HospitalInspections.org

Based on record review and interview, the provider failed to ensure the automatic sprinkler system was continuously maintained in reliable operating condition and inspected and tested periodically in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (five year internal obstruction investigation). Findings include:

1. Document review at 11:50 a.m. on 9/8/15 of the provider's automatic sprinkler system inspection report prepared by Rapid Fire Protection Inc. revealed no documentation of the required five year internal obstruction investigation. The automatic sprinkler was installed with the original construction of the hospital in 1997. Approximately thirteen years had lapsed since the last internal obstruction investigation should have been completed.

Interview with the facility manager at the time of the record review confirmed that condition. He indicated he was unaware of the five year internal obstruction investigation requirement.