HospitalInspections.org

Based on observation, record review and staff interview it was determined the facility failed to meet the applicable provisions of the 2012 Life Safety Code edition of the National Fire Protection Association (NFPA) 101 and NFPA 99. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. Facility census 7.

Findings include:

1. In reference to Life Safety Code citation K 914 it was determined the facility failed to maintain Line isolation monitors in accordance with NFPA 99.

2. In reference to Life Safety Code citation K 353 it was determined the facility failed to maintain sprinkler system in accordance with NFPA 99 for loading of sprinkler piping.

3. In reference to Life Safety Code citation K 712 it was determined the facility failed to conduct fire drills at unexpected times and under varying conditions.

4. The above findings were discussed with the maintenance staff upon discovery and they agreed with the findings.