Failure to Replace Deficient Fire Alarm System Batteries
Penalty
Summary
The facility failed to maintain its fire alarm system in accordance with regulatory requirements. During a facility tour, document review, and interview with maintenance staff, it was observed that two sealed lead acid (SLA) batteries in the Fire Alarm Control Panel (FACP) failed the semi-annual load voltage test. The inspection records dated 12/3/24 confirmed that both batteries did not meet the required standards during the scheduled testing. Despite the failed test results, the two deficient batteries were not replaced and remained connected to the FACP at the time of the survey. The fire alarm system technician acknowledged during the interview that the failure to replace the batteries was an oversight during the inspection process. No documentation was provided to indicate that corrective action had been taken following the failed battery test. This deficiency affected all 59 residents and both smoke compartments within the facility, as the fire alarm system's operational integrity was compromised by the presence of non-compliant batteries. The facility did not adhere to the required maintenance and testing program as outlined in NFPA 70 and NFPA 72, specifically regarding timely battery replacement following failed performance tests.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. No residents were found to be affected at this time. Upon identification of this alleged deficient practice, the facility fire alarm service vendor, Pacific Signaling, was requested to replace batteries. Pacific Signaling fulfilled the service request on 3/18/2025 by replacing the two SLA batteries with expiration dates of 03/18/2028. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. No other residents were found to be affected at this time. All residents are potentially to be affected by this alleged deficient practice as failure to comply with NFPA 101 and maintaining the fire alarm system could potentially cause harm in the event of an emergency. The two SLA batteries were replaced on 3/18/2025 and will be checked at least quarterly for proper functioning. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. It is the policy of the facility to ensure that emergency procedures are followed according to Life Safety Codes. The Administrator and Maintenance Director reviewed NFPA 72 codes regarding fire alarm and signaling testing and inspections on 03/27/2025. The Maintenance Director will inspect the fire alarm system, including the SLA batteries, at least monthly in conjunction with the facility fire alarm and signaling vendor, Pacific Signaling. How the facility plans to monitor its performance to make sure that solutions are sustained. Maintenance Director/Designee will present any findings during our Daily Clinical meetings. Interventions to be reviewed in the facility monthly QAPI meeting x 3 months. The Administrator will bring 2567 and POC to the meeting to discuss and ensure understanding. Date of compliance: 03/27/2025