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Based on document review and interview the facility failed to conduct monthly and annual test of the battery-powered emergency lighting units in the operating room. This deficient practice affects all occupants in the surgical suite. The facility census was 0.

Findings included:

Review of the preventive maintenance documentation of the fire safety equipment, conducted on the morning of 10/20/15, showed there was no documentation of monthly or yearly testing of the battery-powered emergency lighting units in the operating room.

During an interview on 10/20/15 at 9:53 AM, Staff I, LPN, stated that staff had not been conducting any testing of the battery-powered emergency lighting units.

Section 7.9.3 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours.

Based on policy, document review and interview the facility failed to conduct fire drills on at least a quarterly basis on each shift. This deficient practice has the potential to affect all occupants in the facility during an emergency situation. The facility census was 0.

Findings included:

Record review of the facility's policy titled, "Fire Drills,", dated 07/01/99, conducted on the morning of 10/20/15, showed the following:

The Plant Operations Department Manager shall conduct, or cause to be conducted periodic fire drills. Each shift will have at least one drill per quarter.

Review of the fire drill records for the previous 12 months, conducted on the morning of 10/20/15, showed three fire drills were conducted for the day shift, 7:00 AM to 7:00 PM, and three fire drills were conducted for the night shift, 7:00 PM to 7:00 AM.

The fire drills for the day shift were conducted on the following dates:
-09/03/14
-02/27/15
-07/16/15

The fire drills for the night shift were conducted on the following dates:
-09/02/14
-02/10/15
-07/16/15

During an interview on 10/20/15 at 8:55 AM, Staff H, Plant Operations, stated there were only 3 fire drills conducted on each shift during the previous 12 months.

Section 18.7.1.2 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states 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.

Based on document review and interview the facility failed to conduct all required inspections of the sprinkler system throughout the previous year. This deficient practice affects all occupants in the facility. The facility census was 0.

Findings included:

Review of the facility sprinkler system inspection documents, conducted on the morning of 10/20/15, showed an outside contractor had conducted a quarterly inspection of the sprinkler system on 03/28/14. There was no documentation showing any type of inspection had been conducted on the sprinkler system between March of 2014 and the annual certification of the sprinkler system which was conducted on 01/05/15.

During an interview on 10/20/15 at 8:50 AM, Staff H, Plant Operations, stated there were no quarterly inspections of the sprinkler system during that nine month time frame.

Section 2.1 and table 2.1 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 25) states the minimum requirements for the routine inspections, testing, and maintenance of sprinkler systems.

Based on record review and interview the facility failed to establish a policy restricting the use of portable heaters to non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. This deficient practice affects all occupants of the facility. The facility census was 0.

Findings included:

Record review of facility policies dealing with fire safety issues, conducted on the morning of 10/20/15, showed the facility did not have an approved policy regarding the use of portable heating devices in the facility.

During an interview on 10/20/15 at 11:10 AM, Staff J, Human Resources, stated the facility did not currently have a policy regarding the use of portable heating devices.

Section 18.7.8 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states portable space-heating devices shall be prohibited in all health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F.

Based on document review and interview the facility failed to document weekly emergency generator inspections and the monthly 30 minute load test of the emergency generator system. This deficient practice affects all occupants of the facility. The facility census was 0.

Findings included:

Review of the inspection reports for the facility emergency generator system, conducted on the morning of 10/20/15, showed an outside contractor had performed preventive maintenance on the generator on 01/13/15, 05/20/15 and had performed a load bank test on 10/12/15. There was no documentation of an inspection of the generator being conducted on a weekly basis nor was there any documentation of a monthly load test being conducted on the generator for the previous 12 months.

During an interview on 10/20/15 at 9:18 AM, Staff H, Plant Operations, stated there was no documentation of the weekly inspections nor of the monthly load test of the emergency generator system.

Section 8.4.1 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 110) states the emergency power supply system (EPSS) including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Based on interview the facility failed to develop a written procedure to implement any time the facility sprinkler system is non-functional for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 0.

Findings included:

During an interview on 10/20/15 at 9:38 AM, Staff H, Plant Operations, stated the facility did not have a written procedure to implement if the facility sprinkler system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.7.6.2 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states: sprinkler impairment procedures shall comply with NFPA 25, Standards for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems.

Based on interview the facility failed to develop a written procedure to implement any time the facility fire alarm system is non-operational for more than 4 hours. Lack of complete written policies and procedures could result in staff failing to implement interim measures in the event of an emergency, affecting all occupants of the building. The facility census was 0.

Findings included:

During an interview on 10/20/15 at 9:38 AM, Staff H, Plant Operations, stated the facility did not have a written procedure to implement if the facility fire alarm system were non-operational for more than 4 hours in a 24 hour time frame.

Section 9.6.1.8 of the 2000 Edition of the Life Safety Code published by the National Fire Protection Association (NFPA 101) states: where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.