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EDGEFIELD COUNTY HEALTHCARE AN AFFILIATE OF SELF R
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on document review and interview the facility failed to maintain testing of the automatic sprinkler system per the requirements of:
2012 NFPA 101 Life Safety Code (LSC) chapters 9.7.5, 9.7.7, 9.7.8
2011 NFPA 25 chapters 5.1.1.2, table 5.1.1.2, 5.2.5, 5.3.3.1
This deficiency is a widespread event and can affect more than 75% of patients, visitors, and staff.
During record review facility only had an annual inspection on the automatic sprinkler system and no quarterly flow test were done for the 1st, 3rd, and 4th quarter of 2018/2019.
Director of Maintenance was present and verified that no flow test had been done stating he did not know that it needed to be done. This was also verified by the administrator during the exit interview.
Subdivision of Building Spaces - Smoke Barrie
Tag No.: K0372
Based on observation and and interview the facility failed to maintain smoke compartment construction per the requirements of:
2012 NFPA 101 Life Safety Code (LSC) chapters 19.3.7.3, 8.3.5, 8.3.5.1, 8.4.4, 8.4.4.1, 8.5.6 - 8.5.6.3
This deficiency is a widespread event and can affect more than 75% of patients, staff, and visitors.
Observations made during the walk-through the Director of Maintenance found open penetrations in smoke barriers in the following locations:
Emergency Department entrance from main hospital
Main Hall connecting to Swing Bed Hall
All smoke barriers in Swing Bed Hall
The findings were verified by the Director of Maintenance at the time of discovery stating that they had recently had new telemetry cables installed. This was verified by the administrator during the exit interview.