HospitalInspections.org

Based on random observation and performance testing it was determined the hospital failed to maintain all hazardous room doors to be self-closing.

Findings include:

1) On 02/23/10 at approximately 9:30 a.m., one (1) of one (1) soiled linen holding room corridor doors located on the 200 wing was observed not to close and latch (when tested) with the self-closing device.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain all components of the hospital fire alarm system.

Findings include:

1) On 02/23/10 at approximately 1:30 p.m., the hospital fire alarm inspection reports for the previous twelve (12) month period were reviewed. The most current report prepared by Simplex Grinnell Company was dated 12/17/09. This inspection report indicated that five (5) heat detectors failed (no alarm when tested). Also, the report indicated that the deficiencies (heat detectors, no alarm) identified during the inspection were the customer's responsibility to correct.

2) An interview with the Plant Operations Director on this same date and time revealed that the five (5) inoperable heat detectors identified in the report had not been corrected as of this date 02/23/10.

NFPA (National Fire Protection Association) 72 - National Fire Alarm Code
Chapter 7- Inspection, Testing, and Maintenance
7-3.2.1*

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2. The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

This Standard is not met as evidenced by:

Based on documentation review and staff interview it was determined the hospital failed to inspect and test all smoke detectors in accordance with NFPA 72.

Findings include:

1) On 02/23/10 at approximately 9:30 a.m., a fire alarm sensitivity test report prepared by Simplex Grinnell and dated 09/23/09 was reviewed. This report indicated that there was no sensitivity test completed on the smoke detectors for the 2nd floor of the hospital on this date.

2) An interview with the Plant Operations Director on this same date and time revealed that there was no documentation available to confirm the last time the 2nd floor smoke detectors were sensitivity tested.

NFPA (National Fire Protection Association) 13 - Standard for the Installation of Sprinkler Systems
Chapter 5 - Installation Requirements
5-6 Standard Pendent and Upright Spray Sprinklers
5-6.3.4 Minimum Distance Between Sprinklers.

Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Exception No. 1: Sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied:

(a) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(b) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(c) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high. The tops of baffles shall extend between 2 in. and 3 in. (51 mm and 76 mm) above the deflectors of upright sprinklers. The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.

Exception No. 2: In-rack sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center.

Exception No. 3: Old-style sprinklers protecting fur storage vaults shall be permitted to be placed less than 6 ft (1.8 m) on center.

NFPA (National Fire Protection Association) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-3.2* Gauges.
Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-4.1.2*
Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

This Standard is not met as evidenced by:

9-4.2 Check Valves.
9-4.2.1 Inspection.
Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*

Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on review of facility documentation, observation and interview it was determined the hospital failed to maintain, inspect, and test the sprinkler system in accordance with NFPA (National Fire Protection Association) 13 and 25.

Findings include:

1) On 02/23/10 at approximately 2:30 p.m., the hospital sprinkler inspection reports for the previous twelve (12) month period were reviewed. The most current inspection report prepared by Simplex Grinnell Company was dated 12/17/09. This report was found to be incomplete due to the lack of information for the following requirements:

a) Have gauges been tested, calibrated or replaced in the last five (5) years? Answered "no" on report with no explanation or date given.
b) Alarm valves and associated trim internally inspected in the past five (5) years? Answered "no" on report with no explanation or date given.
c) Check valves internally inspected in the last five (5) years? Answered "no" on report with no explanation or date given.
d) Has the private fire main been flow tested in last five (5) years? Answered "no" on report with no explanation or date given.

2) On 02/23/10 at approximately 10:00 a.m., inspection of rooms 214 and 215 found two (2) sprinkler heads in each room approximately thirty-six (36) inches apart. There are no baffles between the heads.

3) An interview with the Plant Operations Director on this same date and time, revealed that a wall had been removed in the area of the sprinkler heads. Due to removal of the wall that was originally constructed between the sprinkler heads, the sprinkler head spacing does not meet the requirement of not less than six feet on center.

4) On 02/24/10 at approximately 10:15 a.m., a tour of the kitchen area of the hospital was conducted. At this time, three (3) sprinkler heads located in the following areas were observed to be corroded.
a) Dish wash room (2).
b) Near rangehood (1).

Based on observation it was determined the hospital failed to maintain all fire extinguishers in accordance with NFPA (National Fire Protection Association) 10.

Findings include:

1) On 02/24/10 at approximately 10:30 a.m., the "K" guard fire extinguisher located in the kitchen was observed to have a manufacture date of 2004. This fire extinguisher was also observed not to have a hydrostatic label attached. Wet chemical fire extinguishers are required to be hydrotested at five (5) year intervals. Therefore, the hydrostatic test is past due as of this date 02/24/10.

NFPA (National Fire Protection Association) 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
7-2.2.1

Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.

(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 9 - Inspection, Maintenance and Recharging
9-3 Maintenance.
9-3.1*

At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual.

This Standard is not met as evidenced by:

Based on review of facility documentation it was determined the hospital failed to maintain and inspect the range hood extinguishing system as required by NFPA 96.

Findings include:

1) On 02/23/10 at approximately 10:30 a.m., the facility range hood extinguishing system reports for the previous twelve (12) month period were reviewed. These reports prepared by Simplex Grinnell Company were dated 03/20/09 and 12/14/09, a time lapse of approximately nine (9) months between inspections. Range hood extinguishing systems are required to be inspected and tested at six (6) month intervals.

NFPA (National Fire Protection Association) 110 - Standard for Emergency and Standby Power Systems
5-3 Lighting.
5-3.1

The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain the facility generator in accordance with NFPA 110.

Findings include:

1) On 02/23/10 at approximately 9:30 a.m., the generator site location and transfer switch room for one (1) of two (2) hospital generators was observed not to have any battery-powered emergency lighting.

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.

The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:

(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.

(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.

(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

NFPA 70 - National Electrical Code
Chapter 5 - Special Occupancies
Article 517 - Health Care Facilities
517-20. Wet Locations

a. All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Reference:

Underwriters Laboratories (UL) Directory Guide: Relocatable Power Taps Use and Installation
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code".

NFPA 70 National Electrical Code- 2002 Edition Article 517 Health Care Facilities
517.2 Definitions

Health Care Facilities. Buildings or portions of buildings that contain, but are not limited to, occupancies such as hospitals; nursing homes; limited care; supervisory care; clinics; medical and dental offices; and ambulatory care, whether permanent or movable.

Patient Care Area: Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification. FPN: Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 70 and 99.

Findings include:

1) On 02/23/10 at approximately 2:30 p.m., an interview with the Plant Operations Director revealed there was no documentation available that would verify the certification of the hospital LIM (line isolation monitor) circuit for the previous twelve (12) month period. Also, on this same date and time a tour of the OR (operating room) area was conducted. At this time, the green safe light for OR #2 LIM was not illuminated. Also, one (1) LIM in the OR area was switched off.

2) On 02/23/10 at approximately 2:40 p.m., a relocatable power tap was observed hanging on the wall in OR #2. An interview with the Interim OR Nurse Manager on this same date and time revealed that the relocatable power tap is sometimes used to raise and lower a patient's bed.

3) On 02/25/10 at approximately 11:00 a.m., the following areas/rooms were observed to have electrical receptacles near a water source (hand sinks) that were not GFCI (ground fault circuit interrupter) protected:

a) 2nd floor men's restroom.
b) Room 221.
c) Emergency area treatment rooms.

Based on random observation and performance testing it was determined the hospital failed to maintain all hazardous room doors to be self-closing.

Findings include:

1) On 02/23/10 at approximately 9:30 a.m., one (1) of one (1) soiled linen holding room corridor doors located on the 200 wing was observed not to close and latch (when tested) with the self-closing device.

Based on review of facility documentation and staff interview it was determined the hospital failed to maintain all components of the hospital fire alarm system.

Findings include:

1) On 02/23/10 at approximately 1:30 p.m., the hospital fire alarm inspection reports for the previous twelve (12) month period were reviewed. The most current report prepared by Simplex Grinnell Company was dated 12/17/09. This inspection report indicated that five (5) heat detectors failed (no alarm when tested). Also, the report indicated that the deficiencies (heat detectors, no alarm) identified during the inspection were the customer's responsibility to correct.

2) An interview with the Plant Operations Director on this same date and time revealed that the five (5) inoperable heat detectors identified in the report had not been corrected as of this date 02/23/10.

NFPA (National Fire Protection Association) 72 - National Fire Alarm Code
Chapter 7- Inspection, Testing, and Maintenance
7-3.2.1*

Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2. The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

This Standard is not met as evidenced by:

Based on documentation review and staff interview it was determined the hospital failed to inspect and test all smoke detectors in accordance with NFPA 72.

Findings include:

1) On 02/23/10 at approximately 9:30 a.m., a fire alarm sensitivity test report prepared by Simplex Grinnell and dated 09/23/09 was reviewed. This report indicated that there was no sensitivity test completed on the smoke detectors for the 2nd floor of the hospital on this date.

2) An interview with the Plant Operations Director on this same date and time revealed that there was no documentation available to confirm the last time the 2nd floor smoke detectors were sensitivity tested.

NFPA (National Fire Protection Association) 13 - Standard for the Installation of Sprinkler Systems
Chapter 5 - Installation Requirements
5-6 Standard Pendent and Upright Spray Sprinklers
5-6.3.4 Minimum Distance Between Sprinklers.

Sprinklers shall be spaced not less than 6 ft (1.8 m) on center.

Exception No. 1: Sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center where the following conditions are satisfied:

(a) Baffles shall be installed and located midway between sprinklers and arranged to protect the actuating elements.
(b) Baffles shall be of noncombustible or limited-combustible material that will stay in place before and during sprinkler operation.
(c) Baffles shall be not less than 8 in. (203 mm) wide and 6 in. (152 mm) high. The tops of baffles shall extend between 2 in. and 3 in. (51 mm and 76 mm) above the deflectors of upright sprinklers. The bottoms of baffles shall extend downward to a level at least even with the deflectors of pendent sprinklers.

Exception No. 2: In-rack sprinklers shall be permitted to be placed less than 6 ft (1.8 m) on center.

Exception No. 3: Old-style sprinklers protecting fur storage vaults shall be permitted to be placed less than 6 ft (1.8 m) on center.

NFPA (National Fire Protection Association) 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-3.2* Gauges.
Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-4.1.2*
Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

This Standard is not met as evidenced by:

9-4.2 Check Valves.
9-4.2.1 Inspection.
Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-based Protection Systems
2-2 Inspection.
2-2.1 Sprinklers.
2-2.1.1*

Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

This Standard is not met as evidenced by:

Based on review of facility documentation, observation and interview it was determined the hospital failed to maintain, inspect, and test the sprinkler system in accordance with NFPA (National Fire Protection Association) 13 and 25.

Findings include:

1) On 02/23/10 at approximately 2:30 p.m., the hospital sprinkler inspection reports for the previous twelve (12) month period were reviewed. The most current inspection report prepared by Simplex Grinnell Company was dated 12/17/09. This report was found to be incomplete due to the lack of information for the following requirements:

a) Have gauges been tested, calibrated or replaced in the last five (5) years? Answered "no" on report with no explanation or date given.
b) Alarm valves and associated trim internally inspected in the past five (5) years? Answered "no" on report with no explanation or date given.
c) Check valves internally inspected in the last five (5) years? Answered "no" on report with no explanation or date given.
d) Has the private fire main been flow tested in last five (5) years? Answered "no" on report with no explanation or date given.

2) On 02/23/10 at approximately 10:00 a.m., inspection of rooms 214 and 215 found two (2) sprinkler heads in each room approximately thirty-six (36) inches apart. There are no baffles between the heads.

3) An interview with the Plant Operations Director on this same date and time, revealed that a wall had been removed in the area of the sprinkler heads. Due to removal of the wall that was originally constructed between the sprinkler heads, the sprinkler head spacing does not meet the requirement of not less than six feet on center.

4) On 02/24/10 at approximately 10:15 a.m., a tour of the kitchen area of the hospital was conducted. At this time, three (3) sprinkler heads located in the following areas were observed to be corroded.
a) Dish wash room (2).
b) Near rangehood (1).

Based on observation it was determined the hospital failed to maintain all fire extinguishers in accordance with NFPA (National Fire Protection Association) 10.

Findings include:

1) On 02/24/10 at approximately 10:30 a.m., the "K" guard fire extinguisher located in the kitchen was observed to have a manufacture date of 2004. This fire extinguisher was also observed not to have a hydrostatic label attached. Wet chemical fire extinguishers are required to be hydrotested at five (5) year intervals. Therefore, the hydrostatic test is past due as of this date 02/24/10.

NFPA (National Fire Protection Association) 96 - Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
7-2.2.1

Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable.

(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

NFPA 17A - Standard for Wet Chemical Extinguishing Systems
Chapter 9 - Inspection, Maintenance and Recharging
9-3 Maintenance.
9-3.1*

At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual.

This Standard is not met as evidenced by:

Based on review of facility documentation it was determined the hospital failed to maintain and inspect the range hood extinguishing system as required by NFPA 96.

Findings include:

1) On 02/23/10 at approximately 10:30 a.m., the facility range hood extinguishing system reports for the previous twelve (12) month period were reviewed. These reports prepared by Simplex Grinnell Company were dated 03/20/09 and 12/14/09, a time lapse of approximately nine (9) months between inspections. Range hood extinguishing systems are required to be inspected and tested at six (6) month intervals.

NFPA (National Fire Protection Association) 110 - Standard for Emergency and Standby Power Systems
5-3 Lighting.
5-3.1

The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain the facility generator in accordance with NFPA 110.

Findings include:

1) On 02/23/10 at approximately 9:30 a.m., the generator site location and transfer switch room for one (1) of two (2) hospital generators was observed not to have any battery-powered emergency lighting.

NFPA (National Fire Protection Association) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.

The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:

(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.

(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.

(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

NFPA 70 - National Electrical Code
Chapter 5 - Special Occupancies
Article 517 - Health Care Facilities
517-20. Wet Locations

a. All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or be served by an isolated power system if such interruption cannot be tolerated.

Reference:

Underwriters Laboratories (UL) Directory Guide: Relocatable Power Taps Use and Installation
Relocatable power taps have not been investigated and are not intended for use with general patient care areas or critical patient care areas of health care facilities as defined in Article 517 of ANSI/NFPA 70, "National Electrical Code".

NFPA 70 National Electrical Code- 2002 Edition Article 517 Health Care Facilities
517.2 Definitions

Health Care Facilities. Buildings or portions of buildings that contain, but are not limited to, occupancies such as hospitals; nursing homes; limited care; supervisory care; clinics; medical and dental offices; and ambulatory care, whether permanent or movable.

Patient Care Area: Any portion of a health care facility wherein patients are intended to be examined or treated. Areas of a health care facility in which patient care is administered are classified as general care areas or critical care areas, either of which may be classified as a wet location. The governing body of the facility designates these areas in accordance with the type of patient care anticipated and with the following definitions of the area classification. FPN: Business offices, corridors, lounges, day rooms, dining rooms, or similar areas typically are not classified as patient care areas.

This Standard is not met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 70 and 99.

Findings include:

1) On 02/23/10 at approximately 2:30 p.m., an interview with the Plant Operations Director revealed there was no documentation available that would verify the certification of the hospital LIM (line isolation monitor) circuit for the previous twelve (12) month period. Also, on this same date and time a tour of the OR (operating room) area was conducted. At this time, the green safe light for OR #2 LIM was not illuminated. Also, one (1) LIM in the OR area was switched off.

2) On 02/23/10 at approximately 2:40 p.m., a relocatable power tap was observed hanging on the wall in OR #2. An interview with the Interim OR Nurse Manager on this same date and time revealed that the relocatable power tap is sometimes used to raise and lower a patient's bed.

3) On 02/25/10 at approximately 11:00 a.m., the following areas/rooms were observed to have electrical receptacles near a water source (hand sinks) that were not GFCI (ground fault circuit interrupter) protected:

a) 2nd floor men's restroom.
b) Room 221.
c) Emergency area treatment rooms.