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AURORA ST LUKES MEDICAL CENTER
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on record review and staff interview, the facility failed to provide a properly maintained fire alarm system in accordance with the NFPA 101 2012 edition 19.3.4.1, 9.6.1.3, NFPA 72 2010 edition 14.3.1, Table 14.3.1(9). This deficiency had a potential to affect 148 patients and an undetermined number of staff and visitors in the facility.
Findings include
On 12/14/21 between 12:40 pm and 1:40 pm, review of the fire alarm system maintenance and inspection report of Johnson Controls revealed that semi-annual visual inspection of smoke detectors, duct smoke detectors, and heat detectors was not performed after the last annual maintenance and testing completed on 12/23/20.
The above deficiency was confirmed by interview with Staff B, Staff M1 and Staff M2 at the time of discovery, and Staff A at exit interview on 12/14/21 at 1:45 pm.