HospitalInspections.org

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Based on record review and interview the facility failed to ensure quarterly sprinkler inspections had been completed by a qualified personnel in accordance with NFPA 25 as referenced by NFPA 101: 9.7.5. This failed practice placed all patients and residents (based on a census of 2 in acute care and 12 in LTC) at risk for exposure to smoke and/or fire environment related to an un-maintained fire suppression system. (Refer to reference tags as listed below) Findings:


Record review on 7/13/17 revealed no quarterly sprinkler inspections had been completed in the last 12 months.

During an interview on 7/13/17 the Facilities Manager confirmed quarterly sprinkler inspections had not been completed by a certified or other qualified person.


Code Reference

NFPA 101, 2012 Edition: 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, 2011 Edition: 4.1.1.2 Inspection, testing, and maintenance shall be performed
by personnel who have developed competence through training and experience.

NFPA 25, 2011 Edition: 5.1.1.2 Table 5.1.1.2 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.



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Based on record review and interview the facility failed to ensure fire drills were conducted quarterly in accordance with NFPA 101: 19.7.1.6. This deficient practice increased the risk of insufficient staff preparedness and reaction under various conditions. This failed practice placed all occupants in the facilities (based on a census of 2 in acute care and 12 in the LTC) at risk for a delay in response during a fire emergency. Findings:

Record review on 7/13/17 of the 2nd quarter fire drill in May revealed a drill was initiated at 5:45 pm and canceled due to high patient volume and resident needs.

During an interview on 7/13/17 the Biomed Technician stated the staff stated they could not participate due to the number of residents on fall risk in Long Term Care and the acute care staff was too busy.


Further review of the fire drills revealed no drill hand been completed 3rd quarter 2016.


Code Reference NFPA 101, 2012 edition

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency
action required under varied conditions.

4.7.4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.



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Based on record review and interview the facility failed to ensure: 1) items found to be non-compliant on a medical gas inspection had been corrected; 2) infractions identified during regular maintenance were corrected; 3) staff were competent to perform the maintenance inspections. This failed practice placed all residents (based on a census of 2 acute care patients and 12 LTC residents) at risk for inadequate functioning medical gas system. Findings:

Record review on 7/13/17 of the Medical Gas Systems inspection report, dated 1/26/16, revealed under definitions of violation ratings: "P-1 [violation] must be corrected immediately - patient safety risk" and a "P-3 [violation] shall be corrected at time of remodeling."

Further review of the inspection report revealed 7 "P-1 must be corrected immediately violations."

During an interview on 7/13/17 at 1:00 pm the Facility Manager confirmed the 7 high priority 1 (P-1) violations had not been corrected and had no documentation of correction for the addition citations on the inspection report dated 1/26/16.

NFPA Code Reference
5.1.14.2.3.1 General. The elements in 5.1.14.2.2.2 through
5.1.15 shall be inspected or tested as part of the maintenance program as follows: (refer to NFPA 99, 2010 for list)

99: 5.1.14.2.2.5 Qualifications. Persons maintaining these systems
shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:

(1) Training and certification through the health care facility
by which such persons are employed to work with specific
equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional
Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional
Qualification Standard for Medical Gas Systems Verifiers



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Based on observation, interview and record review the facility failed to ensure: 1) an annual maintenance of emergency generator was conducted; 2) the installation of a manual remote stop outside of the generator room; 3) a written schedule for routine maintenance and operational testing of the generator was established; and 4) provide documentation of training and competency of staff performing maintenance of the generator in accordance with NFPA 110 as referenced by NFPA 101:9.1.3.1. Findings:

Observation, during the LSC tour, on 7/13/17 with the Facility Manager revealed no remote stop located outside of the generator room.

During an interview on 7/13/17 at 11:45 am the Facility Manager stated no annual maintenance had been done on the generator, the generator had not had a certified mechanic inspection, and he had no certification for the maintenance of the generator.


Code Reference

NFPA 101, 2012

9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, 2010

5.6.5.6* All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.
NFPA 110: 2010

8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.

8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer


NFPA 99: 6.4.4.1.1.4 Inspection and Testing. Criteria, conditions, and personnel requirements shall be in accordance with 6.4.4.1.1.4(A) through 6.4.4.1.1.4(C) ...

(C) Test Personnel. The scheduled tests shall be conducted
by competent personnel to keep the machines ready to function
and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.