HospitalInspections.org

Based upon staff interview and a review of records, the facility fails to assure that fire drills are held at unexpected times under varying conditions. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all staff, visitors and patients in the event of an emergency; affecting 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 it is observed that the times that the Fire Drills are being conducted are not at varied times during the 2 shifts:
1) drills for 1st shift, 3 of 4 drills were conducted between 9:50 AM and 11:00 AM;
2) drills for 2nd shift, 3 of 4 were conducted between 5:30 PM and 5:52 PM;
Maintenance Staff A was present at time of survey and during the review of records and acknowledged the deficiencies.
NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation, staff interview and record review, the facility did not assure that the fire alarm system is in accordance with NFPA 72 and chapter 9.6.4 of NFPA 101 by ensuring that an approved central station appropriately and continuously monitors the fire alarm and summons an organized fire department upon receipt of a fire alarm transmission. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 at 10:00 AM it is observed that the building fire alarm is not monitored by a UL approved central station. The alarm system is connected to the local county dispatch center via direct line.
Maintenance Staff A was present during the interview and record review and acknowledged the deficiency. There is current a wavier that has been accepted by the KSFMO on this deficiency, the waiver is a yearly waiver and has to be applied for yearly.
NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4

Based on observation, record review and staff interview, the facility failed to provide window treatments that are flame resistant in accordance with provisions of NFPA 101, 10.3. These deficient practice would allow curtains and blinds to propagate and spread fire and smoke, affecting all residents, visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 it is observed in the two Birthing Rooms there are curtains that are not tagged as being flame retardant.
Maintenance Staff A was present and acknowledged the deficiencies.
NFPA Standard: Draperies, curtains and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.1

Based on observation and staff interview, the facility failed to maintain electrical wiring that meets 1999 NFPA 72 guidelines. This deficient practice potentially affects all patients, visitors and staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 it is observed that:
1) above the corridor ceiling and clinic door near the Medication Room there is an open 110 volt electrical junction box in the conduit serving the lighting and power systems.
2) in the Post Operation Recovery Room there is a 6 tap surge protector device plugged into a duplex wall outlet being used to power: a ECG Patient Monitor (Medical Equipment), a computer and a plug strip that is powering a small refrigerator (Motorized equipment), a microwave oven and a toaster.
Maintenance Staff A was present and acknowledged the deficiencies.
NFPA Standard: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) thru (d) and as summarized in Section 210-24. A 15 or 20 ampere branch circuit shall be permitted to supply lighting units or other utilization equipment or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23

NFPA Standard: Extensions shall consist of a continuous unbroken length of assembly, without splices, and without exposed conductors between fittings. Taps shall be permitted where approved fittings and boxes completely cover the tap connections that are used. 1999 NFPA 70, Artical 382-56

Based upon staff interview and a review of records, the facility fails to assure that fire drills are held at unexpected times under varying conditions. This deficient practice has the potential of affecting staff preparation and experience in providing for the protection of all staff, visitors and patients in the event of an emergency; affecting 8 of 8 smoke zones. The facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 it is observed that the times that the Fire Drills are being conducted are not at varied times during the 2 shifts:
1) drills for 1st shift, 3 of 4 drills were conducted between 9:50 AM and 11:00 AM;
2) drills for 2nd shift, 3 of 4 were conducted between 5:30 PM and 5:52 PM;
Maintenance Staff A was present at time of survey and during the review of records and acknowledged the deficiencies.
NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 19.7.1.2

Based on observation, staff interview and record review, the facility did not assure that the fire alarm system is in accordance with NFPA 72 and chapter 9.6.4 of NFPA 101 by ensuring that an approved central station appropriately and continuously monitors the fire alarm and summons an organized fire department upon receipt of a fire alarm transmission. This deficient practice affects all occupants of the building, including staff, visitors and residents. This facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 at 10:00 AM it is observed that the building fire alarm is not monitored by a UL approved central station. The alarm system is connected to the local county dispatch center via direct line.
Maintenance Staff A was present during the interview and record review and acknowledged the deficiency. There is current a wavier that has been accepted by the KSFMO on this deficiency, the waiver is a yearly waiver and has to be applied for yearly.
NFPA Standard: A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101 section 9.6.1.4

Based on observation, record review and staff interview, the facility failed to provide window treatments that are flame resistant in accordance with provisions of NFPA 101, 10.3. These deficient practice would allow curtains and blinds to propagate and spread fire and smoke, affecting all residents, visitors and staff in 1 of 8 smoke zones. The facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 it is observed in the two Birthing Rooms there are curtains that are not tagged as being flame retardant.
Maintenance Staff A was present and acknowledged the deficiencies.
NFPA Standard: Draperies, curtains and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.1

Based on observation and staff interview, the facility failed to maintain electrical wiring that meets 1999 NFPA 72 guidelines. This deficient practice potentially affects all patients, visitors and staff in 2 of 8 smoke zones. The facility has a capacity of 25 with a census of 9.
FINDINGS INCLUDE:
During the tour on 06/07/2012 it is observed that:
1) above the corridor ceiling and clinic door near the Medication Room there is an open 110 volt electrical junction box in the conduit serving the lighting and power systems.
2) in the Post Operation Recovery Room there is a 6 tap surge protector device plugged into a duplex wall outlet being used to power: a ECG Patient Monitor (Medical Equipment), a computer and a plug strip that is powering a small refrigerator (Motorized equipment), a microwave oven and a toaster.
Maintenance Staff A was present and acknowledged the deficiencies.
NFPA Standard: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) thru (d) and as summarized in Section 210-24. A 15 or 20 ampere branch circuit shall be permitted to supply lighting units or other utilization equipment or a combination of both. The rating of any one cord- and plug-connected utilization equipment shall not exceed 80 percent of the branch-circuit ampere rating. The total rating of utilization equipment fastened in place, other than lighting fixtures, shall not exceed 50 percent of the branch-circuit ampere rating where lighting units, cord- and plug-connected utilization equipment not fastened in place, or both, are also supplied. 1999 NFPA 70, 210-23

NFPA Standard: Extensions shall consist of a continuous unbroken length of assembly, without splices, and without exposed conductors between fittings. Taps shall be permitted where approved fittings and boxes completely cover the tap connections that are used. 1999 NFPA 70, Artical 382-56