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ERLANGER BLEDSOE HOSPITAL
No Description Available
Tag No.: K0062
Based on observations and records review it was determined the facility failed to maintain the sprinkler system.
The findings included:
1. Observations of the old surgery room area on 11/8/11 at 9:26 AM, revealed a storage rack installed within 18 inches of the sprinkler.
2. Observation of the old dark room on 11/8/11 at 9:40 AM, revealed the sprinkler was painted and corroded.
3. Record review of the sprinkler system annual inspection/test report dated 6/27/11 on 11/8/11 at 10:30 AM,, revealed the sprinkler system had an incorrect tamper and value installed in triage room 126.
4. Record review on 11/8/11 at 10:35 AM, revealed no quarterly inspections were conducted on the sprinkler system during the 1st and 2nd quarters of 2010.
5. Record review on 11/8/11 at 10:37 AM, revealed no annual sprinkler inspection/test was conducted during 2010.
6. Record review on 11/8/11 at 10:40 AM, revealed no quarterly inspections were conducted on the sprinkler system during the 1st and 3rd quarters of 2011.
7. Record review on 11/8/11 at 10:41 AM, revealed the sprinkler system's 5 year obstruction investigation was overdue (Aug 11).
8. Record review on 11/8/11 at 10:42 AM, revealed the sprinklers system's 5 year gage test or replacement was overdue (Aug 11).
These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/8/1.
LIFE SAFETY CODE STANDARD
Tag No.: K0062
Based on observations and records review it was determined the facility failed to maintain the sprinkler system.
The findings included:
1. Observations of the old surgery room area on 11/8/11 at 9:26 AM, revealed a storage rack installed within 18 inches of the sprinkler.
2. Observation of the old dark room on 11/8/11 at 9:40 AM, revealed the sprinkler was painted and corroded.
3. Record review of the sprinkler system annual inspection/test report dated 6/27/11 on 11/8/11 at 10:30 AM,, revealed the sprinkler system had an incorrect tamper and value installed in triage room 126.
4. Record review on 11/8/11 at 10:35 AM, revealed no quarterly inspections were conducted on the sprinkler system during the 1st and 2nd quarters of 2010.
5. Record review on 11/8/11 at 10:37 AM, revealed no annual sprinkler inspection/test was conducted during 2010.
6. Record review on 11/8/11 at 10:40 AM, revealed no quarterly inspections were conducted on the sprinkler system during the 1st and 3rd quarters of 2011.
7. Record review on 11/8/11 at 10:41 AM, revealed the sprinkler system's 5 year obstruction investigation was overdue (Aug 11).
8. Record review on 11/8/11 at 10:42 AM, revealed the sprinklers system's 5 year gage test or replacement was overdue (Aug 11).
These findings were verified by the maintenance supervisor and acknowledged by the administrator during the exit conference on 11/8/1.