HospitalInspections.org

STANDARD is not met as evidenced by: Based on observation, staff interview and record review, it was determined that the facility failed to maintain all portable fire extinguishers as required by 2012 NFPA 101 Section 19.3.5.12, 9.7.4.1 and the 2010 NFPA 10 Section 5.5.5.3 This deficient practice could affect all residents, staff and visitors should the facility fail to provide fire extinguishers. This was evidence by the following.

A placard was not conspicuously place near the K Class fire extinguisher in the kitchen that states (The fire protection system shall be actuated prior to using the fire extinguisher.

The Maintenance Director acknowledged the lack of signage near the fire extinguisher during record review of the facility.

2010 NFPA 10 5.5.5.3* A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be actuated prior to using the fire extinguisher.

This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide an adequate source of input ratings of appliances operating at levels above 2000 feet in accordance with National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Fuel Gas Code. This deficient practice could affect all residents and staff in the core smoke compartment should the natural gas fueled heating equipment malfunction due to improper settings. This was evidenced by the following:

The input ratings of gas fired cloth dryers operating at elevations above 2000 ft (600 m) were not reduced at the rate of 4 percent for each 1000 ft (300 m) above sea level according to dryer data plate.

The dryer deficiencies were discussed with the Maintenance Director during the survey and again during the exit conference with the CEO.

11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:
(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance
(2) As permitted by the authority having jurisdiction
(3) In accordance with the manufacturer's installation instructions

STANDARD is not met as evidenced by: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. This deficient practice could affect all residents, staff and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to lack of testing. This was evidenced by the following:

No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patients care areas was conducted annually.

The non-hospital grade electrical outlets testing at patient's care areas deficiency was discussed with the Director of Maintenance during the survey and again during the exit conference with the Administrator.

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or
general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss.
This was evidenced by the following.

At the time of the survey no records were available to verify testing and recording of battery
conductance testing in connection with the emergency power supply system (emergency generator) monthly.

The emergency power supply system deficiency item was discussed with the Physical Plant Manager and Maintenance during the survey and again during the exit conference with the CEO.

NFPA 110, Section 8.3.7. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.