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SANFORD LUVERNE MEDICAL CENTER
No Description Available
Tag No.: K0054
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, pursuant to NFPA 72 National Fire Alarm Code (1999 edition) and NFPA 101 Life Safety Code (2000 edition), Chapter 9, Section 9.6.1.3. In a fire emergency, this deficient practice could adversely affect 25 of 25 patients, staff and visitors.
FINDINGS INCLUDE:
On 7/28/10 between 8:00 AM and 2:00 PM, during an interview with the assistant building engineer (HH), no documentation could be provided verifying the required sensitivity testing of each smoke detector within the facility had been performed within the past two years. This deficient practice was not in conformance with NFPA 72 (99), Chapter 7, Section 7-3.2.1.
No Description Available
Tag No.: K0062
NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically, and are in conformance with NFPA 101 (2000 edition), Chapter 19, Sections 19.3.5 and 19.7.6, and Chapter 9, Section 9.7 and NFPA 13 (1999 edition) and NFPA 25 (1998 edition).
FINDINGS INCLUDE:
On 7/28/10 between 8:00 AM and 2:00 PM, a review of the facility's annual inspection report of the building fire sprinkler system was made. This report was prepared by the facility's contract vendor and dated 7/22/09. The vendor noted that multiple fire sprinklers within the facility were improperly installed, yet no documentation could be provided verifying that subsequent repairs had been performed.
In a fire emergency, a deficient fire sprinkler system could adversely affect 25 of 25 patients, visitors and staff.
This finding was verified with the assistant building engineer [HH] at the time of discovery.
No Description Available
Tag No.: K0078
NFPA 101 (2000) LIFE SAFETY CODE SURVEY STANDARD - Anesthetizing locations shall be protected in accordance with NFPA 99 (1999 edition) Standard for Health Care Facilities, pursuant to NFPA 101 (2000) Chapter 19, Section 19.3.2.3.
FINDINGS INCLUDE:
On 7/28/10 between 8:00 AM and 2:00 PM, while accompanied by the surgical supervisor and the assistant building engineer [HH], an inspection of the facility's two (2) Operating Rooms was made. The Operating Rooms are wet locations where general anesthesia is administered, and no line isolation monitors could not be located. Further, GFCI circuitry could not be visually confirmed. In a discussion with staff, it could not be verified that a circuit interruption could be tolerated [See NFPA 70 (99) article 517-20(a)]. If an interruption can be tolerated, GFCI protection may be permitted. If an interruption cannot be tolerated, an isolated power system is required [See NFPA 70 (99), article 517-20(a)]. Based upon observation, it could not be determined whether the electrical system within the Operating Room would properly protect patients and staff from an electrical shock, or that this existing arrangement complies with the requirements at NFPA 99 (1999) Chapter 3, Section 3-3.