HospitalInspections.org

Based on record review, the facility failed to ensure fire alarm systems were maintained in accordance with NFPA 72. Failure to conduct sensitivity testing has the potential to hinder system performance as designed. This deficient practice affected patients, staff and visitors on the date of the survey.

Findings include:

During review of provided maintenance and inspection records conducted on 3/12/25 from 9:00 AM - 12:00 PM, no documentation was available demonstrating a sensitivity testing was conducted on the addressable fire alarm/smoke detection system.

Actual NFPA standard:

14.4.5.3% In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through
14.4.5.3.7.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

14.6 Records.
14.6.2.4% A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representati

Based on record review and interview, the facility failed to ensure piped medical gas systems were maintained in accordance with NFPA 99. Failure to test all outlets and verify pressure, flow and concentration, along with valve conditions of gauge readings, labeling and leakage, has the potential to hinder system performance as designed. This deficient practice affected those patients, staff and visitors on the date of the survey.

Findings include:

During review of the provided annual piped medical gas inspection report conducted on 3/12/25 from 9:30 AM - 12:00 PM, records identified five (5) patient rooms that were not tested due to conditions preventing access at that time. Further review did not establish any further testing was performed at these locations when they became available.

Interview of the Engineering Director at approximately 1:00 PM, established he was not aware that all outlets had to be tested at least annually, and that a revisit or other means was required to ensure these locations were included.

Actual NFPA standard:

NFPA 99

5.1.14.2.3 Inspection and Testing Operations.
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through
5.1.15 shall be inspected or tested as part of the maintenance program as follows:
(1)%Medical air source, as follows:
(a) Room temperature
(b) Shaft seal condition
(c) Filter condition
(d) Presence of hydrocarbons
(e) Room ventilation
(f) Water quality, if so equipped
(g) Intake location
(h) Carbon monoxide monitor calibration
(i) Air purity
(j) Dew point
(2)%Medical vacuum source - exhaust location
(3) WAGD source - exhaust location
(4)%Instrument air source - filter condition
(5)%Manifold sources (including systems complying with
5.1.3.5.10, 5

Based on record review and observation, the facility failed to ensure electrical installations were maintained and tested in accordance with NFPA 99. Failure to test those required cord and plug installations at required intervals and ensure maintenance of their installations, has the potential to hinder system performance as designed. This deficient practice affected staff and visitors on the date of the survey.

Findings include:

During review of provided maintenance and inspection records conducted on 3/12/25 from 9:30 AM - 12:00 PM, no documentation was available to establish a continual maintenance and testing procedure, biomed testing program, or verifying performance data for installation and usage of installed UL 1363A relocatable power taps (RPTs), .

During the facility tour conducted on 3/12/25 from 1:00 - 3:00 PM, observation of the mobile monitoring equipment in the Emergency Department, identified a vitals monitoring unit with a UL 1363A RPT attached to the stand, with two (2) open outlets.

Actual NFPA standard:

NFPA 99

Chapter 6 Electrical Systems

6.3.2.2.8.5 In existing construction, the requirements of 6.3.2.2.8.1 shall not be required when a written inspection procedure, acceptable to the authority having jurisdiction, is continuously
enforced by a designated individual at the hospital to indicate that equipment grounding conductors for 120-V, singlephase, 15-A and 20-A receptacles; equipment connected by cord
and plug; and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and the applicable performance requirements of this chapter.
(A) The procedure shall include electrical continuity tests of all required equipment, grounding conductors, and their connections.
(B) Fixed recep