HospitalInspections.org

Based on record review and staff interview, the facility failed to maintain the battery backup emergency light for the Operating Room. This condition had the potential to leave the Operating Room in darkness during the 1-10 second gap before the generator restored power. Facility census was 9 of 25.

Findings are:
Record review revealed the facility failed to provide documentation that the Operating Room Battery Backup Emergency Light was tested monthly.
In an interview conducted at the time of record review (8/28/12, at 11:22 am), Maintenance A acknowledged that the tests were not completed.

Actual NFPA Standard:
NFPA 101, 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 1 ½ hours. Equipment shall be fully operation 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 fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 9 of 25.

Findings are:
Record review of fire alarm inspection reports revealed the most recent semi-annual inspection was 2/10/12. The facility failed to have the fire alarm inspected semi-annually.
In an interview conducted at the time of record review, (8/28/12, at 1:45 pm), Maintenance A confirmed the fire alarm had not been inspected within the last six months.

Based on observation and staff interview, the facility failed to inspect fire extinguishers monthly throughout the facility. This condition had the potential for the fire extinguishers to not operate during a fire. Facility census was 9 of 25.

Findings are:
Observations during the facility tour on 8/28/12, from 11:14 am to 1:40 pm revealed that new fire extinguishers throughout the facility failed to have inspection tags to verify monthly inspections were performed. The facility failed to provide any documentation to verify that the extinguishers were inspected monthly.
In an interview conducted at the time of record review, (8/28/12, from 11:14 am to 1:40 pm) Maintenance A confirmed the findings.

Actual NFPA Standard:
NFPA 10, 4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on record review and staff interview, the facility failed to have the range hood suppression system inspected semi-annually. This condition had the potential for the the suppression system to fail activation during a cooking fire. Facility census was 9 of 25.

Findings are:
Record review revealed the range hood suppression system was last inspected 2/6/12. The facility failed to have the system inspected semi-annually.
In an interview conducted at the time of record review, (8/28/12, at 1:27 pm), Maintenance A confirmed the last date of inspection.

Based on observation and staff interview, the facility failed to provide an enclosure in accordance with the National Fire Protection Association 2001 for the clean agent suppression system. This condition had the potential for the door to the room to be left open after the system activated, which would allow the agent to escape and would fail to suppress a fire. Facility census was 9 of 25.

Findings are:
Observation during the facility tour on 8/28/12, at 1:32 pm revealed that an automatic closure failed to be installed on the Server Room Door, which separated the IT Office from the Server Room that held the clean agent suppression system.
In an interview conducted at the time of observation, (8/28/12, at 1:32 pm), Maintenance A confirmed that the closure installed on the door was not auto-closing.

Actual NFPA Standard:
NFPA 2001, 3-3.4
To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. Where reasonable confinement of agent is not practicable, protection shall be expanded to include the adjacent connected hazards or work areas or additional agent shall be introduced into the protected enclosure using an extended discharge configuration.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. Facility census was 9 of 25.

Findings are:
Record review of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of the generator.
In an interview conducted at the time of record review (8/28/12, at 11:12 am), Maintenance A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Based on record review and staff interview, the facility failed to maintain the battery backup emergency light for the Operating Room. This condition had the potential to leave the Operating Room in darkness during the 1-10 second gap before the generator restored power. Facility census was 9 of 25.

Findings are:
Record review revealed the facility failed to provide documentation that the Operating Room Battery Backup Emergency Light was tested monthly.
In an interview conducted at the time of record review (8/28/12, at 11:22 am), Maintenance A acknowledged that the tests were not completed.

Actual NFPA Standard:
NFPA 101, 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 1 ½ hours. Equipment shall be fully operation 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 fire alarm system in accordance with the National Fire Protection Association, 72. This condition increased the potential that the fire alarm would fail to detect smoke. Facility census was 9 of 25.

Findings are:
Record review of fire alarm inspection reports revealed the most recent semi-annual inspection was 2/10/12. The facility failed to have the fire alarm inspected semi-annually.
In an interview conducted at the time of record review, (8/28/12, at 1:45 pm), Maintenance A confirmed the fire alarm had not been inspected within the last six months.

Based on observation and staff interview, the facility failed to inspect fire extinguishers monthly throughout the facility. This condition had the potential for the fire extinguishers to not operate during a fire. Facility census was 9 of 25.

Findings are:
Observations during the facility tour on 8/28/12, from 11:14 am to 1:40 pm revealed that new fire extinguishers throughout the facility failed to have inspection tags to verify monthly inspections were performed. The facility failed to provide any documentation to verify that the extinguishers were inspected monthly.
In an interview conducted at the time of record review, (8/28/12, from 11:14 am to 1:40 pm) Maintenance A confirmed the findings.

Actual NFPA Standard:
NFPA 10, 4-3.1* Frequency.
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

Based on record review and staff interview, the facility failed to have the range hood suppression system inspected semi-annually. This condition had the potential for the the suppression system to fail activation during a cooking fire. Facility census was 9 of 25.

Findings are:
Record review revealed the range hood suppression system was last inspected 2/6/12. The facility failed to have the system inspected semi-annually.
In an interview conducted at the time of record review, (8/28/12, at 1:27 pm), Maintenance A confirmed the last date of inspection.

Based on observation and staff interview, the facility failed to provide an enclosure in accordance with the National Fire Protection Association 2001 for the clean agent suppression system. This condition had the potential for the door to the room to be left open after the system activated, which would allow the agent to escape and would fail to suppress a fire. Facility census was 9 of 25.

Findings are:
Observation during the facility tour on 8/28/12, at 1:32 pm revealed that an automatic closure failed to be installed on the Server Room Door, which separated the IT Office from the Server Room that held the clean agent suppression system.
In an interview conducted at the time of observation, (8/28/12, at 1:32 pm), Maintenance A confirmed that the closure installed on the door was not auto-closing.

Actual NFPA Standard:
NFPA 2001, 3-3.4
To prevent loss of agent through openings to adjacent hazards or work areas, openings shall be permanently sealed or equipped with automatic closures. Where reasonable confinement of agent is not practicable, protection shall be expanded to include the adjacent connected hazards or work areas or additional agent shall be introduced into the protected enclosure using an extended discharge configuration.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. Facility census was 9 of 25.

Findings are:
Record review of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of the generator.
In an interview conducted at the time of record review (8/28/12, at 11:12 am), Maintenance A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.