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MERCY HOSPITAL BOONEVILLE
No Description Available
Tag No.: K0104
Based on interview, it was determined the facility failed to inspect 80 of 80 fire/smoke dampers in the facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to ensure the reliability of the dampers to close in the event of a fire or smoke event. The facility had a census of three patients on 02/08/16. The findings follow:
In an interview on 02/09/16 at 1340, the Maintenance Director verified there was no documentation available for inspection of the 80 fire/smoke dampers located in the facility.
LIFE SAFETY CODE STANDARD
Tag No.: K0104
Based on interview, it was determined the facility failed to inspect 80 of 80 fire/smoke dampers in the facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). The failed practice had the potential to affect all patients, staff, and visitors because the facility failed to ensure the reliability of the dampers to close in the event of a fire or smoke event. The facility had a census of three patients on 02/08/16. The findings follow:
In an interview on 02/09/16 at 1340, the Maintenance Director verified there was no documentation available for inspection of the 80 fire/smoke dampers located in the facility.