HospitalInspections.org

Based on record review and interview the facility failed to insure that a complete inspection was done on the sprinkler system to include sprinkler flow response times quarterly. This affects all patients at the facility in a census of 18. Findings included:
Review was done of the last three quarterly sprinkler inspection forms (most recent on 10/01/09). The inspection forms were recorded on preventive maintenance work orders and included the steps done for the test. There was no indication on the form or a record that the response time for the flow alarm is recorded. The instructions do indicate that the alarm should be verified.
The 2002 edition of Code 72 , national fire alarm code published by the National Fire Protection Association, states under chapter 5.10.2 that the initiation of the alarm signal shall occur within 90 seconds of water-flow at the alarm initiating device when flow occurs that is equal or greater than that from a single sprinkler of the smallest orifice size installed in the system.
During an interview on 01/04/10 at 3:00 p.m. Staff Z stated that the sprinkler flow alarm test is done quarterly and confirmed that the response time for the alarm is not recorded on these forms.
The facility did not maintain a record of the testing of the sprinkler system flow alarms that indicated that the alarm response met this requirement.