HospitalInspections.org

Based on review of facility documentation and staff interview during a revisit conducted on 04/05/10 and 04/06/10 it was determined the hospital failed to maintain all components of the hospital fire alarm system. Findings include:

On 04/05/10 at approximately 3:00 p.m., a hospital plan of correction dated 03/29/10 for a survey conducted 02/25/10 was reviewed. This plan of correction indicated that it would repair the five (5) heat detectors that failed during a test on 12/17/09 or would get documentation from a certified fire alarm testing contractor that stated the heat detectors were not required and could be removed. An interview with the plant operations director on 04/05/10 at approximately 3:15 p.m. revealed that the five (5) inoperable heat detectors identified in the report had been removed. However, this interview also revealed that the certified fire alarm contractor that was contacted would not give any documentation that indicated the heat detectors were not required and could be removed. Therefore, since the certified fire alarm contractor would not give documentation to indicate the heat detectors were not required components of the hospital fire alarm system, five (5) operable heat detectors would need to be installed in the original location of the heat detectors that were removed.