Obstruction of Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to protect cooking facilities in accordance with Life Safety Code (LSC) 19.3.2.5 and NFPA 17A. During an observation, it was found that the shelf of a newly acquired kitchen stove would obstruct the spray nozzles of the hood fire suppression system if activated. This configuration violates NFPA 17A 10.2.7.3, as the obstruction could prevent the suppression system from functioning as intended. The deficiency was confirmed during an interview with the Maintenance Director at the time of observation. No information about specific patients, their medical history, or their condition at the time of the deficiency is provided in the report.
Plan Of Correction
K324 Cooking Facilities Element 1 No residents were harmed due to this deficient practice. All residents and staff have the potential to be affected by this deficient practice. The shelf of the newly installed kitchen stove was removed so that it does not obstruct the spray nozzles of the hood fire suppression system if activated. Element 2 An audit was completed by the maintenance director to ensure that there are no other objects within the kitchen that could obstruct the spray nozzles of the fire suppression system. No other concerns were identified. Element 3 Education was provided to the maintenance director regarding the requirement that there should be no objects obstructing the spray nozzles of the fire suppression system. Element 4 The Maintenance Director or Designee will audit the kitchen one-time weekly for 4 weeks, then monthly times three months, to ensure that there are no objects obstructing the spray nozzles of the fire suppression system. Any concerns will be addressed at the time they are discovered. Audit findings will be presented to and reviewed by the QAPI Committee monthly until such time that consistent substantial compliance has been achieved and maintained as determined by the committee. The Maintenance Director will be responsible for sustained compliance.