HospitalInspections.org

Based on record review and interview, the facility failed to ensure the automatic sprinkler systems are inspected, tested and maintained in accordance with 19.3.5 and NFPA 25, by a qualified contractor or qualified owner's representative. This deficient practice potentially affects all staff, visitors and the patient census of five.

Findings Included:

1. Record review on 02/06/12 at 3:15 PM showed the last annual inspection, testing and maintenance of the automatic sprinkler system serving the entire hospital was 11/16/10. No documentation of inspections for annual flow tests for the past two years and two months, a total of 26 months without inspection or recertification, that the system would function as required in case of an actual fire event. Record review showed the same contractor had returned to the facility to perform bi-annual maintenance and tests to the kitchen range hood suppression system in July 2011 and January 2012.

During an interview on 02/06/12 at 3:40 PM, Staff H, Maintenance Lead, acknowledged the finding and stated he was unsure if there was any other documentation of sprinkler inspections and it could have been miss-filed or lost.

Based on observation and interview, the facility failed to provide secure storage of compressed medical gases in accordance with NFPA 99, (5.1.3.3.2(7)) with racks, chains or other fastenings to individually secure all cylinders to prevent them from falling or inadvertently being tipped over during change-outs, potentially affecting staff, visitors and the facility census of 37.

Findings included:

1. Observation on 02/07/12 at 9:40 AM showed 10 H size cylinders of compressed gasses lined up along the outside wall in a secure, fenced enclosure. The cylinders were connected to the facility's medical gas system, supplying surgery, emergency and other departments with readily available oxygen. The cylinders were standing upright on the concrete pad and had one long chain around all of them, but were not individually chained or attached with other hardware to ensure they remained upright and secure at all times, including when adjacent tanks were being changed out.

During an interview on 02/07/12 at 10:00 AM Staff G, Maintenance Supervisor, acknowledged the observation and stated he thought they were ok inside the fenced and locked enclosure. He said the off-site contractor who supplies the bulk tank is the only one who changes the cylinders out once they are near empty.