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NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on documentation review and staff interview it was determined the hospital failed to maintain the sprinkler system in accordance with NFPA (National Fire Protection Association) 25. Findings include:

a) On 01/04/10 at approximately 1:00 p.m., a sprinkler system inspection report dated 12/17/09 and prepared by Fire Safety Products was reviewed. This report indicated that there were three (3) corroded sprinkler heads on the 2nd floor of the hospital. An interview with the plant operations director on this same date and time revealed that no corrective action had been taken for the three (3) corroded sprinkler heads at the time of this survey.

Based on observation it was determined the hospital failed to prohibit portable space heaters in all patient rooms.

Findings include:

a) On 01/05/10 at approximately 10:00 a.m., a portable electrical heater was observed in use in patient room 217.

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on facility documentation and staff interview it was determined the hospital failed to test the LIM (line isolation monitor) circuit in accordance with NFPA 99.

Findings include:

a) On 01/05/10 at approximately 10:00 a.m., a testing report for the hospital isolated electrical power system dated 04/02/09 was reviewed. This report was prepared by a hospital plant operations staff person. At the time of this survey, it could not be determined if the hospital LIM circuit had automated self-test and self-calibration capabilities. If the LIM circuit doesn't have automated self-test and self-calibration capabilities it is required to be tested and certified at intervals of not more than six (6) months. Also, an interview with the plant operations director on 01/05/10 at approximately 10:30 a.m. revealed that there was documentation available to verify that the hospital staff person testing the LIM circuit was trained and certified to use the equipment to test the LIM circuit.