HospitalInspections.org

Based on Annual Emergency Lighting System testing documentation review and interview, it was determined the batteries in 10 of 10 battery powered emergency light fixtures were not tested for 1 ½ hours annually as required by NFPA 101, Chapter 7.9.3.1.1(3). The failed practice had the potential to affect all patients, staff, and visitors because the reliability of the light fixtures to illuminate the means of egress for a minimum of 1 ½ hours in the event of the loss of normal power was not verified as required by the Life Safety Code. The facility had a census of 19 patients on 04/07/14. The findings follow:

A. Review of the Annual Test on Emergency Lighting System documentation on 04/08/14 at 0900 revealed the batteries on the emergency light fixtures were all tested for only 30 seconds on 06/10/13.
B. In an interview on 04/09/14 at 1100 the Director of Engineering verified the batteries were not tested for at least 1 ½ hours annually.

Based on Fire Department inspection document review and interview, it was determined the facility failed to meet the Standard 485.623(d) Life Safety from Fire because the facility failed to obtain the services of a central offsite monitoring service to automatically notify the fire department in the event of a fire alarm system activation, as required by NFPA 101, Chapter 9.6.4 from 01/01/13 to 04/09/14. The failed practice had the potential to affect all patients, staff, and visitors because the fire department was not automatically notified of the fire alarm or sprinkler system activation, which had the potential to delay fire department response time to the facility. The facility had a census of 19 inpatients on 04/07/14. The findings follow:

A. Review of the Fire Department inspection documentation on 04/08/14 at 1030 revealed a letter dated 10/04/12 addressed to the Administrator from the city fire department chief that read in part: "Due to fire code changes and emergency run volume increases, we no longer meet the criteria for an off-site monitoring agency. We will continue to monitor your alarms at Crossett Fire Department until January 1, 2013. You will need to have alternative monitoring in place by that date."
B. A letter provided by the Director of Engineering on 04/08/14 at 1035 from the building security system provider read: "The following security systems have the ability to dispatch Fire/Police from the keypad via the Fire Panic Button and the Police Button: Ashley County Medical Center."
C. In an interview on 04/08/14 at 1045, the Director of Engineering verified the only options for the fire department to be notified of a fire alarm or sprinkler system activation was by either the security system keypad or by calling the fire department directly. He confirmed the fire alarm system did not annunciate offsite to automatically dispatch the fire department.

Based on Fire Department inspection document review and interview, it was determined the facility failed to meet the Standard 485.623(d) Life Safety from Fire because the facility failed to obtain the services of a central offsite monitoring service to automatically notify the fire department in the event of a fire alarm system activation, as required by NFPA 101, Chapter 9.6.4 from 01/01/13 to 04/09/14. The failed practice had the potential to affect all patients, staff, and visitors because the fire department was not automatically notified of the fire alarm or sprinkler system activation, which had the potential to delay fire department response time to the facility. The facility had a census of 19 inpatients on 04/07/14. The findings follow:

A. Review of the Fire Department inspection documentation on 04/08/14 at 1030 revealed a letter dated 10/04/12 addressed to the Administrator from the city fire department chief that read in part: "Due to fire code changes and emergency run volume increases, we no longer meet the criteria for an off-site monitoring agency. We will continue to monitor your alarms at Crossett Fire Department until January 1, 2013. You will need to have alternative monitoring in place by that date."
B. A letter provided by the Director of Engineering on 04/08/14 at 1035 from the building security system provider read: "The following security systems have the ability to dispatch Fire/Police from the keypad via the Fire Panic Button and the Police Button: Ashley County Medical Center."
C. In an interview on 04/08/14 at 1045, the Director of Engineering verified the only options for the fire department to be notified of a fire alarm or sprinkler system activation was by either the security system keypad or by calling the fire department directly. He confirmed the fire alarm system did not annunciate offsite to automatically dispatch the fire department.

Based on observation and interview it was determined two of two line isolation panels located in the Surgery Department were not tested monthly as required by NFPA 99, Chapter 6.3.4.1.4. The failed practice had the potential to affect all patients admitted for surgery in the facility because the correct operation of the electric shock prevention devices was not verified. The facility had three patients scheduled for surgery on 04/09/14. The findings follow:

A. On a tour of the Surgery Department with the Maintenance Technician on 04/09/14 at 1330, a line isolation panel was observed in Operating Room #1 and Operating Room #2.
B. In an interview on 04/09/14 at 1430 the Biomedical Director verified there was no documentation of monthly line isolation panel testing available for review.

Based on Annual Emergency Lighting System testing documentation review and interview, it was determined the batteries in 10 of 10 battery powered emergency light fixtures were not tested for 1 ½ hours annually as required by NFPA 101, Chapter 7.9.3.1.1(3). The failed practice had the potential to affect all patients, staff, and visitors because the reliability of the light fixtures to illuminate the means of egress for a minimum of 1 ½ hours in the event of the loss of normal power was not verified as required by the Life Safety Code. The facility had a census of 19 patients on 04/07/14. The findings follow:

A. Review of the Annual Test on Emergency Lighting System documentation on 04/08/14 at 0900 revealed the batteries on the emergency light fixtures were all tested for only 30 seconds on 06/10/13.
B. In an interview on 04/09/14 at 1100 the Director of Engineering verified the batteries were not tested for at least 1 ½ hours annually.

Based on Fire Department inspection document review and interview, it was determined the facility failed to meet the Standard 485.623(d) Life Safety from Fire because the facility failed to obtain the services of a central offsite monitoring service to automatically notify the fire department in the event of a fire alarm system activation, as required by NFPA 101, Chapter 9.6.4 from 01/01/13 to 04/09/14. The failed practice had the potential to affect all patients, staff, and visitors because the fire department was not automatically notified of the fire alarm or sprinkler system activation, which had the potential to delay fire department response time to the facility. The facility had a census of 19 inpatients on 04/07/14. The findings follow:

A. Review of the Fire Department inspection documentation on 04/08/14 at 1030 revealed a letter dated 10/04/12 addressed to the Administrator from the city fire department chief that read in part: "Due to fire code changes and emergency run volume increases, we no longer meet the criteria for an off-site monitoring agency. We will continue to monitor your alarms at Crossett Fire Department until January 1, 2013. You will need to have alternative monitoring in place by that date."
B. A letter provided by the Director of Engineering on 04/08/14 at 1035 from the building security system provider read: "The following security systems have the ability to dispatch Fire/Police from the keypad via the Fire Panic Button and the Police Button: Ashley County Medical Center."
C. In an interview on 04/08/14 at 1045, the Director of Engineering verified the only options for the fire department to be notified of a fire alarm or sprinkler system activation was by either the security system keypad or by calling the fire department directly. He confirmed the fire alarm system did not annunciate offsite to automatically dispatch the fire department.

Based on Fire Department inspection document review and interview, it was determined the facility failed to meet the Standard 485.623(d) Life Safety from Fire because the facility failed to obtain the services of a central offsite monitoring service to automatically notify the fire department in the event of a fire alarm system activation, as required by NFPA 101, Chapter 9.6.4 from 01/01/13 to 04/09/14. The failed practice had the potential to affect all patients, staff, and visitors because the fire department was not automatically notified of the fire alarm or sprinkler system activation, which had the potential to delay fire department response time to the facility. The facility had a census of 19 inpatients on 04/07/14. The findings follow:

A. Review of the Fire Department inspection documentation on 04/08/14 at 1030 revealed a letter dated 10/04/12 addressed to the Administrator from the city fire department chief that read in part: "Due to fire code changes and emergency run volume increases, we no longer meet the criteria for an off-site monitoring agency. We will continue to monitor your alarms at Crossett Fire Department until January 1, 2013. You will need to have alternative monitoring in place by that date."
B. A letter provided by the Director of Engineering on 04/08/14 at 1035 from the building security system provider read: "The following security systems have the ability to dispatch Fire/Police from the keypad via the Fire Panic Button and the Police Button: Ashley County Medical Center."
C. In an interview on 04/08/14 at 1045, the Director of Engineering verified the only options for the fire department to be notified of a fire alarm or sprinkler system activation was by either the security system keypad or by calling the fire department directly. He confirmed the fire alarm system did not annunciate offsite to automatically dispatch the fire department.

Based on observation and interview it was determined two of two line isolation panels located in the Surgery Department were not tested monthly as required by NFPA 99, Chapter 6.3.4.1.4. The failed practice had the potential to affect all patients admitted for surgery in the facility because the correct operation of the electric shock prevention devices was not verified. The facility had three patients scheduled for surgery on 04/09/14. The findings follow:

A. On a tour of the Surgery Department with the Maintenance Technician on 04/09/14 at 1330, a line isolation panel was observed in Operating Room #1 and Operating Room #2.
B. In an interview on 04/09/14 at 1430 the Biomedical Director verified there was no documentation of monthly line isolation panel testing available for review.