Director and Risk Manager:
1. Upblast fan was not installed at proper distances from roof surface and air intakes. Duct work extended 15 inches above the roof surface, exhaust flow directed away from the surface was located at 38 inches from surface, is located within 10 feet of an air intake. Section 4-8.2

The maintenance staff acknowledged the above items during the survey.