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DELTA SPECIALTY HOSPITAL
Sprinkler System - Out of Service
Tag No.: K0354
Based on interviews and record review, the facility failed to take appropriate action during a sprinkler system impairment.
The finding included:
Interviews during a complaint investigation on 6/19/18 at 9:30 AM, revealed the facility had inadequate water supply to the sprinkler system which affected floors 1-4. The impairment was initially discovered in March 2018 by contractors doing renovations at the facility. Upon discovery, the facility failed to notify the Tennessee Department of Health (AHJ) and activate a fire watch. Records revealed the facility did not activate a fire watch until being instructed to by the Tennessee Department of Health on June 15, 2018.
National Fire Protection Association NFPA 25, 15.5.2 (2011 Ed), NFPA 101, 19.1.1.4.3.3 (2012), NFPA 101, 19.3.5.3 (2012 Ed), NFPA 101, 19.3.5.7 (2012 Ed), NFPA 9.7.6 (2012 Ed)
This finding was verified by the plant operations director and the chief executive officer during the complaint investigation on 6/19/18.