HospitalInspections.org

Based on document review and interview the facility failed to document an annual 90 minute test for the required emergency lighting units. This deficient practice affects all occupants in the facility. The facility census was 11.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the morning of 08/25/15, showed there was no documentation of a 90 minute annual testing of the battery-powered emergency lighting units.

During an interview on 08/26/15 at 10:20 AM, Staff JJ, Director of Plant Operations, stated that staff had not been conducting and documenting a 90 minute 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 for not less than 1 1/2 hours.

Based on record review and interview the facility failed to conduct fire drills at various times during the day and evening shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 11.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the afternoon of 08/25/15, showed four of four fire drills for the day shift, 7:00 AM to 3:00 PM, and three of four fire drills for the evening shift, 3:00 PM to 11:00 PM, were conducted within one hour of the previous drill on that shift.

The fire drills for the day shift were conducted at the following times:
-10/28/14 at 10:43 AM
-01/27/15 at 10:20 AM
-04/28/15 at 10:10 AM
-07/28/15 at 10:15 AM

The fire drills for the evening shift were conducted at the following times:
-08/07/14 at 8:30 PM
-11/26/14 at 8:00 PM
-02/24/15 at 8:30 PM

During an interview on 08/26/15 at 11:20 AM, Staff JJ, Director of Plant Operations, confirmed the fire drills for the day and evening shifts has been conducted during the same hour of the day.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.
Section A.19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be scheduled on a random bases to ensure that personnel in health care falsities are drilled no less than once in each 3 month period.

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 11.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the morning of 08/25/15, showed an outside contractor had conducted an annual certification inspection of the sprinkler system on 08/28/14. There was no documentation showing quarterly inspections had been conducted after the annual certification inspection of August 2014.

During an interview on 08/26/15 at 11:21 AM, Staff JJ, Director of Plant Operations, confirmed that quarterly inspections of the sprinkler system were not being conducted.

Section 2.1 and table 2.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the weekly, monthly, quarterly and annual routine inspections, testing, and maintenance of sprinkler systems.

Based on record review and interview the facility failed to restrict the use of portable heaters to non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. This deficient practice affects all occupants of the facility. The facility census was 11.

Findings included:

Record review of the facility's policy "Use of Portable Comfort Heaters," dated 04/01/08 showed portable comfort heaters shall be limited to devices approved by the Safety Committee and portable comfort heaters shall not be placed in close proximity to combustible materials.

During an interview on 08/26/15 at 11:22 AM, Staff JJ, Director of Plant Operations, confirmed the current policy did not specifically exclude the use of portable heating devices from use in patient rooms.

Section 19.7.8 of the National Fire Protection Association (NFPA 101) states portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F.

Based on document review and interview the facility failed to document an annual 90 minute test for the required emergency lighting units. This deficient practice affects all occupants in the facility. The facility census was 11.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the morning of 08/25/15, showed there was no documentation of a 90 minute annual testing of the battery-powered emergency lighting units.

During an interview on 08/26/15 at 10:20 AM, Staff JJ, Director of Plant Operations, stated that staff had not been conducting and documenting a 90 minute 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 for not less than 1 1/2 hours.

Based on record review and interview the facility failed to conduct fire drills at various times during the day and evening shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 11.

Findings included:

Review of the fire drill records for the previous 12 months, conducted on the afternoon of 08/25/15, showed four of four fire drills for the day shift, 7:00 AM to 3:00 PM, and three of four fire drills for the evening shift, 3:00 PM to 11:00 PM, were conducted within one hour of the previous drill on that shift.

The fire drills for the day shift were conducted at the following times:
-10/28/14 at 10:43 AM
-01/27/15 at 10:20 AM
-04/28/15 at 10:10 AM
-07/28/15 at 10:15 AM

The fire drills for the evening shift were conducted at the following times:
-08/07/14 at 8:30 PM
-11/26/14 at 8:00 PM
-02/24/15 at 8:30 PM

During an interview on 08/26/15 at 11:20 AM, Staff JJ, Director of Plant Operations, confirmed the fire drills for the day and evening shifts has been conducted during the same hour of the day.

Section 19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions.
Section A.19.7.1.2 of the National Fire Protection Association (NFPA 101) states drills shall be scheduled on a random bases to ensure that personnel in health care falsities are drilled no less than once in each 3 month period.

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 11.

Findings included:

Review of the facility sprinkler inspection documents, conducted on the morning of 08/25/15, showed an outside contractor had conducted an annual certification inspection of the sprinkler system on 08/28/14. There was no documentation showing quarterly inspections had been conducted after the annual certification inspection of August 2014.

During an interview on 08/26/15 at 11:21 AM, Staff JJ, Director of Plant Operations, confirmed that quarterly inspections of the sprinkler system were not being conducted.

Section 2.1 and table 2.1 of the National Fire Protection Association (NFPA 25) states the minimum requirements for the weekly, monthly, quarterly and annual routine inspections, testing, and maintenance of sprinkler systems.

Based on record review and interview the facility failed to restrict the use of portable heaters to non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. This deficient practice affects all occupants of the facility. The facility census was 11.

Findings included:

Record review of the facility's policy "Use of Portable Comfort Heaters," dated 04/01/08 showed portable comfort heaters shall be limited to devices approved by the Safety Committee and portable comfort heaters shall not be placed in close proximity to combustible materials.

During an interview on 08/26/15 at 11:22 AM, Staff JJ, Director of Plant Operations, confirmed the current policy did not specifically exclude the use of portable heating devices from use in patient rooms.

Section 19.7.8 of the National Fire Protection Association (NFPA 101) states portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F.