HospitalInspections.org

Based on observation, the facility failed to provide separation of hazardous areas from other compartments in accordance with National Fire Protection Association (NFPA) Standard 101, Life Safety Code, 2012 edition, 19.3.2. This deficient practice affects one of three smoke zones and could affect all residents, staff, and visitors within the affected zone. The facility had a capacity of 22 and a census of 7 patients at the time of the survey.

Findings include:

Observation on 8/2/2023 at 11:35 a.m., revealed the facility failed to maintain the walls in the Electrical Room in the Center Hall within the outpatient/business wing of the facility. This room contained multiple approximately 1/2 inch to 2 inch gaps in the gypsum board walls above the door within this room and on the other adjacent walls around pipes and conduit made during construction.

The Maintenance Director confirmed this finding at the time of discovery.

Based on record review and interview, the facility failed to conduct the required biennial sensitivity testing of smoke detectors in accordance with National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.4.5.3.2. This deficient practice affects all occupants as this lack of testing would not ensure the sensitivity of the detectors was within the manufacturer's specification. The facility had a capacity of 22 and a census of 7 patients at the time of the survey.

Findings include:

Record review and interview on 8/2/2023 at 9:30 a.m., of the facility's fire alarm system inspection documentation, revealed the facility was unable to produce documentation that the sensitivity of the smoke detectors had been tested within the previous two years. The last two semi-annual fire alarm inspection reports from Midwest Alarm Services dated 3/28/2023 and 11/4/2022 did not contain any results for sensitivity testing. Review of these records from Midwest Alarm Services from 3/28/2023 and 11/4/2022 included summary test results for the smoke detectors throughout the facility, however, there were columns next to each device listed as "low sensitive", "high sensitive", and "range", but all of these columns were empty and were not filled out. These pages did not list the factory setting range of each device or the test results (pass/fail) along with the sensitivity each device tested. Interview of the Maintenance Director revealed they had switched fire alarm providers from Johnson Controls to Midwest Alarm Services in early 2022, however, none of the records from Johnson Controls that were available for review contained any sensitivity testing. Review of the report from the last inspection for Jones Regional Medical Center revealed a date of October 2018 as the last time the sensitivity testing had been completed. The sensitivity testing for the smoke detectors is approximately 3 years overdue.

The Maintenance Director verified the documentation during the survey.

Based on record review and interview, the facility failed to conduct/document electrical receptacle testing in patient care rooms as required by National Fire Protection Association (NFPA) Standard 99, Health Care Facilities Code, 2012 edition, 6.3.3.2 and 6.3.4.2. The deficient practice affects one of three smoke compartments and all residents, staff, and visitors. The facility had a capacity of 22 and a census of 7 patients at the time of the survey.

Findings include:

Record review and interview on 8/2/2023 at 11:53 a.m., revealed the facility was unable to provide documentation of non-hospital-grade receptacle testing or documentation of testing upon initial installation, replacement, or servicing of hospital-grade receptacles for the outpatient/business wing completed in 2015. Observation revealed non-hospital grade receptacles throughout the entire wing for outpatient/business which was added to the building in 2015. These receptacles within patient care and exam rooms will need to be tested per the NFPA requirements.

The Maintenance Director verified this finding during the survey.

NFPA 99 Health Care Facilities Code, 2012 edition, 6.3.4.2 Record Keeping.

6.3.4.2.1.2 At a minimum, the record shall contain the date,
the rooms or areas tested, and an indication of which items
have met, or have failed to meet, the performance requirements
of this chapter.

Based on record review, observations, and interview, the facility failed to maintain complete documentation of the inspections, tests, exercising, and operation of the emergency generator power supplies as required by National Fire Protection Association (NFPA) Standard 110, Standard for Emergency and Standby Power Systems, 2010 edition, 8.3.4; by not fully documenting monthly tests of the emergency generator and by not ensuring the emergency generator for the building was properly equipped with a remote manual stop mechanism in accordance with NFPA Standard 110, 2010 edition, 5.6.5.6; These deficient practices affect all smoke compartments of the building and all occupants. The facility had a capacity of 22 and a census of 7 patients at the time of the survey.

Findings include:

1. Record review and interview on 8/2/2023 at 10:16 a.m., revealed the facility failed to maintain proper documentation of monthly load tests for the facility's emergency generator. The facility had not documented the generator meter readings or the amperages (each leg) during their monthly 30-minute tests. The generator monthly documentation had columns to record this information, however, it had not been written down. Interview of the Maintenance Director revealed the generator runs automatic tests and the information is displayed at that time, but not written down.

2. Observation on 8/2/2023 at 12:17 p.m., revealed the facility's emergency generator was not equipped with a remote manual stop mechanism (emergency shut-off) external to the weatherproof enclosure. The emergency stop was located internal to the generators' housings and on the control panel.

NFPA 110, Standard for Emergency and Standby Power Systems,
2010 edition, 5.6.5.6

5.6.5.6* All installations shall have a remote manual stop station
of a type to prevent inadvertent or unintentional operation located
outside the room housing the prime mover, where so installed,
or elsewhere on the premises where the prime mover is
located outside the building.

5.6.5.6.1 The remote manual stop station shall be labeled.

A.5.6.5.6 For systems located outdoors, the manual shutdown
should be located external to the weatherproof enclosure
and should be appropriately identified.

The Maintenance Director confirmed these findings during the survey.