HospitalInspections.org

Based on document review and staff interview it was determined the hospital failed to ensure the fire alarm system was tested, including smoke detector sensitivity testing, in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors of the facility. Facility census 3.

Findings include:

1. On 08/22/17 at approximately 3:45 p.m., document review revealed the facility failed to provide documentation of fire alarm system sensitivity testing.

The above finding was verified with the Maintenance Supervisor at the time of discovery.

Based on document review and staff interview it was determined the facility failed to ensure fire drills are held at unexpected times and under varying conditions, at least quarterly on each shift, in accordance with National Fire Protection Association (NFPA) 101. This failure has the potential to affect all patients, staff and visitors of the facility. Facility census 3.

Findings include:

1. On 08/22/17 at approximately 11:30 a.m., document review revealed that first shift fire drills for 01/16/17, 02/20/17 and 09/26/17 were conducted in approximately the same time frame.

The above finding was verified with the Maintenance Supervisor at the time of discovery.

Based on document review and staff interview it was determined the facility failed to maintain the emergency generator in accordance with National Fire Protection Association (NFPA) 110. This failure has the potential to affect all patients, staff and visitors of the facility. Facility Census 3.

Findings include:

1. On 08/23/17 at 9:40 a.m., document review revealed the electrolyte levels were not being checked weekly for the emergency generator batteries.

The above finding was verified with the Maintenance Supervisor at the time of discovery.