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Based on observation and a staff interview, testing of the digital alarm communicator transmitter (DACT) had not been conducted during each month of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.6.1.4, and NFPA 70 (1999) and NFPA 72 (1999) and CMS policy. In a fire emergency, this deficient practice could adversely affect 57 of 57 residents.

FINDINGS INCLUDE:

On 05/29/2014 at 10:55 AM, during a review of available records, no documentation could be provided verifying the digital alarm communicator transmitter (DACT) was tested during the months of June and October of 2013, or January and April of 2014.

This finding was confirmed with the facilities management manager.

Based on observation and a staff interview, the facility failed to provide line isolation monitoring at all anesthetizing locations, in accordance with the requirements at NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). This deficient practice could adversely affect the safety of an anesthetized patient and/or surgical staff.

FINDINGS INCLUDE:

On 05/29/2014 at 12:30 PM, observation revealed Operating Room Number One (OR-1) was a wet location where general anesthesia is administered, and no line isolation monitor could not be located. Further, no GFCI electrical outlets were present. In a discussion with staff, it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (1999) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 99 (1999) Chapter 3, Section 3-3.2.2.3]. Based upon observation, it could not be determined whether the electrical system within OR-1 would properly protect patients and staff from an electrical shock.

This finding was confirmed with the facilities management manager.

Based on observation and a staff interview, testing of the digital alarm communicator transmitter (DACT) had not been conducted during each month of the previous year. This deficient practice was not in accordance with the requirements at NFPA 101 (2000) Chapter 9, Section 9.6.1.4, and NFPA 70 (1999) and NFPA 72 (1999) and CMS policy. In a fire emergency, this deficient practice could adversely affect 57 of 57 residents.

FINDINGS INCLUDE:

On 05/29/2014 at 10:55 AM, during a review of available records, no documentation could be provided verifying the digital alarm communicator transmitter (DACT) was tested during the months of June and October of 2013, or January and April of 2014.

This finding was confirmed with the facilities management manager.

Based on observation and a staff interview, the facility failed to provide line isolation monitoring at all anesthetizing locations, in accordance with the requirements at NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). This deficient practice could adversely affect the safety of an anesthetized patient and/or surgical staff.

FINDINGS INCLUDE:

On 05/29/2014 at 12:30 PM, observation revealed Operating Room Number One (OR-1) was a wet location where general anesthesia is administered, and no line isolation monitor could not be located. Further, no GFCI electrical outlets were present. In a discussion with staff, it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (1999) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 99 (1999) Chapter 3, Section 3-3.2.2.3]. Based upon observation, it could not be determined whether the electrical system within OR-1 would properly protect patients and staff from an electrical shock.

This finding was confirmed with the facilities management manager.