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Based upon a review of available records, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2. In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, while reviewing fire drill reports provided by facility staff, it was confirmed that no fire drills were conducted on the AM-Shift during 2nd Quarter of 2013.

This finding was confirmed with the assistant building engineer.

Based upon a review of available records, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 18, Section 18.7.1.2. In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, while reviewing fire drill reports provided by facility staff, it was confirmed that no fire drills were conducted on the AM-Shift during 2nd Quarter of 2013.

This finding was confirmed with the assistant building engineer.

Based upon a staff interview and a review of available records, the automatic tape-type dialer for the fire alarm system was not properly tested during each month of the previous year. This deficient practice could adversely affect 8 of 8 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, during a review of available records provided by facility staff, no documentation could be provided verifying the the facility's automatic tape-type dialer was tested during the months of February, March, May and June of 2013. The automatic dialer must be tested monthly in accordance with CMS policy, as provided for at NFPA 72 (99) Chapter 7, Section 7-3.2.

This finding was confirmed with the assistant building engineer.

Based on record review and interview, the facility failed to properly maintain the fire sprinkler system in accordance with NFPA 101 Life Safety Code (2000 edition), Chapter 19, Section 19.7.6 and Chapter 4, Section 4.6.12 and NFPA 25 (1998 edition). In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, during a review of available records, it was confirmed that required quarterly flow tests of the fire sprinkler system had not been conducted during the previous year. Quarterly flow tests are designed to test water flow alarm devices, pressure switches, water motor gongs and other required devices of a fire sprinkler system. This deficient practice was not in conformance with NFPA 25 (1998 edition) Chapter 2, Section 2-3 and Chapter 9, Section 9-2.

This finding was confirmed with the assistant building engineer.

Based on record review and interview, the facility failed to properly maintain the fire sprinkler system in accordance with NFPA 101 Life Safety Code (2000 edition), Chapter 18, Section 18.3.5 and Chapter 9, Section 9.7 and NFPA 25 (1998 edition). In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, during a review of available records, it was confirmed that required quarterly flow tests of the fire sprinkler system had not been conducted during the previous year. Quarterly flow tests are designed to test water flow alarm devices, pressure switches, water motor gongs and other required devices of a fire sprinkler system. This deficient practice was not in conformance with NFPA 25 (1998 edition) Chapter 2, Section 2-3 and Chapter 9, Section 9-2.

This finding was confirmed with the assistant building engineer.

Based on observation and a staff interview, the facility's operating room was not equipped with battery-powered emergency lighting, nor line-isolation or GFCI outlets at the anesthetizing location, in accordance with NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). This deficient practice could adversely affect the safety of an anesthetized patient and surgical staff.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, while surveying in the facility's sole operating room, it was verified that general anesthesia is admininstered to surgical patients, and the following observations were made:
A). No battery-powered emergency lighting unit was provided;
B). It could not be verified the operating room was not a wet location, and no line-isolation circuitry or GFCI-type electrical outlets were provided. This arrangement was not in accordance with the requirements at NFPA 99 (1999 edition).

These findings were confirmed with the surgical supervisor at the time of discovery.

Based upon a review of available records, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 19, Section 19.7.1.2. In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, while reviewing fire drill reports provided by facility staff, it was confirmed that no fire drills were conducted on the AM-Shift during 2nd Quarter of 2013.

This finding was confirmed with the assistant building engineer.

Based upon a review of available records, it was determined the facility had failed to conduct one or more quarterly fire drills during the previous year, in accordance with NFPA 101 (2000) Chapter 18, Section 18.7.1.2. In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors throughout the facility.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, while reviewing fire drill reports provided by facility staff, it was confirmed that no fire drills were conducted on the AM-Shift during 2nd Quarter of 2013.

This finding was confirmed with the assistant building engineer.

Based upon a staff interview and a review of available records, the automatic tape-type dialer for the fire alarm system was not properly tested during each month of the previous year. This deficient practice could adversely affect 8 of 8 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, during a review of available records provided by facility staff, no documentation could be provided verifying the the facility's automatic tape-type dialer was tested during the months of February, March, May and June of 2013. The automatic dialer must be tested monthly in accordance with CMS policy, as provided for at NFPA 72 (99) Chapter 7, Section 7-3.2.

This finding was confirmed with the assistant building engineer.

Based on record review and interview, the facility failed to properly maintain the fire sprinkler system in accordance with NFPA 101 Life Safety Code (2000 edition), Chapter 19, Section 19.7.6 and Chapter 4, Section 4.6.12 and NFPA 25 (1998 edition). In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, during a review of available records, it was confirmed that required quarterly flow tests of the fire sprinkler system had not been conducted during the previous year. Quarterly flow tests are designed to test water flow alarm devices, pressure switches, water motor gongs and other required devices of a fire sprinkler system. This deficient practice was not in conformance with NFPA 25 (1998 edition) Chapter 2, Section 2-3 and Chapter 9, Section 9-2.

This finding was confirmed with the assistant building engineer.

Based on record review and interview, the facility failed to properly maintain the fire sprinkler system in accordance with NFPA 101 Life Safety Code (2000 edition), Chapter 18, Section 18.3.5 and Chapter 9, Section 9.7 and NFPA 25 (1998 edition). In a fire emergency, this deficient practice could adversely affect 8 of 8 patients, staff and visitors.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, during a review of available records, it was confirmed that required quarterly flow tests of the fire sprinkler system had not been conducted during the previous year. Quarterly flow tests are designed to test water flow alarm devices, pressure switches, water motor gongs and other required devices of a fire sprinkler system. This deficient practice was not in conformance with NFPA 25 (1998 edition) Chapter 2, Section 2-3 and Chapter 9, Section 9-2.

This finding was confirmed with the assistant building engineer.

Based on observation and a staff interview, the facility's operating room was not equipped with battery-powered emergency lighting, nor line-isolation or GFCI outlets at the anesthetizing location, in accordance with NFPA 101 (2000 edition) Chapter 19, Section 19.3.2.3 and NFPA 99 (1999 edition). This deficient practice could adversely affect the safety of an anesthetized patient and surgical staff.

FINDINGS INCLUDE:

On 7/9/13 between 9:30 AM and 2:30 PM, while surveying in the facility's sole operating room, it was verified that general anesthesia is admininstered to surgical patients, and the following observations were made:
A). No battery-powered emergency lighting unit was provided;
B). It could not be verified the operating room was not a wet location, and no line-isolation circuitry or GFCI-type electrical outlets were provided. This arrangement was not in accordance with the requirements at NFPA 99 (1999 edition).

These findings were confirmed with the surgical supervisor at the time of discovery.