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AVERA HAND COUNTY MEMORIAL HOSPITAL AND CLINIC
Sprinkler System - Maintenance and Testing
Tag No.: K0353
Based on record review and interview, the provider failed to ensure the sprinkler system was properly tested in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems for three of numerous testing requirements (missing quarterly flow test, missing annual backflow valve test, and incorrect quarterly flow testing procedure). Findings include:
1. Record review at 9:45 a.m. on 11/15/16 of the annual fire sprinkler inspection reports prepared by Western States Fire Protection Inc. dated 4/22/16 revealed no indication the required annual backflow valve test was conducted to ensure that valve was functioning properly.
Interview with the director of environmental services at the time of the above record review confirmed that condition. He indicated he was unaware of the required annual backflow testing requirement and was unaware if Western States Fire Protection conducted that test.
2. Further record review at the above time revealed the director of environmental services conducted the required quarterly flow testing. The quarterly flow testing log prepared by the director of environmental services revealed missing quarterly flow testing for the third quarter of 2016.
Interview with the environmental services director at the time of the above review confirmed that condition. He indicated he was unsure how he had missed the third quarter flow testing.
3. Interview at 10:45 a.m. on 11/15/16 with the director of environmental services when asked to simulate how he conducts quarterly flow tests revealed incorrect testing procedure. He was unaware the sprinkler riser was equipped with a dual-use valve that would "drain" when the valve was turned one way and "test" when the valve was turned another way. The "test" orientation would simulate similar flow discharge as an active fire sprinkler head and provide a better test on the waterflow sensor.
He indicated he was unaware the valve was dual-use and indicated he was conducting the quarterly flow test with the valve turned in the "drain" orientation.