HospitalInspections.org

Based on Utilities Management Manual review and interview it was determined in the year 2010 to the current date in 2011 the facility failed to perform the required 30 second monthly test and the required annual 1 ? hour test on 6 of 6 Emergency Battery Powered Light fixtures as required by NFPA 101 Section 7.9.3. Failure to perform the required testing of the emergency light fixtures prevents the facility from ensuring the reliability of the emergency lights to illuminate the area in the event of a loss of normal power. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 15 patients on 03/16/11. The findings follow:

A. Review of the Utilities Management Manual on 03/16/11 at 1005 revealed there was no documentation of four of six emergency battery powered lights receiving monthly testing in November and December 2010 or in January, February, and March in 2011. There was no documentation of two of six emergency battery powered lights receiving monthly testing in July, August, September, October, November, and December in 2010 or in January, February, or March in 2011. There was no documentation of annual testing of 6 of 6 emergency battery powered lights.
B. In an interview conducted on 0316/11 at 1040 the Director of Maintenance stated the required testing was not documented and verified there was no further inspection documentation available for review.

(Reference NFPA 101 Section 7.9.3)

Based on Fire Prevention Management Manual review and interview it was determined the facility failed to inspect 13 of 13 fire dampers in the facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 15 patients on 03/16/11. The findings follow:

A. Review of the Fire Prevention Management Manual on 03/16/11 at 1255 revealed the most recent documentation of fire damper inspection was dated July 2, 2004.
B. In an interview conducted on 03/16/11 at 1430, the Director of Maintenance stated the dampers had not been inspected since 2004 and verified there was no further documentation of damper inspection available for review.
(Reference NFPA 90A, Section 3-4.7)

Based on Fire Prevention Management Manual review, observation, and interview it was determined the kitchen hood fire suppression system was impaired to provide complete coverage over kitchen equipment due to an insufficient number of spray nozzles since 01/22/10. Incomplete coverage of the fire suppression system has the potential to prevent the system from fully and completely extinguishing a fire under the kitchen hood, which could spread fire and smoke throughout the facility and damage cooking equipment required to prepare meals for patients. The failed practice had the potential to affect all patients, visitors, and kitchen staff. The facility had a census of 15 patients on 03/16/11. The findings follow:

A. On 03/16/11 at 1330, review of kitchen hood fire suppression system inspection report dated January 22, 2010, revealed the inspection contractor noted the need to modify the nozzle coverage because an appliance had been added. Work order from the inspection contractor read "System is impaired there is no protection over new 6 burner range. This needs to be fixed in order to meet DOT requirements and county codes."
B. Observation of the kitchen hood suppression system on 03/17/11 at 0900 with the Director of Maintenance revealed the system had a red impairment tag dated 01/12/11.C. In an interview conducted on 03/17/11 at 0930 the Director of Maintenance stated an additional 6 burner stove was added and the inspection contractor told him an additional nozzle was needed to cover the new stove. He stated he was aware of the impairment and that it had not been corrected.

Based on Utilities Management Manual review and interview it was determined in the year 2010 to the current date in 2011 the facility failed to perform the required 30 second monthly test and the required annual 1 ? hour test on 6 of 6 Emergency Battery Powered Light fixtures as required by NFPA 101 Section 7.9.3. Failure to perform the required testing of the emergency light fixtures prevents the facility from ensuring the reliability of the emergency lights to illuminate the area in the event of a loss of normal power. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 15 patients on 03/16/11. The findings follow:

A. Review of the Utilities Management Manual on 03/16/11 at 1005 revealed there was no documentation of four of six emergency battery powered lights receiving monthly testing in November and December 2010 or in January, February, and March in 2011. There was no documentation of two of six emergency battery powered lights receiving monthly testing in July, August, September, October, November, and December in 2010 or in January, February, or March in 2011. There was no documentation of annual testing of 6 of 6 emergency battery powered lights.
B. In an interview conducted on 0316/11 at 1040 the Director of Maintenance stated the required testing was not documented and verified there was no further inspection documentation available for review.

(Reference NFPA 101 Section 7.9.3)

Based on Fire Prevention Management Manual review and interview it was determined the facility failed to inspect 13 of 13 fire dampers in the facility every four years (or every six years under CMS Waiver per S&C Letter 10-04-LSC dated October 30, 2009). Failure to inspect fire dampers prevents the facility from ensuring the reliability of the dampers to close in the event of a fire or smoke event. The failed practice had the potential to affect all patients, staff, and visitors. The facility had a census of 15 patients on 03/16/11. The findings follow:

A. Review of the Fire Prevention Management Manual on 03/16/11 at 1255 revealed the most recent documentation of fire damper inspection was dated July 2, 2004.
B. In an interview conducted on 03/16/11 at 1430, the Director of Maintenance stated the dampers had not been inspected since 2004 and verified there was no further documentation of damper inspection available for review.
(Reference NFPA 90A, Section 3-4.7)

Based on Fire Prevention Management Manual review, observation, and interview it was determined the kitchen hood fire suppression system was impaired to provide complete coverage over kitchen equipment due to an insufficient number of spray nozzles since 01/22/10. Incomplete coverage of the fire suppression system has the potential to prevent the system from fully and completely extinguishing a fire under the kitchen hood, which could spread fire and smoke throughout the facility and damage cooking equipment required to prepare meals for patients. The failed practice had the potential to affect all patients, visitors, and kitchen staff. The facility had a census of 15 patients on 03/16/11. The findings follow:

A. On 03/16/11 at 1330, review of kitchen hood fire suppression system inspection report dated January 22, 2010, revealed the inspection contractor noted the need to modify the nozzle coverage because an appliance had been added. Work order from the inspection contractor read "System is impaired there is no protection over new 6 burner range. This needs to be fixed in order to meet DOT requirements and county codes."
B. Observation of the kitchen hood suppression system on 03/17/11 at 0900 with the Director of Maintenance revealed the system had a red impairment tag dated 01/12/11.C. In an interview conducted on 03/17/11 at 0930 the Director of Maintenance stated an additional 6 burner stove was added and the inspection contractor told him an additional nozzle was needed to cover the new stove. He stated he was aware of the impairment and that it had not been corrected.