HospitalInspections.org

Based upon record review and staff interviews on 07/19/2018 during the review of facility documentation between approximately 1030 and 1130 hours, the facility has failed to maintain the fire alarm system as required by NFPA 72. This could result in the failure of the fire alarm system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

- The facility was unable to produce documentation for the Fire Alarm System sensitivity report.

NFPA 72 - 14.4.4.3.1 Sensitivity shall be checked within 1 year after installation.

NFPA 72 - 14.4.4.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.4.3.3.

NFPA 72 - 14.4.4.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.4.3.3.


The above was discussed and acknowledged by the facilities Director who said that he was unaware of where the sensitivity report was.

Based upon observations and staff interviews on 07/19/2018 during the physical tour of the facility between approximately 1130 and 1500, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70. This could result in an electrical hazard due to misuse, endangering the patients, staff and/or visitors within the facility.


The findings include, but are not limited to:

- There was an extension cord plugged into I.T. Equipment in Server room #2EH2.

- There was a power strip plugged into another power strip in the Radiology Reading Room. Corrected at inspection.


The above was discussed and acknowledged by the facilities director who said they had not previously observed the power strips or extension cord.