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Based on record review an interview, the facility failed to ensure fire alarm inspections were performed in accordance with NFPA 72. Failure to ensure completion of sensitivity testing, and that all installed initiating devices are identified for location, along with identifying those entities responsible for monitoring, has the potential to create confusion in staff response during a fire event. This deficient practice affected patients, staff and visitors on the date of the survey.

Findings include:

During review of provided fire alarm inspection records conducted on 3/25/25 from 9:00 - 11:00 AM, review of the provided annual fire alarm inspection report dated October 8, 2024, established the inspection failed to identify the location in the facility of all devices tested, the responsible party for monitoring of the system, or the last known documented sensitivity testing.

Interview of the Director of Engineering at approximately 1:35 PM, established he was not aware of any sensitivity testing performed on the fire alarm system.

Actual NFPA standard:

NFPA 72

14.4.5% Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
14.4.5.3% In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through
14.4.5.3.7.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicat

Based on record review and observation, the facility failed to ensure the fire suppression system was maintained in accordance with NFPA 25. Failure to ensure fire suppression system pendants are free of obstructions such as non-factory applied paint, and that at a minimum, semi-annual waterflow alarm testing is completed, has the potential to hinder system response during a fire event. This deficient practice affected patients, staff and visitors on the date of the survey.

Findings include:

1) During review of provided fire suppression maintenance and inspection records conducted on 3/25/25 from 9:00 - 11:00 AM, records failed to indicate or establish any waterflow alarm testing had been conducted within the past twelve months.

2) During the facility tour conducted on 3/25/25 from 12:00 - 2:30 PM, observation of installed fire suppression system pendants located in the storage area at the rear of the Laundry, identified both pendants were coated with non-factory applied painting.

Actual NFPA standard:

5.2% Inspection.
5.2.1 Sprinklers.
5.2.1.1% Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1% Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)%Loading
(6) Painting unless painted by the sprinkler manufacturer 5.2.1.1.3% Any sprinkler that has been installed in the incorrect orientation shall be replaced.

13.2.6 Alarm Devices.
13.2.6.1 Mechanical waterflow device

Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 70, and approved, listed assemblies. Failure to enclose live electrical wiring and ensure use of relocatable power taps (RPTs) is not performed with non-approved appliances and installations, has the potential to increase the risk of electrical shock and arc fires. This deficient practice affected patients, staff, and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 3/25/25 from 12:30 - 3:00 PM, observation of facility electrical installations identified the following:

- An open 4-gang electrical junction box with exposed wiring in the housekeeping breakroom.
- An RPT connected in series to another RPT (daisy-chained) in the housekeeping breakroom.
- The Doctor's "Nook" using a RPT to supply power to a portable heating unit.
- Discharge Planning daisy-chained a RPT to a battery backup power supply.
- Anesthesia/Surgery nursing office using a RPT daisy-chained into a battery backup power supply, to supply power to a microwave, mini fridge, and a coffee maker.

Actual NFPA standard:

NFPA 70

Chapter 1 General
Article 110

110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved.
Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved, Identified, Labeled, and Listed.
110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with th

Based on record review and interview, the facility failed to ensure installed electrical receptacles were inspected and tested in accordance with NFPA 99. Failure to inspect and test receptacles in the patient care vicinity, based on type and documented performance data, has the potential to hinder reliability for continual use as designed. This deficient practice affected patients, staff, and visitors on the date of the survey.

Findings include:

During review of provided maintenance and inspection records conducted on 3/25/25 from 9:00 - 11:00 AM, no documentation was available demonstrating receptacles installed in patient bed locations had been tested at any duration. Interview of the Director of Engineering established he was unaware of the requirement for testing of outlets.

Actual NFPA standard:

6.3.4% Administration of Electrical Systems
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

Based on record review and interview, the facility failed to ensure Emergency Power Supply System (EPSS) generator sets were inspected, tested and maintained in accordance with NFPA 110. Failure to ensure inspection maintenance and testing of the EPSS generator is completed per the standard, has the potential to hinder facility response during a loss of power. This deficient practice affected patients, staff, and visitors on the date of the survey.

Findings include:

During review of provided inspection, maintenance and testing records conducted on 3/25/25 from 9:00 - 11:30 AM, no documentation was available for monthly load and battery conductivity testing within the past twelve months.

Interview of the Director of Engineering at approximately 1:30 PM, established he was not aware of the requirement.

Actual NFPA standard:

NFPA 110

8.3 Maintenance and Operational Testing.
8.3.7% Storage batteries, including electrolyte levels or battery voltage, used in connection with systems shall be inspected weekly and maintained in full compliance with manufacturer ' s
specifications.
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing
of specific gravity when applicable or warranted.
8.4 Operational Inspection and Testing.
8.4.1% EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Based on record review, observation, and interview, the facility failed to ensure Patient Care Related Electrical Equipment (PCREE) devices, including multiple outlet connections were inspected and tested in accordance with approved, listed assemblies, and NFPA 99. Failure to conduct testing and performance data for PCREE devices, and multiple outlet connections, has the potential to increase exposure to electrical shock and arc fires. This deficient practice affected patients, staff and visitors on the date of the survey.

Findings include:

1) During record review conducted on 3/25/25 from 9:00 - 11:00 AM, no documentation was available demonstrating UL 1363A power strips used in patient care areas, had been tested, or undergone any performance rating analysis.

2) During the facility tour conducted on 3/25/25 from 12:00 - 2:30 PM, observation of installed PCREE devices, including, but not limited to UL 1363A multiple outlet connections, established the following:

- A UL 1363A power strip located in the procedure room was in use on the floor, with three open and unsecured outlets exposed.
- Both Labor and Delivery rooms (L/D) were using UL 1363A power strips at the patient beds, both located on the floor, and three open outlets for L/D 1; five open outlets for L/D 2.

At approximately 2:15 PM, a interview of the staff responsible for documentation of biomed equipment determined she was not aware of the requirement for UL 1363A testing documentation. Further interview of Engineering staff at approximately 2:45 PM, established a testing program was in place at the facility, but the program was terminated.

Actual NFPA standard:

NFPA 99
Chapter 10 Electrical Equipment
10.2 Performance Criteria and Testing for Patient Care-Related Electrical Appliance