HospitalInspections.org

Based on observation the facility failed to document inspection of the kitchen / cafeteria hood fire suppression system. This deficient practice could affect patients, staff and visitors during a fire event.

The finding is:

On 1/24/22 at 2:30 pm in the company of the DPO, observation of the inspection tags for the manual pull stations for the grease hood fire protection systems, it was noted the record of the date and initials of the person completing the monthly inspection is not provide on the tag. NFPA, 17, 2009, 11.2.4 / NFPA 17A, 2009, 7.2.5.

A smoke detector was not located as required for a compliant fire alarm system installation. Failure to locate devices accordingly may result in failure or delay of alarm initiation device during an emergency event. If alarm initiating devices do not function properly, then the building occupants may not be alerted to an emergency which may result in occupants' safety being compromised.

Findings include:

On 1/24/2022 at 2:49pm, while in the company of the FM it was observed that a smoke detector was within 3"-0" of an exhaust vent on the 2nd floor in the space identified as Soiled Utility 2156 on the Life Safety Plans provided by the facility. The device is installed where airflow may prevent normal operation of the device as stated in NFPA 72-2012 17.7.4.1.

Based upon observation, ground fault circuit interruption (GFCI) is not provided in accordance with Code requirements. If GFCI protection is not provided, the circuit remains an electrical shock hazard to occupants. This deficient practice could affect the safety of patients, staff, and visitors.

Findings include:

A. On 1/24/2022 at 2:44pm, while in the company of the FM it was observed on the 2nd floor in the space identified as Admit/Intake/Recovery 2143 on the Life Safety Plans provided by the facility that an electrical receptacle is within 6'-0" of a sink fixture and not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5).

B. On 1/24/2022 at 2:47pm, while in the company of the FM it was observed on the 2nd floor in the Corridor workstation identified as 2140E on the Life Safety Plans provided by the facility that an electrical receptacle is within 6'-0" of a sink fixture and not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5).

C. On 1/25/2022 at 9:52am, while in the company of the FM it was observed on the 2nd floor in the ICU space identified as Care Station 2501 on the Life Safety Plans provided by the facility that an electrical receptacle is within 6'-0" of a sink fixture and not provided with GFCI protection to comply with NFPA 70-2011, 210.8(B)(5).