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Tag No.: K0353
Based on observation and staff interview it was determined the facility failed to maintain the sprinkler piping free from loading in accordance with National Fire Protection Association (NFPA) 25 and NFPA 13. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. Facility Census 7.
Findings include:
1. On 8/29/17 at approximately 11:00 a.m., an inspection above the hallway suspended ceiling near the entrance to the Central Sterile area revealed there was low voltage wiring draped across the sprinkler piping.
2. On 8/29/17 at approximately 11:10 a.m., an inspection above the hallway suspended ceiling near the entrance to Mammography revealed there was low voltage wiring and a three (3) inch electrical conduit laying on the sprinkler piping.
3. On 8/29/17 at approximately 11:15 a.m., an inspection above the hallway suspended ceiling near the entrance to the pharmacy revealed there was low voltage wiring draped across the sprinkler piping.
4. On 8/29/17 at approximately 11:20 a.m., an inspection above the hallway suspended ceiling near the entrance to the short hall revealed there was low voltage wiring draped across the sprinkler piping.
5. On 8/29/17 at approximately 11:30 a.m., an inspection above the hallway suspended ceiling near Room 108 revealed there was low voltage wiring draped across the sprinkler piping.
6. On 8/29/17 at approximately 11:40 a.m., an inspection above the hallway suspended ceiling near Room 110 revealed there was low voltage wiring and a three (3) quarter inch electrical conduit laying on the sprinkler piping.
7. On 8/29/17 at approximately 11:45 a.m., an inspection above the hallway suspended ceiling near the entrance to the outpatient nurse office revealed there was low voltage wiring draped across the sprinkler piping.
8. On 8/29/17 at approximately 11:50 a.m., an inspection above the hallway suspended ceiling entrance to a near business office revealed there was low voltage wiring draped across the sprinkler piping.
9. The above findings were discussed with the maintenance staff upon discovery who agreed to remove the items from the sprinkler system.
Tag No.: K0712
Based on document review and staff interview it was determined the facility failed to ensure that fire drills are held at unexpected times and under varying conditions, at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Facility census 7.
Findings include:
1. On 08/28/17 at approximately 1:30 p.m., document review revealed that fire drills for the first shift were held at: No fire drill for the first quarter; second quarter - 2:53 p.m.; third quarter - 3:05 p.m.; and, fourth quarter - 3:54 p.m.
2. On 08/28/17 at approximately 1:30 p.m., document review revealed that fire drills for the second shift drills were held at: first quarter - 3:23 p.m.; second quarter - 3:31 p.m.; third quarter - 3:05 p.m.; and, fourth quarter - 3:54 p.m.
3. On 08/28/17 at approximately 1:30 p.m., document review revealed that fire drills for the third shift drills were held at: first quarter - 6:44 a.m.; second quarter - 6:37 a.m.; third quarter - 6:37 a.m.; and, fourth quarter - 6:37 a.m.
4. The above findings were verified with the maintenance staff at the time of discovery.
Tag No.: K0914
Based on document review and staff interview it was determined the facility failed to maintain electrical systems in accordance with National Fire Protection Association (NFPA) 99. This deficient practice has the potential to affect all patients, staff and visitors in the facility. Facility census 7.
1. On 08/28/17 at approximately 2:30 p.m., document review revealed the facility failed to test Line isolation monitors (LIMs) for the previous twelve (12) months.
2. The above findings were verified with the maintenance staff at the time of discovery.