Failure to Provide Fire Extinguisher in Generator Enclosure
Penalty
Summary
The facility failed to properly equip the generator enclosure with the required fire safety equipment, specifically a portable fire extinguisher. During a tour and interview with the Director of Maintenance, it was observed that the diesel fuel storage area, located in an external concrete enclosure with the generator, did not have a fire extinguisher installed within the minimum required travel distance. The closest fire extinguisher was found to be inside the facility, across a courtyard, rather than within 30 or 50 feet of the diesel fuel storage enclosure as required by NFPA 10 standards for Class B hazards. This deficiency was identified during an inspection and affected all 114 residents and four smoke compartments in the facility. The absence of a fire extinguisher in the specified location was directly observed, and the Director of Maintenance confirmed the lack of appropriate fire safety equipment in the generator enclosure area.
Plan Of Correction
1. How corrective action will be accomplished for those residents found to have been affected by this deficient practice. A fire extinguisher was put in place within the diesel fuel storage area. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and Environmental Service Director. 2. How the facility will identify other residents having the potential to be affected. All residents have the potential to be affected. No other negative findings were noted. 3. What measures systems will be put into place to ensure the deficient practice does not recur. To ensure that the alleged deficient practice does not recur, the facility staff were in-serviced by the DSD and/or Maintenance Director regarding "The protocols for addressing a grease fire and the appropriate procedures to address such an occurrence." The DSD and/or Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction. Maintenance Director conducted monthly through random facility staff interviews will verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. Any negative findings will be immediately corrected and reported to the Administrator. 4. How the facility plans to monitor its performance to make sure that solutions are sustained. The Administrator will monitor monthly with the Safety Committee the findings from the random facility staff interviews to verify that staff are aware of the protocols for addressing a grease fire and the appropriate procedures to address such an occurrence. The findings will be reported to the QA/QAPI Committee monthly for analysis, review, modification and/or correction.