HospitalInspections.org

.

Based on review of documentation, the facility failed to maintain the fire alarm system per the requirements of:

2012 NFPA 101, 19.3.4.1, and 9.6.1.3
2010 NFPA 72, Table 14.3.1(9)(h)

This deficiency affects all smoke detectors.

Findings include:

During a tour of the facility, the facility failed to provide documentation of conducting semi-annual visual inspections on the smoke detectors within the past 12 months.

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

.

.

Based on observation, the facility failed to install quick-response sprinklers per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.1.1(1)
2010 NFPA 13, 8.3.3.2, and 8.3.3.4

This deficiency affects 1 of 5 smoke compartments.

Findings include:

During a tour of the facility, the surveyor observed one quick-response sprinkler head installed in the same compartment (Emergency Department Room 3) with one standard-response sprinkler head.

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

.

.

Based on observation, the facility failed to provide a NFPA approved tamper switch (electronic supervisory signal) for the automatic the sprinkler system valve per the requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.2.1
2010 NFPA 72, 10.16.2

This deficiency affects the whole facility.

Findings include:

During a tour of the facility, the facility failed to provide a supervisory tamper switch for one of the two valves in the automatic sprinkler pit. The other valve was supervised by the post indicator.

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

.

.

Based on observation and review of documentation, the facility failed to maintain the automatic sprinkler system per requirements of:

2012 NFPA 101, 19.3.5.1, and 9.7.5
2011 NFPA 25, 5.3.1.1.1.3

This deficiency affects the complete sprinkler system.

Findings include:

During a tour of the facility, the facility failed to provide documentation that the 2003 fast-response sprinklers found throughout the facility had been replaced or had a representative sample test completed within 20 years of installation.

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

.

.

Based on review of documentation, the facility failed to maintain the testing of the emergency generator per the requirements of:

2012 NFPA 99, 6.5.4.1.1.2, 6.5.4.1.3, 6.5.4.2, 6.4.4.1.1.3, and 6.4.4.1.3
2010 NFPA 110, 8.3.7.1

This deficiency affects 2 of 2 generators.

Findings include:

During a tour of the facility, the facility failed to provide documentation of performing monthly testing and recording, of the electrolyte or conductance, of the batteries in both of the facility's emergency generators for the past 12 months.

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

.

.

Based on observation, the facility failed to maintain the oxygen cylinders per the requirements of:

2012 NFPA 99, 11.6.5.4

This deficiency affects all of the back-up oxygen cylinders.

Findings include:

During a tour of the facility, the facility failed to protect the outside back-up oxygen cylinders in the storage area against continuous exposure to direct rays of the sun where extreme temperatures prevail.

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