HospitalInspections.org

Based on document review and interview the facility failed to conduct all required inspections of the sprinkler system throughout the year. This deficient practice affects all occupants in the facility. The facility census was 53.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the afternoon of 09/12/11, showed an outside contractor had last conducted a semi-annual inspection of the sprinkler system May 3, 2011. There was no documentation showing any type of inspection had been conducted on any portion of the sprinkler system since the semi-annual inspection in May.

During an interview on 09/13/11 at 9:45 AM, Staff X, Engineering, stated an inspection of the sprinkler system was not being conducted on at least a quarterly basis.

National Fire Protection Association (NFPA 25) Section 5.1 states the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems.

Based on observation and interview the facility failed to ensure all portable medical gas cylinders were individually secured. This deficient practice affects the operation of the facility. The facility census was 53.

Findings included:

Observation, during a tour of the facility conducted on the morning of 09/13/11 at 10:05 AM, showed 23 portable medical gas cylinders all not individually secured in a chained area on the outside of the facility.

Staff X, Engineering, confirmed at that time the portable medical gas cylinders were not individually secured.

Chapter 5.1.3.3.2 of the 2002 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 99) states that locations for the central supply systems and the storage of medical gas shall meet the following requirements: (7) be provided with racks, chains or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty from falling.