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Based on document review and staff interview it was determined the hospital failed to conduct fire drills quarterly at unexpected times on each shift.

Findings include:

1. A review of the hospital fire drill records on 10/26/15 at approximately 11:30 a.m. revealed fire drills were being conducted on the 3:00 p.m. to 11:00 p.m. shift between the time frame of 3:00 p.m. to 3:04 p.m., and the 11:00 p.m. to 7:00 a.m. shift between the time frame of 6:15 a.m. to 6:25 a.m., for the past year. Fire drills should be conducted at unexpected times for all shifts.

2. During an interview with the Director of Engineering on 10/26/15 at approximately 11:50 a.m., he agreed fire drills were not conducted at unexpected times for the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift, for the past year.

NFPA 72 National Fire Alarm Code 1999 edition
Chapter 2 Initiating Devices
2-10 Smoke Detectors for Control of the Spread.
Figure 2-10.6.5.1.1 Detector location requirements for wall sections.
This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain the fire alarm system in accordance with NFPA 72.

Findings include:

1. On 10/27/15 at approximately 2:00 p.m., an inspection of the operating room was conducted. At this time, the WAG area open to the corridor would require smoke detector coverage.

2. The above findings were discussed with the Director of Engineering on 10/27/15 at approximately 2:10 p.m. and he agreed there was no smoke detector coverage for the above noted area.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition

Chapter 6 Maintenance and Operational Testing

6-3.6 Storage battery's ,including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufactures specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

This Standard is not met as evidenced by:

Based on record review, observation and staff interview it was determined the hospital failed to maintain the emergency generator in accordance with NFPA 110. Facility census 10.

Findings include:

1. On 10/26/15 at approximately 11:45 a.m., a review of the generator log for the past twelve (12) months indicated the facility failed to test and record the specific gravity of electrolyte fluid in the generator's battery's weekly.

2. These findings were discussed with the Director of Engineering on 10/26/15 at approximately 11:50 a.m. and he agreed the generator battery was not tested for a specific gravity of electrolyte fluid weekly.

Based on document review and staff interview it was determined the hospital failed to conduct fire drills quarterly at unexpected times on each shift.

Findings include:

1. A review of the hospital fire drill records on 10/26/15 at approximately 11:30 a.m. revealed fire drills were being conducted on the 3:00 p.m. to 11:00 p.m. shift between the time frame of 3:00 p.m. to 3:04 p.m., and the 11:00 p.m. to 7:00 a.m. shift between the time frame of 6:15 a.m. to 6:25 a.m., for the past year. Fire drills should be conducted at unexpected times for all shifts.

2. During an interview with the Director of Engineering on 10/26/15 at approximately 11:50 a.m., he agreed fire drills were not conducted at unexpected times for the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift, for the past year.

NFPA 72 National Fire Alarm Code 1999 edition
Chapter 2 Initiating Devices
2-10 Smoke Detectors for Control of the Spread.
Figure 2-10.6.5.1.1 Detector location requirements for wall sections.
This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain the fire alarm system in accordance with NFPA 72.

Findings include:

1. On 10/27/15 at approximately 2:00 p.m., an inspection of the operating room was conducted. At this time, the WAG area open to the corridor would require smoke detector coverage.

2. The above findings were discussed with the Director of Engineering on 10/27/15 at approximately 2:10 p.m. and he agreed there was no smoke detector coverage for the above noted area.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition

Chapter 6 Maintenance and Operational Testing

6-3.6 Storage battery's ,including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufactures specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

This Standard is not met as evidenced by:

Based on record review, observation and staff interview it was determined the hospital failed to maintain the emergency generator in accordance with NFPA 110. Facility census 10.

Findings include:

1. On 10/26/15 at approximately 11:45 a.m., a review of the generator log for the past twelve (12) months indicated the facility failed to test and record the specific gravity of electrolyte fluid in the generator's battery's weekly.

2. These findings were discussed with the Director of Engineering on 10/26/15 at approximately 11:50 a.m. and he agreed the generator battery was not tested for a specific gravity of electrolyte fluid weekly.