HospitalInspections.org

A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Fire alarm system wiring or other transmission paths are monitored for integrity. Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations. Occupant notification is provided by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of fire. The fire alarm automatically activates required control functions. System records are maintained and readily available.
18.3.4, 19.3.4, 9.6

On facility tour between 09:30 AM and 01:30 PM on September 13, 2016, based on observation and interview revealed that findings include:

1.There was no fire alarm strobe found in sleeping room 1-531.
2. There was no documentation to review on magnet locks to release on a fire alarm in the ER department.

This deficient practice could affect the safety of the Doctor in sleeping room and the (3) patient within the Emergency area.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

(a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside.
4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4

On facility tour between 09:30 AM and 01:30 PM on September 13, 2016, based on observation and interview revealed that there was no sign stating oxygen is stored in room 2-115. Add sign age to all oxygen storage rooms.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

On facility tour between 09:30 AM and 01:30 PM on September 13, 2016, based on observation and interview revealed that there was no interlock switch for kitchen stove in room 2-150 to turn off power to when not used. .

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Fire alarm system wiring or other transmission paths are monitored for integrity. Initiation of the fire alarm system is by manual means and by any required sprinkler system alarm, detection device, or detection system. Manual alarm boxes are provided in the path of egress near each required exit. Manual alarm boxes in patient sleeping areas shall not be required at exits if manual alarm boxes are located at all nurse's stations. Occupant notification is provided by audible and visual signals. In critical care areas, visual alarms are sufficient. The fire alarm system transmits the alarm automatically to notify emergency forces in the event of fire. The fire alarm automatically activates required control functions. System records are maintained and readily available.
18.3.4, 19.3.4, 9.6

On facility tour between 09:30 AM and 01:30 PM on September 13, 2016, based on observation and interview revealed that findings include:

1.There was no fire alarm strobe found in sleeping room 1-531.
2. There was no documentation to review on magnet locks to release on a fire alarm in the ER department.

This deficient practice could affect the safety of the Doctor in sleeping room and the (3) patient within the Emergency area.


This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

(a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside.
4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4

On facility tour between 09:30 AM and 01:30 PM on September 13, 2016, based on observation and interview revealed that there was no sign stating oxygen is stored in room 2-115. Add sign age to all oxygen storage rooms.

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.

Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

On facility tour between 09:30 AM and 01:30 PM on September 13, 2016, based on observation and interview revealed that there was no interlock switch for kitchen stove in room 2-150 to turn off power to when not used. .

This deficient practice was confirmed by the Facility Maintenance Director at the time of discovery.