HospitalInspections.org

Based on observation and staff interview, the facility failed to provide complete sprinkler coverage for two of two elevator hoistway pits (the area at the bottom of the elevator shaft that has the hydraulic cylinder and hydraulic hoses to raise and lower the elevator). The absence of sprinklers in the hoistway pits puts patients, staff and visitors at risk in the event of a fire caused by the ignition of accumulated combustible debris or flammable hydraulic fluid. This deficient practice affects all facility staff, patients and visitors. The facility census was 41.

Findings:

1. Observation on 11/17/15 at 1:52 PM showed no sprinkler head in the Number 4 elevator hoistway pit, located across the hallway from the laundry on the ground floor.
2. Observation on 11/17/15 at 2:00 PM showed no sprinkler heads in the elevator hoistway pit for elevators 1, 2, and 3, located near the cafeteria entrance on the ground floor.
All four facility elevators employ a hydraulic elevator lift mechanism that uses petroleum-based hydraulic fluids which is combustible.
3. During an interview on 11/18/15 at 11:25 AM Staff 00, Operations Manager acknowledged the finding and stated that he did not know the elevator hoistway required a sprinkler head at the bottom of the shaft.

The National Fire Protection Association (NFPA) 13: "Installation of Sprinkler Systems" (1999 edition) Section 5-13.6.1: Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft (0.61 m) above the floor of the pit.

Exception: For enclosed, noncombustible elevator shafts that do not contain combustible hydraulic fluids, the sprinklers at the bottom of the shaft are not required.