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Based on record review and staff interview, the facility failed to test the battery system of the emergency generator. This condition increased the likelihood of the generator failing to start during loss of power.

Findings are:

Record review of monthly generator load test reports on 2/11/25 at 1:42 pm revealed there was no documentation of monthly specific gravity testing or conductance testing for the lead-acid batteries, only the battery charge rate was checked.

In an interview on 2/11/25 at 1:42 pm, Maintenance A confirmed the generator battery was not tested.

NFPA 110, 2010, 8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

NFPA 110, 2010, 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

Based on record review and staff interview, the facility failed to provide documentation that battery backup emergency lights were tested. This condition would increase the potential to leave occupants in reduced lighting during the one to ten second gap between loss of normal power and generator power.

Findings are:
Record review on 2/11/25, at 2:13 pm revealed no documentation to verify the OR and Mental Health battery backup emergency lights were function tested monthly and annually tested on battery power for one- and one-half hours.

In an interview on 2/11/25, at 2:13 pm, Maintenance A confirmed the documentation was not available for review.

Based on observation and staff interview, the facility failed to separate a hazardous area with smoke resistive doors. This condition would allow smoke to migrate into an occupied space.

Findings are:
Observation on 2/11/25, at 3:20 pm revealed the room inside the Mental Health Small Conference Room was used for combustible storage and measured approximately 60 square feet. The door did not self-close.

In an interview on 2/11/25, at 3:20 pm, Maintenance A acknowledged the door did not self-close.

Based on record review and staff interview, the facility failed to have an approved fire watch policy in the event the fire alarm system is out of service. This practice would allow fire to spread undetected in the event of system outage.

Findings are:

Record review on 2/11/25, at 2:10 pm revealed the facility did not have an approved fire watch policy that detailed actions to be taken in the event the fire alarm system is out of service for more than 4 hours in a 24-hour period. A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. Such individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes.

In an interview on 2/11/25, at 2:10 pm, Maintenance A acknowledged the findings.

Based on record review and staff interview, the facility failed to have the fire sprinkler system inspected/tested semiannually. This deficient practice increased the potential that the fire sprinkler system would fail to operate in a fire emergency.

Findings are:
Record review of fire sprinkler inspection reports on 2/11/25, at 2:33 pm revealed the most recent inspection report was dated 10/9/24, with no semi-annual inspection report provided for 2024.

In an interview on 2/11/25, at 2:33 pm, Maintenance A confirmed there were no other reports available for 2024.

NFPA 25, 2011, 5.1.1.1 This chapter shall provide the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 5.1.1.2 Summary of Sprinkler System Inspection, Testing, and Maintenance.

Based on record review and staff interview, the facility failed to have an approved fire watch policy in the event the fire sprinkler system is out of service. This practice would allow fire to spread unsuppressed in the event of system outage.

Findings are:

Record review on 2/11/25, at 2:10 pm revealed the facility did not have an approved fire watch policy that detailed actions to be taken in the event of preplanned or emergency impairments to the sprinkler system when out of service for more than 10 hours in a 24-hour period.

In an interview on 2/11/25, at 2:10 pm, Maintenance A acknowledged the findings.

NFPA 25, 2011, 15.5* Preplanned Impairment Programs. 15.5.1 All preplanned impairments shall be authorized by the impairment coordinator. 15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b)*An approved fire watch (c)*Establishment of a temporary water supply (d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site. 15.6 Emergency Impairments. 15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. 15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. 15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on record review and staff interview, the facility failed to conduct fire drills at varying times and conditions. The facility failed to conduct simulated fire drills for the night shift. This practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels.

Findings are:

Record review on 2/11/25 at 2:01 pm of fire drills revealed:
1. Fire drills were not conducted at least one hour apart for the following shifts: First Shift - 3/20/24 at 7:30 am and 9/10/24 at 7:05 am and Second Shift - 6/24/24 at 8:53 pm and 12/4/24 at 8:30 pm.
2. Fire drill notes indicated that the night shift fire drills were a table-top discussion only, especially the 8/16/24 report. Fire procedures were not simulated for this shift.

In an interview on 2/11/25 at 2:01 pm, Maintenance A acknowledged the fire drill times, and that they were not at least one hour apart for each shift throughout the last 12 months. Maintenance A confirmed not all night drills were simulated.

Based on observation and staff interview, the facility allowed portable space heaters into staff-occupied rooms. This condition created the potential for the ignition of combustibles.

Findings are:
Observation on 2/11/25, at 3:17 pm revealed a portable space heater was observed in use in the Maintenance, Billing and Specialty Clinic offices.

In an interview on 2/11/25, at 3:17 pm, Maintenance A acknowledged the use of the portable space heaters.

Based on observation and staff interview, the facility failed to separate a construction zone with a fire barrier where approved fire sprinkler coverage was not provided. Flame retardant plastic was not used in a construction dust barrier. This condition would allow fire to spread outside of the construction zone into the occupied hospital.

Findings are:
Observations on 2/11/25, from 2:45 pm to 3:00 pm revealed:
1. Plain plastic was used in lieu of flame-retardant plastic as a dust barrier for construction zone door in the occupied hospital corridor across from HIM.
2. The MRI construction zone was not protected by an approved fire sprinkler system. The suspended ceiling was removed, and pendant fire sprinklers on flexible pipe were zip tied upright. In addition, fire sprinklers were removed from a portion of the construction zone. The construction zone lacked a 1-hour fire wall that extended to roof deck for the corridor separation and above the wall south of the corridor separation to the outside wall.

In an interview on 2/11/25, from 2:45 pm to 3:00 pm, Maintenance A was informed that the construction zone lacked a complete 1-hour fire wall and fire suppression, so a fire watch was required until the fire wall or fire suppression was restored. Maintenance A acknowledged the findings and the need for fire watch in the construction zone.

Based on record review and staff interview, the facility failed to test the battery system of the emergency generator. This condition increased the likelihood of the generator failing to start during loss of power.

Findings are:

Record review of monthly generator load test reports on 2/11/25 at 1:42 pm revealed there was no documentation of monthly specific gravity testing or conductance testing for the lead-acid batteries, only the battery charge rate was checked.

In an interview on 2/11/25 at 1:42 pm, Maintenance A confirmed the generator battery was not tested.

NFPA 110, 2010, 8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

NFPA 110, 2010, 8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.