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Based on record review and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to conduct a semi-annual fire alarm inspections of the devices. This affected 11 of 11 patients in two of two smoke compartments. This could result in a malfunction of the fire alarm system.

NFPA 101: Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72: National Fire Alarm and Signaling Code, 2010 Edition
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3.1 * Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.
Table 14.3.1
Frequencies-Semiannually
9. Initiating devices
13. Alarm notification appliances
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies
14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4 * A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)* Functional test of required sequence of operations
(10) Check of all smoke detectors

Findings:

During record review and interview with the Director of Facilities on 8/27/24, fire alarm system records were requested and reviewed.

At 11:00 a.m., the facility failed to provide a semi-annual FAS inspections record upon request. The report titled, "Fire Alarm Inspection Report" dated 8/19 to 8/20 of 2024, listed under "1st Floor East Wing (K1E)" showed 2 manual pull stations (By Elevator, 2M123), 27 smoke detectors (Corr. by Elevator, Nurse Station Corridor, Nurse Station at Elev, Meds RM, two in Nurse Station, Conf RM, Shower RM, Group RM, In Activity RM, Fire Doors East, Fire Doors West, Corr by RM 635, Corr by RM 631, In Room 626, In Room 628, In Room 630, In Room 632, In Room 634, In Room 636, In Room 638, In Room 637, In Room 635, In Room 633, In Room 631, In Room 629, In Room 627), and 8 duct detectors (Two In Activity RM, Corr by RM 626, In Soiled Linen Closet RM 156, In Closet by RM 625, In Room 625, Nurse Station, Corr Entrance to Wing) were last tested on 8/19/24. Upon interview, the Director of Facilities stated that the vendor was likely inspecting using different codes.

Based on record review and interview, the facility failed to maintain the smoke detectors. This was evidenced by the failure to provide a smoke detector sensitivity test. This affected 11 of 11 patients and two of two smoke compartments. This could result in a delay of notification in the event of smoke and fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.15* Protection of Fire Alarm System. In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s), notification appliance circuit power extenders, and supervising station transmitting equipment to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.
14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

Findings:

During record review and interview with the Director of Facilities on 8/27/24, the smoke detector sensitivity test records were requested.

At 2:41 p.m., the facility failed to provide records that a smoke detector sensitivity test was conducted. No prior sensitivity records for the unit were provided for review. Upon interview, the Director of Facilities stated that the missing sensitivity was likely due to a vendor error.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the failure to maintain the sprinkler system components. This affected 11 of 11 patients in one of two smoke compartments. This could result in the failure of the sprinkler system to operate.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7 unless otherwise permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
5.2.1 Sprinklers.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Findings:

During a tour of the facility and interview with the Director of Facilities on 8/26/24, the sprinkler heads were observed.

At 4:30 p.m., one of two sprinkler heads in Resident Room 627 was covered by an accumulation of foreign material. Upon interview, the Director of Facilities stated that the sprinkler head was likely overlooked.

Based on record review and interview, the facility failed to maintain the receptacles at patient bed locations. This was evidenced by no receptacles test records. This affected 11 of 11 patients and one of two smoke compartments. This could result in a delay in notification of a malfunctioning receptacle.

Findings:

During record review and interview with the Director of Facilities on 8/27/24, the receptacle testing records were requested and reviewed.

At 2:00 p.m., the facility failed to provide documentation indicating the hospital grade receptacles at patient bed locations were tested after the initial installation, replacement, or servicing of the devices. There were no prior receptacle test and interval defined by documented performance data provided for review. Upon interview, the Director of Facilities stated that the receptacles had not been cited on previous surveys.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by a power strip plugged into a power strip. This affected one of two smoke compartments in the Nurse Station's Conference room. This could result in the increased risk of an electrical fire.

Findings:

During a tour of the facility and interview with the Director of Facilities on 8/26/24, the electrical equipment was observed.

At 4:40 p.m., a white power strip was plugged into another white power strip in the Conference Room of the Nursing Station. The first power strip was powering the second power strip and a laptop charger. The second power strip was powering two walkies-talkies and a phone charger. Upon interview, the Director of Facilities stated that a vendor likely set up the electrical equipment.