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4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system,
condition, arrangement, level of protection, or any other feature
is required for compliance with the provisions of this Code,
such device, equipment, system, condition, arrangement, level
of protection, or other feature shall thereafter be continuously
maintained in accordance with applicable NFPA requirements
or as directed by the authority having jurisdiction.

4.6.12.2* Existing life safety features obvious to the public, if
not required by the Code, shall be either maintained or
removed.
4.6.12.3 Equipment requiring periodic testing or operation
to ensure its maintenance shall be tested or operated as specified
elsewhere in this Code or as directed by the authority having
jurisdiction.

4.6.12.4 Maintenance and testing shall be under the supervision
of a responsible person who shall ensure that testing and
maintenance are made at specified intervals in accordance
with applicable NFPA standards or as directed by the authority
having jurisdiction.


Based on observation and interview, the facility failed to maintain and test equipment in accordance with NFPA 101. This was evidenced by no maintenance and testing program established for equipment in the facility. This affected the one of three floors and the basement.

Findings:

On 4/23/12, review of the entity reported event that the food warmer caught fire on 3/26/12, a fire extinguisher was used and the fire department was called. The fire department instructed the facility that the steam table (food warmer) be inoperable until repaired or replaced.

On 4/24/12, during a facility tour with facility staff, the steam table (food warmer) was observed.

During an interview, Staff 1 reported the main gas header has been capped off. He stated that the steam table (food warmer) had a bad seal on the gas valve for the middle burner causing the gas leak. The steam table (food warmer) is lit manually and caused a fire after the pilot was lit and staff had walked away. Staff 1 was asked if there was a maintenance and testing program for the steam table (food warmer) that caused the flames as the pilot was lit. Staff 1 reported there was no maintenance and testing program for the steam table (food warmer) or any safety checks. He reported that the only time the equipment is looked at is when the kitchen/cafe staff submit a work order for repairs. Staff 1 stated that the food warmer was so old that the facility was unable to obtain any new parts. He reported there was no manual available for the equipment but would conduct some research on the Internet. He reported that the facility has ordered a new food warmer but were told it would take four to six weeks for delivery.

On 5/1/12, during a phone interview, Staff 1 reported he was unable to obtain the manufactures specifications for the steam table (food warmer). He stated he contacted the manufacturer and provided the model number as there was no serial number on the equipment. Staff 1 reported that the manufacturer was unable to locate the model number for the steam table (food warmer) in their files.

Staff 1 reported that the facility was built in the early 1960's and that the steam table (food warmer) was purchased at that time. He also stated that some of the equipment purchased when the facility first opened was used equipment, therefore, the equipment could possibly be from1950's.

Based on observation and interview, the facility failed to maintain their electrical equipment in accordance with NFPA 99. This was evidenced by no testing/inspection records for the maintenance of electrical equipment. This affected the entire facility and could result in an increased risk of an electrical fire to occur.

NFPA 99
7-6.2.1.2 Testing Intervals.
(a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below:

General care areas-12 months
Critical care areas-6 months
Wet locations-6 months

Findings:

On 4/23/12, record review of the entity reported event that an oscillating fan was plugged into the wall and it quickly emitted a strong smoke smell on 4/16/12 and a fire alarm was activated and fire department responded.

On 4/24/12, during a facility tour with facility staff, the patient room where the oscillating fan was located was observed.

On 4/24/12, at 10:39 a.m., during an interview, Staff 1 reported that the fan which caused smoke had a frozen motor. Staff 1 was asked for maintenance and testing records for electrical appliance, fans, that were used in patients rooms and throughout the facility.

Staff 1 reported that there were no testing/inspections records available for review. He reported that the fans in the patients rooms are fairly new, and that they are in use no more than 2 to 3 years. Staff 1 reported that the only maintenance on the fans is when housekeeping clean the fans as needed, the covers are removed and the dust is cleaned off the blades. Staff 1 was asked for the manufacture's specifications and he reported he did not have any.

At 10:41 a.m., Staff 1 reported there is an initial safety check on equipment before it is placed in the facility, but other than the initial check, nothing is else is done on the fans, unless they go bad.

At 12:21 Staff 1 was asked if there are records on the date the fans are placed in service or if there are tags on the fans. Staff 1 reported there are no records and the fans are not tagged. He provided 2 print out sheets from the Internet which provided general information on the wall mounted fans. No manufacturer specifications were on the print outs.