HospitalInspections.org

Degraff, Douglas P.
Based upon a review of the facilitity AFA testing records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility has failed to maintain smoke detectors in accordance with the requirements of the National Fire Alarm Code (NFPA 72). The facility has failed to conduct sensitivity testing of smoke detectors as required (Chapter 10). This could allow for a device to initiate nuisance alarms or failure of a device to initiate the fire alarm causing a delay in the reporting of a fire, putting patients, visitors and staff at risk. These findings were acknowledged by the Maintenance Manager.

The findings include but are not limited to:

There is no documentation or knowledge that sensitivity of smoke detectors has been tested in the last 5 years.

During the post survey conducted 11/17/2014 at 1530, staff interview with the Maintenance Manager reveals testing has not been completed.

Based upon a review of the facility fire drill records and staff interview with the Maintenance Manager during the record review portion of the facility survey of 09/09/2014, between the hours of 1015 and 1115, it was discovered that the facility is out of compliance with NFPA 96. This could result in failure of the kitchen hood suppression system to function properly, putting staff at risk. This finding was acknowledged by the Maintenance Manager.

The deficiency is as follows:

1. Documentation shows the system was inspected by Cascade 03/14 and 09/14 documenting the gas shut-off is not functioning, but there is no record of repairs per NFPA 96.


During the post survey conducted 11/17/2014 at 1530, staff interview with the Maintenance Manager reveals the test report is stated to be inaccurate; the shut-off is functional, but is reporting as a pull station to the FAP. There is no supporting documentation available at this time.

During the survey tour of 09/09/2014, between the hours of 1115 and 1215, while accompanied by the Maintenance Manager, through observation and staff interview, it was discovered that the facility failed to maintain their emergency generator in accordance with the requirements of National Fire Protection Association (NFPA) Standard 110. This could compromise the ability of the emergency power supply to operate in the event of a power outage. These findings were acknowledged by the Maintenance Manager.

The findings are as follows:
1. Generator is lacking a Remote Stop Switch (per NFPA 110 3-5.5.6)

During the post survey conducted 11/17/2014 at 1600, staff interview with the Maintenance Manager and Safety Officer reveals the generator remote stop switch has not yet been ordered.