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Based on a review of documentation, a walk through tour of the ICU Suite, and discussions with the director of support services during the onsite investigation on 12/01/2010, it was noted that there was a defective area alarm panel located within the ICU Suite. Documentation of an annual testing of the Medical gas system by a testing company in July 2010, reported that the area alarm for the ICU Suite was not functioning. During the walk-thourgh tour on 12/01/2010, for this investigation, it was observed that the area alarm for the ICU Suite was still not working. There was no visual or audible alarm for the oxygen alarm when tested. There was no visual alarm for the vacuum, when tested.

Based on a revew of the documentation, and discussions with the director support services, during this onsite investigation on 12/01/2010, it was noted that the two new alarm panels, one located in the ER, and one located at the OB Nurses station, had not been tested/verified by a third party ASSE certified 6030 verifier, as required by NFPA 99(2002) 5.1.12.3. The documents indicated that the same supplier, installed and tested the installation of the two alarms.

Based on a review of documentation, a walk through tour of the ICU Suite, and discussions with the director of support services during the onsite investigation on 12/01/2010, it was noted that there was a defective area alarm panel located within the ICU Suite. Documentation of an annual testing of the Medical gas system by a testing company in July 2010, reported that the area alarm for the ICU Suite was not functioning. During the walk-thourgh tour on 12/01/2010, for this investigation, it was observed that the area alarm for the ICU Suite was still not working. There was no visual or audible alarm for the oxygen alarm when tested. There was no visual alarm for the vacuum, when tested.

Based on a revew of the documentation, and discussions with the director support services, during this onsite investigation on 12/01/2010, it was noted that the two new alarm panels, one located in the ER, and one located at the OB Nurses station, had not been tested/verified by a third party ASSE certified 6030 verifier, as required by NFPA 99(2002) 5.1.12.3. The documents indicated that the same supplier, installed and tested the installation of the two alarms.