HospitalInspections.org

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all of the occupants of the facility in the event the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 08/06/13 at approximately 10:35 AM, during review of records it was observed that the facility failed to document bi-annual sensitivity testing of the smoke detectors. This observation was verified by the Director of Facilities/Environmental Services.


.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all of the occupants of the facility in the event the automatic sprinkler system failed to operate as designed during a fire emergency. Findings include:

1. On 08/06/13 at approximately 10:50 AM, during review of records it was observed that the facility failed to document quarterly flow tests of the automatic sprinkler system. This observation was verified by the Director of Facilities/Environmental Services.


.

Based on observation and/or review of records the facility failed to provide and/or maintain smoke detection devices in accordance with the LSC section 9.6.1.3. This deficient practice could potentially affect all of the occupants of the facility in the event the smoke detectors failed to operate as designed during a fire emergency. Findings include:

1. On 08/06/13 at approximately 10:35 AM, during review of records it was observed that the facility failed to document bi-annual sensitivity testing of the smoke detectors. This observation was verified by the Director of Facilities/Environmental Services.


.

Based on observation and/or review of records the facility failed to provide documentation that the automatic sprinkler system is maintained and/or tested in accordance with the LSC sections 19.7.6, 4.6.12, 9.7.5. This deficient practice could potentially affect all of the occupants of the facility in the event the automatic sprinkler system failed to operate as designed during a fire emergency. Findings include:

1. On 08/06/13 at approximately 10:50 AM, during review of records it was observed that the facility failed to document quarterly flow tests of the automatic sprinkler system. This observation was verified by the Director of Facilities/Environmental Services.


.