HospitalInspections.org

STANDARD is not met as evidenced by: Based on observation, testing and staff interview of the emergency lighting during the facility tour, it was determined the facility failed to maintain the battery-powered emergency lights in accordance with 7.9.2 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenced by the following:

1. The battery back-up emergency in the electrical room 1733 would not illuminate when the test button was pressed.
2. No documentation was available during record review of the facility required testing of the battery-powered emergency lighting
system at 30 day intervals for not less than 30 seconds or annually for not less than 1 ½ hours.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30 day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 ½ hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The Maintenance Director acknowledge the required testing of the emergency lighting during the tour of the facility.

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain the door opining on cross-corridor doors in accordance with the Life Safety Code Section 19.3.7.5. 19.3.7.6, 19.3.7.7 and 8.3.4. This deficient practice could affect all residents within wing smoke compartments should the egress become untenable, due to smoke and heat transfer.

Storage room door 1717 opening into the cross-corridor self-closing device has been removed allowing door to remain open.

Door openings in smoke barriers have at least a 20-minute fire protected rating or are at least 1 3/4- inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets; bevels or astragals are required at the meeting adages.

The Director of Maintenance acknowledge the corridor doors condition during the facility tour.

This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to provide an adequate source of input ratings of appliances operating at levels above 2000 feet in accordance with National Fire Protection Association (NFPA) Life Safety Code and NFPA 54 Natural Fuel Gas Code. This deficient practice could affect all residents and staff in the core smoke compartment should the natural gas fueled heating equipment malfunction due to improper settings. This was evidenced by the following:


The input ratings of gas fired cloth dryers operating at elevations above 2000 ft (600 m) were not reduced at the rate of 4 percent for each 1000 ft (300 m) above sea level.

11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:
(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance
(2) As permitted by the authority having jurisdiction
(3) In accordance with the manufacturer's installation instructions

The dryer orifice deficiencies was discussed with the Maintenance Director during the survey and again during the exit conference with the CEO.

STANDARD is not met as evidenced by: Based on record review and documentation of inspection and testing of the non-hospital grade electrical outlets in patient care areas as required by sections 6.3.4.1.3 and 6.3.4.2.1.1 of NFPA 99, Health Care Facilities Code. This deficient practice could affect all residents, staff and visitors throughout the facility if the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade were to fail due to lack of testing. This was evidenced by the following:

No written test records of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patients care areas was conducted annually.

NFPA Standard: NFPA 99 Health Care Facilities Code (2012)
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.4.1 Maintenance and Testing of Electrical System.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or
general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.

The non-hospital grade electrical outlets testing at patient's care areas deficiency was discussed with the Facility Maintenance during the survey and again during the exit conference with the CEO.

STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with section 19.2.9.1 of the Life Safety Code and the referenced 2010 NFPA 110, Section 8.3.7.1 Maintenance and Operational Testing. This deficient practice has the potential to affect all residents, staff and visitors in the event of power loss. This was evidenced by the following.

At the time of the survey no records were available to verify testing and recording of battery
conductance testing in connection with the emergency power supply system (emergency generator) monthly.

NFPA 110, Section 8.3.7. Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

The emergency power supply system deficiency item was discussed with the Facility Director during the survey and again during the exit conference with the CEO