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Based on observations made during the tour of the facility, and subsequent interviews with the staff, it was determined that the facility failed to ensure that the automatic sprinkler system was installed in accordance with NFPA 101 Chapters 9.7; and 19.3 which requires supervision of the system. This would deny notification to the fire alarm control panel and those who monitor it in when a non-supervised control valve is put into the closed position, and thereby disabling the sprinkler system with no one knowing.


Findings include:
On November 23, 2011 at 9:48 AM while on tour of the facility with facility staff at the Ocala Regional Medical Center campus, the sprinkler water supply at the backflow and Outside Stem and Yoke (OS&Y) valves was located outside the building in a vault between the west parking lot and the street. Staff opened the vault and no evidence of electronic supervision or monitoring was observed. An interview with the facilities staff revealed that these valves are part of the sprinkler system. NFPA 101( 2000) 19.3.5.1; 9.7.2.1 and NFPA 72(1999) 2-9.1.1


On November 22, 2011 at 3:24 PM while on tour of the facility with facility staff at the West Marion Community Hospital campus, the sprinkler water supply at the backflow and Outside Stem and Yoke (OS&Y) valves was located outside the building in a vault at the southwest corner of the property. Staff opened the vault and no evidence of electronic supervision or monitoring was observed. An interview with the facilities staff revealed that these valves are part of the sprinkler system. NFPA 101( 2000) 19.3.5.1; 9.7.2.1 and, NFPA 72(1999) 2-9.1.1

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that automatic sprinkler system was not installed in accordance with NFPA 13, or maintained and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include:
On November 21, 2011 at 2:30 PM while on tour of the Ocala Regional Medical Center facility with facility staff, on the second floor roof, three fire department hose connections were not provided with a reliable water supply. The water supply was shut off at valves that were not marked as valves controlling the water supply to the hose connection and not provided with wrenches to operate the valves at the hose connections. "Water supply piping shall be free of internal obstructions that can be caused by debris or by closed control valves." NFPA 25 (2008) 10.2.6.2* (Quoted from Annex A), NFPA 13 (1999) 5-1.2; 5-15.5.2, "Each control valve shall be identified and have a sign indicating the system or portion of the system it controls." NFPA 13 (1999) 9-3.1 NFPA 14

Based on observation, the facility failed to provide equipment listed for use in oxygen atmospheres where oxygen is administered.

Findings include:

On November 22, 2011 at 1:05 PM while on tour of the facility with facility staff at the West Marion Community Hospital campus in the Intensive Care Unit, nurse call pillow speakers were observed at patient beds. They were labeled "Not for use by patients undergoing oxygen therapy."

At 2:15 PM in the outpatient/PACU nurse call pendants were observed at patient beds. They were labeled "Not for use by patients undergoing oxygen therapy." Devices used in the areas of intentional expulsion shall be listed for use in oxygen enriched atmospheres. NFPA (1999) 2.1.9.3

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that the facility failed to provide required inspection maintenance and testing of the emergency power supply system components in accordance with NFPA 110 "Standard for Emergency and Standby Power Systems"

Findings include:

During the course of records review on November 21, 2011 the generator weekly run and inspection logs were reviewed and entries for battery testing were marked as "N/A." Facility staff indicated that they thought the batteries were of the sealed type.

On November 22, 2011 at 10:25 AM while on tour of the Ocala Regional Medical Center facility, with facility staff in the emergency generator enclosures, wet type lead acid batteries providing starting power to the generators were observed.

On November 22, 2011 at 3:15 PM while on tour of the West Marion Community Hospital facility with facility staff in the emergency generator enclosure, wet type lead acid batteries providing starting power to the generators were observed. "Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects." NFPA 110 (1999) 6-3.6*; "Maintenance of batteries should include checking and recording the value of the specific gravity." NFPA 110 (1999) A-6-3.6 [See NFPA 70, National Electrical Code, Section 700-4(c).]

Based on observations made during the tour of the facility, and subsequent interviews with the staff, it was determined that the facility failed to ensure that the automatic sprinkler system was installed in accordance with NFPA 101 Chapters 9.7; and 19.3 which requires supervision of the system. This would deny notification to the fire alarm control panel and those who monitor it in when a non-supervised control valve is put into the closed position, and thereby disabling the sprinkler system with no one knowing.


Findings include:
On November 23, 2011 at 9:48 AM while on tour of the facility with facility staff at the Ocala Regional Medical Center campus, the sprinkler water supply at the backflow and Outside Stem and Yoke (OS&Y) valves was located outside the building in a vault between the west parking lot and the street. Staff opened the vault and no evidence of electronic supervision or monitoring was observed. An interview with the facilities staff revealed that these valves are part of the sprinkler system. NFPA 101( 2000) 19.3.5.1; 9.7.2.1 and NFPA 72(1999) 2-9.1.1


On November 22, 2011 at 3:24 PM while on tour of the facility with facility staff at the West Marion Community Hospital campus, the sprinkler water supply at the backflow and Outside Stem and Yoke (OS&Y) valves was located outside the building in a vault at the southwest corner of the property. Staff opened the vault and no evidence of electronic supervision or monitoring was observed. An interview with the facilities staff revealed that these valves are part of the sprinkler system. NFPA 101( 2000) 19.3.5.1; 9.7.2.1 and, NFPA 72(1999) 2-9.1.1

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that automatic sprinkler system was not installed in accordance with NFPA 13, or maintained and tested in accordance with NFPA 25. This in the event of fire could delay or deny extinguishment of a fire.
Findings include:
On November 21, 2011 at 2:30 PM while on tour of the Ocala Regional Medical Center facility with facility staff, on the second floor roof, three fire department hose connections were not provided with a reliable water supply. The water supply was shut off at valves that were not marked as valves controlling the water supply to the hose connection and not provided with wrenches to operate the valves at the hose connections. "Water supply piping shall be free of internal obstructions that can be caused by debris or by closed control valves." NFPA 25 (2008) 10.2.6.2* (Quoted from Annex A), NFPA 13 (1999) 5-1.2; 5-15.5.2, "Each control valve shall be identified and have a sign indicating the system or portion of the system it controls." NFPA 13 (1999) 9-3.1 NFPA 14

Based on observation, the facility failed to provide equipment listed for use in oxygen atmospheres where oxygen is administered.

Findings include:

On November 22, 2011 at 1:05 PM while on tour of the facility with facility staff at the West Marion Community Hospital campus in the Intensive Care Unit, nurse call pillow speakers were observed at patient beds. They were labeled "Not for use by patients undergoing oxygen therapy."

At 2:15 PM in the outpatient/PACU nurse call pendants were observed at patient beds. They were labeled "Not for use by patients undergoing oxygen therapy." Devices used in the areas of intentional expulsion shall be listed for use in oxygen enriched atmospheres. NFPA (1999) 2.1.9.3

Based on a review of the facility records, interviews with the staff, and observations made during tour of the facility, it was determined that the facility failed to provide required inspection maintenance and testing of the emergency power supply system components in accordance with NFPA 110 "Standard for Emergency and Standby Power Systems"

Findings include:

During the course of records review on November 21, 2011 the generator weekly run and inspection logs were reviewed and entries for battery testing were marked as "N/A." Facility staff indicated that they thought the batteries were of the sealed type.

On November 22, 2011 at 10:25 AM while on tour of the Ocala Regional Medical Center facility, with facility staff in the emergency generator enclosures, wet type lead acid batteries providing starting power to the generators were observed.

On November 22, 2011 at 3:15 PM while on tour of the West Marion Community Hospital facility with facility staff in the emergency generator enclosure, wet type lead acid batteries providing starting power to the generators were observed. "Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects." NFPA 110 (1999) 6-3.6*; "Maintenance of batteries should include checking and recording the value of the specific gravity." NFPA 110 (1999) A-6-3.6 [See NFPA 70, National Electrical Code, Section 700-4(c).]