Fire Extinguisher Maintenance Deficiency
Summary
During a Life Safety Code survey, it was observed that portable fire extinguishers in the facility were not properly maintained. Specifically, the safety seal or tamper indicator was missing from the fire extinguishers located in the Unit 6 Resident Lounge and the B Wing Laundry room in the Basement. The last recorded monthly inspection for these extinguishers was on November 4, 2024. The Maintenance Director, when interviewed, was unaware of the missing safety seals and stated that they checked the safety seals during monthly inspections. Additionally, in the B Wing Central Supply/Medical Supply room in the Basement, a large metal rack filled with medical supplies was found obstructing access to a portable fire extinguisher. The Maintenance Director explained that a staff member had been organizing the room and must have moved the rack in front of the extinguisher. The facility's fire extinguisher check sheets confirmed that monthly inspections had been conducted throughout the year.
Plan Of Correction
Plan of Correction: Approved December 30, 2024 1. Portable fire extinguisher located in the Unit 6 Resident Lounge tamper seal was replaced by Maintenance Director. Portable fire extinguisher located in the B Wing Laundry room had tamper seal replaced by Maintenance Director. Basement in the B Wing Central Supply/Medical Supply room had items removed from obstruction of portable fire extinguisher by Maintenance Director. 2. All residents are at risk for deficient practice of fire extinguishers missing safety seal and obstruction of fire extinguishers. 3. A complete audit of all fire extinguishers was completed by Maintenance Director. Any deficient practices were fixed. 4. All staff were educated on keeping all fire extinguishers free of obstruction by RN Educator. Maintenance Director/Tech were educated by Administrator to ensure tamper seals are in place on portable fire extinguishers. 5. A monthly audit of all fire extinguishers to check for obstruction and tamper seals will be done for the next 6 months. Any deficient practices will be corrected and brought to QAPI for further discussion. Person Responsible: Maintenance Director
Penalty
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