Smoke Detector Failed to Activate During Functional Test
Penalty
Summary
During a facility tour and interview, surveyors observed that a smoke detector located in the hallway near Nurse Station 1 and resident rooms 730 and 743 failed to activate the fire alarm system when tested. The test involved spraying the smoke detector three times with smoke detector test spray, but the device did not trigger an alarm. The Director of Subacute, present during the test, was unable to explain why the smoke detector did not respond. This deficiency affected 24 out of 59 residents in one of four smoke compartments. Records of system acceptance, maintenance, and testing were expected to be readily available and the fire alarm system was required to be maintained in reliable operating condition in accordance with NFPA 70 and NFPA 72 standards.
Plan Of Correction
Smoke detector located in the hallway by nurse station 1 and resident rooms 730 and 743 was repaired by contracted company (Please see the attachment). MONITORING: 1. The plant operations team, headed by the plant operations director or qualified designee, will be inspecting all smoke detectors on a semi-annual basis. Monitoring will be conducted during Environment of Care (EOC) rounding on a quarterly basis. Action plans are generated with findings and deadlines for completion. Findings and data trends are reported to the environment of care committee on a quarterly basis for further review and recommendations.