HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that the fire alarm system is tested to include smoke detector sensitivity testing.

Findings include:

1. Review of the fire alarm inspection reports revealed no documented credible evidence of smoke detector sensitivity testing.

2. Interview with the Maintenance Director on 06/09/15 at 2:30 pm confirmed that there was no documentation to support the completion of sensitivity testing.

NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
NFPA 13 Standard for Installation of Sprinklers
8.3.3 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the facility failed to continuously maintain the sprinkler system in reliable operating condition in accordance with NFPA twenty-five (25) and thirteen (13).

Findings include:

1. On 6/8/15 at approximately 1:00 p.m. sprinkler gauges on the fire pump riser were observed to not have a date listed on them that would indicate they have been changed or calibrated in the last five (5) years. Sprinkler report from the vendor also did not indicate gauges had been changed or calibrated.

2. On 6/10/15 at approximately 11:15 a.m. sprinkler piping above the dropped ceiling was observed to have cables draped on them throughout the facility.

3. These findings were discussed with the facility's Maintenance Director on 05/31/15 at approximately 11:00 a.m. whom agreed that the facility sprinkler system needed to be corrected.

National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 1999 Edition

Chapter 6 Maintenance and Operational Testing

6-3.6 Storage battery's, 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 manufacture's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the facility failed to maintain the emergency generator in accordance with NFPA 110.

Findings include:

1. On 05/09/15 at approximately 2:15 p.m. a review of the generator log for the past twelve (12) months indicated the facility failed to test and record the specific gravity of electrolyte fluid in generator's battery each week.

2. These findings were discussed with the facility's Maintenance Director on 05/09/15 at approximately 2:30 p.m. whom agreed the generator's battery electrolyte fluid was not being monitored.

Based on document review and interview, the hospital failed to ensure that the fire alarm system is tested to include smoke detector sensitivity testing.

Findings include:

1. Review of the fire alarm inspection reports revealed no documented credible evidence of smoke detector sensitivity testing.

2. Interview with the Maintenance Director on 06/09/15 at 2:30 pm confirmed that there was no documentation to support the completion of sensitivity testing.

NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
NFPA 13 Standard for Installation of Sprinklers
8.3.3 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the facility failed to continuously maintain the sprinkler system in reliable operating condition in accordance with NFPA twenty-five (25) and thirteen (13).

Findings include:

1. On 6/8/15 at approximately 1:00 p.m. sprinkler gauges on the fire pump riser were observed to not have a date listed on them that would indicate they have been changed or calibrated in the last five (5) years. Sprinkler report from the vendor also did not indicate gauges had been changed or calibrated.

2. On 6/10/15 at approximately 11:15 a.m. sprinkler piping above the dropped ceiling was observed to have cables draped on them throughout the facility.

3. These findings were discussed with the facility's Maintenance Director on 05/31/15 at approximately 11:00 a.m. whom agreed that the facility sprinkler system needed to be corrected.

National Fire Protection Association (NFPA) 110 Standard for Emergency and Standby Power Systems 1999 Edition

Chapter 6 Maintenance and Operational Testing

6-3.6 Storage battery's, 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 manufacture's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the facility failed to maintain the emergency generator in accordance with NFPA 110.

Findings include:

1. On 05/09/15 at approximately 2:15 p.m. a review of the generator log for the past twelve (12) months indicated the facility failed to test and record the specific gravity of electrolyte fluid in generator's battery each week.

2. These findings were discussed with the facility's Maintenance Director on 05/09/15 at approximately 2:30 p.m. whom agreed the generator's battery electrolyte fluid was not being monitored.