HospitalInspections.org

Based on record review and interview, the facility failed to document the emergency egress lighting annually. This deficient practice affects one of one smoke zones and all occupants of the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 04/30/10 at 10:15 a.m., revealed no documentation regarding the 90 minute testing of the emergency battery lighting system. Maintenance Staff A verified this observation and stated they were not aware they were required to conduct this annual test.

Based on observation, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 4.

Findings include:

Observations on 04/30/10 at 11:00 a.m., revealed the facility failed to provide a properly maintained fire alarm system. Fire alarm breaker #8 located along the south wall of the Mechanical Room was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by this deficient practice.

Maintenance Staff A verified this observation.

Based on observation and, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all occupants of the building. The facility has a capacity of 25 and a census of 4.

Findings include:

1. Observations on 04/30/2010 at 10:22 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near near the Medical Records Storage Room. This corridor contained a smoke detector with in three feet of an air diffuser.

2. Observations on 04/30/2010 at 10:49 a.m., revealed the facility failed to maintain the Fire Alarm System in the Cardiac Rehabilitation Room. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations on 04/30/2010 at 10:50 a.m., revealed the facility failed to maintain the Fire Alarm System in the Rehabilitation Office. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations on 04/30/2010 at 10:54 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near near the Emergency Room Admitting Office. This corridor contained a smoke detector with in three feet of an air diffuser.

5. Observations on 04/30/2010 at 10:56 a.m., revealed the facility failed to maintain the Fire Alarm System in the Emergency Room Admitting Office. This room contained a smoke detector with in three feet of an air diffuser.

6. Observations on 04/30/2010 at 10:55 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near near Emergency Exam Room #2. This corridor contained a smoke detector with in three feet of an air diffuser. Maintenance Staff A verified these observations.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 4.

Findings Include:


Observations on 04/30/10 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Radiology Room (CT). Electrical breakers #29, #30 and #31 in the Electrical Panel were not identified or labeled in the electrical panel directory.

Maintenance Staff verified these observations.

Based on record review and interview, the facility failed to document the emergency egress lighting annually. This deficient practice affects one of one smoke zones and all occupants of the facility. This facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 04/30/10 at 10:15 a.m., revealed no documentation regarding the 90 minute testing of the emergency battery lighting system. Maintenance Staff A verified this observation and stated they were not aware they were required to conduct this annual test.

Based on observation, the facility did not assure that the fire alarm system is in accordance with NFPA 72, and chapter 9.6.4 of NFPA 101 by ensuring that the fire alarm breaker is mechanically protected. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 4.

Findings include:

Observations on 04/30/10 at 11:00 a.m., revealed the facility failed to provide a properly maintained fire alarm system. Fire alarm breaker #8 located along the south wall of the Mechanical Room was not secured with a mechanical lock to assure that the breaker is not inadvertently shut off. All occupants would be directly affected by this deficient practice.

Maintenance Staff A verified this observation.

Based on observation and, the facility is not assuring that the fire alarm system is installed and maintained in accordance with NFPA 72, 2-3.5, which requires that smoke detectors are not placed within direct airflow, nor closer than three feet to an air supply or air return. Installation of a smoke detector close to an air diffuser can impede the operation of the smoke detector and can affect all occupants of the building. The facility has a capacity of 25 and a census of 4.

Findings include:

1. Observations on 04/30/2010 at 10:22 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near near the Medical Records Storage Room. This corridor contained a smoke detector with in three feet of an air diffuser.

2. Observations on 04/30/2010 at 10:49 a.m., revealed the facility failed to maintain the Fire Alarm System in the Cardiac Rehabilitation Room. This room contained a smoke detector with in three feet of an air diffuser.

3. Observations on 04/30/2010 at 10:50 a.m., revealed the facility failed to maintain the Fire Alarm System in the Rehabilitation Office. This room contained a smoke detector with in three feet of an air diffuser.

4. Observations on 04/30/2010 at 10:54 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near near the Emergency Room Admitting Office. This corridor contained a smoke detector with in three feet of an air diffuser.

5. Observations on 04/30/2010 at 10:56 a.m., revealed the facility failed to maintain the Fire Alarm System in the Emergency Room Admitting Office. This room contained a smoke detector with in three feet of an air diffuser.

6. Observations on 04/30/2010 at 10:55 a.m., revealed the facility failed to maintain the Fire Alarm System in the corridor near near Emergency Exam Room #2. This corridor contained a smoke detector with in three feet of an air diffuser. Maintenance Staff A verified these observations.

Based on observation, it was determined the facility failed to maintain the buildings electrical wiring system in accordance with National Fire Protection Association (NFPA) Standard 70, National Electrical Code, 1999 edition, placing the Staff and Residents of the facility at risk in the event of a fire. The facility had a capacity of 25 and a census of 4.

Findings Include:


Observations on 04/30/10 at 10:20 a.m., revealed the facility failed to maintain the electrical system in the Radiology Room (CT). Electrical breakers #29, #30 and #31 in the Electrical Panel were not identified or labeled in the electrical panel directory.

Maintenance Staff verified these observations.