HospitalInspections.org

29422

Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in the walls and ceilings. This affected 6 of 20 smoke compartments on 1 of 3 floors in the hospital and 1 of 1 smoke compartment in the outpatient building. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff on 12/20 and 12/21/10, the walls and ceilings were observed. Where escutcheon rings were displaced or missing, penetrations were exposed around the sprinklers. An escutcheon ring is a shield that covers the penetration around the sprinkler pipe.

Emanuel Medical Center - 12/20/10
1. At 11:18 a.m., there were four approximately 1/4 inch penetrations in the wall of Storage Room 10107.
2. At 1:40 p.m., there were twelve approximately 1/4 inch penetrations in the wall of Storage Room 1 located near the Admitting area.
3. At 1:41 p.m., there were two approximately 1/4 inch penetrations in the wall of Storage Room 2 located near the Admitting area.
4. At 1:50 p.m., there was an approximately 1 x 1 inch penetration in the ceiling of the Physician Library, Room 11136.
5. At 1:56 p.m., there was an approximately 1 x 1 inch penetration in the ceiling of the Medical Records Office.


27994

6. At 1:25 p.m., one escutcheon ring was missing between lab Rooms 2 and 3. There was an approximately 3 inch penetration on the ceiling around the sprinkler pipe.
7. At 1:26 p.m., there was an approximately 1/8 inch penetration around a gray wire in the ceiling and an approximately 1/4 inch penetration on the ceiling, in the lab urinalysis area.
8. At 1:27 p.m., there was an approximately 2 x 4 cut out around a bundle of gray wires, in the wall, in the lab serology area.
9. At 1:31 p.m., there was an approximately 1/4 inch penetration around a yellow wire on the wall. There was an approximately 3 x 6 inch cut out around a bundle of wires in the wall, below a desk, in the lab blood bank area.
10. At 1:33 p.m., there were two approximately 1/4 inch penetrations on the wall, next to a alcohol base hand rub dispenser, in the microbiology lab room.
11. At 1:34 p.m., there were two approximately 1/4 inch penetrations on the wall outside of the microbiology lab. There was an approximately ? inch penetration on the ceiling.
12. At 1:40 p.m., there was an approximately 1/4 inch penetration on the dirty equipment wall, next to a telephone, in respiratory therapy.
13. At 2:23 p.m., one escutcheon ring was displaced. There was an approximately ? inch penetration on the ceiling, around the sprinkler, in the EMT work room.
14. At 2:56 p.m., one escutcheon ring was displaced. This exposed an approximately 1/8 inch penetration on the ceiling, in the radiology receptionist area.
15. At 3:10 p.m., there were two approximately 1/4 inch penetrations on the back wall, next to a network box, in the entrance of pharmacy.
16. At 3:30 p.m., one escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling of the NICU wash area.

Outpatient Services, 12/21/10
17. At 9:26 a.m., there was an approximately 1 x 3 inch penetration around two metal conduits in the ceiling, of electrical Room 1.

Based on observation, the facility failed to maintain the corridor walls to resist the passage of smoke. This was evidenced by penetrations in the ceilings in various areas of the facility. This affected 1 of 20 smoke compartments in the hospital and 1 of 1 smoke compartments in the outpatient service building. This could result in the spread of smoke from one smoke compartment to another.

Findings:

During a tour of the facility with staff, the corridor walls and ceiling were observed.

Emanuel Medical Center, 12/20/10
1. At 11:53 a.m., one escutcheon ring was displaced in the hemodialysis corridor. There was an approximately 1/8 inch penetration around the sprinkler, in the second floor medical records area.
2. At 11:54 a.m., one escutcheon ring was displaced in the staff only corridor (20135). There was an approximately 1/8 inch penetration around the sprinkler, at the second floor medical records.

Outpatient Services, 12/21/10
3. At 9:33 a.m., there was an approximately 1/4 inch penetration around a clean out pipe on the right lower wall, in the MA work station.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors that were impeded from closing and by doors that failed to latch. This affected 5 of 20 smoke compartments on 2 of 3 floors in 2 of 2 buildings. This could result in the spread of smoke or flame, in the event of a fire.

Findings:

During the facility tour with staff on 12/20 and 12/21/10, the doors were observed.

Emanuel Medical center, 12/20/10
First Floor -
1. At 11:54 a.m., the door to the janitor's closet was held open by a wooden door wedge, across from Operating Room 5.
2. At 11:58 a.m., a rubber door wedge was holding open the door to the sterile storage room, 11024.
3. At 3:30 p.m., the door was impeded from latching, on the patient supply closet, across from the nurse station, in the Post Partum Wing. The strike plate had been taped over and the latch would not engage.



27994

Third Floor -
4. At 11:15 a.m., the door to Room 341 was obstructed by a night stand, on the 3rd floor of medical telemetry. The table prevented the door from closing .
5. At 11:17 a.m., the door to Room 324 was obstructed by a night stand that prevented the door from closing.
6. At 11:18 a.m., the door to Room 323 was obstructed by a chair that prevented the door from closing.
7. At 3:17 p.m., the door to labor/delivery work room, Room 10034, was held open by a rubber door stop. The door was equipped with a self closure.
8. At 3:20 p.m., the door to the labor/delivery clean utility, Room 10036, was held open by seven boxes. The door was equipped with a self closure.

Outpatient Services, 12/21/10
9. At 9:30 a.m., the door that leads to stairwell 12057 was wedged open by a rubber door stop. The door was equipped with a self closure.

Based on observation, the facility failed to maintain the integrity of the fire rated construction for the smoke barriers. This was evidenced by penetrations in 2 of 9 smoke barrier walls. This affected 4 of 20 smoke compartments on 1 of 3 floors and could result in the spread of fire or smoke from one compartment to another, in the event of a fire.

Findings:

During the facility tour with staff on 12/20/10, the smoke barrier walls were observed.

Emanuel Medical Center, 12/20/10
First Floor -
1. At 11:15 a.m., there was an approximately 2 inch by 4 inch penetration around two 3/4 inch conduits in the 2-hour fire/smoke barrier wall. This was located above the ceiling in Corridor 2, next to the Post Anesthesia Care Unit (PACU), adjacent to a bubble mirror. There was an approximately 3/4 inch penetration around the top portion of a 3 inch roof drain pipe, penetrating the same wall above the ceiling, near a ceiling grid location labeled FATB.



29422

2. At 2:15 p.m., there was an approximately 1 inch cut out around a six inch pipe in the smoke barrier wall opposite the Garden Terrace and Serving area.

Based on observation, the facility failed to maintain the smoke barrier doors. This was evidenced by smoke barrier doors that were impeded from closing or failed to latch. This affected 3 of 20 smoke compartments on 1 of 3 floors. This could result in the spread of smoke or flame, in the event of a fire.

Findings:

During a tour of the facility with staff on 12/20/10, the smoke barrier doors were observed.

Emanuel Medical Center,
1. At 11:44 a.m., a one hour fire/smoke barrier door failed to close and latch, on the door next to the OR Department nursing station.

2. During fire alarm testing, on 12/22/10, the smoke barrier doors were observed. The double doors, in the service corridor, were impeded from closing. These doors were located across from a surgical floor entrance. Both doors were obstructed by a sheet of protective material placed over newly installed flooring.



27994

3. At 11:40 a.m., the smoke barrier door, by Social Service 20149, had a vita sign stored in front of the right door leaf.

Based on observation and interview, the facility failed to provide emergency illumination in anesthetizing locations. This was evidenced by no battery-powered emergency lighting in the operating rooms (OR). This affected 2 of 20 smoke compartments on 1 of 3 floors and could potentially result in a loss of lighting in the OR during surgical procedures.

NFPA 99 Health Care Facilities, 1999 edition
3-3.2.1.2, All Patient Care Areas.
(5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a tour of the facility with staff, the OR rooms were observed.

Emanuel Medical Center, 12/21/10
At 9 a.m., the operating rooms in labor and delivery and surgery rooms 1-6, did not have battery-powered emergency back-up lighting.

During a interview, at 9:05 a.m., Staff 1 confirmed there were no battery powered emergency back-up lights in these OR rooms.

Based on observation and interview, the facility failed to maintain glow in the dark exit signs. This was evidenced by one glow in the dark exit light that was expired. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in a delayed egress in the event of an emergency.

Findings:

During a tour of the facility with staff, on 12/20/10, the exit lights were observed.

Emanuel Medical Center
At 2:55 p.m., the exit light in the radiology file area was expired. The expiration date listed on the exit light was 10/2010. The exit light has a life expectancy, per the manufacturer's specifications.

During a interview, at 3 p.m., Staff 2, 3, and 8 confirmed the exit light was expired.

Based on record review and interview, the facility failed to provide documentation of all required fire drills. This was evidenced by incomplete records for fire drills and missing staff participation during fire drills. This affected 119 of 119 patients in the hospital and 26 of 26 patients in the outpatient services. This could result in a delay of staff response in the event of a fire.

Findings:

During record review with staff, on 12/21/10, the fire drill records were requested and reviewed.

Outpatient Services
1. At 10:40 a.m., the facility provided one report titled "Emanuel Medical Center Fire Drill Report," dated 1/28/10. There were no records of fire drill for the second, third, or fourth quarter of 2010.

During an interview at 10:45 a.m., Staff 1 stated he was unable to produce additional fire drill records.



27994

Emanuel Medical Center, 12/21/10
2. At 1:20 p.m., the documentation titled "Fire Drill Report" indicated all department staff did not participate during fire drills.
On 10/12/10, there was no documented staff participation in OR, NICU, and the admitting department.
On 9/26/10, there was no documented staff participation in surgical north, the Mom/Baby unit, and the OR areas.
On 7/17/10, there was no documented staff participation in Nuclear Med and labor/delivery.
On 6/26/10, there was no documented staff participation in the Mom/Baby unit.
On 5/17/10, there was no documented staff participation in the lab, pharmacy, and in radiology.
On 4/18/10, there was no documented staff participation in material management, pediatrics, and pharmacy.
On 3/8/10, there was no documented staff participation in pediatrics.
On 12/19/10, there was no documented staff participation in Cypress, Station 1, and Station 2.

During a interview, at 1:40 p.m., Staff 1 and 8 confirmed there were no additional records for staff participation during fire drills in all departments.



29752

Emanuel Medical Center, 12/22/10
3. During fire alarm testing, Emergency Department staff were asked questions about fire safety training.
At 9:28 a.m., on 12/22/10, Staff 11 did not know the procedure in the event of a fire.

Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by the failure of one notification device. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in a delay in notification in the event of a fire.

Findings:

During fire alarm testing with staff, on 12/22/10, the fire alarm system notification devices were observed.

Emanuel Medical Center
At 10:10 a.m., the audible portion of an audio-visual notification device failed to operate. The device was labeled 7-1-004 and was located in the corridor next to door 11362, Service Kitchen.

Based on observation and interview, the facility failed to maintain their tamper alarm valve. This was evidenced by 1 of 2 Post Indicator Valves (PIV) that did not send a visual/audible notification to the PBX monitoring station and the fire alarm control panel (FACP). This could result in the increased potential for delayed notification of staff, if the supervisory valve is closed, turning off the water supply to the sprinkler system. This affected 119 of 119 patients and could result in an increased spread of fire that could affect all patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system...

NFPA 72 National Fire Alarm Code, 1999 edition
6-11.4 Trouble Signals 6-11.4.1 Trouble signals shall actuate a sounding device located where there is a responsible person on duty at all time.

6-11.4.2 Trouble signals shall be distinct from alarm signals and shall be indicated by both a visual light and an audible signal.

Findings:

During fire alarm testing with staff, on 12/22/10, the PIV valves were closed.

Emanuel Medical Center
1. At 9:48 a.m., the PIV, located in the north/east receiving dock was closed. The valve did not activate a signal to the FACP and to the PBX monitoring station. The tamper valve was tested twice. The post indicator valve is equipped with a tamper alarm and should activate a trouble signal, in the event the water supply for the sprinkler system is turned off.

During a interview, at 9:55 a.m., Staff 1 stated the plant operation staff are in the process of trouble shooting the problem. If the tamper is not repaired within four hours, a fire watch will be issued.

At 11:04 a.m., the PIV was retested. The PIV activated a trouble signal to the PBX monitoring station and the FACP.

Based on observation, the facility failed to maintain and inspect the sprinkler system as required by NFPA 25. This was evidenced by escutcheon rings that were not flush with the ceiling and by the failure to maintain 18 inches of clearance below the sprinkler. This affected 1 of 20 smoke compartments in the hospital and 1 of 1 smoke compartments in the outpatient services. This could result in the spread of smoke or fire, in the event of a fire.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-2 Inspection.
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.

NFPA 13, 1999 edition 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During the facility tour with staff, the sprinkler heads were observed.

Emanuel Medical Center, 12/20/10
1. At 11:09 a.m., the escutcheon ring was not flush with the ceiling, in the rear room of the Materials Management area. This exposed an approximately 1/4 inch penetration around the sprinkler head.



27994

Outpatient Services, 12/21/10
2. At 9:43 a.m., the sprinkler head in the closet across from MRI did not have 18 inches of clearance around its deflector plate. The sprinkler was obstructed by a blue bin that was placed approximately 5 inches from the deflector plate.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable ABC fire extinguisher that was obstructed and by extinguishers that were not secured. This affected 2 of 20 smoke compartments on 2 of 3 floors and could result in a delay in accessing an extinguisher and in potential damage to the fire extinguisher if it were knocked over.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.

1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with staff, the portable fire extinguishers were observed.

Emanuel Medical Center, 12/20/10
1. At 11:50 a.m., a portable fire extinguisher was blocked by a "wow" machine, on the second floor of medical records, near Room 202.
2. At 2:03 p.m., the storage room in the emergency room (ER) hallway, contained 54 portable fire extinguishers that were not secured.
There were 10 - five pound and 32 - two pound fire extinguishers that were labeled, "out of service," placed along the right front wall.
There were 5 - two pound, 1 - five pound, and one 20 pound fire extinguishers, dated 11/15/10, along the left wall.
There were 3 - two pound and 2 - one pound fire extinguishers, dated 11/15/10, behind the door. All 54 portable fire extinguishers were freestanding and unsecured in the storage room.

During a interview, at 2:10 p.m., Staff 2 confirmed the fire extinguishers were not secured. He stated that the fire extinguishers that were labeled out of service will be use for training purposes.

Based on observation, the facility failed to provide a metal self closing container for the safe disposal of cigarette ashes. This was evidenced by a trash can filled with combustible materials and cigarettes butts. This affected one courtyard and could result in the increased risk of fire.

Findings:

During the facility tour with staff on 12/20/10, the trash containers were observed.

Emanuel Medical Center
At 11:30 a.m., eight cigarette butts were mixed with combustible trash in an open top waste container located in an interior courtyard.

Based on observation and interview, the facility failed to provide an unobstructed exit, that was continuously maintained. This was evidenced by equipment placed in the emergency exit corridors. This affected 5 of 20 smoke compartments and could potentially slow evacuation of staff and patients, in the event of a fire.

Findings:

During a tour of the facility with staff, on 12/20/10, the emergency exit corridors were observed.

Emanuel Medical Center
1. On 12/20/10 at 11:15 a.m., Corridor 2 was lined with 12 or more items of medical equipment, including gurneys, beds, fixed chairs, and carts.
During an interview at 11:16 a.m., Staff 4 stated that the equipment was located here while the flooring was being replaced in the service/storage corridor.
2. On 12/21/10 at 9:42 a.m., during fire alarm testing, Corridor 2 had approximately the same volume of storage as on 12/20/10. The corridor was lined on one side, the full length of the hallway, with the equipment.

3. On 12/22/10 at 8:10 a.m., Corridor 2 was rechecked with Staff 10 present. Equipment was stored on one side of the corridor with environmental service carts. There were 7 gurneys, 13 electric beds, 13 chairs, one crib, and one desk on wheels.



27994

4. At 2:30 p.m., the emergency exit door was blocked by a Stryker bed, in the emergency hallway, by Room 11.

During a interview, at 2:30 p.m., Staff 2 and Staff 8 confirmed the Stryker bed blocked access to the emergency exit door by Room 11.

Based on observation, the facility failed to properly store empty oxygen cylinders in accordance with NFPA 99. This was evidenced by three empty oxygen cylinders stored unsecured in one area. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in damage to the cylinders.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1
(b) Special Precautions - Oxygen Cylinders and Manifolds.
Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, grease, organic lubricants, rubber or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:

27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with staff, the patient care units were observed.

Emanuel Medical Center, 12/20/10
At 11:39 a.m., three empty (E) oxygen cylinders were freestanding and unsecured in utility room 10416.

Based on document review and interview, the facility failed to maintain their piped in medical gas. This was evidenced by no records for repairs of items identified on the discrepancy report for the piped in medical gas system. This affected 119 of 119 patients and could result in a delay or failure of the medical gas system.

Findings:

During document review with staff, the medical gas report was reviewed.

Emanuel Medical Center, 12/21/10
At 10:45 a.m., the documentation titled, "Medical Gas PM Inspection 2010 (System Remedial Action)" was dated 10/18/10. There were discrepancies noted on the first, second, and third floor, regarding leaking or station outlets and source equipment, the air compressor, warning alarm and zone valve mechanism disrepair.
On 10/25/10, the facility received a proposal for repair.

During a interview, at 11 a.m., Staff 3 stated the repairs were not completed and were not yet scheduled. Staff 4 confirmed the repairs were not completed.

Based on document review and interview, the facility failed to maintain the relative humidity equal to or greater than 35%. This was evidenced by humidity reports that indicated the humidity was below 35%. This affected 1 of 3 floors and could result in the potential risk of fire.

Findings:

During document review with staff, the relative humidity logs were reviewed.

Emanuel Medical Center, 12/21/10
1. At 11 a.m., the documentation titled, "OR Humidity/Temperature Checks " indicated the relative humidity fell below 35%.
On 3/23/10, OR 1 and 5 were at 30%, and OR 3 and 4 were at 32%.
On 3/25/10, OR 1 was at 30%.
On 4/15/10, OR 2 was at 34%.
On 5/6/10, OR 1 was 27%, and OR 3 and 6 were at 32%. OR 4 was at 31%, and OR 5 was at 25%.
On 5/7/10, OR 1 was at 30%.
On 10/28/10, OR 4 was at 32%.
On 11/24/10, OR 1 was at 24%, OR 2 was at 33%, and OR 4 was at 27%. On 11/26/10, OR 4 was at 34%.
On 11/30/10, OR 1 was at 32%.

2. At 11:30 a.m., the documentation titled, "OR Temperature Documentation Log, Labor and Delivery" indicated the relative humidity fell below 35%.
On 5/6/10, the OR was at 32%.
On 11/24/10, the OR was at 30%.
On 11/25/10, the OR was at 28%.
On 11/26/10, the OR was at 30%.
On 11/28/10, the OR was at 34%.
On 11/29/10, the OR was at 31%.
On 11/30/10, the OR was at 31%.

During a interview, at 11:10 a.m., Staff 6 stated when the humidity falls below 35%, she would notify plant operations.

During a interview, at 11:30 a.m., Staff 4 stated plant operations does not have any work orders for maintenance or repair for OR rooms 1 - 6 and the OR in labor and delivery.

Based on record review, the facility failed to test the Automatic Transfer Switches (ATS) as required. This was evidenced by three months of records for partial testing of Automatic Transfer Switches. Failure to test all emergency power Automatic Transfer Switches each month could result in a delay of repair to the emergency power circuit. In the event of a power outage, this could potentially affect the availability of utilities provided to 119 of 119 patients.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition,
6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Findings:

During record review with staff, on 12/21/10, the emergency generator monthly testing logs were reviewed.

Emanuel Medical Center
At 10:35 a.m., the "Automatic Transfer Switch (ATS) Check List" for each month was reviewed. During the first three months of 2010, the check list did not indicate all ATS were transferred.
On 1/5/10, the emergency power ATS Check List did not indicate a transfer on ATS-CPATS-1, ATS-CPATS-2, and PCS.
On 2/2/10, the emergency power ATS Check List did not indicate a transfer on ATS-CPATS-1, ATS-CPATS-2, PCS, ATS1-1-MECH1, and ATS1-2-MECH1.
On 3/2/10, the emergency power Check List did not indicate a transfer on ATS-CPATS-1, ATS-CPATS-2, PCS, ATS1-1-MECH1, and ATS1-2-MECH1.

Staff 3 was interviewed during the record review, on 12/21/10. When asked about the missed testing on the ATS Checklist, he explained that this was done before he came on board with the hospital. He also stated that corrections had been made to ensure all ATS testing was performed and the check list was changed to improve the accuracy of ATS labeling.

Based on observation, the facility failed to ensure electrical equipment is in accordance with NFPA 70. This was evidenced by obstructed access to electrical panels, by the use of extension cords, and by missing cover plates. This affected 4 of 20 smoke compartments on 1 of 3 floors in the hospital and 1 of 1 smoke compartments in the outpatient services. This could result in a delay in accessing the electrical panel.

NFPA 70 National Electrical Code, 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. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(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). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.

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, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour with staff, the electrical equipment and utilities were observed.

Emanuel Medical Center, 12/20/10
1. At 9:10 a.m., six plastic traffic barriers were stored within 24 inches of electrical panel CPATS-1.



27994

2. At 1:20 p.m., a junction box was missing a cover plate in hall 2 Room 160-10902. There were wires hanging out from the junction box.

Outpatient Services, 12/21/10
3. At 9:28 a.m., an Internet server was plugged into a orange extension cord, in the electrical room 2-12046.


29752

Emanuel Medical Center, 12/20/10
4. At 11:33 a.m., a dolly with twelve O2 cylinders, a storage rack on wheels stocked with sterile supplies, and a wooden rocking chair were stored in front of the electrical breaker panels in the sterile storage room adjacent to Central Supply. These were stored within 8 to 18 inches of the electrical panels.

5. At 3:30 p.m., a vitals monitor was plugged into a multi-outlet cord in the equipment storeroom for the baby nursery.

6. At 3:33 p.m., an approximately 10 foot long yellow extension cord was plugged into a multi-outlet cord that was supplying a desktop computer, monitor, fax, and labeler. This was located in the equipment storeroom for the baby nursery.

Based on observation and interview, the facility failed to maintain the installation of the alcohol based hand rub dispensers (ABHR). This was evidenced by four ABHR dispensers mounted over or adjacent to an ignition source. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in an increased potential for an alcohol based hand rub to ignite a fire.

Findings:

During a tour of the facility with staff, the alcohol based hand rub dispensers were observed.

Emanuel Medical Center, 12/20/10
1. At 1:22 p.m., an ABHR was installed over a light switch, in lab Room 1. The ABHR contained 62.5% ethyl alcohol and was mounted approximately 3-4 inches directly above the light switch.
2. At 1:23 p.m., an ABHR was installed over a light switch in lab Room 2. The ABHR contained 62.5% ethyl alcohol and was mounted 3-4 inches directly above the light switch.
3. At 1:32 p.m., an ABHR in microbiology was installed over a light switch. The ABHR contained 62.5% ethyl alcohol and was mounted 3-4 inches directly above the light switch.
4. At 1:36 p.m., an ABHR was installed over a light switch in cardiac testing service room 10331. The ABHR contained 62.5% ethyl alcohol and was mounted 3-4 inches directly above the light switch.

During interviews, between 1:23 p.m. to 1:36 p.m., Staff 3 confirmed all four ABHRs were installed over a light switch.

29422

Based on observation, the facility failed to maintain the building construction, as evidenced by penetrations in the walls and ceilings. This affected 6 of 20 smoke compartments on 1 of 3 floors in the hospital and 1 of 1 smoke compartment in the outpatient building. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff on 12/20 and 12/21/10, the walls and ceilings were observed. Where escutcheon rings were displaced or missing, penetrations were exposed around the sprinklers. An escutcheon ring is a shield that covers the penetration around the sprinkler pipe.

Emanuel Medical Center - 12/20/10
1. At 11:18 a.m., there were four approximately 1/4 inch penetrations in the wall of Storage Room 10107.
2. At 1:40 p.m., there were twelve approximately 1/4 inch penetrations in the wall of Storage Room 1 located near the Admitting area.
3. At 1:41 p.m., there were two approximately 1/4 inch penetrations in the wall of Storage Room 2 located near the Admitting area.
4. At 1:50 p.m., there was an approximately 1 x 1 inch penetration in the ceiling of the Physician Library, Room 11136.
5. At 1:56 p.m., there was an approximately 1 x 1 inch penetration in the ceiling of the Medical Records Office.


27994

6. At 1:25 p.m., one escutcheon ring was missing between lab Rooms 2 and 3. There was an approximately 3 inch penetration on the ceiling around the sprinkler pipe.
7. At 1:26 p.m., there was an approximately 1/8 inch penetration around a gray wire in the ceiling and an approximately 1/4 inch penetration on the ceiling, in the lab urinalysis area.
8. At 1:27 p.m., there was an approximately 2 x 4 cut out around a bundle of gray wires, in the wall, in the lab serology area.
9. At 1:31 p.m., there was an approximately 1/4 inch penetration around a yellow wire on the wall. There was an approximately 3 x 6 inch cut out around a bundle of wires in the wall, below a desk, in the lab blood bank area.
10. At 1:33 p.m., there were two approximately 1/4 inch penetrations on the wall, next to a alcohol base hand rub dispenser, in the microbiology lab room.
11. At 1:34 p.m., there were two approximately 1/4 inch penetrations on the wall outside of the microbiology lab. There was an approximately ? inch penetration on the ceiling.
12. At 1:40 p.m., there was an approximately 1/4 inch penetration on the dirty equipment wall, next to a telephone, in respiratory therapy.
13. At 2:23 p.m., one escutcheon ring was displaced. There was an approximately ? inch penetration on the ceiling, around the sprinkler, in the EMT work room.
14. At 2:56 p.m., one escutcheon ring was displaced. This exposed an approximately 1/8 inch penetration on the ceiling, in the radiology receptionist area.
15. At 3:10 p.m., there were two approximately 1/4 inch penetrations on the back wall, next to a network box, in the entrance of pharmacy.
16. At 3:30 p.m., one escutcheon ring was not flush against the ceiling. There was an approximately 1/8 inch penetration in the ceiling of the NICU wash area.

Outpatient Services, 12/21/10
17. At 9:26 a.m., there was an approximately 1 x 3 inch penetration around two metal conduits in the ceiling, of electrical Room 1.

Based on observation, the facility failed to maintain the corridor walls to resist the passage of smoke. This was evidenced by penetrations in the ceilings in various areas of the facility. This affected 1 of 20 smoke compartments in the hospital and 1 of 1 smoke compartments in the outpatient service building. This could result in the spread of smoke from one smoke compartment to another.

Findings:

During a tour of the facility with staff, the corridor walls and ceiling were observed.

Emanuel Medical Center, 12/20/10
1. At 11:53 a.m., one escutcheon ring was displaced in the hemodialysis corridor. There was an approximately 1/8 inch penetration around the sprinkler, in the second floor medical records area.
2. At 11:54 a.m., one escutcheon ring was displaced in the staff only corridor (20135). There was an approximately 1/8 inch penetration around the sprinkler, at the second floor medical records.

Outpatient Services, 12/21/10
3. At 9:33 a.m., there was an approximately 1/4 inch penetration around a clean out pipe on the right lower wall, in the MA work station.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors that were impeded from closing and by doors that failed to latch. This affected 5 of 20 smoke compartments on 2 of 3 floors in 2 of 2 buildings. This could result in the spread of smoke or flame, in the event of a fire.

Findings:

During the facility tour with staff on 12/20 and 12/21/10, the doors were observed.

Emanuel Medical center, 12/20/10
First Floor -
1. At 11:54 a.m., the door to the janitor's closet was held open by a wooden door wedge, across from Operating Room 5.
2. At 11:58 a.m., a rubber door wedge was holding open the door to the sterile storage room, 11024.
3. At 3:30 p.m., the door was impeded from latching, on the patient supply closet, across from the nurse station, in the Post Partum Wing. The strike plate had been taped over and the latch would not engage.



27994

Third Floor -
4. At 11:15 a.m., the door to Room 341 was obstructed by a night stand, on the 3rd floor of medical telemetry. The table prevented the door from closing .
5. At 11:17 a.m., the door to Room 324 was obstructed by a night stand that prevented the door from closing.
6. At 11:18 a.m., the door to Room 323 was obstructed by a chair that prevented the door from closing.
7. At 3:17 p.m., the door to labor/delivery work room, Room 10034, was held open by a rubber door stop. The door was equipped with a self closure.
8. At 3:20 p.m., the door to the labor/delivery clean utility, Room 10036, was held open by seven boxes. The door was equipped with a self closure.

Outpatient Services, 12/21/10
9. At 9:30 a.m., the door that leads to stairwell 12057 was wedged open by a rubber door stop. The door was equipped with a self closure.

Based on observation, the facility failed to maintain the integrity of the fire rated construction for the smoke barriers. This was evidenced by penetrations in 2 of 9 smoke barrier walls. This affected 4 of 20 smoke compartments on 1 of 3 floors and could result in the spread of fire or smoke from one compartment to another, in the event of a fire.

Findings:

During the facility tour with staff on 12/20/10, the smoke barrier walls were observed.

Emanuel Medical Center, 12/20/10
First Floor -
1. At 11:15 a.m., there was an approximately 2 inch by 4 inch penetration around two 3/4 inch conduits in the 2-hour fire/smoke barrier wall. This was located above the ceiling in Corridor 2, next to the Post Anesthesia Care Unit (PACU), adjacent to a bubble mirror. There was an approximately 3/4 inch penetration around the top portion of a 3 inch roof drain pipe, penetrating the same wall above the ceiling, near a ceiling grid location labeled FATB.



29422

2. At 2:15 p.m., there was an approximately 1 inch cut out around a six inch pipe in the smoke barrier wall opposite the Garden Terrace and Serving area.

Based on observation, the facility failed to maintain the smoke barrier doors. This was evidenced by smoke barrier doors that were impeded from closing or failed to latch. This affected 3 of 20 smoke compartments on 1 of 3 floors. This could result in the spread of smoke or flame, in the event of a fire.

Findings:

During a tour of the facility with staff on 12/20/10, the smoke barrier doors were observed.

Emanuel Medical Center,
1. At 11:44 a.m., a one hour fire/smoke barrier door failed to close and latch, on the door next to the OR Department nursing station.

2. During fire alarm testing, on 12/22/10, the smoke barrier doors were observed. The double doors, in the service corridor, were impeded from closing. These doors were located across from a surgical floor entrance. Both doors were obstructed by a sheet of protective material placed over newly installed flooring.



27994

3. At 11:40 a.m., the smoke barrier door, by Social Service 20149, had a vita sign stored in front of the right door leaf.

Based on observation and interview, the facility failed to provide emergency illumination in anesthetizing locations. This was evidenced by no battery-powered emergency lighting in the operating rooms (OR). This affected 2 of 20 smoke compartments on 1 of 3 floors and could potentially result in a loss of lighting in the OR during surgical procedures.

NFPA 99 Health Care Facilities, 1999 edition
3-3.2.1.2, All Patient Care Areas.
(5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a tour of the facility with staff, the OR rooms were observed.

Emanuel Medical Center, 12/21/10
At 9 a.m., the operating rooms in labor and delivery and surgery rooms 1-6, did not have battery-powered emergency back-up lighting.

During a interview, at 9:05 a.m., Staff 1 confirmed there were no battery powered emergency back-up lights in these OR rooms.

Based on observation and interview, the facility failed to maintain glow in the dark exit signs. This was evidenced by one glow in the dark exit light that was expired. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in a delayed egress in the event of an emergency.

Findings:

During a tour of the facility with staff, on 12/20/10, the exit lights were observed.

Emanuel Medical Center
At 2:55 p.m., the exit light in the radiology file area was expired. The expiration date listed on the exit light was 10/2010. The exit light has a life expectancy, per the manufacturer's specifications.

During a interview, at 3 p.m., Staff 2, 3, and 8 confirmed the exit light was expired.

Based on record review and interview, the facility failed to provide documentation of all required fire drills. This was evidenced by incomplete records for fire drills and missing staff participation during fire drills. This affected 119 of 119 patients in the hospital and 26 of 26 patients in the outpatient services. This could result in a delay of staff response in the event of a fire.

Findings:

During record review with staff, on 12/21/10, the fire drill records were requested and reviewed.

Outpatient Services
1. At 10:40 a.m., the facility provided one report titled "Emanuel Medical Center Fire Drill Report," dated 1/28/10. There were no records of fire drill for the second, third, or fourth quarter of 2010.

During an interview at 10:45 a.m., Staff 1 stated he was unable to produce additional fire drill records.



27994

Emanuel Medical Center, 12/21/10
2. At 1:20 p.m., the documentation titled "Fire Drill Report" indicated all department staff did not participate during fire drills.
On 10/12/10, there was no documented staff participation in OR, NICU, and the admitting department.
On 9/26/10, there was no documented staff participation in surgical north, the Mom/Baby unit, and the OR areas.
On 7/17/10, there was no documented staff participation in Nuclear Med and labor/delivery.
On 6/26/10, there was no documented staff participation in the Mom/Baby unit.
On 5/17/10, there was no documented staff participation in the lab, pharmacy, and in radiology.
On 4/18/10, there was no documented staff participation in material management, pediatrics, and pharmacy.
On 3/8/10, there was no documented staff participation in pediatrics.
On 12/19/10, there was no documented staff participation in Cypress, Station 1, and Station 2.

During a interview, at 1:40 p.m., Staff 1 and 8 confirmed there were no additional records for staff participation during fire drills in all departments.



29752

Emanuel Medical Center, 12/22/10
3. During fire alarm testing, Emergency Department staff were asked questions about fire safety training.
At 9:28 a.m., on 12/22/10, Staff 11 did not know the procedure in the event of a fire.

Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by the failure of one notification device. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in a delay in notification in the event of a fire.

Findings:

During fire alarm testing with staff, on 12/22/10, the fire alarm system notification devices were observed.

Emanuel Medical Center
At 10:10 a.m., the audible portion of an audio-visual notification device failed to operate. The device was labeled 7-1-004 and was located in the corridor next to door 11362, Service Kitchen.

Based on observation and interview, the facility failed to maintain their tamper alarm valve. This was evidenced by 1 of 2 Post Indicator Valves (PIV) that did not send a visual/audible notification to the PBX monitoring station and the fire alarm control panel (FACP). This could result in the increased potential for delayed notification of staff, if the supervisory valve is closed, turning off the water supply to the sprinkler system. This affected 119 of 119 patients and could result in an increased spread of fire that could affect all patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system...

NFPA 72 National Fire Alarm Code, 1999 edition
6-11.4 Trouble Signals 6-11.4.1 Trouble signals shall actuate a sounding device located where there is a responsible person on duty at all time.

6-11.4.2 Trouble signals shall be distinct from alarm signals and shall be indicated by both a visual light and an audible signal.

Findings:

During fire alarm testing with staff, on 12/22/10, the PIV valves were closed.

Emanuel Medical Center
1. At 9:48 a.m., the PIV, located in the north/east receiving dock was closed. The valve did not activate a signal to the FACP and to the PBX monitoring station. The tamper valve was tested twice. The post indicator valve is equipped with a tamper alarm and should activate a trouble signal, in the event the water supply for the sprinkler system is turned off.

During a interview, at 9:55 a.m., Staff 1 stated the plant operation staff are in the process of trouble shooting the problem. If the tamper is not repaired within four hours, a fire watch will be issued.

At 11:04 a.m., the PIV was retested. The PIV activated a trouble signal to the PBX monitoring station and the FACP.

Based on observation, the facility failed to maintain and inspect the sprinkler system as required by NFPA 25. This was evidenced by escutcheon rings that were not flush with the ceiling and by the failure to maintain 18 inches of clearance below the sprinkler. This affected 1 of 20 smoke compartments in the hospital and 1 of 1 smoke compartments in the outpatient services. This could result in the spread of smoke or fire, in the event of a fire.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-2 Inspection.
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.

NFPA 13, 1999 edition 5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During the facility tour with staff, the sprinkler heads were observed.

Emanuel Medical Center, 12/20/10
1. At 11:09 a.m., the escutcheon ring was not flush with the ceiling, in the rear room of the Materials Management area. This exposed an approximately 1/4 inch penetration around the sprinkler head.



27994

Outpatient Services, 12/21/10
2. At 9:43 a.m., the sprinkler head in the closet across from MRI did not have 18 inches of clearance around its deflector plate. The sprinkler was obstructed by a blue bin that was placed approximately 5 inches from the deflector plate.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable ABC fire extinguisher that was obstructed and by extinguishers that were not secured. This affected 2 of 20 smoke compartments on 2 of 3 floors and could result in a delay in accessing an extinguisher and in potential damage to the fire extinguisher if it were knocked over.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.

1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with staff, the portable fire extinguishers were observed.

Emanuel Medical Center, 12/20/10
1. At 11:50 a.m., a portable fire extinguisher was blocked by a "wow" machine, on the second floor of medical records, near Room 202.
2. At 2:03 p.m., the storage room in the emergency room (ER) hallway, contained 54 portable fire extinguishers that were not secured.
There were 10 - five pound and 32 - two pound fire extinguishers that were labeled, "out of service," placed along the right front wall.
There were 5 - two pound, 1 - five pound, and one 20 pound fire extinguishers, dated 11/15/10, along the left wall.
There were 3 - two pound and 2 - one pound fire extinguishers, dated 11/15/10, behind the door. All 54 portable fire extinguishers were freestanding and unsecured in the storage room.

During a interview, at 2:10 p.m., Staff 2 confirmed the fire extinguishers were not secured. He stated that the fire extinguishers that were labeled out of service will be use for training purposes.

Based on observation, the facility failed to provide a metal self closing container for the safe disposal of cigarette ashes. This was evidenced by a trash can filled with combustible materials and cigarettes butts. This affected one courtyard and could result in the increased risk of fire.

Findings:

During the facility tour with staff on 12/20/10, the trash containers were observed.

Emanuel Medical Center
At 11:30 a.m., eight cigarette butts were mixed with combustible trash in an open top waste container located in an interior courtyard.

Based on observation and interview, the facility failed to provide an unobstructed exit, that was continuously maintained. This was evidenced by equipment placed in the emergency exit corridors. This affected 5 of 20 smoke compartments and could potentially slow evacuation of staff and patients, in the event of a fire.

Findings:

During a tour of the facility with staff, on 12/20/10, the emergency exit corridors were observed.

Emanuel Medical Center
1. On 12/20/10 at 11:15 a.m., Corridor 2 was lined with 12 or more items of medical equipment, including gurneys, beds, fixed chairs, and carts.
During an interview at 11:16 a.m., Staff 4 stated that the equipment was located here while the flooring was being replaced in the service/storage corridor.
2. On 12/21/10 at 9:42 a.m., during fire alarm testing, Corridor 2 had approximately the same volume of storage as on 12/20/10. The corridor was lined on one side, the full length of the hallway, with the equipment.

3. On 12/22/10 at 8:10 a.m., Corridor 2 was rechecked with Staff 10 present. Equipment was stored on one side of the corridor with environmental service carts. There were 7 gurneys, 13 electric beds, 13 chairs, one crib, and one desk on wheels.



27994

4. At 2:30 p.m., the emergency exit door was blocked by a Stryker bed, in the emergency hallway, by Room 11.

During a interview, at 2:30 p.m., Staff 2 and Staff 8 confirmed the Stryker bed blocked access to the emergency exit door by Room 11.

Based on observation, the facility failed to properly store empty oxygen cylinders in accordance with NFPA 99. This was evidenced by three empty oxygen cylinders stored unsecured in one area. This affected 1 of 20 smoke compartments on 1 of 3 floors and could result in damage to the cylinders.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers - Level 1
(b) Special Precautions - Oxygen Cylinders and Manifolds.
Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, grease, organic lubricants, rubber or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:

27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with staff, the patient care units were observed.

Emanuel Medical Center, 12/20/10
At 11:39 a.m., three empty (E) oxygen cylinders were freestanding and unsecured in utility room 10416.

Based on document review and interview, the facility failed to maintain their piped in medical gas. This was evidenced by no records for repairs of items identified on the discrepancy report for the piped in medical gas system. This affected 119 of 119 patients and could result in a delay or failure of the medical gas system.

Findings:

During document review with staff, the medical gas report was reviewed.

Emanuel Medical Center, 12/21/10
At 10:45 a.m., the documentation titled, "Medical Gas PM Inspection 2010 (System Remedial Action)" was dated 10/18/10. There were discrepancies noted on the first, second, and third floor, regarding leaking or station outlets and source equipment, the air compressor, warning alarm and zone valve mechanism disrepair.
On 10/25/10, the facility received a proposal for repair.

During a interview, at 11 a.m., Staff 3 stated the repairs were not completed and were not yet scheduled. Staff 4 confirmed the repairs were not completed.

Based on document review and interview, the facility failed to maintain the relative humidity equal to or greater than 35%. This was evidenced by humidity reports that indicated the humidity was below 35%. This affected 1 of 3 floors and could result in the potential risk of fire.

Findings:

During document review with staff, the relative humidity logs were reviewed.

Emanuel Medical Center, 12/21/10
1. At 11 a.m., the documentation titled, "OR Humidity/Temperature Checks " indicated the relative humidity fell below 35%.
On 3/23/10, OR 1 and 5 were at 30%, and OR 3 and 4 were at 32%.
On 3/25/10, OR 1 was at 30%.
On 4/15/10, OR 2 was at 34%.
On 5/6/10, OR 1 was 27%, and OR 3 and 6 were at 32%. OR 4 was at 31%, and OR 5 was at 25%.
On 5/7/10, OR 1 was at 30%.
On 10/28/10, OR 4 was at 32%.
On 11/24/10, OR 1 was at 24%, OR 2 was at 33%, and OR 4 was at 27%. On 11/26/10, OR 4 was at 34%.
On 11/30/10, OR 1 was at 32%.

2. At 11:30 a.m., the documentation titled, "OR Temperature Documentation Log, Labor and Delivery" indicated the relative humidity fell below 35%.
On 5/6/10, the OR was at 32%.
On 11/24/10, the OR was at 30%.
On 11/25/10, the OR was at 28%.
On 11/26/10, the OR was at 30%.
On 11/28/10, the OR was at 34%.
On 11/29/10, the OR was at 31%.
On 11/30/10, the OR was at 31%.

During a interview, at 11:10 a.m., Staff 6 stated when the humidity falls below 35%, she would notify plant operations.

During a interview, at 11:30 a.m., Staff 4 stated plant operations does not have any work orders for maintenance or repair for OR rooms 1 - 6 and the OR in labor and delivery.

Based on record review, the facility failed to test the Automatic Transfer Switches (ATS) as required. This was evidenced by three months of records for partial testing of Automatic Transfer Switches. Failure to test all emergency power Automatic Transfer Switches each month could result in a delay of repair to the emergency power circuit. In the event of a power outage, this could potentially affect the availability of utilities provided to 119 of 119 patients.

NFPA 110 Standard for Emergency and Standby Power Systems 1999 Edition,
6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

Findings:

During record review with staff, on 12/21/10, the emergency generator monthly testing logs were reviewed.

Emanuel Medical Center
At 10:35 a.m., the "Automatic Transfer Switch (ATS) Check List" for each month was reviewed. During the first three months of 2010, the check list did not indicate all ATS were transferred.
On 1/5/10, the emergency power ATS Check List did not indicate a transfer on ATS-CPATS-1, ATS-CPATS-2, and PCS.
On 2/2/10, the emergency power ATS Check List did not indicate a transfer on ATS-CPATS-1, ATS-CPATS-2, PCS, ATS1-1-MECH1, and ATS1-2-MECH1.
On 3/2/10, the emergency power Check List did not indicate a transfer on ATS-CPATS-1, ATS-CPATS-2, PCS, ATS1-1-MECH1, and ATS1-2-MECH1.

Staff 3 was interviewed during the record review, on 12/21/10. When asked about the missed testing on the ATS Checklist, he explained that this was done before he came on board with the hospital. He also stated that corrections had been made to ensure all ATS testing was performed and the check list was changed to improve the accuracy of ATS labeling.

Based on observation, the facility failed to ensure electrical equipment is in accordance with NFPA 70. This was evidenced by obstructed access to electrical panels, by the use of extension cords, and by missing cover plates. This affected 4 of 20 smoke compartments on 1 of 3 floors in the hospital and 1 of 1 smoke compartments in the outpatient services. This could result in a delay in accessing the electrical panel.

NFPA 70 National Electrical Code, 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. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(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). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in.
(762 mm), whichever is greater.

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, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour with staff, the electrical equipment and utilities were observed.

Emanuel Medical Center, 12/20/10
1. At 9:10 a.m., six plastic traffic barriers were stored within 24 inches of electrical panel CPATS-1.



27994

2. At 1:20 p.m., a junction box was missing a cover plate in hall 2 Room 160-10902. There were wires hanging out from the junction box.

Outpatient Services, 12/21/10
3. At 9:28 a.m., an Internet server was plugged into a orange extension cord, in the electrical room 2-12046.


29752

Emanuel Medical Center, 12/20/10
4. At 11:33 a.m., a dolly with twelve O2 cylinders, a storage rack on wheels stocked with sterile supplies, and a wooden rocking chair were stored in front of the electrical breaker panels in the sterile storage room adjacent to Central Supply. These were stored within 8 to 18 inches of the electrical panels.

5. At 3:30 p.m., a vitals monitor was plugged into a multi-outlet cord in the equipment storeroom for the baby nursery.

6. At 3:33 p.m., an approximately 10 foot long yellow extension cord was plugged into a multi-outlet cord that was supplying a desktop computer, monitor, fax, and labeler. This was located in the equipment storeroom for the baby nursery.