HospitalInspections.org

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 10:30 PM and 3:30 PM on 8/25/10, the review of the fire drill documentation for the past 12 months (August 2009 to July 2010) revealed, that the facility failed to conduct a fire drill.



This was confirmed by the Maintenance Supervisor (TS).

Based on documentation review, the fire/smoke damper system has not been maintained in accordance with the requirements of NFPA 90(99) section 3-4.7. This deficient practice does not ensure the proper operation of the fire/smoke dampers and could allow smoke migration to negatively affect all patients, staff and visitors in the event of a fire.


Findings include:

On facility tour between 10:30 PM and 3:30 PM on 8/25/10, it was revealed during the review of facility fire and smoke damper test and inspection documentation and confirmed by interview with the Maintenance Supervisor (TS), that the facility failed to provide documentation that the fire and smoke dampers had been tested/inspected within the last 6 years in accordance with NFPA 90(99) section 3-4.7.


This was confirmed by the Maintenance Supervisor (TS).

This STANDARD is not met as evidenced by:

Based on documentation review and staff interview, the facility failed to assure fire drills were conducted once per shift for all staff under varying times and conditions as required by 2000 NFPA 101, Section 19.7.1.2.

Findings include:

On facility tour between 10:30 PM and 3:30 PM on 8/25/10, the review of the fire drill documentation for the past 12 months (August 2009 to July 2010) revealed, that the facility failed to conduct a fire drill.



This was confirmed by the Maintenance Supervisor (TS).

Based on documentation review, the fire/smoke damper system has not been maintained in accordance with the requirements of NFPA 90(99) section 3-4.7. This deficient practice does not ensure the proper operation of the fire/smoke dampers and could allow smoke migration to negatively affect all patients, staff and visitors in the event of a fire.


Findings include:

On facility tour between 10:30 PM and 3:30 PM on 8/25/10, it was revealed during the review of facility fire and smoke damper test and inspection documentation and confirmed by interview with the Maintenance Supervisor (TS), that the facility failed to provide documentation that the fire and smoke dampers had been tested/inspected within the last 6 years in accordance with NFPA 90(99) section 3-4.7.


This was confirmed by the Maintenance Supervisor (TS).