FOCUS on LS.02.01.35 - Sprinkler maintenance
LS.02.01.35 EP5 states that sprinkler heads must not be damaged and must be free from corrosion, foreign materials, and paint. Per NFPA 25, sprinklers are to be inspected from the floor level annually. This inspection is to determine if the sprinklers have the ability to perform properly.
ISSUE & IMPACT
An analysis of the 2014 Joint Commission findings shows that 58 percent of the findings within EP 5 were in relation to dust, corrosion, or foreign materials being observed on sprinkler heads. Foreign materials such as paint or excessive dust build up can insulate the frangible bulbs or thermal linkages, affecting the sprinklers ability to properly activate. These materials could also impede the sprinkler’s water distribution pattern, making the sprinkler less effective in controlling or containing a fire. The other major findings within this EP were related to ceiling tiles and escutcheons. While these items being broken, missing or damaged do not directly impact the sprinkler’s performance, they do create a barrier that limits the spread of smoke and toxic fumes. When ceiling tiles or escutcheons are missing or damage, controlling the fire and smoke is impeded.
Dust and foreign material along with a physical obstruction can impede the performance of sprinklers.
Including the inspection of sprinkler system components visible from the floor on the environmental rounds check list will help to make sure that this important inspection is completed. When dust or foreign materials are found on sprinkler heads, this should be addressed by the use of compressed air or by a vacuum as long as the equipment does not touch the sprinkler head. Additionally, this required annual inspection should be included in the facility’s environmental rounds policy and procedure. Making sure the responsibility to perform the necessary cleaning is assigned appropriately will help to make certain this inspection is properly completed.