Failure to Maintain Fire Extinguisher Inspection Records
Summary
The facility failed to maintain proper records of monthly inspections for portable fire extinguishers as required by NFPA 101 and NFPA 10 standards. During a life safety survey, it was observed that the fire extinguisher located in the 1st floor atrium had a hang tag with no monthly inspections recorded. A vendor was seen changing the tag on this extinguisher shortly before the finding, and the Director of Maintenance explained that it was their policy to remove old tags if the record was full. However, the new tag also lacked any recorded inspections. Further inspection revealed that no monthly inspections were recorded for any extinguishers on all four floors of the building. Additionally, the facility's fire extinguisher inspection log was incomplete, lacking a full inventory of all extinguishers in the building. This deficiency indicates a failure to comply with the required standards for fire safety equipment maintenance and documentation.
Plan Of Correction
Plan of Correction: Approved January 13, 2025 Element 1 Immediate Corrective Action: All fire extinguishers in the building including the 1st floor atrium, were inspected immediately to ensure compliance with fire safety standards. The maintenance staff will ensure that each extinguisher has a correctly dated inspection tag. Old hangtags will only be removed after transferring all records to the new tag. A specific protocol was established for transitioning all records to the new tag. A specific protocol will be established for transitioning between old and new tags to prevent lapses in inspection documentation. A meeting will be held with the vendor to review their inspection responsibilities and documentation standards. Element 2: All residents have the potential to be affected by this practice; however, no residents were affected as a result of this practice. Element 3 Systemic Changes: Policy was reviewed and revised to reflect that old hand tags will only be removed after transferring all records to the new tag. A specific protocol will be established for transitioning between old tags to prevent lapses in inspection documentation. The maintenance will implement a Fire Extinguisher log to ensure compliance. The maintenance director will audit to ensure all fire extinguishers are inspected and documentation is up to date. Element 4: The maintenance director will audit to ensure all fire extinguishers are inspected monthly and documentation is up to date. The maintenance director will monitor compliance and report findings to the administrator monthly. The maintenance director will report findings to the QAPI Committee on a quarterly basis for 3 quarters. The QAPI Committee will determine if further action is required. Element 5: Person responsible: Maintenance director.
Penalty
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