HospitalInspections.org

Based on plan review, observation and staff interview, the facility failed to ensure the minimum construction requirements were met for a steel frame Type II unprotected building on 1 of 2 floors. The findings were:

Review of the plans showed the facility was designed as a two story, Type II (000) unprotected steel frame building, with a complete sprinkler system. Observation on 7/31/13 at 12:19 PM showed the old cardiac catheterization lab room was 480 square feet and did not have sprinkler coverage. At the time of the observation, the director of plant operations reported he was unaware the area did not have sprinkler coverage. He further reported plans have not been developed to install sprinklers in this area.

Reference NFPA 101, 2000 Edition;
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations

Construction Type Stories
________________________________________
1 2 3 4 or More
________________________________________
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
_________________________________________

X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)

Based on observation and staff interview, the facility failed to ensure corridor doors were smoke resistant and dutch doors closed as a single unit in 5 of 10 smoke compartments. The findings were:

1 Observation of the chapel on 7/30/13 at 1:32 PM showed the corridor door had two unsealed holes where the existing lock was replaced. At the time of the observation the director of plant operations could not explain why the holes were not sealed after the locking hardware was removed.

2. Observation of the pine ridge nurses ' station on 7/30/13 at 2:20 PM showed the corridor door was a dutch door. Further observation showed the meeting edge of the upper and lower leaves were not equipped with an astragal, rabbet or bevel. At the time of the observation, the director of plant operations reported he was unaware of the aforementioned requirement for meeting edges.

3. Observation of the ambulatory surgical center on 7/30/13 at 3:16 PM showed the break room corridor door was not equipped with latching hardware. At the time of the observation, the director of plant operations could not explain why the latching hardware was not installed. He also could not explain why this issue was not noticed and addressed during the quarterly safety inspections.

4. Observation of the surgical department on 7/30/13 at 8:37 PM showed the corridor door to operating room #4 would bind against the door frame preventing the door from closing into the door frame. At the time of the observation, the director of plant operations reported the operating area was not routinely involved in safety inspections.

5. Observation of the emergency department on 7/31/13 at 9:36 AM showed the nutrition kitchen corridor door was warped so the door would not latch into the door frame. At the time of the observation, the director of plant operations could not explain why the door was not noticed and repaired during the quarterly safety inspections.

6. Observation of the emergency department on 7/31/13 at 9:56 AM showed the corridor door for treatment room #4 would not latch into door frame. Further observation showed the smoke gasket along the door frame impeded the door so the latch bolt could not insert into the strike plate. At the time of the observation, the director of plant operations could not explain why the door was not noticed and repaired during the quarterly safety inspections.

7. Observation of the emergency department on 7/31/13 at 9:57 AM showed the staff break room corridor door was not equipped with latching hardware. Further observation showed the corridor door frame was not equipped with a strike plate. At the time of the observation, the director of plant operations could not explain why the latching hardware was not installed. He also could not explain why this issue was not noticed and addressed during the quarterly safety inspections.

Based on observation and staff interview, the facility failed to ensure hazardous areas were separated from use areas in 2 of 10 smoke compartments. The findings were:

1 Observation of the surgical department on 7/30/13 at 8:42 PM showed the storeroom near operating room #4 was 118 square feet. Further observation showed the corridor door was not equipped with a self-closing device. At the time of the observation, the director of plant operations could not explain why the door was not equipped with a self-closing device as the room exceeded 50 square feet. He also reported the operating area was not routinely involved in safety inspections.

2. Observation of the surgical department on 7/30/13 at 9 PM showed the anesthesia work room stored combustible material. Further observation showed a wedge under the corridor door prevented the self-closing device from closing. The door was posted with a sign reading; "close this door before leaving the area". At the time of the observation, the director of plant operations reported he was unaware the sign was posted. He also confirmed that he was aware only hold open device that released with the activation of the fire alarm system were allowed on hazardous areas.

3. Observation of the infection control department on 7/31/13 at 1:42 PM showed the clean linen room stored combustible material and was 120 square feet. Further observation showed the corridor door was not equipped with a self-closing device. At the time of the observation, the director of plant operations could not explain why the door was not equipped with a self-closing device as the room exceeded 50 square feet.

4. Observation of the infection control department on 7/31/13 at 1:49 PM showed 30 cardboard boxes filled with combustible supplies were being stored in the corridor alcove. The alcove was not separated from the corridor by smoke resistant partitions. At the time of the observation, the director of plant operations confirmed the cardboard boxes were not supposed to be stored in the alcove. He could not explain why these items had not been noticed and removed during the quarterly safety inspections.

5. Observation of the infection control department on 7/31/13 at 1:55 PM showed combustible supplies were being stored in the cleanup room. Further observation showed the room was 60 square feet and the corridor door was not equipped with a self-closing device. At the time of the observation, the director of plant operations could not explain why the door was not equipped with a self-closing device as the room exceeded 50 square feet.

Based on observation and staff interview, the facility failed to ensure access-control egress doors were properly installed in 2 of 10 smoke compartments. The findings were:

1 Observation of the medical surgical floor on 7/31/13 at 1:05 PM showed the egress pathway lead into the intensive care unit. Further observation showed the two cross corridor doors were locked with magnetic locks that released with the activation of the fire alarm system, sprinkler system, loss of utility power and a combination key pad. The locks did not release with the activation of a sensor from the egress side. At the time of the observation, the director of plant operations reported he was unaware the doors were required to release from the egress side of the medical surgical floor.

2. Observation of the women ' s health department on 7/31/13 at 1:20 PM showed the two cross corridor doors between the medical surgical floor were locked with magnetic locks. Further observation showed the south pair of cross corridor doors were also locked with magnetic locks. The cross corridor doors were locked with magnetic locks that released with the activation of the fire alarm system, sprinkler system, loss of utility power and a combination key pad. The locks did not release with the activation of a sensor from the egress side. At the time of the observation, the director of plant operations reported he was unaware the doors were required to release from the egress side.

Reference NFPA 101, 2000 Edition, 19.2.2.2.4;
7.2.1.6.2 Access-Controlled Egress Doors. Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on observation, plan review, and staff interview, the facility failed to ensure exit signs were placed above cross corridor doors in the path of egress in 1 of 10 smoke compartments. The findings were:

Observation of the infection control department on 7/31/13 at 1:53 PM showed the northeast corridor was isolated by two sets of double, cross corridor doors. Further observation showed neither set of doors was marked with an exit sign to direct individuals to the nearest exit. At the time of the observation, the director of plant operations could not explain why an exit sign was not present. Review of the plans showed that all other cross corridor doors were equipped with exit signs. He could not explain why this issue was not noticed and modified during the quarterly safety inspections.

Reference NFPA 101, 2000 Edition, 19.2.10.1;
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on record review and staff interview, the facility failed to ensure 1 of 7 fire alarm system components was tested. The findings were:

Review of the fire alarm system testing records showed the fire alarm control panel batteries semi-annual load voltage test was last conducted on 2/27/13. Further review showed the semi-annual load voltage test was only being conducted during the annual fire alarm system test. On 7/31/13 at 4 PM, the maintenance manager reported he was unaware of the aforementioned test requirement.

Reference NFPA 101, 2000 Edition, 19.3.4.1, 9.6.1.4, NFPA 72, 1999 Edition;
Table 7-3.2 Testing Frequencies.
6. Batteries-Fire alarm systems
d. Sealed Lead-Acid Type
3. Load Voltage Test, ... ... ... ... ..... semi-annually

Based on observation, plan review, and staff interview, the facility failed to ensure 2 of 10 smoke compartments had complete sprinkler coverage, failed to ensure sprinkler heads in newly renovated areas had the same activation type in 1 of 10 smoke compartments, failed to ensure shut off valves were electronically monitored in 1 of 10 smoke compartments, and failed to ensure backflow preventers were properly installed in 1 of 10 smoke compartments. The findings were:

1 Observation of the surgical department female locker room on 7/30/13 at 2:40 PM showed the shower area did not have sprinkler coverage because the sprinkler head in the area was obstructed by a vertical wall. The unprotected area was 15 square feet. At the time of the observation, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

2. Observation of the emergency department on 7/31/13 between 9:30 AM and 10 AM showed the corridor to the new treatment rooms had four quick response sprinkler heads installed. The sprinkler heads in the existing corridor were all standard response heads. Further observation showed the renovated emergency room exterior entrance had three quick response heads installed. The single existing sprinkler head was a standard response head. On 7/31/13 at 9:40 AM, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

3. Observation of the loading dock antifreeze sprinkler system on 7/31/13 at 11:03 AM showed an outside stem and yoke shut off valve was not electronically supervised by the fire alarm system. The valve was held in the open position by a steel chain locked with a keyed pad lock. At the time of the observation, the director of plant operations could not explain why the shut off valve was not electronically monitored.

4. Observation on of the old cardiac catheterization lab on 7/31/13 at 12:49 PM showed the room was 480 square feet and did not have sprinkler coverage. Plan review showed the facility was a two story building of Type II (000) construction and required a complete sprinkler system. At the time of the observation, the director of plant operations reported he was unaware the area did not have sprinkler coverage. He further reported that plans have not been developed to install sprinklers in this area.
5. Observation of the intensive care unit on 7/31/13 at 1:12 PM showed the alcove behind the soiled work room did not have sprinkler coverage. The alcove was 6 square feet and the nearest sprinkler head was obstructed by a vertical wall. At the time of the observation, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

6. Observation of the ambulatory surgical department sprinkler riser on 7/31/13 at 2:10 PM showed the control, drain, and test connection valves were not posted with identification signs. At the time of the observation, the maintenance manager could not explain why the valves were not posted when the area was built in 2010.

Reference, NFPA 101, 2000 Edition;
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
Table 19.1.6.2 Construction Type Limitations

Construction Type Stories
________________________________________
1 2 3 4 or More
________________________________________
I(443) X X X X
I(332) X X X X
II(222) X X X X
II(111) X X* X* NP
II(000) X* X* NP NP
III(211) X* X* NP NP
III(200) X* NP NP NP
IV(2HH) X* X* NP NP
V(111) X* X* NP NP
V(000) X* NP NP NP
_________________________________________

X: Permitted type of construction.
NP: Not permitted.
*Building requires automatic sprinkler protection. (See 19.3.5.1.)
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
NFPA 13, 1999;
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
5-1.1 The requirements for spacing, location, and position of sprinklers are based on the following principles:
1) Sprinklers installed throughout the premises
2) Sprinkler located so as not to exceed maximum protection area per sprinkler
3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
5-3.1.4 Temperature Ratings.
5-3.1.4.2 The following practices shall be observed to provide sprinklers of other than ordinary temperature classification unless other temperatures are determined or unless high-temperature sprinklers are used throughout ...
1) Sprinklers in the high-temperature zone shall be of the high-temperature classification, and sprinklers in the intermediate-temperature zone shall be of the intermediate-temperature classification.
5-3.1.4.3 In case of occupancy change involving temperature change, the sprinklers shall be changed accordingly.
5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.
5-5.3.1 Maximum Distance Between Sprinklers. The maximum distance permitted between sprinklers shall be based on the centerline distance between sprinklers on the branch line or on adjacent branch lines. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.

Based on observation and staff interview, the facility failed to ensure ceilings were smoke resistant to maintain heat flow to sprinkler heads, failed to ensure sprinklers were unobstructed, failed to ensure sprinkler heads were not obstructed by foreign material, failed to ensure sprinkler heads were maintained to installation requirements in 6 of 10 smoke compartments and failed to ensure the facility had adequate spare sprinkler heads. The findings were:

1 Observation of the sprinkler system showed the following locations did not have smoke resistant ceilings which could delay sprinkler activation times:
a. The telephone room had six unsealed cable penetrations on 7/30/13 at 12:36 PM.
b. Patient room #222 had a warped ceiling tile on 7/30/13 at 1:58 PM.
c. The telecommunication room had six unsealed cable penetrations on 7/30/13 at 3:11 PM.
d. The environmental service storeroom was missing a ceiling tile on 7/31/13 at 11:33 AM.
e. The bathroom in patient room #118 was missing a ceiling tile on 7/31/13 at 1:34 PM.
On 7/30/13 at 1:58 PM, the maintenance manager reported the ceilings were not routinely inspected to ensure they were smoke resistant. He further reported ceiling penetrations were repaired by the maintenance staff when hospital staff submitted work orders.

2. Observation of patient room #204 on 7/30/13 at 2:01 PM showed the sprinkler head in the restroom was a recess type head. Further observation showed a light fixture had been secured over a portion of the sprinkler cover plate preventing the head from activating in a fire emergency. At the time of the observation, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

3. Observation of the sprinkler system on 7/30/13 between 2:30 PM and 3PM showed three sprinkler heads in the surgical department female locker room had a mineral deposit, crystal appearance material, at the water orifice cover. Further observation showed one sprinkler head in the cardiology office had a similar mineral deposit material at the water orifice cover. On 7/30/13 at 2:39 PM, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

4. Observation of operating room (OR) #3 on 7/30/13 at 8:29 PM showed two sprinkler heads were obstructed by ceiling mounted fluorescent lights. The lights were 12 inches from and 3 inches below the sprinkler heads.

5. Observation of the kitchen on 7/31/13 between 10:30 AM and 11 AM showed one sprinkler head in the dish washing room was corroded. Further observation showed one sprinkler head in the environmental services closet was corroded. On 7/31/13 at 10:56 AM, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

6. Observation of the sprinkler system showed sprinkler heads were obstructed by steel beams in the following locations:
a. A sprinkler head was located 6 inches from and 1 inch above the bottom a steel beam under the first landing in the south stairwell on 7/30/13 at 2:59 PM.
b. A sprinkler head was located 8 inches from and 1 inch above the bottom a steel beam under the first landing in the north stairwell on 7/31/13 at 1:35 PM.
On 7/30/13 at 2:59 PM, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

7. Observation of the environmental service office on 7/31/13 at 11:35 AM showed two sprinkler heads were located 5 feet apart. Further observation showed that one head was located 11 feet from the far wall and would not supply adequate sprinkler coverage if the nearest head to the wall was cold soldered by the far head. At the time of the observation, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

8. Observation of the spare sprinkler cabinet on 7/31/13 at 11:47 AM showed there was only one 200 degree upright sprinkler head to replace heads in mechanical rooms. At the time of the observation, the maintenance manager reported the sprinkler heads were supplied by the sprinkler contractor. He further reported the facility did not monitor the spare sprinkler supply.

9. Observation of the infection control department on 7/31/13 at 1:51 PM showed a sprinkler head installed over the work station was 12 feet from the wall. At the time of the observation, the director of plant operations reported the sprinkler system was inspected annually by an outside sprinkler contractor and this issue had not been addressed by the contractor.

Reference NFPA 101, 2000 Edition, 19.3.5.1, 9.7.1.1, NFPA 13, 1999 Edition;
3-2.7.2 Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
5-5.3.1 Maximum Distance Between Sprinklers. The maximum distance permitted between sprinklers shall be based on the centerline distance between sprinklers on the branch line or on adjacent branch lines. The maximum distance shall be measured along the slope of the ceiling. The maximum distance permitted between sprinklers shall comply with the value indicated in the section for each type or style of sprinkler.
5-5.3.2 Maximum Distance From Walls. The distance from sprinklers to walls shall not exceed one-half of the allowable maximum distance between sprinklers. The distance from the wall to the sprinkler shall be measured perpendicular to the wall.
5-5.6 Clearance to storage. The clearance between the deflector and the top of storage shall be 18 in. or greater.
Table 5-6.2.2 (b) Protection Areas and Maximum Spacing (Standard Spray Upright/Standard Spray Pendent) for Ordinary Hazard
Construction Type, ... ..... ... ... ... ... All
System Type, ... ... ... ... ... ... ... ..... All
Protection Area, ... ... ... ... ... .... .... 130 ft2
Spacing, ... ... ... ... ... ... ... ... .... ... 15 ft
5-6.3.4 Minimum Distance Between Sprinklers. Sprinklers shall be spaced not less than 6 ft on center.
Exception No. 1. Sprinklers shall be permitted to be placed less than 6 ft 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. with and 6 in. high ...
5-6.4.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. and a maximum of 12 in.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (Standard Spray Upright/Standard Spray Pendent)

Distance from Maximum allowable
sprinkler to side distance from
of obstruction deflector above
bottom of obstruction
-------------------------------------------------------
Less than 1 ft, ... ... ... ... ... ... ... ... 0
1 ft to less than 1 ft 6 in ... ... ... .... 2 ?
1 ft 6 in. to less than 2 ft ... ... ... ... 3 ?
2 ft to less than 2 ft 6 in ... ... ... ... 5 ?
2 ft 6 in. to less than 3 ft ... ... ...... 7 ?
3 ft to less than 3 ft 6 in ... ... ... ... 9 ?
3 ft 6 in. to less than 4 ft ... ... ...... 12
4 ft to less than 4 ft 6 in ... ... ... ... 14

Reference NFPA 101, 2000 Edition, 19.3.5.1, 9.7.5, NFPA 25, 1998 Edition;
2-2.1.1* Sprinklers shall be visually 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 or loaded, or in the improper orientation.
2-4.1.5 The stock of Spare Sprinklers shall be as follows:
(a) ...Under 300 sprinklers - no fewer than 6 sprinklers
(b) ...300-1000 sprinklers - no fewer than 12 sprinklers
(c) ...Over 1000 sprinklers - no fewer than 24 sprinklers

Based on observation and staff interview, the facility failed to ensure 2 of 3 outdoor medical gas storage areas were posted with "No Smoking" signs, and failed to ensure 1 of 3 outdoor medical gas storage areas were separated from combustible storage. The findings were:

1 Observation of the outdoor medical gas storage areas on 7/31/13 between 11 AM and 11:30 AM showed the outdoor medical gas storage area was not posted with a "No Smoking" sign. Further observation showed the outdoor oxygen storage area was not posted with a "No Smoking" sign. On 7/31/13 at 11:11 AM, the director of plant operations could not explain why the aforementioned areas were not posted with "No Smoking" signs.

2. Observation of the outdoor oxygen storage area on 7/31/13 at 11:15 AM showed combustible materials were being stored less than 5 feet from oxygen cylinders. Wood doors and cardboard boxes were stored 2 feet from oxygen cylinders. At the time of the observation, the director of plant operations could not explain why the combustible items were stored less than 5 feet from the oxygen storage area.

Reference NFPA 101, 2000 Edition, 19.3.2.4, NFPA 99, 1999 Edition;
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3.
(a) Storage locations shall be ...within an enclosed interior space or noncombustible or limited-combustible construction, with doors that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible material by either:
2. A minimum distance of 5 ft if the entire storage location is protected by an automatic sprinkler system designed in accordance with NPA 13, standard for the installation of sprinkler systems, ...
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft, shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and staff interview, the facility failed to ensure the 1 of 2 emergency generators was equipped with a remote emergency stop button. The findings were:

Observation of the main emergency generator on 7/31/13 at 11:17 AM showed the generator was not equipped with an emergency stop button outside of the generator room. At the time of the observation, the maintenance manager reported the generator was replaced in 2007. He also reported that he was unaware an emergency stop button was required outside of the room of the prime mover.

Reference, NFPA 101, 2000 Edition, 19.2.9.1, 7.9.2.3, NFPA 110, 1999 Edition;
3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to the break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Based on observation, plan review, and staff interview, the facility failed to ensure the essential electrical system was separated into three distinct branches for 3 of 7 electrical panels. The findings were:

1 Observation of electrical panel 1LEA on 7/31/13 at 11:51 AM showed the panel was supplied with power from an Equipment Branch automatic transfer switch. Further review showed circuit #9, #17, #19, #21, #23, #25 supplied power to business office plugs, which are Critical Branch equipment. Review also showed Circuit #18 supplied power to the sprinkler flow alarm. Circuit #20 supplied power to an outlet on the oxygen pad. Circuit #24 supplied power to a desiccant medical air dryer. The equipment supplied by circuit #18, #20 and #24 were all Life Safety Branch equipment. At the time of the observation, the maintenance manager reported the essential electrical system was not inspected to ensure equipment was properly separated.

2. Observation of electrical panel 1LSA on 7/31/13 at 12:02 PM showed the panel was supplied with power from a Life Safety Branch automatic transfer switch. Further review showed circuit #6 and #8 supplied power to the cardiac catheterization lab dark room. This equipment is Critical Branch equipment. At the time of the observation, the maintenance manager reported the essential electrical system was not inspected to ensure equipment was properly separated.

3. Observation of electrical panel 1LCC on 7/31/13 at 12:15 PM showed the panel was supplied with power from a Critical Branch automatic transfer switch. Further review showed circuit #27 supplied power to an elevator sump pump. This equipment is Equipment Branch equipment. At the time of the observation, the maintenance manager reported the essential electrical system was not inspected to ensure equipment was properly separated.

4. Review of the electrical one line plans on 7/31/13 at 2:35 PM confirmed panel 1LEA was supplied with power from an Equipment Branch automatic transfer switch. Panel 1LSA was supplied with power from a Life Safety Branch automatic transfer switch. Panel 1LCC was supplied with power from a Critical Branch automatic transfer switch. These findings were confirmed with the maintenance manager.

Reference NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
517-30. Essential Electrical Systems for Hospitals.
(a) Applicability
FPN No. 2. For additional information, see Standard for Health Care Facilities, NFPA 99...
517-32 ...The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(b) General.
(1) Essential electrical systems for hospitals shall comprise of two separate systems capable of supplying limited amount of lighting and power services, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
NFPA 99, Healthcare Facilities, 1999 Edition;
3-4.2. Distribution (Type 1 EES)
3-4.2.2.1 General. Type I essential electrical system are comprised of two separate systems capable of supplying a limited amount of lighting and power services, which is considered essential for the life safety and effective facility operation during the time the normal electrical service is interrupted for any reason. These two systems are the emergency system and the equipment system. The emergency system shall be limited to circuits essential to life safety and critical patient care. They are designated the life safety branch and the critical branch ...
3-4.2.2.2 Emergency System.
(a) General. These functions of patient care depending on lighting or appliances that are permitted to be connected to the emergency system are divided into two mandatory branches, described in 3-4.2.2.2 (b) and (c).
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles and equipment ...
(c) Critical Branch. The critical branch of the emergency system shall supply power to task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches ...
3-4.2.2.3 Equipment system.
(a) General. The equipment system shall be connected to equipment described in 3-4.2.2 (c) through (e) ...

Based on observation and staff interview, the facility failed to provide adequate work space in front of electrical panels, failed to ensure temporary electrical wiring did not replace permanent fixed wiring, failed to ensure damaged electrical equipment was removed in 5 of 10 smoke compartments, and failed to ensure temporary electrical adapters were not an integral part of surgical equipment in 4 of 5 operating rooms. The findings were:

1 Observation of the second floor electrical room on 7/30/13 at 1:36 PM showed a radio router was permanently mounted in front of an electrical circuit panel. At the time of the observation, the maintenance manager reported he was unaware of the current installation. He also reported the electrical equipment rooms were not routinely inspected to ensure electrical panel were provided with 36 inches of work space.

2. Observation of operating room (OR) #5 on 7/30/13 at 8:20 PM showed an IV pole was equipped with a surge protector attached to the pole. On 7/31/13 at 9:10 AM, the director of surgical services reported any electrical equipment that accompanied the patient from the pre-operation department was plugged into the surge protector to limit the trip hazard in the surgical field. He confirmed the surge protectors attached to the IV poles were not tested by the bio med department as an integral part of the equipment assembly. He also reported electrical receptacles were limited in the operating rooms. Further observation showed similar IV poles with attached surge protectors were in place in OR #6, #2, and #1. On 7/30/13 at 8:20 PM, the director of plant operations reported he was unaware the surge protector were in use. He further reported the surgical department was not routinely inspected.

3. Observation of operating room (OR) #3 on 7/30/13 at 8:29 PM showed the anesthesia tower was plugged into a hospital grade surge protector that was marked by the bio-med department. Further review showed this surge protector had a non-listed UL approved power cord. The power cord was replaced with a longer cord. The replacement of this cord voids the UL rating of this electrical adapter. At the time of the observation, the director of plant operations reported he was unaware this cord was in use. He further reported that he assumed the bio-med department would know that surge protector cannot be modified without voiding the UL listing.

4. Observation of the administration main office on 7/31/13 at 10:34 AM showed a computer was plugged into a surge protector which was plugged into an extension cord. At the time of the observation, the director of plant operations could not explain why the extension cord had not been noticed and removed during the quarterly safety inspections.

5. Observation of the marketing office on 7/31/13 at 10:49 AM showed the computer was plugged into a surge protector. Further observation showed the surge protector's power cord was damaged at the plug with exposed wires. At the time of the observation, the director of plant operations could not explain why the damaged surge protector had not been noticed and removed during the quarterly safety inspections.

6. Observation of the nursery on 7/31/13 at 1:38 PM showed the computer was plugged into a 3-way electrical adapter. At the time of the observation, the director of plant operations could not explain why the adapter had not been noticed and removed during the quarterly safety inspections.

Reference NFPA 101, 2000 Edition, 19.3.2.3, NFPA 99, 1999 Edition;
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment ...
(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in table 110-26(a) ...
Table 110-26(a)
Nominal Voltage Minimum Clear Distance (ft)
To Ground
_______________________________________
0/150 3 ft.

(b) Clear Space. Working space required by this section shall not be used for storage ...
110-27. Guarding of Live Parts.
(b) Prevent physical damage. In locations where electric equipment would be exposed to physical damage, enclosure of guards shall be so arranged and of such strength so to prevent such damage.
7-5.1.2.5 Line Voltage Equipment-Anesthetizing Locations. Flexible cord for portable lamps or portable electrical appliances operating at more than 12 V between conductors, intended for use in anesthetizing locations, shall be continuous and without switches from the appliance to the attachment plug and of a type designated for extra-hard usage in accordance with Article 501-11 of NFPA 70 ...
Exception No.2. Two or more power receptacles supplied by a flexible card are permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, or pedestal-mounted provided:
(a) The receptacles are an integral part of the equipment assembly, permanently attached; and
(b) The sum of the ampacity of all appliances connected to the receptacles shall not exceed 75 percent of the ampacity of the flexible cord supplying the receptacles; and
(c) The ampacity of the flexible cord is suitable and in accordance with the current edition of NFPA 70; and
(d) The electrical and mechanical integrity of the assembly is regularly verified and documented through an ongoing maintenance program.
Reference NFPA 101, 2000 Edition, 19.5.1, 9.1.2, NFPA 70, 1999 Edition;
400-8. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls ...
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces