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Based on record review, the facility failed to produce documentation for laboratory staff exit drills and all facility personnel participation in a fire drill once a quarter, The facility failed to conduct fire exit drills in the laboratory to familiarize staff with the specific procedures and features of a laboratory. The facility failed to include all compartments and personal on quarterly fire drills to familiarize facility personnel ( nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

The findings include:

During record review February 26, 2014, with the Maintenance Director:
1. The facility failed to produce documentation for quarterly fire exit drills and participation in a fire exit drill by all laboratory staff as required by NFPA 99( 1999 edition ) chapter 10-2.1.4. The Maintenance Director confirmed the laboratory has not conducted exit drills.

2. The facility failed to produce documentation for inclusion of all facility personnel in quarterly fire drills as require by NFPA 101(2000 edition) chapter 19.7.1.6. The Maintenance Director confirmed all personnel do not participate in fire drills.

Based on observation and record review, the facility failed to provide an environment free from electrical hazards, by failing to ensure two OB operating rooms had battery powered emergency lights. Battery powered emergency lights are necessary to bridge the lapse in power for a possible ten seconds during an invasive procedure from the time normal power is lost until the emergency generator is on line. The facility also failed to produce documentation for the exercising of their main and feeder circuit breakers. Exercising main and feeder circuit breakers is necessary to insure corrosion does not prevent the operation of the circuit breakers.


The findings include:

1. While on tour February 26, 2014, at 1:31 PM, in the two OB operating rooms, with the Maintenance Director, battery-powered emergency lights were not observed. The Maintenance Director confirmed the operating rooms have no battery-powered emergency lights.

2. During record review February 26, 2014, with the Maintenance Director, the facility failed to produce documentation for the exercising of the facility main and feeder circuit breakers as required by NFPA 99(1999 edition) chapter 3-4.4.1.2. The Maintenance Director confirmed the breakers were not tested.

Based on record review, the facility failed to produce documentation for laboratory staff exit drills and all facility personnel participation in a fire drill once a quarter, The facility failed to conduct fire exit drills in the laboratory to familiarize staff with the specific procedures and features of a laboratory. The facility failed to include all compartments and personal on quarterly fire drills to familiarize facility personnel ( nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

The findings include:

During record review February 26, 2014, with the Maintenance Director:
1. The facility failed to produce documentation for quarterly fire exit drills and participation in a fire exit drill by all laboratory staff as required by NFPA 99( 1999 edition ) chapter 10-2.1.4. The Maintenance Director confirmed the laboratory has not conducted exit drills.

2. The facility failed to produce documentation for inclusion of all facility personnel in quarterly fire drills as require by NFPA 101(2000 edition) chapter 19.7.1.6. The Maintenance Director confirmed all personnel do not participate in fire drills.

Based on observation and record review, the facility failed to provide an environment free from electrical hazards, by failing to ensure two OB operating rooms had battery powered emergency lights. Battery powered emergency lights are necessary to bridge the lapse in power for a possible ten seconds during an invasive procedure from the time normal power is lost until the emergency generator is on line. The facility also failed to produce documentation for the exercising of their main and feeder circuit breakers. Exercising main and feeder circuit breakers is necessary to insure corrosion does not prevent the operation of the circuit breakers.


The findings include:

1. While on tour February 26, 2014, at 1:31 PM, in the two OB operating rooms, with the Maintenance Director, battery-powered emergency lights were not observed. The Maintenance Director confirmed the operating rooms have no battery-powered emergency lights.

2. During record review February 26, 2014, with the Maintenance Director, the facility failed to produce documentation for the exercising of the facility main and feeder circuit breakers as required by NFPA 99(1999 edition) chapter 3-4.4.1.2. The Maintenance Director confirmed the breakers were not tested.