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PROVIDENCE SEWARD MEDICAL CENTER
Sprinkler System - Installation
Tag No.: K0351
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Based on observation and interview with the Facilities Operations Manager (FOM), the facility failed to ensure it provided complete sprinkler coverage in accordance with NFPA 13 (2010 edition) section 8.1.1. Lack of sprinkler coverage could allow for the advancement of fire/smoke. This had the potential to affect all four current patients in the facility.
Findings:
Observations of the "Phoenix Room" measuring 320 square feet on 11/16/21 at 9:55 AM revealed the ceiling was vaulted with a soffit surrounding the ceiling. The soffit had sprinkler coverage, but above the soffit, there was no sprinkler coverage. The area above the soffit contained combustible materials including ceiling tile, drywall, and electrical fixtures/lighting.
During an interview with the FOM at the time of the observation indicated the facility management team had reviewed this issue and determined it was a problem but has not corrected the situation to date.
The code requires under NFPA 13 (2010 edition) section 8.1.1. that "sprinkler coverage shall be installed throughout the premises."
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Electrical Systems - Essential Electric Syste
Tag No.: K0918
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Based on observation and interview with the Facility Operations Manager (FOM) the facility failed to ensure that an emergency battery powered light was provided in the transfer switch room in accordance with NFPA 110 (2010 edition) section 7.3.1. The lack of emergency lighting could impair the ability to visualize and correct a faulty transfer switch in a power failure. This had the potential to affect the four current inpatients.
Findings:
Observation of the transfer switch room for the level I Emergency Power System (EPS) system on 11/16/21 at 10:10 AM revealed three transfer switches located in the attic area. The area was lacking emergency battery powered lighting for the transfer switches.
Interview with the FOM at the time of the observation verified the room lacked emergency lighting of any type.
The code requires under NFPA 110 (2010 edition) section 7.3.1. that "The level I and level II EPS shall be provided with battery powered emergency lighting in accordance with 7.3.2. requiring the light to be supplied on the load side of the transfer switch."
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