HospitalInspections.org

Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (quarterly flow tests not done in 2021). Findings include:

1. Record review on 8/10/22 at 4:15 p.m. revealed the required quarterly flow tests had not been performed in the past year. Flow tests were only done as a part of the annual maintenance on 10/10/21.

Interview with CEO at the time of the record review confirmed that condition.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests on the automatic sprinkler system.

Based on record review and interview, the provider failed to ensure staff were familiar with the provider's fire drill procedures (no drills conducted on second or third shift). Findings include:

1. Record review on 8/10/22 at 4:15 p.m. revealed there was no documentation of drills being conducted during second or third shift over the last twelve month period. The requirement is for drills to be conducted once per shift per quarter, or every other month on each shift if only two shifts are used.

Interview with the maintenance supervisor at the time of the record review confirmed those findings. He was unaware of the requirement to conduct drills on all shifts.

The deficiency had the potential to affect 100% of the occupants of the building.