HospitalInspections.org

Based on document review and interview the facility failed to conduct annual tests of the battery-powered emergency lighting units. This deficient practice affects all occupants of the facility. The facility census was seven.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the afternoon of 02/24/15, showed there was no documentation of annual testing of the battery-powered emergency lighting units.

During an interview on 02/25/15 at 8:37 AM, Staff LL, Director Plant Operations, stated that staff had not been conducting a 1 1/2 hour annual test of the battery-powered emergency lighting units.

Section 7.9.3 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours.

Based on document review and interview the facility failed to conduct all required inspections of the sprinkler system throughout the year. This deficient practice affects all occupants in the facility. The facility census was seven.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the afternoon of 02/24/15, showed an outside contractor had conducted an annual certification inspection of the sprinkler system on 07/15/14. There was no documentation showing quarterly inspections had been conducted prior to the annual certification inspection nor after the inspection.

During an interview on 02/25/15 at 8:35 AM, Staff LL, Director of Plant Operations, stated that quarterly inspections of the sprinkler system were not being conducted.

Section 5.1 of the National Fire Protection Association, (NFPA 25) states the minimum requirements for the routine inspections, testing, and maintenance of sprinkler systems.

Based on document review and interview the facility failed to conduct annual tests of the battery-powered emergency lighting units. This deficient practice affects all occupants of the facility. The facility census was seven.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the afternoon of 02/24/15, showed there was no documentation of annual testing of the battery-powered emergency lighting units.

During an interview on 02/25/15 at 8:37 AM, Staff LL, Director Plant Operations, stated that staff had not been conducting a 1 1/2 hour annual test of the battery-powered emergency lighting units.

Section 7.9.3 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours.

Based on document review and interview the facility failed to conduct all required inspections of the sprinkler system throughout the year. This deficient practice affects all occupants in the facility. The facility census was seven.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the afternoon of 02/24/15, showed an outside contractor had conducted an annual certification inspection of the sprinkler system on 07/15/14. There was no documentation showing quarterly inspections had been conducted prior to the annual certification inspection nor after the inspection.

During an interview on 02/25/15 at 8:35 AM, Staff LL, Director of Plant Operations, stated that quarterly inspections of the sprinkler system were not being conducted.

Section 5.1 of the National Fire Protection Association, (NFPA 25) states the minimum requirements for the routine inspections, testing, and maintenance of sprinkler systems.