Failure to Provide Fire Watch and Staff Notification During Sprinkler System Outage
Penalty
Summary
The facility failed to ensure that when the sprinkler system was out of service for more than 10 hours in a 24-hour period, the affected areas were either evacuated or an approved fire watch was provided, as required by relevant fire safety codes. Record review showed that the annual dry sprinkler inspection revealed the system failed due to the attic dry system being capped and only six heads active. Despite this, the facility was not conducting fire watch in the unprotected areas, and required 'out of service' signage was not posted throughout the building, contrary to the facility's fire watch policy. Additionally, staff interviews indicated a lack of awareness regarding the non-operational status of the sprinkler system. A CNA stated she was not informed about the sprinkler system being out of service and expressed that this information was important for responding to a fire. Similarly, the ADON was unaware that a portion of the sprinkler system was not working. These findings demonstrate that both procedural and communication lapses contributed to the deficiency.
Plan Of Correction
1. The facility failed to follow its fire watch policy and procedures when the dry sprinkler system was not functioning properly. Per policy, the facility must either evacuate or initiate a fire watch if the system is non-operational for 10 or more hours within a 24-hour period. 2. Failure to implement fire watch procedures as required could have endangered the safety of all residents, staff, and visitors during a fire emergency. 3. Corrective actions have been taken as follows: - The facility promptly initiated fire watch procedures once the system malfunction was identified, including posting Out of Service signage and conducting regular monitoring rounds. - Excel Fire Protection replaced the 3-inch and 4-inch system piping. - Superiorland Electronics installed a second air compressor, replaced 12 feet of main sprinkler piping, and conducted a system water test. Two leaks (above a resident room and in the boiler room) were identified and repaired. - A trip test will be performed to confirm the full functionality of the system. - Documentation of all system repairs has been received from Excel and Superiorland. - All staff have been re-educated on the fire watch policy, including the requirement for timely implementation when the sprinkler system is out of service. - Superiorland Electronics will complete the hydrostatic testing of the system by 5/23/25. 4. The Administrator is responsible for ensuring fire watch policies and procedures are implemented without delay during any future system outage and for reporting compliance status to the Quality Assurance (QA) Committee.