HospitalInspections.org

1. Based on observation and interview, the facility failed to ensure 4 of 4 elevator equipment rooms throughout the facility were provided with sprinkler coverage. NFPA 13, 5-13.6.2 states automatic sprinklers in elevator machine rooms shall be of ordinary or intermediate temperature rating. ASME/ANSI A17.1 permits sprinklers in elevator machine rooms when there is a means for disconnecting the main power supply to the affected elevator automatically upon, or prior to, the application of water from the sprinkler located in the elevator machine room. The elevator equipment machine rooms were located on the first and second floor and the basement and could affect any patient as well as visitors and staff using the elevators.

Findings include:

Based on observations on 07/10/14 during the tour between 1:09 p.m. and 3:00 p.m. with the Maintenance Supervisor, the following elevator equipment rooms which were provided with smoke detector protection only:
1. One on first floor north hall by Surgery entrance,
2. Two in the basement, one next to Maintenance office and the other by the fan room,
3. One on second floor next to Specialty Suites north hall.
Based on interview on 07/10/14 concurrent with the observations with the Maintenance Supervisor, it was acknowledged the elevator equipment room located in the aforementioned locations were not sprinklered.

2. Based on observation and interview, the facility failed to ensure 1 of 2 exit access corridors in the basement were provided with sprinkler protection to ensure sprinkler coverage in all portions of the building as required for Type II (111), three story building construction. This deficient practice could affect any patient above the corridor on west hall as well as visitors or staff.

Findings include:

Based on observation on 07/10/14 at 2:10 p.m. with the Maintenance Supervisor, the twenty foot long exit access corridor leading out of the west part of the basement was not provided with sprinkler protection. Based on interview on 07/10/14 concurrent with the observation it was acknowledge by the Maintenance Supervisor, the aforementioned twenty foot west hall was not equipped with sprinkler protection in order to provide complete sprinkler coverage to all areas of the facility

Based on observation and interview, the facility failed to ensure 1 of 1 automatic sprinkler systems was continuously maintained in reliable operating condition. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1-11.1 requires maintenance shall be performed to keep the sprinkler system equipment operable or to make repairs. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

Based on observation on 07/10/14 at 3:17 p.m. with the Maintenance Supervisor, the electrical line from the fire alarm panel to the tamper switch on the Post Indicator Valve (PIV) had been cut. Based on interview on 07/10/14 at 3:17 p.m. with the Maintenance Supervisor, it was acknowledged the facility knew about the failure of the tamper switch on the PIV, but repairs have not been done.