July 06, 2020 | | Comments 1
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Brother/Sister, can you spare a sprinkler head?

This week, I continue my ruminations on all things relating to outpatient care sites (Quick question: Is there anyone out there who doesn’t have responsibility for any outpatient care locations? I hope not, because this is probably getting a little tedious, though I guess in that hope it means that your existence has become more complicated over time, but if you don’t, you probably will). At any rate, this week’s tidbit revolves around the requirements for all (and I do mean “all”) properties having sprinkler heads to have a list of the sprinkler heads installed in the property, with the list being posted in the sprinkler cabinet. I think everyone is familiar with the requirements to have a stock of spare sprinklers, which would include all the types and ratings installed, with the number of spares guided by the following algorithm: The stock of spare sprinklers shall include all types and ratings installed and shall be as follows (this also shows up in NFPA 25-2011 in Chapter 5) :

(1) For protected facilities having under 300 sprinklers – no fewer than 6 sprinklers

(2) For protected facilities having 300 to 1000 sprinklers – no fewer than 12 sprinklers

(3) For protected facilities having over 1000 sprinklers – no fewer than 24 sprinklers

By the way, the information contained in this week’s missive is sourced from the 2010 edition of NFPA 13 Standard for Installation of Sprinkler Systems, which came into play when CMS adopted the 2012 edition of the Life Safety Code® (LSC). As a cautionary note, now this information “lives” in NFPA 25 Standard for the Inspection, Testing & Maintenance of Water-Based Fire Protection Systems, so if you happen to have a state authority having jurisdiction that’s using a more recent edition of the LSC, then NFPA 25 is where you’ll find this stuff.

At any rate, back to that all-important list (and kudos to those of you who have your lists in place), bopping back to NFPA 13, we find the following:* The list shall include the following:

(1) Sprinkler identification number (SIN) if equipped; or the manufacturer, model, orifice, deflector type, thermal sensitivity, and pressure rating

(2) General description

(3) Quantity of each type to be contained in the cabinet

(4) Issue or revision date of the list

The Appendix provides a little more info:

A. The minimum information in the list contained in the spare sprinkler cabinet should be marked with the following:

(1) General description of the sprinkler, including upright, pendent, residential, ESFR, and so forth

(2) Quantity of sprinklers to be maintained in the spare sprinkler cabinet

Where the rubber meets the road, so to speak, is the requirement for an annual verification of all this stuff:

NFPA 25-2011: The supply of sprinklers shall be inspected annually for the following:

(1) The correct number and type of sprinklers as required by and

(2) A sprinkler wrench for each type of sprinkler as required by* A supply of at least six spare sprinklers shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced.

A. – A minimum of two sprinklers of each type and temperature rating installed should be provided. The sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperatures will at no time exceed 100 degrees F. Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

So that’s the partial skinny on sprinklers; the primary reason for plunking this down in front of you is because this showed up as a finding (mostly the list, but the other stuff is fair game) in a recent survey (not The Joint Commission, but these things tend to move through the various regulatory tribes).

I did want to leave you with a final thought for the week. I subscribe to a weekly email newsletter from James Clear (the following lives here); I find the newsletter interesting and much more often than not, useful, so I give you:

“What is the real goal?

  • The real goal is not to ‘beat the market.’ The goal is to build wealth.
  • The real goal is not to read more books. The goal is to understand what you read.
  • Don’t let a proxy become the target. Don’t optimize for the wrong outcome.”

Stay well and stay safe—that’s all I need you to do!

Entry Information

Filed Under: Hospital safety


Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Hi Steve, Good article. One thing not covered is when sprinklers need to replaced. I think it’s at 50 years at least in California. A LA hospital hospital I was at had to replace most of there’s because of this requirement. I don’t have my paperwork on it handy to send you. Hope you are doing well and staying safe.
    Take care,

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