HospitalInspections.org

Based on record review, the facility failed to inspect and test the fire alarm system in accordance with National Fire Protection Association (NFPA) Standard 72, 1999 edition, Chapter 7. The fire alarm system shall be inspected and tested at the frequencies established in Chapter 7. This deficient practice affects all occupants of the building. The facility has a capacity of 25 and at the time of the survey had a census of 16.

Findings include:
Record review of the fire alarm test records on 11/09/10, revealed the initiating and supervisory devices were not documented as being inspected or tested in accordance with the frequencies established in NFPA 72. Record review showed 0 of 9 manual pull stations were inspected or tested during the fire alarm inspection conducted on 2/8/10, and the 7/16/10 inspection report 3 manual pull stations were listed as being tested but the locations were not documented in the initiating and supervisory device test and inspection section of the report.
Record review also showed the only items listed in the initiating and supervisory device test and inspection section of the report on 7/16/10 were the batteries, and flow and tamper switches. Absent was the list of remaining initiating devices.
Record review at the time of the revisit on 2/17/11, revealed on the 11/22/10 inspection report the initiating and supervisory devices had not been listed individually showing if they were visually inspected or functionally tested and if they passed or failed. Attached to the inspection report was a computer generated print out listing the smoke detectors and duct detectors but it did not contain the required documentation showing if they were functional tested or visual inspected in accordance with NFPA 72. 20 manual pull stations, 234 smoke detectors, 30 duct detectors, and 2 heat detectors were listed as being tested but were not listed individually.