HospitalInspections.org

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 quarters. This deficient practice could effect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the facility's Fire Drill records and interview on 03/23/11 at 12:45 p.m. with the maintenance supervisor, there was no record of a first shift fire drill for the fourth quarter of 2010. The maintenance supervisor acknowledged the fire drill was not conducted during the quarter.

Based on observation and interview, the facility failed to ensure 2 of 2 private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected and the necessary corrective action shall be taken. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation and interview on 03/23/11 at 1:50 p.m. with the maintenance supervisor, the facility failed to document annual inspections and maintenance for the two private fire hydrants on the facility's property. The maintenance supervisor stated at the time of observation, he did not recall the hydrants ever being inspected or maintained.

Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with remote manual stops. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the Generator Maintenance records on 03/23/11 at 1:20 p.m. with the maintenance supervisor, there was no documentation available which indicated the horsepower rating of the generator engine. Based on interview with the maintenance supervisor, he stated no remote shut off device existed for the generator, furthermore, the maintenance supervisor indicated he was not sure if the generator was 100 horsepower or more. The maintenance supervisor indicated the generator was installed before 2003.

Based on record review and interview, the facility failed to ensure fire drills were conducted quarterly on each shift for 1 of the last 4 quarters. This deficient practice could effect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the facility's Fire Drill records and interview on 03/23/11 at 12:45 p.m. with the maintenance supervisor, there was no record of a first shift fire drill for the fourth quarter of 2010. The maintenance supervisor acknowledged the fire drill was not conducted during the quarter.

Based on observation and interview, the facility failed to ensure 2 of 2 private fire hydrants were continuously maintained in reliable operating condition and inspected and tested periodically. NFPA 25, 1998 Edition, the Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems at Section 4-2.2.4 requires dry barrel hydrants to be inspected annually and after each operation. Hydrants shall be inspected and the necessary corrective action shall be taken. This deficient practice affects all occupants in the facility including staff, visitors and patients.

Findings include:

Based on observation and interview on 03/23/11 at 1:50 p.m. with the maintenance supervisor, the facility failed to document annual inspections and maintenance for the two private fire hydrants on the facility's property. The maintenance supervisor stated at the time of observation, he did not recall the hydrants ever being inspected or maintained.

Based on record review and interview, the facility failed to ensure 1 of 1 emergency generators was equipped with remote manual stops. LSC 7.9.2.3 requires emergency generators providing power to emergency lighting systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. NFPA 110, 1999 edition, 3-5.5.6 requires Level II installations shall have a remote manual stop station of a type similar to a break-glass station located elsewhere on the premises where the prime mover is located outside the building. NFPA 37, Standard for the Installation and Use of Stationary Combustion Engines and Gas Turbines, 1998 Edition, at 8-2.2(c) requires engines of 100 horsepower or more have provision for the shutting down the engine at the engine and from a remote location. This deficient practice could affect all patients, staff and visitors in the event of an emergency.

Findings include:

Based on review of the Generator Maintenance records on 03/23/11 at 1:20 p.m. with the maintenance supervisor, there was no documentation available which indicated the horsepower rating of the generator engine. Based on interview with the maintenance supervisor, he stated no remote shut off device existed for the generator, furthermore, the maintenance supervisor indicated he was not sure if the generator was 100 horsepower or more. The maintenance supervisor indicated the generator was installed before 2003.