HospitalInspections.org

.
Based on review of documentation and interview, the facility failed to maintain the automatic sprinkler system riser gauges per the requirements of:

2012 NFPA 101, 19.3.5.1
2012 NFPA 101, 9.7.5
2011 NFPA 25, 5.3.2.1

Findings include:

On 06/06/2017, upon review of documentation during a tour of the facility from 12:30 p.m. to 3:30 p.m., the automatic sprinkler system riser gauges had not been calibrated or replaced within the past 5 years. The gauges were installed in 2011 per interview and documentation.

A member of the maintenance staff was present when this deficiency was identified.
.

.
Based on review of documentation and interview, the facility failed to provide documentation of testing the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, and 8.4.2.3

This could affect 3 patients.

Findings include:

On 06/06/2017, during a tour of the facility from 12:30 p.m. to 5:30 p.m., based on review of documentation and interview the facility failed to test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

A member of the maintenance staff was present when this deficiency was identified.

.
Based on review of documentation and interview, the facility failed to provide documentation of testing the diesel generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.4.4.1.1.3, and 6.5.4.2
2010 NFPA 110, 1.3, 8.3.2.1, 8.4.1, 8.4.2, and 8.4.2.3

This could affect 3 patients.

Findings include:

On 06/06/2017, during a tour of the facility from 12:30 pm to 15:30 pm, based on review of documentation and interview the facility failed to test the diesel generator once monthly for a minimum of 30 minutes under loading that maintains the minimum exhaust gas temperature OR under operating temperature conditions at not less than 30% of the nameplate kW rating OR provide an annual 1.5 hour supplemental load test at not less than 50% of the EPS nameplate kW rating for 30 continuous minutes and at not less 75% of the EPS nameplate KW rating for one continuous hour for a total test duration of not less than 1.5 continuous hours.

A member of the maintenance staff was present when this deficiency was identified.