HospitalInspections.org

NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
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.
8.14.3.2.1 In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the hospital failed to continuously maintain the sprinkler system in reliable operating condition in accordance with NFPA (National Fire Protection Association) 13.

Findings include:

1. On 10/20/14 at approximately 2:35 p.m., the spare sprinkler head box located in the maintenance department was not provided with a newly installed spare head for the kitchen area.

2. On 10/21/14 at approximately 12:00 p.m., quick response sprinkler heads were observed mixed with a standard type in the 1st floor corridor between the gift shop and nurse station. Sprinkler heads in this smoke zone had been changed to a quick response type and would require all sprinkler heads to be change to a quick response type within this zone.

3. During a tour of the hospital exit stairwell near the maintenance department on 10/21/14 at approximately 11:20 a.m., the lower floor was observed not sprinklered.

4. During a tour of the hospital cardiac rehab area on 10/21/14 at approximately 11:30 a.m., two areas approximately two (2) feet by thirteen (13) feet was observed not to have sprinkler coverage.

5. During a tour of the hospital operating room on 10/21/14 at approximately 11:20 a.m., the steam sterilizer was observed not to have proper sprinkler coverage.

6. On 10/21/14 at approximately 3:30 p.m., quick response sprinkler heads were observed mixed with a standard type throughout the radiology area. Sprinkler heads in this smoke zone had been changed to a quick response type and would require all sprinkler heads to be change to a quick response type within this zone.

7. On 10/22/14 at approximately 2:30 p.m., quick response sprinkler heads were observed mixed with a standard type throughout the( ICU) Intensive Care Unit area. Sprinkler heads in this smoke zone had been changed to a quick response type and would require all sprinkler heads to be change to a quick response type within this zone.

8. These findings were discussed with the hospital director of engineering on 10/21/14 at approximately 3:45 p.m. and agreed with the above findings.

Based on observation and staff interview, the facility failed to provide metal containers with self-closing devices into which ashtrays can be emptied.

Findings include:

1. Observation on 10/20/14 at approximately 2:00 p.m. revealed the designated outdoor smoking area was not equipped with a metal container with self-closing cover into which ashtrays could be emptied and permit smoking materials to be completely extinguished prior to disposal with combustible trash.

2. These findings were discussed with the hospital director of engineering on 10/21/14 at approximately 2:10 p.m. and agreed with the above findings.

NFPA (National Fire Protection Association) 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. Facility census is 18.

Findings include:

1. On 10/20/14 at approximately 2:25 p.m., the Hospital 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 12 months.

2. An interview with the hospital director of engineering on 10/20/14 at approximately 3:30 p.m., revealed a monthly inspection was not conducted on the range hood extinguishing system.

NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.
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.
8.14.3.2.1 In noncombustible stair shafts with noncombustible stairs, sprinklers shall be installed at the top of the shaft and under the first landing above the bottom of the shaft.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined the hospital failed to continuously maintain the sprinkler system in reliable operating condition in accordance with NFPA (National Fire Protection Association) 13.

Findings include:

1. On 10/20/14 at approximately 2:35 p.m., the spare sprinkler head box located in the maintenance department was not provided with a newly installed spare head for the kitchen area.

2. On 10/21/14 at approximately 12:00 p.m., quick response sprinkler heads were observed mixed with a standard type in the 1st floor corridor between the gift shop and nurse station. Sprinkler heads in this smoke zone had been changed to a quick response type and would require all sprinkler heads to be change to a quick response type within this zone.

3. During a tour of the hospital exit stairwell near the maintenance department on 10/21/14 at approximately 11:20 a.m., the lower floor was observed not sprinklered.

4. During a tour of the hospital cardiac rehab area on 10/21/14 at approximately 11:30 a.m., two areas approximately two (2) feet by thirteen (13) feet was observed not to have sprinkler coverage.

5. During a tour of the hospital operating room on 10/21/14 at approximately 11:20 a.m., the steam sterilizer was observed not to have proper sprinkler coverage.

6. On 10/21/14 at approximately 3:30 p.m., quick response sprinkler heads were observed mixed with a standard type throughout the radiology area. Sprinkler heads in this smoke zone had been changed to a quick response type and would require all sprinkler heads to be change to a quick response type within this zone.

7. On 10/22/14 at approximately 2:30 p.m., quick response sprinkler heads were observed mixed with a standard type throughout the( ICU) Intensive Care Unit area. Sprinkler heads in this smoke zone had been changed to a quick response type and would require all sprinkler heads to be change to a quick response type within this zone.

8. These findings were discussed with the hospital director of engineering on 10/21/14 at approximately 3:45 p.m. and agreed with the above findings.

Based on observation and staff interview, the facility failed to provide metal containers with self-closing devices into which ashtrays can be emptied.

Findings include:

1. Observation on 10/20/14 at approximately 2:00 p.m. revealed the designated outdoor smoking area was not equipped with a metal container with self-closing cover into which ashtrays could be emptied and permit smoking materials to be completely extinguished prior to disposal with combustible trash.

2. These findings were discussed with the hospital director of engineering on 10/21/14 at approximately 2:10 p.m. and agreed with the above findings.

NFPA (National Fire Protection Association) 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. Facility census is 18.

Findings include:

1. On 10/20/14 at approximately 2:25 p.m., the Hospital 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 12 months.

2. An interview with the hospital director of engineering on 10/20/14 at approximately 3:30 p.m., revealed a monthly inspection was not conducted on the range hood extinguishing system.