Failure to Report Sprinkler System Failure to DOH
Penalty
Summary
The facility failed to notify the Department of Health (DOH) about an event that compromised quality assurance and patient safety. The issue involved the dry sprinkler system, which serves the entire facility. The problem was known before a repair quote was received on December 24, 2024, but the facility did not address the issue identified in the quote. This inaction led to the failure of the dry sprinkler system on January 27, 2025, which caused a fire alarm activation. As of February 6, 2025, these events had not been reported to the DOH. During an exit conference on February 5, 2025, the Maintenance Manager confirmed that the cause of the dry sprinkler system failure had not been repaired at the time of the survey. Although the dry system was operational with the use of a temporary air compressor, the failure to report the incident to the DOH was a significant oversight. This deficiency was noted under the NFPA 101 General Requirements, specifically referencing Title 28, Health and Safety, Part IV. Health Facilities § 51.3. Notification. (e)(f).
Plan Of Correction
The facility had identified an issue with the dry system prior to this event. Staff have been educated on events that need to be reported to the department of health and will do so in a timely manner. Two vendor quotes were obtained for the repairs. The dry system was functioning fully until the permanent repairs can be completed. The vendor is scheduled to be onsite March 3, 2025, to complete the permanent repairs to the dry system.