HospitalInspections.org

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 18.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, during a documentation review and interview with the Maintenance Supervisor (RH), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 18, sec 18.2.9.1.


This was confirmed by the Maintenance Supervisor (RH).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, during a documentation review and interview with the Maintenance Supervisor (RH), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 19, sec 19.2.9.1.


This was confirmed by the Maintenance Supervisor (RH).

Based on observations, the facility has failed to properly install a smoke detectors that are part of the buildings the fire alarm system. This deficient practice could affect the safety all patients, staff and visitors in the event the alarm system failed activate properly and quickly.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, observations reveled that the several smoke detectors throughout the facility were located within 36 inches of heating, ventilation and air conditioning (HVAC) supply diffusers.


This was confirmed by the Maintenance Supervisor (RH).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all patients, visitors, and staff.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, a review of the facility's available fire alarm test documentation revealed that the facility failed to conducted the required sensitivity test of each smoke detector.


This was confirmed by the Maintenance Supervisor (RH).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 18.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, a review of documentation and interview with the facility Maintenance Supervisor (RH), revealed the facility failed to provide documentation for any of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This was confirmed by the Maintenance Supervisor (RH).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, a review of documentation and interview with the facility Maintenance Supervisor (RH), revealed the facility failed to provide documentation for any of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This was confirmed by the Maintenance Supervisor (RH).

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 10:00 AM and 5:00 PM on 9/1/10, it was revealed during the review of facility fire and smoke damper test and inspection documentation and confirmed by interview with the Maintenance Supervisor (RH), that the facility failed to provide documentation that the fire and smoke dampers had been tested/inspected within the last 4 years in accordance with NFPA 90(99) section 3-4.7.


This was confirmed by the Maintenance Supervisor (RH).

Based on documentation review and observations, it was determined that the facility has failed to ensure that 1 of 2 of required test/inspections of the fire suppression system protecting the kitchen cooking appliances has been completed. NFPA 96 requires that the system be inspected and maintained every 6 months. This deficient practice could affect all patients, staff and visitors.

Findings Include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, during the review of the available hood suppression system test reports and observations made of the hood systems inspection tags revealed that the facility failed to ensure that the hood suppression system has been inspected every 6 months. the last inspection was completed on 1/8/10 and there were no other prior reports available at the time of the inspection.

This was confirmed by the Maintenance Supervisor (RH).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 18.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, during a documentation review and interview with the Maintenance Supervisor (RH), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 18, sec 18.2.9.1.


This was confirmed by the Maintenance Supervisor (RH).

Based on an interview with staff, the facility has failed to ensure that emergency lighting has been tested in accordance with NFPA LSC (00) Section 7.9, 19.2.9.1. This deficient practice could affect all patients, staff and visitors in the event of an emergency evacuation during a power outage.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, during a documentation review and interview with the Maintenance Supervisor (RH), it was revealed that there was no documentation of monthly 30 second testing, and the annual 1 1/2 hour testing for all of the battery powered emergency lights throughout the facility per NFPA 101, 2000 Edition Chapter 19, sec 19.2.9.1.


This was confirmed by the Maintenance Supervisor (RH).

Based on observations, the facility has failed to properly install a smoke detectors that are part of the buildings the fire alarm system. This deficient practice could affect the safety all patients, staff and visitors in the event the alarm system failed activate properly and quickly.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, observations reveled that the several smoke detectors throughout the facility were located within 36 inches of heating, ventilation and air conditioning (HVAC) supply diffusers.


This was confirmed by the Maintenance Supervisor (RH).

Based on interview and review of available documentation, the facility has not been conducting sensitivity testing of the smoke detectors on the fire alarm system in accordance with NFPA 72 (99), Sec. 7-3.2.1. This deficient practice could affect all patients, visitors, and staff.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, a review of the facility's available fire alarm test documentation revealed that the facility failed to conducted the required sensitivity test of each smoke detector.


This was confirmed by the Maintenance Supervisor (RH).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 18.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, a review of documentation and interview with the facility Maintenance Supervisor (RH), revealed the facility failed to provide documentation for any of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This was confirmed by the Maintenance Supervisor (RH).

Based on documentation review and interview with staff, the facility has failed to properly inspect and maintain the automatic sprinkler system in accordance with NFPA 101 LSC (00) section 19.7.6, 4.6.12. This deficient practice does not ensure that the fire sprinkler system is functioning properly and is fully operational in the event of a fire and could negatively affect all patients, staff and visitors.

Findings include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, a review of documentation and interview with the facility Maintenance Supervisor (RH), revealed the facility failed to provide documentation for any of the quarterly fire sprinkler flow tests inspections required by NFPA 13(99) and NFPA 25(98).


This was confirmed by the Maintenance Supervisor (RH).

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 10:00 AM and 5:00 PM on 9/1/10, it was revealed during the review of facility fire and smoke damper test and inspection documentation and confirmed by interview with the Maintenance Supervisor (RH), that the facility failed to provide documentation that the fire and smoke dampers had been tested/inspected within the last 4 years in accordance with NFPA 90(99) section 3-4.7.


This was confirmed by the Maintenance Supervisor (RH).

Based on documentation review and observations, it was determined that the facility has failed to ensure that 1 of 2 of required test/inspections of the fire suppression system protecting the kitchen cooking appliances has been completed. NFPA 96 requires that the system be inspected and maintained every 6 months. This deficient practice could affect all patients, staff and visitors.

Findings Include:

On facility tour between 10:00 AM and 5:00 PM on 9/1/10, during the review of the available hood suppression system test reports and observations made of the hood systems inspection tags revealed that the facility failed to ensure that the hood suppression system has been inspected every 6 months. the last inspection was completed on 1/8/10 and there were no other prior reports available at the time of the inspection.

This was confirmed by the Maintenance Supervisor (RH).