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Based on visual observation the facility failed to assure that the fire alarm system was inspected and tested in accordance with the approved maintenance and testing program in NFPA 72. The fire alarm system gives a sense of security to offer an advance warning in fire and/or smoke emergency. This deficient practice could potentially affect 2 of 2 patients.

Findings:

During the facility tour on October 3, 2019, between the hours of 10:15 am and 3:45 pm it was observed the main fire alarm panel had indicated silenced troubles and silenced alarms, due to the fire alarm panel falsely alarming. While conducting the complaint survey, a false alarm had occurred and the local fire department promptly responded to the this facility. Additionally, the main fire alarm was last annually certified by a contracted licensed fire alarm company on August 31, 2018 which had exceeded the required one year expiration date of September 1, 2019.

NFPA 72: 10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

NFPA 72:10.4.1.2 State or local licensure regulations shall be followed to determine qualified personnel. Depending on state or local licensure regulations, qualified personnel shall include, but not be limited to, one or more of the following: (1) Personnel who are registered, licensed, or certified by a state or local authority.

LRS 40:1646 (A)(B)(C) The fire marshal is authorized to cause the inspection and testing of all life safety systems and equipment in the state, whether in public or private buildings, during installation or immediately after installation to determine compliance with applicable standards. The owner of any building containing a life safety system and equipment shall cause at a minimum an annual inspection to be made of the life safety system and equipment in that building to assure compliance with applicable safety standards and to determine whether structural changes in the building or in the contents of the building mandate alteration of a system. Life safety systems and equipment includes but is not limited to fire sprinkler, fire alarm, fire suppression, special locking systems and equipment, and portable fire extinguishers.


Interview with the Administrative Assistant at 12:30 pm on October 3, 2019, revealed the facility was aware the fire alarm system had been in trouble and alarming which created numerous false alarms. The fire alarm panel, located at the nurses station, was repeatedly reset by nursing staff on each false fire alarm event for the past month with the intention of clearing the silenced troubles and alarms. After the nursing staff would reset the fire alarm, the strobes and horns would initiate throughout the facility and would continue to initiate each time the fire alarm was reset. Thus, the nursing staff on each false fire alarm occasion, over the past month, decided to simply silence the alarms and troubles to quiet the fire alarm horns and stop the fire alarm visual strobes from illuminating each fire alarm incident. The Administrative Assistant had contacted the licensed contracted fire alarm company over this month long period to schedule a appointment to service the fire alarm for the consistant troubles and alarms. The fire alarm panel was last serviced by the contracted fire alarm company on May 14, 2019. The Administrative Assistant was not aware that the required annual inspection had not been conducted on the fire alarm system.

Interview on 10:20 am on October 3, 2019 with the local fire deparmtnet Chif revealed within the past month, there have been numerous false alarms, "some days at least four in one day".

NOTE: The Administrative Assistant, was notified to begin conducting a fire watch at the time of 12:30 pm October 3, 2019. The fire watch guidelines and daily log sheets were explained to the Administrative Assistant. The fire watch shifts were immediately implemented by the staff until 5:00 pm with next shift following from 5 pm - 5 am. The shifts are set to continue with a fire watch for the future shifts times of 5:00 am to 5:00 pm and 5:00 pm to 5:00 am until the fire alarm is serviced properly by a licensed fire alarm agent.

Based on visual observation the facility failed to assure that the generator or other alternate power source is capable of restoring electrical service within 10 seconds to all essential life safety equipment for the facility such as exit signs, lighting and to all patient care rooms dedicated emergency electrical receptacles. Generator sets are inspected weekly and a monthly testing program on the emergency generator must be conducted a min. of 12 times a year under load for a min. of 30 minutes. In addition, generator sets load bank tests meeting the kilowatt requirement during monthly load tests are tested annually. The deficient practice had the potential to affect 2 of 2 patients.


Findings:

During the generator tour on October 3, 2019, between the hours of 10:45 am to 3:30 pm the it was observed the natural gas fuel source was shut off to the facility as well as the generator due to the natural gas piping not being completely installed. Thus, the generator was not capable of operating when onsite functions test was attempted with the maintenance personnel. This failure of the generator to operate resulted in the enforcement of a IJ (Immediate Jeopardy). The record of review of the maintenance generator logs identified the weekly inspections and monthly load test over the last year were consistently not being completed in proper sequential order with the last weekly inspection being conducted on August 03, 2019 and last monthly load test being completed on July 4, 2019.

NFPA 101: 8.3 Maintenance and Operational Testing.
NFPA 101:8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. NFPA 101: A.8.3.1 The suggested maintenance procedure and frequency should follow those recommended by the manufacturer. In the absence of such recommendations, Figure A.8.3.1(a) and Figure A.8.3.1(b) indicate alternate suggested procedures.

NFPA 110:8.4.2 generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
1.) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacture.
2.) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating.

In an interview at 1:00 pm with the Administrative Assistant, revealed the facility was not aware the generator was not functioning due to lacking a fuel source of natural gas. The Administrative Assistant was not sure of the exact date, but she approximated a date of August 1, 2019 as the earliest day of the natural gas piping being disconnected to the generator which would had resulted in the generator not functioning. The failure of the maintenance staff to complete the generator maintenance logs properly in a timely manner contributed to the administrative staff from being unaware the generator was not operational for emergency purposes. At 2:40 pm on October 3, 2019 the IJ (Immediate Jeopardy) notification was explained and signed by the Administrator.