Sprinkler System Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain the automatic sprinkler system in six instances, affecting four of twenty-seven smoke compartments. On December 16, 2024, observations revealed deficiencies such as insulation supported by the sprinkler line in the 6300 attic and gaps greater than 1/8 inch in rooms #5328, #4116, and #4118. On December 17, 2024, further deficiencies were observed, including a gap greater than 1/8 inch in the track of the ceiling tile outside room 4321 and flexible insulated ductwork laying on a sprinkler line above the double doors next to room 4172. Interviews with the Unit Director of TCU, Facility Staff, and the Safety Manager confirmed these deficiencies.
Plan Of Correction
The insulation will be relocated off of the sprinkler pipe in the 6300 attic. The ceiling tile will be replaced in rooms 5328, 4116, 4118, and 4321. The insulated ductwork will be relocated off of the sprinkler pipe in room 4172. All of these resolutions will be reported to the hospital safety committee and included in the hospital quality assurance program. All sprinkler lines are monitored and will continue to be monitored annually as part of the "Annual Fire and Smoke barrier above the ceiling program." Ceiling tiles are monitored and will continue to be monitored during hazard surveillance rounds by a multi-disciplinary team including representatives from safety, infection control, facilities, and environmental services.