HospitalInspections.org

Based on observation and staff interview on 01/05/2022 between approximately 1030 to 1300 hours the facility failed to properly maintain their elevator. This could cause the firefighters recall to fail in the event of an alarm.
The findings include:
The facility has not been conducting monthly recall testing of the elevator.
The above was discussed and acknowledged by the facility staff. Maintenance manager stated that he was not aware of this requirement.
Ref: Monthly Elevator Recall Testing: NFPA (2012 ed) 19.1.1.1.1, 19.5.3, 9.4.6.2

Based on record review and staff interview on 01/05/2022 between approximately 1030 to 1300 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff, and/or visitors.
The findings include:
There is no documentation for the following fire drills:
3rd quarter 2021 - Day & NOC shifts
4th quarter 2021 - Day & NOC
The above was discussed and acknowledged by the maintenance director in the presence of the administrator.
Ref: NFPA 101 (2012 ed) 19.1.1.1.1, 19.7.1.6

Based on observation and staff interview on 01/05/2022 between approximately 1000 to 1500 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

Findings include:


Facility staff cannot documentation of monthly load testing.



Monthly Load Testing: NFPA 99 (2012 ed) 6.4.4.1.1.3, 2.1, NFPA 110 (2010 ed)1.1, 6.4.4.1.1.4, 8.3.1