HospitalInspections.org

Based on record review and staff interview, the facility failed to test Operating Room battery backup task lighting in accordance with the National Fire Protection Association, 101 in 2 of 2 ORs. This condition had the potential of the ORs to lose all illumination during the 1-10 second gap from loss of normal power to emergency generator power.

Findings are:
Record review during the facility tour on 3/26/13, at 9:32 am revealed that the battery backup lights in ORs 1 and 2 failed to be tested monthly and annually.
In an interview conducted at the time of record review, (3/26/13, at 9:32 am), Maintenance A confirmed that the lights were not being tested.

Actual NFPA Standard:
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association, 13 in the Business Office. This condition had the potential that the sprinkler system would fail to suppress a fire.

Findings are:
Record review on 3/27/13, at 3:54 pm revealed the 10/25/12 annual sprinkler inspection noted the " Business office sprinkler heads on the south side of the new wall are out of distance. " The facility failed to provide a work order to verify that the deficiency was corrected.
In an interview conducted at the time of record review, (3/28/13, at 9:12 am), Maintenance B confirmed that the work was not yet completed.

Actual NFPA Standard:
NFPA 13, 5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution

Based on record review and staff interview, the facility failed to test Operating Room battery backup task lighting in accordance with the National Fire Protection Association, 101 in 2 of 2 ORs. This condition had the potential of the ORs to lose all illumination during the 1-10 second gap from loss of normal power to emergency generator power.

Findings are:
Record review during the facility tour on 3/26/13, at 9:32 am revealed that the battery backup lights in ORs 1 and 2 failed to be tested monthly and annually.
In an interview conducted at the time of record review, (3/26/13, at 9:32 am), Maintenance A confirmed that the lights were not being tested.

Actual NFPA Standard:
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on record review and staff interview, the facility failed to maintain the sprinkler system in accordance with the National Fire Protection Association, 13 in the Business Office. This condition had the potential that the sprinkler system would fail to suppress a fire.

Findings are:
Record review on 3/27/13, at 3:54 pm revealed the 10/25/12 annual sprinkler inspection noted the " Business office sprinkler heads on the south side of the new wall are out of distance. " The facility failed to provide a work order to verify that the deficiency was corrected.
In an interview conducted at the time of record review, (3/28/13, at 9:12 am), Maintenance B confirmed that the work was not yet completed.

Actual NFPA Standard:
NFPA 13, 5-1.1*
The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution