HospitalInspections.org

Based on document review with maintenance staff, the facility failed to conduct and document the required annual Internal/External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation.

The findings include:
During the document review with maintenance staff at 12:00 pm on 2/12/2013, it was found that the annual Internal drill had not been done. This was confirmed by the maintenance staff at the time of review. "Each organizational entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year". 59A-4.126 & -4.106(5)(c)2, Florida Administrative Code; NFPA 99 Chapter 12 & 17.3.12

Based on records review and staff interview, it was determined that the facility failed to properly test and maintain the generator as required as evidenced by the lack of documentation for the annual inspection and 4-hour load bank test. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During Document review at 11:10 am on 3/5/2013 with the Maintenance Director, it was noticed that there was no documentation for the 4-hour load bank test as required. 4 hour load banks are required every 36 months. NFPA 101 (2000), NFPA 99, NFPA 110 8.4.9

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the exercising of the main and feeder breakers. Not exercising as required by the manufacturer can lead to corrosion among other issues which can cause delay or the inability to transfer power in a time of emergency.

The findings include:
During document review with the Director of Maintenance at 11:45 am on 3/5/2012, it was found that the proper documentation for maintenance and testing was not being kept in accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker.

Based on document review with maintenance staff, the facility failed to conduct and document the required annual Internal/External disaster drills. These drills increase the knowledge of staff of the action to take in an emergency situation.

The findings include:
During the document review with maintenance staff at 12:00 pm on 2/12/2013, it was found that the annual Internal drill had not been done. This was confirmed by the maintenance staff at the time of review. "Each organizational entity shall implement two or more (Internal & External) specific responses of the emergency operations plan during each year". 59A-4.126 & -4.106(5)(c)2, Florida Administrative Code; NFPA 99 Chapter 12 & 17.3.12

Based on records review and staff interview, it was determined that the facility failed to properly test and maintain the generator as required as evidenced by the lack of documentation for the annual inspection and 4-hour load bank test. This deficiency could affect all occupants of the facility in case of a fire or other emergency.

Findings include:
During Document review at 11:10 am on 3/5/2013 with the Maintenance Director, it was noticed that there was no documentation for the 4-hour load bank test as required. 4 hour load banks are required every 36 months. NFPA 101 (2000), NFPA 99, NFPA 110 8.4.9

Based on document review and interview with the Director of Maintenance, it was noted that the facility failed to maintain documentation on the exercising of the main and feeder breakers. Not exercising as required by the manufacturer can lead to corrosion among other issues which can cause delay or the inability to transfer power in a time of emergency.

The findings include:
During document review with the Director of Maintenance at 11:45 am on 3/5/2012, it was found that the proper documentation for maintenance and testing was not being kept in accordance with NFPA 70, National Electrical Code. 9.1.2 for the exercise of the Main and Feeder Breaker.