HospitalInspections.org

Based on documentation review and staff interview, the facility failed to provide all required documentation for the annual fire alarm system inspection. This deficient practice did not ensure that all fire alarm devices were inspected and increased the potential that the fire alarm would fail to operate during a fire. This deficient practice would affect all occupants. The facility has a capacity of 15, with a census of 0 on the day of survey.

Findings are:
Record review on 7-11-23 at 10:35 am revealed the facility had no documentation that the annual fire alarm test had been completed for the current year. The last documented inspection was done on 11-7-22.

During an interview on 7-11-23 at 10:35 am, the findings of documentation review were acknowledged and verified by Administrative A.

Based on interview and documentation review, the facility failed to implement a testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. These deficient practices failed to ensure that the fire doors would operate as designed to prevent the spread of fire and smoke and would affect all occupants in all smoke compartments. The facility capacity was 15, with a census of 0 on the day of survey.

Findings are:
Documentation review on 7-11-23 at 11:05 am revealed that the facility failed to provide written documentation of annual inspections and testing of all fire rated doors throughout the facility.

During an interview on 7-11-23 at 11:05 am, Administrative Staff A confirmed the lack of complete fire rated door inspections.

Based on record review and interview, the facility failed to conduct an individualized assessment for non-hospital grade receptacles at patient bed locations, including the continuity of the grounding circuit, polarity and retention force. This deficient practice increased the risk of fire from an outlet. The facility has the capacity for 15 beds with a census of 1 on the day of survey.

Findings are:
Record review on 7-11-23, at 11:40 am revealed: documentation of annual patient bed location receptacle testing was not provided for review.

During an interview on 7-11-23 at 11:40 am, Administrative Staff A confirmed the testing documentation was not provided and testing was not implemented.

NFPA Standard:
NFPA 99, 2012, 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.
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).