HospitalInspections.org

Based on record review and interview, the provider failed to continuously maintain automatic sprinklers in reliable operating condition (quarterly flow test not done). Findings include:

1. Record review and interview on 9/21/22 at 9:30 a.m. revealed the required quarterly flow tests had not been performed in 2021 or 2022.

Interview with maintenance supervisor at the time of the record review confirmed that condition.

Failure to continuously maintain the automatic sprinkler system as required increases the risk of death or injury due to fire.

The deficiency affected one of numerous required tests on the automatic sprinkler system.

Based on observation and interview, the provider failed to maintain the required clearance for one randomly observed piece of electrical equipment (main automatic transfer switch) in the electrical room. Findings include:

1. Observation on 9/21/22 at 10:00 a.m. revealed the essential electrical room with the automatic transfer switch gear for the generator had data shred containers kept in the room. The containers were wheeled and were approximately 50 gallons in size. The required 36 inches of clear space in front of the electrical panels was not maintained. The floor was not marked to indicate the required 36 inches of clearance for the electrical circuit panels.

Interview with the maintenance supervisor at the time of the observation confirmed that finding.

The deficiency affected one of numerous requirements for the maintenance of electrical equipment.