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Tag No.: K0052
National Fire Protection Association (NFPA) 72, 1-5.6, 1999 edition: In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location. Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted."
This standard is not met as evidence by:
Based on observation and staff interview, the facility failed to provide electronic supervision of the fire alarm panel that was installed in an area that was not continuously occupied.
Findings include:
1. During a tour of the hospital on 07/07/15 at approximately 9:00 a.m. the automatic dialer panel for the fire alarm system and fire alarm panel located in a housekeeping room that was not continuously occupied was not electronically supervised to provide notification of fire at that location.
2. An interview with the Hospital Materials Management Supervisor on 07/07/15 at approximately 9:07 a.m. revealed the hospital was not aware the automatic dialer and fire alarm panel was required to be electronically supervised since it was not located in a continuously occupied location.
Tag No.: K0062
NFPA 25 2-3.2 Gauges: Gauges shall be replaced every five (5) years or tested every five (5) years by comparison with a calibrated gauge. Gauges not accurate to within three (3) percent of the full scale shall be recalibrated or replaced.
NFPA 13, 1999 edition
6-1.1.5: Sprinkler piping on hangers shall not be used to support non system components.
A-6-1.1.5: The rules covering the hanging of sprinkler piping take into consideration the weight of water-filled pipe plus a safety factor. No allowance has been made for hanging of non system components from sprinkler piping.
This standard is not met as evidence by:
Based on observation, record review and staff interview it was determined the hospital failed to maintain sprinkler system gauges in accordance with NFPA 25, 1998 edition and NFPA 13 1999 edition.
Findings include:
1. During a tour of the hospital sprinkler room and record review conducted on 07/07/15 at approximately 8:59 a.m., there was no evidence or date recorded of when sprinkler gauges had been tested.
2. During an inspection of the hospital sprinkler piping above the drop ceiling near the Emergency Room entrance area on 07/07/15 at approximately 2:35 p.m. communication wiring was observed laying on the sprinkler piping.
3. During an inspection of the facility sprinkler piping above the drop ceiling at the central supply corridor on 07/07/15 at approximately 3:00 p.m. communication wiring was observed laying on the sprinkler piping.
4. These findings were discussed with the Hospital Material Management Supervisor on 07/07/15 at approximately 3:15 p.m. and agreed that the aforementioned sprinklers needed to be corrected.
Tag No.: K0069
NFPA 17A: Standard for Wet Chemical Extinguishing Systems
Chapter 5: Inspection, Maintenance, and Recharging
5-2 Owner's Inspection.
5-2.1: On a monthly basis, inspection shall be conducted in accordance with the manufacturer's listed installation and maintenance manual or owner's manual. As a minimum, this "quick check" or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) The system shows no physical damage or condition that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps, where provided, are intact and undamaged.
(h) Neither the protected equipment nor the hazard has been replaced, modified, or relocated.
5-2.2: If any deficiencies are found, appropriate corrective action shall be taken immediately.
5-2.3: Personnel making inspections shall keep records for those extinguishing systems that were found to require corrective actions.
5-2.4: At least monthly, the date the inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained until the next semiannual maintenance.
This Standard is not met as evidenced by:
Based on observation and staff interview it was determined the hospital failed to inspect the range hood extinguishing system in accordance with NFPA 17A.
Findings include:
1. On 07/08/15 at approximately 9:30 a.m. the hospital's range hood extinguishing system located in the kitchen was inspected. During this inspection, observation of the service tag attached to the range hood extinguishing system indicated dates and initials were not recorded to verify monthly inspections were conducted on the system. Therefore, a monthly inspection record was not available for the past twelve (12) months.
2. An interview with the Hospital Materials Management Supervisor on 07/08/15 at approximately 9:35 a.m. revealed a monthly inspection was not conducted on the range hood extinguishing system.
Tag No.: K0144
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 One (1) and Level Two (2) systems shall be inspected at intervals of not more than seven (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 record review, observation and staff interview it was determined the hospital failed to maintain the emergency generator in accordance with NFPA 110.
Findings include:
1. On 07/07/15 at approximately 8:45 a.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 batteries weekly.
2. These findings were discussed with the Hospital Material Management Supervisor on 07/07/15 at approximately 8:50 a.m. and he agreed that the generator's battery was not tested for a specific gravity of electrolyte fluid weekly.