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Tag No.: E0041
Based on record review and staff interview, the facility failed to inspect all emergency electrical system (EES) circuit breakers annually, and to exercise those breakers periodically. This practice allowed the potential for generator failure during loss of normal power.
Findings are:
Record review on 6/29/23, at 10:34 am revealed documentation of annual circuit breaker inspection, and periodic testing was not provided for review.
In an interview on 6/29/23, at 10:34 am, Maintenance A confirmed the documentation was not available.
NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.
6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.
Tag No.: K0345
Based on record review and staff interview, the facility failed to have 1 of 2 fire alarm systems (newest addition) inspected/tested semiannually. This practice increased the potential of the fire alarm system failing to detect and notify occupants of a fire.
Findings are:
Record review on 6/29/23, at 11:45 am revealed the fire alarm that served the newest addition was not inspected since 3/16/22.
In an interview on 6/29/23, at 11:45 am, Administration A confirmed this was the most recent report of testing.
Tag No.: K0712
Based on record review and staff interview, the facility failed to conduct fire drills quarterly for each shift. This practice would not provide the necessary training for staff to respond effectively in the event of a fire.
Findings are:
Record review on 6/29/23, at 11:03 am revealed:
1. Fire drills were not conducted quarterly for the following shifts: 1st and 2nd shifts in the 4th quarter of 2022, and the 2nd shift in 3rd quarter of 2022.
2. Various drills over the last 12 months did not have times recorded for when drills were conducted.
In an interview on 6/29/23, at 11:03 am, Administration A acknowledged the findings.
Tag No.: K0918
Based on record review and staff interview, the facility failed to inspect all emergency electrical system (EES) circuit breakers annually, and to exercise those breakers periodically. This practice allowed the potential for generator failure during loss of normal power.
Findings are:
Record review on 6/29/23, at 10:34 am revealed documentation of annual circuit breaker inspection, and periodic testing was not provided for review.
In an interview on 6/29/23, at 10:34 am, Maintenance A confirmed the documentation was not available.
NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.
6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.
Tag No.: K0921
Based on record review, observation and staff interview, the facility failed to implement documentation of inspection and testing, as well as an inspection and testing program for all power strips used in the facility. This practice increased the potential of electrical equipment throughout the facility causing injury or a fire.
Findings are:
Record review on 6/29/23, at 10:42 am revealed written policies and procedures for conducting audits and testing of power strips was not provided.
Observation on 6/29/23, at 12:01 pm revealed a microwave and coffee maker were plugged into a power strip in the Lab Office, and not directly into a hardwired outlet.
In an interview on 6/29/23, from 10:42 am to 12:01 pm, Administration A confirmed the findings, and that testing was not conducted, and policies not provided.
Tag No.: K0923
Based on observation and staff interview, the facility failed to store oxygen cylinders so they were restrained from tipping over. This condition had the potential for an oxygen cylinder to tip over and become a projectile.
Findings are:
Observation on 6/29/23, at 11:34 am revealed four oxygen cylinders were freestanding in the Oxygen Storage Room, and were not restrained.
In an interview on 6/29/23, at 11:34 am, Maintenance A acknowledged that the oxygen cylinders were not restrained.
NFPA 99, 2012, 11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:
(11) Freestanding cylinders shall be properly chained or supported
in a proper cylinder stand or cart.