HospitalInspections.org

Based on interview and record review, the facility failed to ensure the sprinkler system for the building was in compliance with the 1999 editions of National Fire Protection Association 25 and 13. This has the potential to affect all patients, staff, and visitors to the facility. The facility has a capacity of 794 beds with a census of 522 patients.

Findings include:

Review of the facility's documentation for its annual sprinkler inspection of this building, building 1, was completed on 04/08/15. The review revealed the sprinkler system had been inspected on 06/14/14 to 06/16/14. The review revealed the facility had multiple riser rooms.

1. The review revealed for the riser located in main surgery, and north expansion MRI, gauges were over five years old and should be replaced in accordance with National Fire Protection Association 25, 2-3.2 (1999 edition).

2. The review revealed the sprinkler system for main surgery, north expansion surgery, and north expansion MRI required obstruction investigation and prevention in accordance with National Fire Protection Association 25 10-2.1 and 10-2.2, 1999 edition.

3. The review revealed a lack of sprinkler head box with spare sprinkler heads and a wrench for main surgery, north expansion surgery, north expansion MRI, and ambulance canopy system in accordance with National Fire Protection Association 25 2-4.1.4 to 25-4.1.6, 1999 edition.

4. The review revealed for the main surgery system, a need for signs on control valves and main drain for main surgery and ambulance canopy systems in accordance with National Fire Protection Association 13, 3-8.3, 1999 edition.

5. The review revealed an annual main drain test was unable to be fully conducted at the north expansion MRI system and ambulance canopy system. For the north expansion MRI system, the review revealed a 1.25 inch main drain with 155 static psi, but a residual of "n/a". For the ambulance canopy system, it was not completed because "slop sink will not take full residual test. "

On 04/07/15 at 3:12 PM in an interview, Staff Q confirmed the items have not been addressed.

Based on interview and record review, the facility failed to ensure the sprinkler system for the helicopter landing pad was in compliance with the 1999 editions of National Fire Protection Association 13 and 25. This has the potential to affect all patients, staff, and visitors to the facility. The facility has a capacity of 794 beds with a census of 522 patients.

Findings include:

Review of the facility's documentation for its annual sprinkler inspection of helipad area of the building was completed on 04/08/15. The review revealed the sprinkler system had been inspected on 06/14/14 to 06/16/14.

1. The review revealed two water gauges were over five years old and should have been replaced in accordance with National Fire Protection Association 25, 2-3.2 (1999 edition).

2. The review revealed the sprinkler system required obstruction investigation and prevention in accordance with National Fire Protection Association 25 10-2.1 and 10-2.2, 1999 edition.

3. The review revealed a need for signs on control valves and main drain in accordance with National Fire Protection Association 13, 3-8.3, 1999 edition.

4. The review revealed an annual main drain test was unable to be fully conducted, stating, "Can't do full residual test, floor drain backs up. "

On 04/07/15 at 3:12 PM in an interview, Staff Q confirmed the items have not been addressed.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients, staff, and visitors to the facility. The facility has a capacity of 794 beds with a census of 522 patients.

Findings include:

Review of the facility's smoke and fire damper documentation revealed all 176 smoke or fire dampers had not been tested since January, 2009.

On 04/07/14 at 3:12 PM in an interview, Staff Q confirmed the dampers had not been tested since January, 2009.

Based on interview and record review, the facility failed to ensure the sprinkler system for the building was in compliance with the 1999 editions of National Fire Protection Association 25 and 13. This has the potential to affect all patients, staff, and visitors to the facility. The facility has a capacity of 794 beds with a census of 522 patients.

Findings include:

Review of the facility's documentation for its annual sprinkler inspection of this building, building 1, was completed on 04/08/15. The review revealed the sprinkler system had been inspected on 06/14/14 to 06/16/14. The review revealed the facility had multiple riser rooms.

1. The review revealed for the riser located in main surgery, and north expansion MRI, gauges were over five years old and should be replaced in accordance with National Fire Protection Association 25, 2-3.2 (1999 edition).

2. The review revealed the sprinkler system for main surgery, north expansion surgery, and north expansion MRI required obstruction investigation and prevention in accordance with National Fire Protection Association 25 10-2.1 and 10-2.2, 1999 edition.

3. The review revealed a lack of sprinkler head box with spare sprinkler heads and a wrench for main surgery, north expansion surgery, north expansion MRI, and ambulance canopy system in accordance with National Fire Protection Association 25 2-4.1.4 to 25-4.1.6, 1999 edition.

4. The review revealed for the main surgery system, a need for signs on control valves and main drain for main surgery and ambulance canopy systems in accordance with National Fire Protection Association 13, 3-8.3, 1999 edition.

5. The review revealed an annual main drain test was unable to be fully conducted at the north expansion MRI system and ambulance canopy system. For the north expansion MRI system, the review revealed a 1.25 inch main drain with 155 static psi, but a residual of "n/a". For the ambulance canopy system, it was not completed because "slop sink will not take full residual test. "

On 04/07/15 at 3:12 PM in an interview, Staff Q confirmed the items have not been addressed.

Based on interview and record review, the facility failed to ensure the sprinkler system for the helicopter landing pad was in compliance with the 1999 editions of National Fire Protection Association 13 and 25. This has the potential to affect all patients, staff, and visitors to the facility. The facility has a capacity of 794 beds with a census of 522 patients.

Findings include:

Review of the facility's documentation for its annual sprinkler inspection of helipad area of the building was completed on 04/08/15. The review revealed the sprinkler system had been inspected on 06/14/14 to 06/16/14.

1. The review revealed two water gauges were over five years old and should have been replaced in accordance with National Fire Protection Association 25, 2-3.2 (1999 edition).

2. The review revealed the sprinkler system required obstruction investigation and prevention in accordance with National Fire Protection Association 25 10-2.1 and 10-2.2, 1999 edition.

3. The review revealed a need for signs on control valves and main drain in accordance with National Fire Protection Association 13, 3-8.3, 1999 edition.

4. The review revealed an annual main drain test was unable to be fully conducted, stating, "Can't do full residual test, floor drain backs up. "

On 04/07/15 at 3:12 PM in an interview, Staff Q confirmed the items have not been addressed.

Based on interview and record review, the facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. This has the potential to affect all patients, staff, and visitors to the facility. The facility has a capacity of 794 beds with a census of 522 patients.

Findings include:

Review of the facility's smoke and fire damper documentation revealed all 176 smoke or fire dampers had not been tested since January, 2009.

On 04/07/14 at 3:12 PM in an interview, Staff Q confirmed the dampers had not been tested since January, 2009.