HospitalInspections.org

A. The facility did not meet the requirements of NFPA 101, 19.2.2.2.6

The Standard: Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings: During the hours of 10:00 am and 12:30 pm, accomplanied by the facilities director, the inspector observed the cross corridor doors in the Nursing wing did not have smoke detectors located between 12" and 5'-0" from the centerline of the doors on the ceiling, for door release.


B. The facility failed to comply with NFPA 101, 19.3.6.1.

The Standard: Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.) Exception No. 7*: Waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(a) Each area does not exceed 600 ft2 (55.7 m2).
(b) The area is equipped with an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(c) The area does not obstruct any access to required exits.

Findings: During the hours of 10:00 am and 12:30 pm, accomplanied by the facilities director, the inspector observed the Outpatient Waiting Room opened onto the corridor. It did not have a smoke detector and was not in visual observation of a Nurse Station.

C. Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the facilities director, during the hours of the inspection from 10:00 am to 12:30 pm that there was not cross referencing of the fire alarm control panel and the panel and breaker (E1-16) supplying power. The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

It is unclear whether the facility is meeting the requirement of NFPA 72, 7-3.2.1.

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

Findings: During the hours of 10:00 am and 12:30 pm, accompanied by the facilities director, review of the records indicated smoke alarms were tested, however, they did not indicate whether that testing included sensitivity testing.

The facility failed to provide monthly inspections of the fire extinguishers as required by NFPA 10, 6.2.1 and 6.2.2.

The standard: Fire extinguishers shall be inspected when initailly placed inservice and thereafter at approximately 30-day intervals.
Periodic inspection of fire extinguishers shall include a check of at least the following items:
(1) Located in designated place.
(2) No obstruction to access or visibility.
(3) Operating instructions on nameplate legible and facing outward.
(4) Safety seals and tamper indicators not broken or missing.
(5) Fullness determined by weighing or "hefting."
(6) Examined for obvious physical damage, corrsion, leagage, or clogged nozzle.
(7) Pressure gauge reading or indicator in operable range or position.
(8) Condition of tires, wheels, carriage, hose and nozzle cheched (for wheeled units).
(9) HMIS label in place

Findings: During the hours of 10:00 am and 12:30 pm, accompanied by the facilities director, no records were found indicating the monthly inspection of the fire extinguishers.

Based on observation the facility failed to provide an acceptable electrical system in accordance to NFPA 99.

The Standard: (b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
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 facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.
3-4.2.2.3 Equipment System.
(a) General. The equipment system shall be connected to equipment described in 3-4.2.2.3(c)through (e).
(b) Connection to Alternate Power Source. The equipment system shall be installed and connected to the alternate power source, such that equipment described in 3-4.2.2.3(d) 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 3-4.2.2.3(e) by either delayed-automatic or manual operation.
(c) AC Equipment for Nondelayed Automatic Connection. Generator accessories, including but not limited to, the transfer fuel pump, electrically operated louvers, and other generator accessories essential for generator operation, shall be arranged for automatic connection to the alternate power source.
(d) * 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. It shall be permitted to place such suction systems 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. It shall be permitted to place such air systems on the critical branch.
4. Smoke control and stair pressurization systems
5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood
(e) 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 [also see A-3-4.2.2.3(d)]:
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 during disruption of the normal source shall not be required under any of the following conditions:
a. The outside design temperature is higher than +20?F (-6.7?C), or
b. The outside design temperature is lower than +20?F (-6.7?C) and a selected room(s) is provided for the needs of all confined patients [then only such room(s) need be heated], or
c. The facility is served by a dual source of normal power as described in 3-3.2.1.1.
2. Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]
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 are confined between floors.
3. Supply, return, and exhaust ventilating systems for surgical and obstetrical delivery suites, intensive care, coronary care, nurseries, and emergency treatment spaces.
4. 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.
5. Hyperbaric facilities
6. Hypobaric facilities
7. Autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
8. Controls for equipment listed in 3-4.2.2.3.
9. * Other selected equipment shall be permitted to be served by the equipment system.


The inspector observed while accompanied by the facilities director, during the hours of the inspection from 10:00 am to 12:30 pm that 3 circuits on Life Safety Panel E1 were for general lighting and 1 cicuit on Life safety panel E3 was for a server router. These items are not allowable items on the Life Saftey branch.

A. The facility did not meet the standard of NFPA 90A, 3-4.6.4 and NFPA 101, 8.3.6.1

The Standard: NFPA 90A, 3-4.6.4 - Where air ducts pass through walls, floors, or partitions that are required to have a fire resistance rating and where fire dampers are not required, the opening in the construction around the air duct shall be as follows:
(1) Not exceeding a 1-in. (2.54-cm) average clearance on all sides
(2) Filled solid with an approved material capable of preventing the passage of flame and hot gases sufficient to ignite cotton waste when subjected to the time-temperature fire conditions required for fire barrier penetration as specified in, NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials
Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)
NFPA 101, 8.3.6.1 - Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Findings: Observation between the inspection hours of 10:00 am and 12:20 pm, accompanied by the facilities director, revealed the duct, pipe and miscellaneous penetrations at barrier walls did not have the proper sealant at the ancillary space. The sealent was not colored red to indicate it is an approved material.

B. Based on observation, between the hours of 10:00 am and 12:30 pm the Fire damper Access panels were not labeled as required by 1999 NFPA 90A, 2-3.4.2.

The Standard: Service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

C. Based on observation, between the inspection hours of 10:00 am and 12:30 pm, the Isolation Panel LSP2 appeared to not be functioning properly.

The Standard: 1999 NFPA 99, 2-7 4(e) A visual (lighted red lamp) or audible warning signal from the line isolation monitor serving an anesthetizing location indicates that the total hazard current has exceeded allowable limits. This suggests that one or more electrical devices is contributing an excessively low impedance to ground, which might constitute a fault that would expose the patient or hospital personnel to an unsafe condition should an additional fault occur. Briefly and sequentially unplugging the power cord of each electrical device in the location will usually cause the green signal lamp to light, showing that the system has been adequately isolated from ground, when the potentially defective device has been unplugged. The continuing use of such a device, so identified, should be questioned, but not necessarily abandoned. At the earliest opportunity the device should be inspected by the hospital engineer or other qualified personnel and, if necessary, repaired or replaced.

Findings: Isolation Panel LSP2 had indicator lights on the front of the panel. Neither the green safe light or the red trouble light was lit and a separate indicator was showing to be in the grey area.

A. The facility did not meet the requirements of NFPA 101, 19.2.2.2.6

The Standard: Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings: During the hours of 10:00 am and 12:30 pm, accomplanied by the facilities director, the inspector observed the cross corridor doors in the Nursing wing did not have smoke detectors located between 12" and 5'-0" from the centerline of the doors on the ceiling, for door release.


B. The facility failed to comply with NFPA 101, 19.3.6.1.

The Standard: Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.) Exception No. 7*: Waiting areas shall be permitted to be open to the corridor, provided that the following criteria are met:
(a) Each area does not exceed 600 ft2 (55.7 m2).
(b) The area is equipped with an electrically supervised automatic smoke detection system in accordance with 19.3.4.
(c) The area does not obstruct any access to required exits.

Findings: During the hours of 10:00 am and 12:30 pm, accomplanied by the facilities director, the inspector observed the Outpatient Waiting Room opened onto the corridor. It did not have a smoke detector and was not in visual observation of a Nurse Station.

C. Based on observation the facility failed to provide an acceptable cross referencing of the fire alarm control panel and the panel and breaker supplying power.

The inspector observed while accompanied by the facilities director, during the hours of the inspection from 10:00 am to 12:30 pm that there was not cross referencing of the fire alarm control panel and the panel and breaker (E1-16) supplying power. The fire alarm control panel must have a label indicating the panel and breaker supplying power and the breaker in the electrical panel must have a label adjacent to the breaker indicating " FIRE ALARM CIRCUIT CONTROL " and the breaker shall be colored red.

It is unclear whether the facility is meeting the requirement of NFPA 72, 7-3.2.1.

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

Findings: During the hours of 10:00 am and 12:30 pm, accompanied by the facilities director, review of the records indicated smoke alarms were tested, however, they did not indicate whether that testing included sensitivity testing.

The facility failed to provide monthly inspections of the fire extinguishers as required by NFPA 10, 6.2.1 and 6.2.2.

The standard: Fire extinguishers shall be inspected when initailly placed inservice and thereafter at approximately 30-day intervals.
Periodic inspection of fire extinguishers shall include a check of at least the following items:
(1) Located in designated place.
(2) No obstruction to access or visibility.
(3) Operating instructions on nameplate legible and facing outward.
(4) Safety seals and tamper indicators not broken or missing.
(5) Fullness determined by weighing or "hefting."
(6) Examined for obvious physical damage, corrsion, leagage, or clogged nozzle.
(7) Pressure gauge reading or indicator in operable range or position.
(8) Condition of tires, wheels, carriage, hose and nozzle cheched (for wheeled units).
(9) HMIS label in place

Findings: During the hours of 10:00 am and 12:30 pm, accompanied by the facilities director, no records were found indicating the monthly inspection of the fire extinguishers.

Based on observation the facility failed to provide an acceptable electrical system in accordance to NFPA 99.

The Standard: (b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, " Gas and Vacuum Systems "
4. * Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.
(c) * Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.
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 facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.
3-4.2.2.3 Equipment System.
(a) General. The equipment system shall be connected to equipment described in 3-4.2.2.3(c)through (e).
(b) Connection to Alternate Power Source. The equipment system shall be installed and connected to the alternate power source, such that equipment described in 3-4.2.2.3(d) 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 3-4.2.2.3(e) by either delayed-automatic or manual operation.
(c) AC Equipment for Nondelayed Automatic Connection. Generator accessories, including but not limited to, the transfer fuel pump, electrically operated louvers, and other generator accessories essential for generator operation, shall be arranged for automatic connection to the alternate power source.
(d) * 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. It shall be permitted to place such suction systems 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. It shall be permitted to place such air systems on the critical branch.
4. Smoke control and stair pressurization systems
5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood
(e) 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 [also see A-3-4.2.2.3(d)]:
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 during disruption of the normal source shall not be required under any of the following conditions:
a. The outside design temperature is higher than +20?F (-6.7?C), or
b. The outside design temperature is lower than +20?F (-6.7?C) and a selected room(s) is provided for the needs of all confined patients [then only such room(s) need be heated], or
c. The facility is served by a dual source of normal power as described in 3-3.2.1.1.
2. Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]
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 are confined between floors.
3. Supply, return, and exhaust ventilating systems for surgical and obstetrical delivery suites, intensive care, coronary care, nurseries, and emergency treatment spaces.
4. 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.
5. Hyperbaric facilities
6. Hypobaric facilities
7. Autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
8. Controls for equipment listed in 3-4.2.2.3.
9. * Other selected equipment shall be permitted to be served by the equipment system.


The inspector observed while accompanied by the facilities director, during the hours of the inspection from 10:00 am to 12:30 pm that 3 circuits on Life Safety Panel E1 were for general lighting and 1 cicuit on Life safety panel E3 was for a server router. These items are not allowable items on the Life Saftey branch.

A. The facility did not meet the standard of NFPA 90A, 3-4.6.4 and NFPA 101, 8.3.6.1

The Standard: NFPA 90A, 3-4.6.4 - Where air ducts pass through walls, floors, or partitions that are required to have a fire resistance rating and where fire dampers are not required, the opening in the construction around the air duct shall be as follows:
(1) Not exceeding a 1-in. (2.54-cm) average clearance on all sides
(2) Filled solid with an approved material capable of preventing the passage of flame and hot gases sufficient to ignite cotton waste when subjected to the time-temperature fire conditions required for fire barrier penetration as specified in, NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials
Exception: Where fire dampers are installed, proper clearance for expansion shall be maintained. (See 3-4.6.)
NFPA 101, 8.3.6.1 - Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Findings: Observation between the inspection hours of 10:00 am and 12:20 pm, accompanied by the facilities director, revealed the duct, pipe and miscellaneous penetrations at barrier walls did not have the proper sealant at the ancillary space. The sealent was not colored red to indicate it is an approved material.

B. Based on observation, between the hours of 10:00 am and 12:30 pm the Fire damper Access panels were not labeled as required by 1999 NFPA 90A, 2-3.4.2.

The Standard: Service openings shall be identified with letters having a minimum height of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

C. Based on observation, between the inspection hours of 10:00 am and 12:30 pm, the Isolation Panel LSP2 appeared to not be functioning properly.

The Standard: 1999 NFPA 99, 2-7 4(e) A visual (lighted red lamp) or audible warning signal from the line isolation monitor serving an anesthetizing location indicates that the total hazard current has exceeded allowable limits. This suggests that one or more electrical devices is contributing an excessively low impedance to ground, which might constitute a fault that would expose the patient or hospital personnel to an unsafe condition should an additional fault occur. Briefly and sequentially unplugging the power cord of each electrical device in the location will usually cause the green signal lamp to light, showing that the system has been adequately isolated from ground, when the potentially defective device has been unplugged. The continuing use of such a device, so identified, should be questioned, but not necessarily abandoned. At the earliest opportunity the device should be inspected by the hospital engineer or other qualified personnel and, if necessary, repaired or replaced.

Findings: Isolation Panel LSP2 had indicator lights on the front of the panel. Neither the green safe light or the red trouble light was lit and a separate indicator was showing to be in the grey area.