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CUMBERLAND RIVER HOSPITAL
Fire Alarm System - Testing and Maintenance
Tag No.: K0345
Based on observations and document review, the facility failed to maintain the fire alarm system.
The finding included:
Observations and document review on 04/22/2020 at 11:05 AM, revealed the fire alarm panel had a "yellow" tag for a trouble in the system. Interview with the maintenance director, revealed the alarm company had stated they would have to send someone back to diagnose the trouble and repair. Document review of the fire alarm inspection report dated 04/10/2020 revealed the panel located in the mechanical room failed inspection due to intermittent system trouble light going on and off and power trouble light goes dim.
NFPA 101, 19.3.4.1 (2012 Edition), NFPA 101, 9.6.1.3 (2012 Edition), NFPA 72, 14.2.1.2.2 (2010 Edition), NFPA 72, 14.2.2.1 (2010 Edition)
The maintenance director was present when the deficiency was identified and was acknowledged by the maintenance director and administrator during the exit conference on 04/22/2020.
Gas and Vacuum Piped Systems - Inspection and
Tag No.: K0908
Based on document review, the facility failed to maintain the medical gas system.
The finding included:
Document review on 04/22/2020 at 11:45 AM, revealed the medical gas inspection conducted on 04/10/2020 listed the following deficiencies:
1. Insufficient signals for vacuum system in mechanical room.
2. No area alarm panel in the emergency room.
3. Rooms 212 (X2), 213 and 209 had patient terminal leaks.
4. Room 210 vacuum terminal does not release secondary equipment.
NFPA 101, 19.3.2.4 (2012 Edition) NFPA 99, 5.1.14.2.2.5 (2012 Edition) NFPA 99, 5.1.9.2 (2012 Edition), NFPA 99, 5.1.9.2.1 (2012 Edition) NFPA 99, 5.1.12.3.2 (2012 Edition) NFPA 99, 5.1.12.2.6 (2012 Edition)
The maintenance director was present when these deficiencies were identified and were acknowledged by the maintenance director and administrator during the exit conference on 04/22/2020.
Electrical Equipment - Power Cords and Extens
Tag No.: K0920
Based on observations, the facility failed to maintain the electrical equipment.
The findings included:
Observations on 04/22/2020 between 10:00 AM - 12:00 PM, revealed the facility was using surge protected multiplug adapters throughout the facility without evidence of meeting UL1363 or UL1363-A standards.
NFPA 99, 10.2.4 (2012 Edition), CMS S&C 14-46
The maintenance director was present when the deficiency was identified and was acknowledged by the maintenance director and administrator during the exit conference on 04/22/2020.