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Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect three of three patients.

Findings:

During the facility tour on December 21, 2022 between the hours of 2:00 p.m. to 4:00 p.m. the fire alarm system was yellow tagged by the licensed company on November 23, 2022 due to the fire alarm panel not communicating to the annunciator.

NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

LAC 55:V:3033. Fixed Fire Suppression and Fire Detection and Alarm Systems and Equipment... B. All existing required fixed fire suppression systems including kitchen, pre-engineered and engineered systems, and fire detection and alarm systems shall be certified, hydrostatically tested, inspected, integrated, maintained and serviced in an operational condition in accordance with the manufacturer's installation manuals, specifications, and per the inspection, testing and maintenance chapters of the applicable codes and standards adopted in L.A.C.55:V.103 or noted in these rules.

LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers.


The interview with the maintenance personnel revealed the facility was aware that the fire alarm was impaired and was in the process of having a licensed fire alarm company install a new fire alarm system.

Based on visual observation and record review the facility failed to maintain documentation for fire drills conducted during each quarter on each shift. Fire drills provide training in procedures in cases of emergency. The deficient practice had the potential to affect three of three patients. There were two of the four quarters in the year 2021-2022 were that deficient.

Findings:

During the facility record of review on December 21, 2022 between the hours of 2:00 p.m. to 4:00 p.m. the fire drill documentation was lacking for the third quarter of the 2022 6:00 a.m. to 2:00 p.m. shift and the second quarter of the year 2022 6:00 a.m. to 2:00 p.m.

NFPA 101:19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

The interview with the maintenance personnel revealed the facility was not aware fire drills were not being held for each work shift of each quarter.

Based on review of the documentation, the facility failed to provide records of a annual inspection from a qualified medical gas specialist. The proper maintenance and inspection of all medical gas equipment is essential to ensure compliance with NFPA 99 and to provide a safe environment for all patients, staff and the general public.

Findings:

During the facility record of review on December 21, 2022 between the hours of 2:00 p.m. to 4:00 p.m the annual medical gas piping certificate conducted by a qualified company was lacking a time of documentation review.

NFPA 101:19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.
101:20.3.2.3 Medical gas piping shall be systems inspections and testing reports shall be prepared and submitted in accordance with the provisions of NFPA 99. The systems shall be successfully tested in accordance with NFPA 99.

NFPA 99: 4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code
NFPA 99:5.1.14.2.2.5 Qualifications. Persons maintaining these systems shall be qualified to perform these operations. Appropriate qualification shall be demonstrated by any of the following:
(1) Training and certification through the health care facility by which such persons are employed to work with specific equipment as installed in that facility
(2) Credentialing to the requirements of ASSE 6040, Professional Qualification Standard for Medical Gas Maintenance Personnel
(3) Credentialing to the requirements of ASSE 6030, Professional Qualification Standard for Medical Gas Systems Verifiers

NFPA 99: 5.1.14.4.4 Central supply systems for nonflammable medical gases shall conform to the following:
(1) They shall be inspected annually.
(2) They shall be maintained by a qualified representative of the equipment owner.
(3) A record of the annual inspection shall be available for review by the authority having jurisdiction.

NFPA 99: 5.1.15* Category 1 Maintenance. Facilities shall have a routine maintenance program for their piped medical gas and vacuum systems.

A.5.1.15 Medical gas and vacuum systems should be surveyed at least annually for the items that follow and deficient items corrected. Survey of medical air and instrument air sources should include, but not be limited to, the following:
(1) Dew point monitor (operation and calibration)
(2) Carbon monoxide monitor (medical air only) (operation and calibration)
(3) Aftercoolers (condition, operation of drains)
(4) Operating pressures (cut-in, cut-out, and control pressures)
(5) All local alarms (verify presence of required alarms, perform electrical test, test lag alarm)
(6) Receiver elements (auto drain, manual drain, sight glass, pressure gauge)
(7) Filters (condition)
(8) Pressure regulators (condition, output pressure)
(9) Source valve (labeling)
(10) Intake (location and condition)
(11) Housekeeping around compressors

Survey of the medical vacuum and the WAGD source(s) should include, but not be limited to, the following:
(1) Operating vacuum (cut-in, cut-out, and control pressures)
(2) All local alarms (verify presence of required alarms, perform electrical test, test lag alarm)
(3) Receiver elements (manual drain, sight glass, vacuum gauge)
(4) Source valve (labeling)
(5) Exhaust (location and condition)
(6) Housekeeping around pump

Survey of the medical gas manifold source(s) should include, but not be limited to, the following:
(1) Number of cylinders (damaged connectors)
(2) Cylinder leads (condition)
(3) Cascade (switching from one header to another)
(4) All local alarms (verify presence of required alarms, perform electrical test, test all alarms)
(5) Source valve (labeling)
(6) Relief valves (discharge location and condition)
(7) Leaks
(8) Security (door or gate locks and signage)
(9) Ventilation (general operation, housekeeping)
(10) Housekeeping around manifolds

Survey of medical gas area alarms should include, but not be limited to, the following:
(1) Locations (visible to staff)
(2) Signals (audible and visual, use test function)
(3) Activation at low pressure
(4) Housekeeping around alarm

Survey of medical gas master alarms should include, but not be limited to, the following:
(1) Locations (visible to appropriate staff)
(2) Signals (audible and visual, use test function)
(3) Activation at low pressure
(4) Housekeeping around alarm

Survey of zone valves should include, but not be limited to, the following:
(1) Locations (relationship to terminals controlled)
(2) Leaks
(3) Labeling
(4) Housekeeping around alarm Survey of medical gas outlet/inlets should include, but not be limited to, the following:
(1) Flow and function
(2) Latching/delatching
(3) Leaks
(4) General condition (noninterchangeable indexing)
NFPA 99:5.1.10.11 and 5.2.10 Brazing shall be performed by individuals who are qualified. (NOTE: LRS 37:1367 requires licensure by the State Plumbing Board for medical gas piping installers and system verifiers).
NFPA 101:18.3.2.4 Medical gas system inspections and testing reports shall be prepared and submitted in accordance with the provisions of NFPA 99:5.1.12. The systems shall be successfully tested in accordance with 99:5.1.12.2 and 5.1.12.3.

The facility should retain a written or an electronic copy of all findings and any corrections performed.

The interview with the maintenance personnel revealed the facility had a annual medical gas piping inspection conducted. However, the maintenance personnel was not aware the annual medical gas piping inspection documentation was not available for review by the Life Safety Code Specialist at time of survey.

Based on record review, the facility failed to assure that a polarity, ground and retention resident / patient room electrical receptacle test had been conducted and documented. When the correct protocols are routinely completed by qualified personnel for the resident / patient electrical receptacle outlets; the chances of creating a unsafe electrical event or possible fire emergency are reduced or possibly eliminated. The deficient practice had the potential to affect three of three patients.

Findings:

During the facility record of review on December 21, 2022 between the hours of 2:00 p.m. to 4:00 p.m. the polarity ground and retention testing documentation for all patient care areas was lacking.

NFPA 99:6.3.3.2 Receptacle Testing in Patient Care Rooms 6.3.3.2.1

NFPA 99:6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.

NFPA 99:6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.

NFPA 99:6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

NFPA 99:6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall not be less than 115 g (4oz.)
Section 3-3 Section 3-3.4.3.1 A record shall be maintained of the tests required by this chapter and associated repairs of modifications. At a minimum, this record shall contain date, the rooms or areas tested and an indication of which items have met or have failed to meet the performance requirements of the chapter.

NFPA 99:6.3.4.1 Maintenance and Testing of Electrical System.

NFPA 99:6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.

NFPA 99:6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.

NFPA 99:6.3.4.1.3 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.


The interview with the maintenance personnel revealed the facility was not aware that all documentation was not complete regarding the inspection/testing of the patient electrical receptacles.