HospitalInspections.org

Facility failied to maintain corridor door in accordance with the 2000 edition of the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings include:

Surveyour observaed on October 13, 2010, between 10 and 10:30 am, that door to storage room in Emergency Department had the latching mechanism taped so as to prevent the latching of the door.

Facility failed to maintain automatic sprinkler system in accordance with the 1999 edition of NFPA 13, Standard for Fire Sprinklers. Findings included:

Surveyor observed on 10/13/10, between 9:30 and 10:00 am the following:
1. Escutcheon plate was missing from recessed sprinkler in corridor between rediology and emergency departments. This is not in accordance with NFPA 13, 1999: 3.2.7.2. Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

2. Annual inspection report, dated 11/10/09 by ABCO Fire Protection Inc., indicated that "heads throughout building are painted, some have corrosion, and some have lint". This does not meet NFPA 13, 1999: 3-2.6.3. Unless appliced by the manufacturer, sprinklers shall not be painted, and any sprinklers that which have been painted shall be replaced with new listed sprinklers of the same characteristics, including orifice size, themal response, and water distribution.

3. Supply of spare sprinklers was not evident in engineering/maintenance department of hospital. This does not meet NFPA 13, 1999: 3-2.9 Stock of Spare Sprinklers.
3-2.9.1 A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have been operated or damaged in any way can be promptly replaced. These sprinklers shall correspon to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed. 100 deg. F.
3-2.9.2 A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
3-2.9.3 The stock of spare sprinklers shall included all types and ratings installed and shall be as follows:
(1) For systems having less than 300 sprinklers, not fewer than six sprinklers.
(2) For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers, not fewer than 24 sprinklers.