HospitalInspections.org

Based on review of the hospital documentation and staff interview, it was determined the facility failed to inspect and test all components of the facility fire alarm system annually in accordance with NFPA (National Fire Protection Association) 72.

Findings include:

1. On 02/24/15 at approximately 9:30 a.m., a review of the hospital fire alarm inspection reports was conducted. At this time the hospital offered reports dated 05/01/14 prepared by Fire Fighter Sales and Services, for the past twelve (12) months. In review of these reports it was not indicated that the hospital's seventeen (17) magnetic delayed egress exit door locks were tested in the past twelve (12) months. This practice does not meet the requirement of annually inspecting and testing of all components of the facility fire alarm system.

2. These findings were discussed with the hospital maintenance director on 02/24/15 at approximately 10:00 a.m. and he agreed the aforementioned fire alarm inspection did not record that seventeen (17) exit door magnetic locks were tested.

NFPA (National Fire Protection Association) 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation
NFPA 13, Standard for the Installation of Sprinkler Systems
1-6 Level of Protection.
1-6.1
A building, where protected by an automatic sprinkler system installation, shall be provided with sprinklers in all areas.

This Standard is not met as evidenced by:

Based on observation and staff interview, it was determined that the hospital failed to
maintain sprinklers in accordance with NFPA 25 and NFPA 13.

Findings Include:

1. On 02/23/15 at approximately 11:30 a.m., thru-ceiling penetrations for sprinkler heads near the front entrance and 1st floor conference room were found missing escutcheons in the acoustical ceilings.

2. On 02/24/15 at approximately 11:30 a.m., a tour of the hospital kitchen was conducted. At this time all sprinkler heads located in the kitchen area were observed to be corroded and rusted.

3. On 02/24/15 at approximately 11:45 a.m., a tour of the hospital outpatient therapy was conducted. At this time the Activities of Daily Living (ADL) bathroom was observed with a closet approximately thirty (30) inches by forty-five (45) inches that was not sprinklered.

4. These findings were discussed with the hospital maintenance director on 02/24/15 at approximately 11:55 a.m., and he agreed that the above mentioned sprinkler areas would need corrected.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition

Chapter 6 Maintenance and Operational Testing

6-3.6 Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

This Standard is not met as evidenced by:

Based on record review, observation and staff interview, it was determined the hospital failed to maintain the emergency generator in accordance with NFPA 110.

Findings include:

1. On 02/23/15 at approximately 1:30 p.m., a review of the generator log for the past twelve (12) months indicated that the facility fail to test and record the specific gravity of electrolyte fluid in generator's batteries weekly.

2. These findings were discussed with the hospital maintenance director on 02/23/15 at approximately 2:00 p.m., and he agreed that the generator battery was not tested for a specific gravity of electrolyte fluid weekly.

Based on observation and interview, it was determined that the hospital failed to maintain electrical wiring and equipment in accordance with NFPA 70, National Electric Code.

Findings include:

1. During an inspection of the hospital kitchen compressor room on 02/24/15 at approximately 11:32 a.m., the compressor time clock and electrical contactor was observed missing the required cover allowing electrical wires to be exposed.

2. These findings were discussed with the hospital maintenance director on 02/24/15 at approximately 11:32 a.m., and he agreed that the aforementioned electrical issues needed corrected.