HospitalInspections.org

Based on record review and interview, the facility failed to provide inspection, testing, and maintenance records that include all required information for the fire alarm system in accordance with the National Fire Protection Association (NFPA) Standard 72, National Fire Alarm and Signaling Code, 2010 edition, 14.6.2.4. This deficient practice could affect all occupants within the facility. The facility had a capacity of 25 patients.

Findings include:

Record review and interview on 11/03/2020 at about 10:00 a.m. during the revisit of the facility's fire alarm inspection records, revealed the dampers and relays had not been tested. The hospital has gone through substantial amounts of construction and has many new areas added. Dampers are now being used to separate new and old areas. Contractors have been hired and are currently adding and have added access's doors to allow for the testing of these dampers. Interview of the Maintenance Supervisor revealed the relays for these damper systems will need to be tested by a separate state certified contractor. The Maintenance Supervisor stated testing of both the Dampers and the relays are scheduled to be done soon. The Maintenance Supervisor verified these findings during the Revisit survey process.