HospitalInspections.org

Based on record review, observation and staff interview during the course of the survey conducted on August 16, 2022, it was determined the facility failed to maintain the automatic fire sprinkler system in accordance with NFPA 101, section 18.3.5.1, 9.7, 9.7.5, NFPA 25 and NFPA 13. The following evidenced this:

1) Missing escutcheon plate in PT Belongings 874

The fire sprinkler deficiencies have the potential to affect all room occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.

NFPA 101 Life Safety Code Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Based on record review and staff interview during the survey on August 16, 2022, it was determined the facility failed to conduct fire drills in accordance with NFPA 101, 19.7.1. The following evidenced this:

1) Missing fire drills for 2nd shift 2nd quarter and 2nd shift 4th quarter.

The fire drill deficiencies have the potential to affect all occupants, who might include staff, residents and visitors within all smoke compartments; items were discussed during the survey and again during the exit conference.

Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

Through observation and record review during the survey on August 16, 2022, it was determined that the facility failed to maintain Electrical Systems in accordance with Life Safety Code, NFPA 70, and NFPA 99 Ch 6.

1) Life Safety electrical panel has vending machine on it.

The maintenance director acknowledged the deficiency during the facility tour.

This deficiency has the potential to affect all occupants, who might include staff, residents and visitors within associated smoke compartments; items were discussed during the survey and again during the exit conference.