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Reference NFPA 25, 1-4.2, 1998 Edition

The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.

Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.


Reference NFPA 25, 1-4.4

The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.


Based on record review and interview, the facility failed to ensure the automatic sprinkler system was being inspected, tested and maintained in accordance with NFPA 25 (Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems). Not properly inspecting, testing and and maintaining this system in accordance with this Standard could result in unreliable sprinkler system performance in the event of fire, which presents a risk of potential harm to all patients in the facility.


The findings are:


A. Record review of the automatic sprinkler system testing and maintenance records, Report of Inspection, dated 03/11/14, 05/28/14, 09/29/14, and 12/11/14 revealed the following:


1. Side wall sprinkler head under second garage door needs to be lengthen, not under door.

2. 3 sprinkler heads located near dryer are lint loaded.

3. Switch gear room has no sprinkler heads, sprinkler pipe has plugs.

4. Sprinkler head located in ICU is too high in ceiling and needs to be lowered.

5. Sprinkler head located in Medical Surgery room #1 is too high in ceiling and needs to be lowered.

6. There was no record a 5-year obstruction investigation has been conducted.

7. Medical Surgery area has 14 recalled Central O-Ring sprinkler heads that need to be replaced.

8. Birthing Unit has 16 Central O-Ring sprinkler heads that need to be replaced.

9. Sprinkler head located in Electrical room #160 is too high in ceiling and needs to be lowered.

10. Sprinkler head located at Emergency Room door is lint loaded and needs to be replaced.


B. On 02/03/15 at 1:15 pm, during interview, the Director of Plant Operations/Maintenance and Interim CEO stated the above items had not been corrected.

Reference NFPA 99, 1999 Edition

4-3.1.2.10* Installation Requirements.
(a) Equipment and Component Installation.
1. The installation of individual components shall be made in accordance with the instructions of the manufacturer. Such instructions shall include directions and information deemed by the manufacturer to be adequate for attaining proper installation, testing, maintenance, and operation of the medical gas systems. These instructions shall be left with the owner.


Based on record review and interview, the facility failed to ensure the hospital's piped in medical gas and vacuum systems were installed, tested and maintained for proper operation in accordance with the manufacture's instruction as required by NFPA 99 (Standard for Health Care Facilities). Medical gas and vacuum systems are essential for supplying piped in oxygen, nitrous oxide, carbon dioxide, medical air and vacuum to various parts of the hospital. Not performing periodic maintenance of these systems could result in unreliable system performance, which presents a risk of potential harm to all patients.


The findings are:


A. Record review of medical gas and vacuum testing report dated 01/28/14 revealed the following:

1. Cardiopulmonary room 403, 405 and Lab, Zone Valves located inside the rooms served.

2. Med Surg 3A/B, 5A/B, 7A/B, 15A/B, areas require alarm panel.

3. LDRP Workroom, Zone Valve Box located in room where gases are served.

4. Medical Air Compressor, Carbon Monoxide/dewpoint monitor alarm signals not landed in master alarm panel.

5. Medical Air Compressor, Lag Compressor in use, signal not landed in master alarm panel.

6. Medical Air Compressor, Pressure switch piped on wrong side of source valve.

7. Medical Air Compressor, Pressure switch hard piped into main line.

8. Surgical Vacuum Pump, Lag pump in use signal not landed at master alarm panel.

9. Surgical Vacuum Pump, burned out lamps in control panel.

10. Surgical Vacuum Pump, Pressure switch hard piped into main line.

11. Oxygen Main Line, Pressure switch hard piped into main line.

12. Bilk Oxygen System, reserve oxygen low liquid level signal not landed in master alarm panels.

13. Nitrogen Main Line, pressure switch hard piped into main line.

14. Nitrous Oxide Main Line, pressure switch hard piped into main line.


B. On 02/03/15 at 1:30 pm, during interview, the Director of Plant Operations/Maintenance stated above items are being addressed.

Reference NFPA 99, 1999 Edition

3-4.4.2 Record keeping.
A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.


Reference NFPA 110, 1999 Edition:

2-2 Classification of Emergency Power Supply Systems (EPSS)
2-3.4 Level.
2-2.3.1 - Level 1 defines the most stringent equipment performance requirements for application where failure of equipment to perform could result in loss of human life or serious injuries. All Level 1 equipment shall be permanently installed.


Based on record review and interview, the facility failed to ensure emergency generator was tested and maintained as required by NFPA 110 (Emergency and Stand by Power Systems) and NFPA 99 (Health Care Facilities), this failed practice presents a risk of potential harm to all patients in the facility.


The findings are:


A. Record review of the emergency generators testing and maintenance records revealed the following:

1. Fuel levels were not checked for March, April and the first half of May, 2014.

2. A work order performed by [Name of company] on 12/15/14 indicated that a full service was performed on the emergency generator. This work order indicated that the voltage gauge and amp gauge were not reading correctly and needed to be replaced. Additionally, a test was not performed on the generator after the maintenance because the gauges did not read properly.


3.The facility did not have a owners manual for the emergency generator.

4. The transfer time was not 10 seconds or less for the year of 2014. The transfer times recorded by the facility were as follows:

a. January, 2014 - 10.59 seconds
b. February, 2014 - 15.79 seconds
c. March, 2014 - 14.40 seconds
d. Aprli 2014 - Not documented
e. May, 2014 - 14.99 seconds
f. June, 2014 - 13.10 seconds
g. July, 2014 - 11.76 seconds
h. August, 2014 - 12.90 seconds
i. September, 2014 - 13.56 seconds
j. October, 2014 - 14.10 seconds
k. November, 2014 - 9.00 seconds (in compliance)
l. December, 2014 - Not documented
m. January, 2014 - 11.00 seconds


F. On 02/03/15 at 1:25 pm, during interview, Director of Plant Operations/Maintenance stated contractors were already contacted for repairs.