HospitalInspections.org

Based on observation and interview, the facility failed to maintain the doors protecting corridor openings, in other than required enclosures of vertical openings, exits, or hazardous areas, such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. The facility census was 5 patients.

Findings are:
Observations on 10-20-10, from 11:55 am and 12:17 pm revealed:
1. The door to Respitory Care Director office was held open with a rubber chock.
2. Surgery door failed to close and latch within door frame.

During an interview on 10-20-11 at both times of observations, Maintenance A confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, the facility failed to ensure that smoke separation doors protecting corridor openings in a sprinklered building are capable of resisting the passage of smoke. This deficient practice affected all patients, staff and visitors on both the lower level and main level of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 from 10:36 am to 12:35 pm, revealed:
1. Lower level east fire rated door at medical center failed to close and latch.
2. The north fire rated door in lower level next to dietary failed to close and latch.
3. Fire rated OR corridor door behind nurse ' s station failed to close, dragging on new carpet.

During an interview on 10-20-10 at times of observations, Maintenance A confirmed the doors failed to close and provide a smoke tight separation.


NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview the facility failed to provide smoke protection for hazard areas, by not providing doors which closed within the door frame. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 from 10:45 am to 12:50 pm, revealed:
1. Staff coat closet door next to dining room, failed to close and latch within door frame.
2. Soiled utility room door next to nurse ' s station failed to close and latch within door frame.
3. Both sterile room doors failed to close and latch within door frame.

During an interview on 10-20-10 from 10:45 am to 12:50 pm, Maintenance A confirmed the doors to the hazard areas failed to close and latch within the door frame.

Based on interview and record review, the facility failed to provide documentation of testing of emergency lighting of at least 1-? hour duration. This deficient practice affected all patients, visitors and staff. The facility census was 5 patients.

Findings are:
Record review of the Emergency Light Maintenance Log on 10-20-10, revealed that emergency lights were tested on an annual basis.

During an interview on 10-20-10 at 1:10 pm Maintenance A confirmed that no annual testing had been done, and was not aware of the requirement

NFPA Standard:
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 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on interview and documentation the facility failed to provide one sound for the fire alarm on the first level. This deficient practice has the potential to affect all occupants of the facility, and cause confusion during a fire emergency. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 1:22 revealed, several sounds heard on the first level, while conducting a test of the fire alarm system.

During an interview on 10-20-10 at 1:22 pm, Maintenance A revealed that the facility failed to provide a single sound for the fire alarm.

Regulation:
Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building. 2000 NFPA 101, 9.6.3.9, Official State Interpretation 01-02

Based on observation and staff interview the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building in accordance with NFPA in the facility. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 12:45 pm and 12:50 pm, revealed:
1. Facility failed to provide sprinkler protection in areas throughout the corridor and some rooms in the basement.
2. The sprinkler main in the basement mechanical room failed to provide sprinkler protection.

During an interview on 10-20-10 at 12:45 pm and 12:50 pm, Maintenance A confirmed that the lower level failed to be sprinkler protected throughout.

NFPA Standard:
Where required by 18/19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 18/19.3.5.1

Based on interview and observation, the facility failed to ensure kitchen staff is trained on the use of kitchen hood extinguishing system. This deficient practice affected all staff, visitors and patients that use or are near the kitchen area. The facility census was 5 patients.

Findings are:
Observations and interview on 10-20-10 at 12:45 pm, the kitchen staff failed to identify manual pull for the kitchen hood suppression, and was unfamiliar with facility emergency procedure for a fire under the hood.

During an interview on 10-20-10 at 12:45 pm, Maintenance A confirmed that the kitchen staff was unfamiliar with the emergency procedures for the kitchen hood.

Based on observation, interview and documentation review the facility failed to maintain the facility free of heat producing devices in all areas of the building. This deficient practice affected all residents, staff and visitors in the facility.

Findings are:
Observations on 10-20-10 at 12:20 pm and 1:05 pm revealed:
1. Space heater in the Ballet Room, under Administrative Assistants desk.
2. Space heater in medical records office.

During an interview on 10-20-10 at both times of observations, Maintenance A confirmed the space heater in the offices. No documentation was provided to verify the temperature requirement.

NFPA Standard:
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212?. 2000 NFPA 101, 19.7.8

Based on observation and interview the facility failed to provide protection to the gravity soiled linen chute by not providing fire rated door on the bottom of chute to protect the chute. The discharge room failed to provide fire rating and the intake door in the corridor failed to close. This deficient practice has the potential to affect all patients and occupants by having the fire spread from the discharge room into other areas of the building. Facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 12:40 pm and 12:42 pm revealed:
1. Lower level laundry chute door to corridor failed to provide fire rating.
2. Lower level laundry chute door failed to engage door frame.

During an interview on interview on 10-20-10 at both times of observations, Maintenance A confirmed the findings.

NFPA Standards:
3-2.2.9 Chute Discharge Doors.
Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.

3-2.4 Chute Loading Doors.
3-2.4.1 General Access Gravity Waste Chutes.
All chute loading doors into a waste chute shall be provided with a self-closing, positive latching frame and gasketed fire door assembly approved for Class B openings and having a fire resistance rating of not less than 1 hour. The door frame shall be fastened into the chute and the shaft wall. The design and installation shall be such that no part of the frame or door projects into the chute.
The area of each chute loading door shall be limited to one-third of the cross-sectional area of a square chute and 44 percent of the area of a round chute.

3-2.6.1 Chute Discharge Room Criteria.
Waste and linen chutes shall terminate or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute. Openings to such rooms shall be protected by approved automatic-closing or self-closing 1 1/2-hour fire doors suitable for Class B openings.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, staff and visitors in the facility. Facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 12:12 pm and 12:42 pm revealed:
1. Several potted plants, cardboard box and an air purifier stored in front of dining room exit.
2. Baby warmer and air purifier stored in the surgery exit corridor.

During an interview on 10-20-10 at 12:12 pm and 12:42 pm, Maintenance A confirmed obstruction in the path of egress.

Based on interview and observation the facility failed to provide smoke protection for hazard areas by not providing self-closing devices, by allowing paper recycling containers larger than 32 gallons. This deficient practice affected all patients, visitors and staff on the first level. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 11:35 pm, revealed:
1. Three paper recycling barrels with a capacity of 17 gallons each found in one smoke zone on the main level in the " pink " room, mail room and medical records. No self-closing devices provided on any of the door.

During an interview on 10-20-10 at 11:35 pm, Maintenance A confirmed the combined capacity of three paper recycle barrels were over the allowed 32 gallons within a smoke zone.

Based on interview and observation the facility failed to maintain a piped-in medical gas system by providing proper room identification. This deficient practice affected all patients, visitors and staff on the first level. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 11:40 am, revealed that the medical gas shut off in CT hall failed to be labeled.

During an interview on 10-20-10 at 11:40 am, Maintenance A confirmed the label for the medical gas was not present.

Based on documentation review and interview the facility failed to maintain all anesthetizing location operating rooms with humidity level of 35 per cent or greater. This has the potential to affect all patients in the operating rooms of the hospital. The facility census was 5 patients.

Findings are:
1. During documentation review on 10-20-10, of humidity log for a ten month period of time, revealed the facility failed to maintain the humidity of 35% or greater the OR on multiple occasions.

During an interview on 10-20-10 at 1:31 pm, Maintenance A confirmed the documentation review of the humidity levels.

NFPA Standard:
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent.1998 NFPA 99, 5-4.1.1

Based on interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice affected all smoke compartments of the building and all of the occupants. The facility census was 5 patients.

Findings are:
Review of documentation and interview on 10-20-10 at 1:04 pm with Maintenance A revealed:

Documentation review on 10-20-10 revealed the facility not documenting the time to transfer from normal power to generator power during testing of the generator.

Documentation review on 10-20-10 revealed the lack of monthly testing of the generator under a 30% load.

During an interview on 10-20-10 at 1:04 pm, Maintenance A confirmed the facility failed to be aware of the generator testing requirements.

NFPA Standard:
Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard:
Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

NFPA Standard:
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: 1999 NPPA 110, 6-4.2
a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
c) The date and time of day for required testing shall be decided by the owner, based on facility operations

Based on observation and interview the facility failed to verify a Type I essential Electrical system for the facility and by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice affected all patients, staff and visitors of the facility by affecting the emergency systems of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 11:29 am revealed:
1. The facility failed to verify that the Type I EES was provided.
2. The critical branch, life safety branch and the equipment system branch were intermixed in panel boxes throughout the facility.
3. The electrical system appeared to have one transfer switch.

During an interview on 10-20-10 at 11:29 am, Maintenance A confirmed that the panel boxes throughout the facility had an intermix of the required branches within each panel.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, 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) Emergency Systems. 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) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for
the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7?C (20?F).
(b) The outside design temperature is lower than -6.7?C (20?F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This deficient practice affected all patients, visitors and staff that are in the area of open junction boxes and power strips. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 between 10:15 am and 12:32 pm revealed:
1. Electrical wire for a ceiling light in the Materials Management room ran through the wall and ceiling tiles and plugged was into a power-strip in the south-west corner of room.
2. Power-strip plugged into another power-strip in the south-west corner of Materials Management room.
3. Microwave and refrigerator plugged into a power-strip in the south-east desk area of Home Health office.
4. Blood pressure machine plugged into a non-hospital grade power-strip.


During an interview on 10-20-10 between 10:15 am and 12:32 pm, Maintenance A confirmed the all findings.

Based on observation and interview, the facility failed to maintain the doors protecting corridor openings, in other than required enclosures of vertical openings, exits, or hazardous areas, such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. The facility census was 5 patients.

Findings are:
Observations on 10-20-10, from 11:55 am and 12:17 pm revealed:
1. The door to Respitory Care Director office was held open with a rubber chock.
2. Surgery door failed to close and latch within door frame.

During an interview on 10-20-11 at both times of observations, Maintenance A confirmed the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and interview, the facility failed to ensure that smoke separation doors protecting corridor openings in a sprinklered building are capable of resisting the passage of smoke. This deficient practice affected all patients, staff and visitors on both the lower level and main level of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 from 10:36 am to 12:35 pm, revealed:
1. Lower level east fire rated door at medical center failed to close and latch.
2. The north fire rated door in lower level next to dietary failed to close and latch.
3. Fire rated OR corridor door behind nurse ' s station failed to close, dragging on new carpet.

During an interview on 10-20-10 at times of observations, Maintenance A confirmed the doors failed to close and provide a smoke tight separation.


NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview the facility failed to provide smoke protection for hazard areas, by not providing doors which closed within the door frame. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 from 10:45 am to 12:50 pm, revealed:
1. Staff coat closet door next to dining room, failed to close and latch within door frame.
2. Soiled utility room door next to nurse ' s station failed to close and latch within door frame.
3. Both sterile room doors failed to close and latch within door frame.

During an interview on 10-20-10 from 10:45 am to 12:50 pm, Maintenance A confirmed the doors to the hazard areas failed to close and latch within the door frame.

Based on interview and record review, the facility failed to provide documentation of testing of emergency lighting of at least 1-? hour duration. This deficient practice affected all patients, visitors and staff. The facility census was 5 patients.

Findings are:
Record review of the Emergency Light Maintenance Log on 10-20-10, revealed that emergency lights were tested on an annual basis.

During an interview on 10-20-10 at 1:10 pm Maintenance A confirmed that no annual testing had been done, and was not aware of the requirement

NFPA Standard:
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 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on interview and documentation the facility failed to provide one sound for the fire alarm on the first level. This deficient practice has the potential to affect all occupants of the facility, and cause confusion during a fire emergency. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 1:22 revealed, several sounds heard on the first level, while conducting a test of the fire alarm system.

During an interview on 10-20-10 at 1:22 pm, Maintenance A revealed that the facility failed to provide a single sound for the fire alarm.

Regulation:
Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building. 2000 NFPA 101, 9.6.3.9, Official State Interpretation 01-02

Based on observation and staff interview the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building in accordance with NFPA in the facility. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 12:45 pm and 12:50 pm, revealed:
1. Facility failed to provide sprinkler protection in areas throughout the corridor and some rooms in the basement.
2. The sprinkler main in the basement mechanical room failed to provide sprinkler protection.

During an interview on 10-20-10 at 12:45 pm and 12:50 pm, Maintenance A confirmed that the lower level failed to be sprinkler protected throughout.

NFPA Standard:
Where required by 18/19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. 2000 NFPA 101, 18/19.3.5.1

Based on interview and observation, the facility failed to ensure kitchen staff is trained on the use of kitchen hood extinguishing system. This deficient practice affected all staff, visitors and patients that use or are near the kitchen area. The facility census was 5 patients.

Findings are:
Observations and interview on 10-20-10 at 12:45 pm, the kitchen staff failed to identify manual pull for the kitchen hood suppression, and was unfamiliar with facility emergency procedure for a fire under the hood.

During an interview on 10-20-10 at 12:45 pm, Maintenance A confirmed that the kitchen staff was unfamiliar with the emergency procedures for the kitchen hood.

Based on observation, interview and documentation review the facility failed to maintain the facility free of heat producing devices in all areas of the building. This deficient practice affected all residents, staff and visitors in the facility.

Findings are:
Observations on 10-20-10 at 12:20 pm and 1:05 pm revealed:
1. Space heater in the Ballet Room, under Administrative Assistants desk.
2. Space heater in medical records office.

During an interview on 10-20-10 at both times of observations, Maintenance A confirmed the space heater in the offices. No documentation was provided to verify the temperature requirement.

NFPA Standard:
Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212?. 2000 NFPA 101, 19.7.8

Based on observation and interview the facility failed to provide protection to the gravity soiled linen chute by not providing fire rated door on the bottom of chute to protect the chute. The discharge room failed to provide fire rating and the intake door in the corridor failed to close. This deficient practice has the potential to affect all patients and occupants by having the fire spread from the discharge room into other areas of the building. Facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 12:40 pm and 12:42 pm revealed:
1. Lower level laundry chute door to corridor failed to provide fire rating.
2. Lower level laundry chute door failed to engage door frame.

During an interview on interview on 10-20-10 at both times of observations, Maintenance A confirmed the findings.

NFPA Standards:
3-2.2.9 Chute Discharge Doors.
Gravity chutes shall be constructed so that the base opening of the chute or shaft, or both, shall be protected by an approved automatic-closing or self-closing 1-hour fire door suitable for a Class B opening.

3-2.4 Chute Loading Doors.
3-2.4.1 General Access Gravity Waste Chutes.
All chute loading doors into a waste chute shall be provided with a self-closing, positive latching frame and gasketed fire door assembly approved for Class B openings and having a fire resistance rating of not less than 1 hour. The door frame shall be fastened into the chute and the shaft wall. The design and installation shall be such that no part of the frame or door projects into the chute.
The area of each chute loading door shall be limited to one-third of the cross-sectional area of a square chute and 44 percent of the area of a round chute.

3-2.6.1 Chute Discharge Room Criteria.
Waste and linen chutes shall terminate or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute. Openings to such rooms shall be protected by approved automatic-closing or self-closing 1 1/2-hour fire doors suitable for Class B openings.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected all patients, staff and visitors in the facility. Facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 12:12 pm and 12:42 pm revealed:
1. Several potted plants, cardboard box and an air purifier stored in front of dining room exit.
2. Baby warmer and air purifier stored in the surgery exit corridor.

During an interview on 10-20-10 at 12:12 pm and 12:42 pm, Maintenance A confirmed obstruction in the path of egress.

Based on interview and observation the facility failed to provide smoke protection for hazard areas by not providing self-closing devices, by allowing paper recycling containers larger than 32 gallons. This deficient practice affected all patients, visitors and staff on the first level. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 11:35 pm, revealed:
1. Three paper recycling barrels with a capacity of 17 gallons each found in one smoke zone on the main level in the " pink " room, mail room and medical records. No self-closing devices provided on any of the door.

During an interview on 10-20-10 at 11:35 pm, Maintenance A confirmed the combined capacity of three paper recycle barrels were over the allowed 32 gallons within a smoke zone.

Based on interview and observation the facility failed to maintain a piped-in medical gas system by providing proper room identification. This deficient practice affected all patients, visitors and staff on the first level. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 11:40 am, revealed that the medical gas shut off in CT hall failed to be labeled.

During an interview on 10-20-10 at 11:40 am, Maintenance A confirmed the label for the medical gas was not present.

Based on documentation review and interview the facility failed to maintain all anesthetizing location operating rooms with humidity level of 35 per cent or greater. This has the potential to affect all patients in the operating rooms of the hospital. The facility census was 5 patients.

Findings are:
1. During documentation review on 10-20-10, of humidity log for a ten month period of time, revealed the facility failed to maintain the humidity of 35% or greater the OR on multiple occasions.

During an interview on 10-20-10 at 1:31 pm, Maintenance A confirmed the documentation review of the humidity levels.

NFPA Standard:
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater. Advantages claimed for humidity include avoidance of hypothermia in patients, especially during long operative procedures; the fact that floating particulate matter increases in conditions of low relative humidity; and the fact that the incidence of wound infections can be minimized following procedures performed in those operating rooms in which the relative humidity is maintained at the level of 50 to 55 percent.1998 NFPA 99, 5-4.1.1

Based on interview and record review, the facility failed to maintain and test the emergency generator power supply as required. The deficient practice affected all smoke compartments of the building and all of the occupants. The facility census was 5 patients.

Findings are:
Review of documentation and interview on 10-20-10 at 1:04 pm with Maintenance A revealed:

Documentation review on 10-20-10 revealed the facility not documenting the time to transfer from normal power to generator power during testing of the generator.

Documentation review on 10-20-10 revealed the lack of monthly testing of the generator under a 30% load.

During an interview on 10-20-10 at 1:04 pm, Maintenance A confirmed the facility failed to be aware of the generator testing requirements.

NFPA Standard:
Generator sets or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures. 1999 NFPA 99, 3-4.4.1.1

NFPA Standard:
Inspection and Testing of Level 3 generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b). 1999 NFPA 99, 3-6.4.1.1

NFPA Standard:
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: 1999 NPPA 110, 6-4.2
a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
c) The date and time of day for required testing shall be decided by the owner, based on facility operations

Based on observation and interview the facility failed to verify a Type I essential Electrical system for the facility and by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice affected all patients, staff and visitors of the facility by affecting the emergency systems of the facility. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 at 11:29 am revealed:
1. The facility failed to verify that the Type I EES was provided.
2. The critical branch, life safety branch and the equipment system branch were intermixed in panel boxes throughout the facility.
3. The electrical system appeared to have one transfer switch.

During an interview on 10-20-10 at 11:29 am, Maintenance A confirmed that the panel boxes throughout the facility had an intermix of the required branches within each panel.

NFPA Standard:
NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, 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) Emergency Systems. 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) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for
the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7?C (20?F).
(b) The outside design temperature is lower than -6.7?C (20?F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This deficient practice affected all patients, visitors and staff that are in the area of open junction boxes and power strips. The facility census was 5 patients.

Findings are:
Observations on 10-20-10 between 10:15 am and 12:32 pm revealed:
1. Electrical wire for a ceiling light in the Materials Management room ran through the wall and ceiling tiles and plugged was into a power-strip in the south-west corner of room.
2. Power-strip plugged into another power-strip in the south-west corner of Materials Management room.
3. Microwave and refrigerator plugged into a power-strip in the south-east desk area of Home Health office.
4. Blood pressure machine plugged into a non-hospital grade power-strip.


During an interview on 10-20-10 between 10:15 am and 12:32 pm, Maintenance A confirmed the all findings.