HospitalInspections.org

Based on record review and staff interview, the facility failed to maintain the fire alarm system in accordance with National Fire Protection Association (NFPA) 72. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 12/06/18 revealed the following deficiencies:

1. At 10:37 a.m., the fire alarm system test documentation failed to list the locations of the initiating devices.
2. At 10:40 a.m., the date on the most recent smoke detector sensitivity test documentation was 02/25/16. Sensitivity testing is required every 2 years.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide an outage policy in accordance with National Fire Protection Association (NFPA) 101, 2012 edition. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 12/06/18 at 10:02 a.m. revealed the following deficiencies:

1. The fire alarm system outage policy did not state to contact the Iowa Department of Inspections and Appeals at the beginning and end of the fire watch.
2. The fire alarm system outage policy did not list the contact numbers for the Iowa Department of Inspections and Appeals, the Iowa State Fire Marshal, or the local fire department.
2. The fire alarm system outage policy did not state the fire watch is "continuous" with rounds covering all affected areas at least once every 30 minutes.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide an outage policy in accordance with National Fire Protection Association (NFPA) 25, 2011 edition. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 12/06/18 at 10:02 a.m. revealed the following deficiencies:

1. The sprinkler system outage policy did not address system leakage, interruption of water supply, ruptured piping, or equipment failure.
2. The sprinkler system outage policy did not address the notification of the supervisors in the areas affected by the outage.
3. The sprinkler system outage policy did not address a tag impairment system.
4. The sprinkler system outage policy did not address the assembly of all necessary tools and materials on the impairment site.
5. The sprinkler system outage policy did not address contacting the Iowa Department of Inspections and Appeals or the facility's insurance carrier.
6. The sprinkler system outage policy did not include the contact numbers for the Iowa State Fire Marshal, the Iowa Department of Inspections and Appeals, the local fire department, or the facility's insurance company.
7. The sprinkler system outage policy did not state the fire watch is "continuous" with rounds of the affected areas completed at least every 30 minutes.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to provide a Fire Safety Plan in accordance with National Fire Protection Association (NFPA) 101, 2012 edition, section 19.7.2.2. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and interview on 12/06/18 at 11:10 a.m. revealed the facility's Fire Safety Plan failed to address the following information:
a. Use of the hood & duct extinguishment system in the Kitchen.
c. Use of the different types of fire extinguishers.

Administrative Staff A and Maintenance Staff A observed these findings.

Based on record review and staff interview, the facility failed to provide documentation for fire drills conducted quarterly on each shift. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 12/06/18 at 10:28 a.m., revealed the facility failed to provide documentation of a fire drill for the 2nd shift of the 1st quarter of 2018.

Administrative Staff A and Maintenance Staff A observed this finding.

Based on record review and staff interview, the facility failed to maintain the fire doors in accordance with National Fire Protection Association (NFPA) 80. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Record review and staff interview on 12/06/18 revealed the following deficiencies:

1. At 10:51 a.m., the facility failed to provide documentation of annual testing of the fire doors which includes the following information:

a. no open holes or breaks in the surface of the door or frame
b. Glazing, vision light frames, and glazing beads are intact and securely fastened in place
c. The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage
d. no parts are missing or broken
e. door clearances do no exceed clearances listed in 4.8.4 & 6.3.1.7 of NFPA 80
f. The self-closing device is operational, the door completely closed from the full open position
g. If a coordinator is installed, the inactive leaf closes before the active leaf
h. Latching hardware operates and secures the door when it is in the closed position
i. Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame
j. No field modifications to the door assembly have been performed and void the label
k. Gasketing and edge seals, where required, are inspected to verify their presence and integrity

Administrative Staff A and Maintenance Staff A observed this finding.

Based on observation, record review, and staff interview, the facility failed to maintain the emergency generator in accordance with National Fire Protection Association (NFPA) 99. This deficient practice affects 4 patients in 7 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observation, record review, and staff interview on 12/06/18 revealed the following deficiencies:

1. At 10:29 a.m., the generator test documentation failed to indicate at what percentage of nameplate the generator was running during the load tests.
2. At 10:29 a.m., the generator weekly inspection log failed to address the belts/hoses.
3. At 10:51 a.m., the facility failed to provide documentation of an annual test (in accordance with ASTM) of the emergency generator fuel supply.
4. At 12:23 p.m., the generator emergency stop was located on the side of the generator instead of at a remote location.

Administrative Staff A and Maintenance Staff A observed these findings.

Based on surveyor observation and staff interview, the facility failed to maintain the electrical system in accordance with National Fire Protection Association (NFPA) 70. This deficient practice affects 1 staff member in 1 of 7 zones. The facility has a capacity of 25 and a census of 4.

Findings include:

Observations and interview on 12/06/18 at 12:15 p.m., revealed an extension cord in use in the IT Manager's Office.

Administrative Staff A and Maintenance Staff A observed this finding.