HospitalInspections.org

Based on document review and interview the facility failed to conduct at least quarterly inspections of the facility sprinkler system. This deficient practice affects all occupants in the facility. The facility census was 25 patients.

Findings included:

1. Review of the facility sprinkler system inspection documents, conducted on the afternoon of 10/15/12, showed an outside contractor had conducted semi-annual inspections on 01/06/12 and 07/03/12. There was no documentation showing a quarterly inspection of the system was being conducted.

2. During an interview on 10/16/12 at 9:55 AM, Staff K, Facilities Manager, stated quarterly inspections of the sprinkler system were not being conducted.

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 record review the facility failed to develop a procedure to implement any time the facility sprinkler system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the facility. The facility census was 25 patients.

Findings included:

1. Record review of the facility ' s policy titled, " Safety Management Plan " revised December 2011, stated the following:

e. Emergency Impairments

i. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

ii. Impairments may include but are not limited to system leakage, interruption of water supply, frozen or ruptured piping and equipment failure, and fire suppression systems.

iii Response to the impairment is dependent on the type and/or location of the damage and to the length of time expected for the impairment.

National Fire Protection Association (NFPA 101) Chapter 9.7.6.2 states sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Based on record review the facility failed to develop a procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants. The facility census was 25 patients.

Findings included:

1. Record review of the facility ' s policy titled " Safety Management Plan " revised December 2011, stated the following:

e. Emergency Impairments

i. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.

ii. Impairments may include but are not limited to system leakage, interruption of water supply, frozen or ruptured piping and equipment failure, and fire suppression systems.

iii. Response to the impairment is dependent on the type and/or location of the damage and to the length of time expected for the impairment.

National Fire Protection Association (NFPA 101) Chapter 9.6.1.8 states where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.