HospitalInspections.org

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Support Services Manager that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for the universe entire building. This resulted in the potential for system failure during fire emergencies (LSC 19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25).

Findings include:

On 6/27/2023, at 10:37 am. the fire sprinkler in the Kitchen Cooler was loaded which could insulate the thermal element, thus reducing the heat transferring to it and affecting the release time.

Surveyor was accompanied by the Vice President, Support Services Manager and Quality Manager who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Support Services Manager that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for universe all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 10).

Findings include:

1. On 6/27/2023, at 10:33 am, the portable fire extinguisher in the Kitchen Area was blocked by a garbage can and not readily accessible.

1. On 6/27/2023, at 11:34, monthly inspection for the fire extinguishers in the MRI Trailer were not being completed by a third party vendor or by facility staff as evidence of inspection tags on the fire extinguishers were not filled out.

Surveyor was accompanied by the Vice President, Support Services Manager, and Quality Manager who acknowledged the existence of these conditions.