HospitalInspections.org

Based on observation and interview, it was determined the facility failed to meet the requirements of Protection of Hazards in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to provide self-closing devices for doors protecting hazardous areas.


The findings include:

Observation, on 01/17/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager and the Administrator revealed rooms required being self-closing or containing a hazardous amount of combustibles did not have self-closing device to keep the door closed. The rooms are identified as:

1) The 4th Floor Pulmonary Function Room located in the Sleep Lab.
2) The Pain Clinic Medical Records Room #A-118.


Interview, on 01/17/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager revealed they were not aware the doors to these rooms were required to be self-closing.


Interview, on 01/17/13 between 11:00 AM and 4:00 PM, with the Administrator revealed she was not aware the doors to these rooms were required to be self-closing.






8.4.1.3
Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.





Reference:

NFPA 101 (2000 Edition).

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas. Any hazardous areas
shall be safeguarded by a fire barrier having a
1-hour fire resistance rating or shall be provided
with an automatic extinguishing system in
accordance with 8.4.1. The automatic
extinguishing shall be permitted to be in
accordance with 19.3.5.4. Where the sprinkler
option is used, the areas shall be separated
from other spaces by smoke-resisting partitions
and doors. The doors shall be self-closing or
automatic-closing. Hazardous areas shall
include, but shall not be restricted to, the
following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2
(9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2),
including repair shops, used for storage of
combustible supplies
and equipment in quantities deemed hazardous
by the authority having jurisdiction
(8) Laboratories employing flammable or
combustible materials in quantities less than
those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be
permitted to have nonrated, factory or field-applied
protective plates extending not more than
48 in. (122 cm) above the bottom of the door.

Based on observation and interview, it was determined the facility failed to ensure exits were equipped with lighting in accordance with NFPA standards. The deficiency had the potential to affect seven (7) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey.

The findings include:

Observation, on 01/18/13 at 10:16 AM, with the Physical Plant Manager and the Administrator revealed exterior an exit with only one light bulb outside to light the egress path. The exit with only one light was located on the first floor at Stairwell G.

Interview, on 01/18/13 at 10:15 AM, with the Physical Plant Manager revealed he was not aware the exit did not have the required illumination for egress lighting.

Interview, on 01/18/13 at 10:15 AM, with the Administrator revealed she was not aware of the requirements for egress lighting.



Reference: NFPA 101 (2000 Edition)

19.2.8 Illumination of Means of Egress.
Means of egress shall be illuminated in accordance with Section 7.8.


7.8 ILLUMINATION OF MEANS OF EGRESS
7.8.1 General.
7.8.1.1*
Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.2
Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified.
Exception: Automatic, motion sensor-type lighting switches shall be permitted within the means of egress, provided that the switch controllers are equipped for fail-safe operation, the illumination timers are set for a minimum 15-minute duration, and the motion sensor is activated by any occupant movement in the area served by the lighting units.
7.8.1.3*
The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 lux) measured at the floor.
Exception No. 1: In assembly occupancies, the illumination of the floors of exit access shall be at least 0.2 ft-candle (2 lux) during periods of performances or projections involving directed light.
Exception No. 2*: This requirement shall not apply where operations or processes require low lighting levels.
7.8.1.4*
Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 lux) in any designated area.

Based on observation, and interview it was determined the facility failed to test emergency lighting in accordance with NFPA standards. The deficiency had the potential to affect thirty six (36) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to provide emergency battery lighting for the transfer switch located inside the building.

The findings include:

Observation, on 01/17/13 at 3:43 PM, with the Physical Plant Manager and the Administrator revealed the facility did not have emergency battery lighting in the transfer switch to illuminate the transfer switch in the event of a problem with the generator transferring power during a power failure.

Interview, on 01/17/13 at 3:43 PM, with the Physical Plant Manager confirmed the observation.

Interview, on 01/17/13 at 3:40 PM, with the Administrator revealed she was not aware the transfer switch room did not have emergency battery lighting.


Reference: NFPA 101 (2000 edition)
7.9.2.1* Emergency illumination shall be provided for not less than 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10 lux) and, at any point, not less than 0.1 ft-candle (1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6 lux) and, at any point, not less than 0.06 ft-candle (0.6
lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

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
11/2 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.


Reference: NFPA 110 (1999 Edition).

5-3.1 The Level 1 or Level 2 EPS equipment location shall be
provided with battery-powered emergency lighting. The emergency
lighting charging system and the normal service room
lighting shall be supplied from the load side of the transfer
switch.

Based on Fire Drill record review and interview, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect all smoke compartments, patients, staff, and visitors. The facility is licensed for five hundred eighty-nine (589) beds and the census was four hundred seventy-five (475) on the day of the survey.

The findings include:

Fire Drill record review, on 01/17/13 at 1:30 PM, with the Safety Manager revealed the fire drills were not conducted and documented for the weekend shift staff. Fire drills must be conducted at least quarterly on each shift.

Interview, on 01/17/13 at 1:30 PM, with the Safety Manager revealed he was unaware the fire drills were not being conducted as required.


Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on interview and fire drill record review, it was determined the facility failed to ensure fire drills were conducted quarterly on each shift at unexpected times, in accordance with NFPA standards. The deficiency had the potential to affect thirty six (36) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to ensure the fire drills were conducted at unexpected times quarterly.

The findings include:

Fire Drill review, on 01/17/13 at 10:05 AM, with the Physical Plant Manager and the Hospital Safety Officer revealed the facility failed to conduct fire drills at unexpected times on third shift.


Interview, on 01/17/13 at 10:05 AM, with the Physical Plant Manager and the Hospital Safety Officer revealed they were not aware the fire drills were not being conducted as required.

Interview, on 01/18/13 at 11:45 AM, with the Administrator revealed she was not aware the fire drills were not being conducted as required.



Reference: NFPA Standard NFPA 101 19.7.1.2.
Fire drills shall be conducted at least quarterly on each shift and at unexpected times under varied conditions on all shifts.

Based on observation and interview it was determined the facility failed to ensure the building had a complete sprinkler system, installed in accordance with NFPA Standards. The deficiency had the potential to affect two (2) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to ensure sprinkler heads were not blocked by light fixtures on the ceiling, installed in all area, and the sprinkler heads in the same compartment were all of the same response type.

The findings include:

Observations, on 01/16/13 at 11:21 AM with the Physical Plant Manager and the Administrator revealed mixed response sprinkler heads located in the A - 100 Hall. The sprinkler heads located in the compartment were rated at 155 degrees and 165 degrees.

Interview, on 01/16/13 at 11:21 AM with the Physical Plant Manager revealed he was not aware of the requirement for sprinkler heads being of the same response rating.

Interview, on 01/16/13 at 11:21 AM, with the Administrator revealed she was not aware of the installation requirements for sprinklers.

Observations, on 01/17/13 at 1:58 PM with the Physical Plant Manager and the Administrator revealed a closet on the second floor identified as #A222, did not have a sprinkler head installed inside the closet.

Interview, on 01/17/13 at 1:58 AM with the Physical Plant Manager revealed he was not aware the closet did not have sprinkler protection.

Interview, on 01/17/13 at 1:58 PM, with the Administrator revealed she was not aware the closet did not have sprinkler protection.

Observations, on 01/17/13 at 3:08 PM with the Physical Plant Manager and the Administrator revealed light fixtures mounted too close to sprinkler heads and extending below the sprinkler deflector. The light fixtures too close to sprinkler heads are located in the First Floor Emergency Room Clean Utility Room #C101M, Soiled Utility Room #C101K, and Housekeeping Closet #C101G.

Interview, on 01/17/13 at 3:08 PM with the Physical Plant Manager revealed he was not aware of the requirement.

Interview, on 01/17/13 at 3:08 PM, with the Administrator revealed she was not aware of the requirement.




Reference: NFPA 13 (1999 Edition)

7-2.3.2.4 Where listed quick-response sprinklers are used
throughout a system or portion of a system having the same
hydraulic design basis, the system area of operation shall be
permitted to be reduced without revising the density as indicated
in Figure 7-2.3.2.4 when all of the following conditions
are satisfied:
(1) Wet pipe system
(2) Light hazard or ordinary hazard occupancy
(3) 20-ft (6.1-m) maximum ceiling height
The number of sprinklers in the design area shall never be
less than five. Where quick-response sprinklers are used on a
sloped ceiling, the maximum ceiling height shall be used for
determining the percent reduction in design area. Where
quick-response sprinklers are installed, all sprinklers within a
compartment shall be of the quick response type.
Exception: Where circumstances require the use of other than ordinary
temperature-rated sprinklers, standard response sprinklers shall be
permitted to be used.






Reference: NFPA 13 (1999 Edition)

5-13 8.1 Actual NFPA Standard: NFPA 101, Table 19.1.6.2 and 19.3.5.1. Existing healthcare facilities with construction Type V (111) require complete sprinkler coverage for all parts of a facility.
Actual NFPA Standard: NFPA 101, 19.3.5.1. Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Actual NFPA Standard: NFPA 101, 9.7.1.1. Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Actual NFPA Standard: NFPA 13, 5-1.1. The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution.

Reference: NFPA 13 (1999 edition)

5-6.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall.


Reference: NFPA 13 (1999 ed.)
5-5.5.2.2 Sprinklers shall be positioned in accordance with
the minimum distances and special exceptions of Sections 5-6
through 5-11 so that they are located sufficiently away from
obstructions such as truss webs and chords, pipes, columns,
and fixtures.
Table 5-6.5.1.2 Positioning of Sprinklers to Avoid Obstructions to Discharge (SSU/SSP)

Maximum Allowable Distance
Distance from Sprinklers to of Deflector above Bottom of
Side of Obstruction (A) Obstruction (in.) (B
Less than 1 ft 0
1 ft to less than 1 ft 6 in. 21/2
1 ft 6 in. to less than 2 ft 31/2
2 ft to less than 2 ft 6 in. 51/2
2 ft 6 in. to less than 3 ft 71/2
3 ft to less than 3 ft 6 in. 91/2
3 ft 6 in. to less than 4 ft 12
4 ft to less than 4 ft 6 in. 14
4 ft 6 in. to less than 5 ft 161/2
5 ft and greater 18

For SI units, 1 in. = 25.4 mm; 1 ft = 0.3048 m.
Note: For (A) and (B), refer to Figure 5-6.5.1.2(a).

Based on observation and interview, it was determined the facility failed to maintain the sprinkler system in accordance with NFPA standards. The deficiency had the potential to affect thirty six (36) of thirty six (36) smoke compartments, residents, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to ensure sprinkler heads located in the facility were not loaded with foreign material.


The findings Include:



Observation, on 01/16/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager and the Administrator revealed the sprinkler heads located throughout the facility were loaded with lint and dust.

Interview, on 01/16/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager revealed he was not aware of the lint and dust build-up on the sprinkler heads.

Interview, on 01/16/13 between 11:00 AM and 4:00 PM, with the Administrator revealed she was aware of the requirement for maintaining sprinkler heads, however she was not aware of the lint and dust build-up on the sprinkler heads.






Reference: NFPA 13 (1999 Edition)


5-5.5.2* Obstructions to Sprinkler Discharge
Pattern Development.
5-5.5.2.1 Continuous or noncontiguous
obstructions less Than or equal to 18 in.
(457 mm) below the sprinkler deflector
That prevent the pattern from fully developing
shall comply With 5-5.5.2.



2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
hydraulic design basis, the system area of operation shall be
permitted to be reduced without revising the density as indicated
in Figure 7-2.3.2.4 when all of the following conditions
are satisfied:
(1) Wet pipe system
(2) Light hazard or ordinary hazard occupancy
(3) 20-ft (6.1-m) maximum ceiling height
The number of sprinklers in the design area shall never be
less than five. Where quick-response sprinklers are used on a
sloped ceiling, the maximum ceiling height shall be used for
determining the percent reduction in design area. Where
quick-response sprinklers are installed, all sprinklers within a
compartment shall be of the quick response type.
Exception: Where circumstances require the use of other than ordinary
temperature-rated sprinklers, standard response sprinklers shall be
permitted to be used.

Based on observation and interview, the facility failed to ensure the fire extinguishers were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to provide required signage for fire extinguishers.


The findings include:

Observation, on 01/18/13 at 10:00 AM, with the Physical Plant Manager and the Administrator revealed there was no placard stating that the hood suppression system must be used before the class K fire extinguisher. This type of extinguisher is used as a secondary measure to the range hood extinguishing system.

Interview, on 01/18/13 at 10:10 AM, with the Physical Plant Manager revealed he was not aware of the signage requirement.

Interview, on 01/18/13 at 10:10 AM, with the Administrator revealed she was not aware of the signage requirement.




Reference: NFPA 10 (1998 Edition).
2-3.2.1 A placard shall be conspicuously placed near the extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview it was determined the facility failed to ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect two (2) of thirty six (36) smoke compartments, residents, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey.

.
The findings include:

Observation, on 01/17/13 at 3:34 PM, with the Physical Plant Manager and the Administrator revealed a portable space heater located in rooms #C112, and C123. The facility did not have a policy for portable heaters or documentation that the heaters did not exceed 212 degrees.

Interview, on 01/17/13 at 3:34 PM, with the Physical Plant Manager and the Administrator revealed he was not aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas, they thought this requirement was only for patient care areas.

Interview, on 01/17/13 at 3:34 PM, with the Administrator revealed she was aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas.



Observation, on 01/18/13 at 10:10 AM, with the Physical Plant Manager and the Administrator revealed a portable space heater located in the Pain Clinic Medical Records Room #A-118. The facility did not have a policy for portable heaters or documentation that the heaters did not exceed 212 degrees.

Interview, on 01/18/13 at 10:10 AM, with the Physical Plant Manager and the Administrator revealed he was not aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas, they thought this requirement was only for patient care areas.

Interview, on 01/18/13 at 10:10 AM, with the Administrator revealed she was aware the heaters could not exceed 212°F in non-sleeping, staff, and employee areas.




Reference: NFPA 101 (2000 edition)
19.7.8 Portable Space-Heating Devices. 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°F (100°C).

Based on observation and interview, it was determined the facility failed to ensure that combustible decorations were used in accordance with NFPA standards. The deficiency had the potential to affect thirty six (36) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey.

The findings include:

Observation, on 01/17/13 at 10:00 AM, with the Physical Plant Manager and the Hospital Safety Manager revealed the facility did not have a flame retardant policy or documentation that newly introduced personal decorations for patients or staff has been treated with a flame retardant material.

Interview, on 01/17/13 at 10:00 AM, with the Physical Plant Manager and the Hospital Safety Manager revealed they were not aware decorations were required to be treated with a fire retardant and documentation was to be kept on the items that had been treated.

Interview, on 01/18/13 at 11:40 AM, with the Administrator revealed she was not aware decorations were required to be treated with flame retardant and the items were required to be documented.

Reference: NFPA 101 (2000 Edition)

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.

Based on observation and interview, it was determined the facility failed to ensure oxygen cylinders were stored in accordance with NFPA standards. This deficiency had the potential to affect two (2) of thirty six (36) smoke compartments, patients, staff, and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey.

The findings include:

Observation, on 01/17/13 at 1:09 PM, with the Physical Plant Manager and the Administrator revealed the facility failed to provide proper signage stating oxygen was stored inside the oxygen storage room located in room #C446.

Interview, on 01/17/13 at 1:09 PM, with the Physical Plant Manager revealed the facility was not aware the sign had been removed.

Interview, on 01/17/13 at 1:09 PM, with the Administrator revealed she was not aware the signage had been removed.


Observation, on 01/17/13 at 3:21 PM, with the Physical Plant Manager and the Administrator revealed the Nitrogen tanks located in room #C106A were not secured to prevent the tanks from falling over.

Interview, on 01/17/13 at 3:21 PM, with the Physical Plant Manager revealed the vendor had just delivered new tanks and did not secure the tanks properly.

Interview, on 01/17/13 at 3:21 PM, with the Administrator revealed she was not aware the tanks were not secured properly.




Reference: NFPA 99 (1999 edition)
8-3.1.11.2
Storage for nonflammable gases greater than 8.5 m3 (300 ft3) but less than 85 m3 (3000 ft3)
(A) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(B) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(C) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) A minimum distance of 6.1 m (20 ft)
(2) A minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems
(3) An enclosed cabinet of noncombustible construction having a minimum fire protection rating of ½ hour. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.


8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Based on observation, generator testing record review, and interview, it was determined the facility failed to ensure the emergency generator was maintained in accordance with NFPA standards. The deficiency had the potential to affect thirty six (36) of thirty six (36) smoke compartments, patients, staff and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey.


The findings include:



Observation, on 01/18/13 at 10:38 AM, with the Physical Plant Manager revealed corrosion on each of the two (2) generators batteries.

Interview, on 01/18/13 at 10:38 AM, with the Physical Plant Manager revealed he was not aware of the corrosion on the generators batteries.

Interview, on 01/18/13 at 11:40 AM, with the Administrator revealed she was not aware of the corrosion on the generators batteries.





Reference: NFPA 99 (1999 Edition)

Actual NFPA Standard: NFPA 99, 3-5.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set 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 3-5.3.1.
(b) Inspection and Testing. Generator sets shall be inspected and tested in accordance with 3-4.4.1.1(b).
Actual Standard: NFPA 110, 6-4.5 Level 1 and Level 2 transfer switches shall be operated monthly. The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.
Actual Standard: NFPA 99, 3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set 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.
(b) Inspection and Testing.
1. Test Criteria. 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.
2. Test Conditions. 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.
3. Test Personnel. 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.
Actual Standard: NFPA 99, 3- 3-4.4.2. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.



Reference: NFPA 110 (1999 Edition).

5-12.6
The starting battery units shall be located as close as practicable to the prime mover starter to minimize voltage drop. Battery cables shall be sized to minimize voltage drop in accordance with the manufacturers ' recommendations and accepted engineering practices.
Battery charger output wiring shall be permanently connected. Connections shall not be made at the battery terminals.

Based on observation and interview, it was determined the facility failed to ensure electrical wiring was maintained in accordance with NFPA standards. The deficiency had the potential to affect twelve (12) of thirty six (36) smoke compartments, residents, staff, and visitors. The facility is certified for three hundred two (302) beds with a census of one hundred twenty four (124) on the day of the survey. The facility failed to ensure the proper use of power strips, extension cords, and multi-plug adapters.

The findings include:

Observations, on 01/16/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager and the Administrator revealed:

1) An extension cord in use located in the General Surgery Workroom.
2) A defibrillator was plugged into a power strip located in the 6th Floor Nurses Station.
3) An air pump and bed were plugged into a power strip located in room #610.
4) A coffee maker, tea brewer, and microwave were plugged into a power strip located in room #C502.
5) A refrigerator was plugged into a damaged power strip located in room #C502.
6) A Pyxis Med Station was plugged into a power strip located in room #B533.

Interview, on 01/16/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager revealed he was not aware of the requirements for power strips and extension cords.

Interview, on 01/16/13 between 11:00 AM and 4:00 PM, with the Administrator revealed she was not aware of the proper use of power strips and extension cords.


Observations, on 01/17/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager and the Administrator revealed:

1) A power strip was plugged into another power strip located in room #C314-A.
2) Medical equipment was plugged into a power strip located in the 4th Floor Nurses Station.
3) Medical equipment was plugged into a power strip located in the Neurological Etratragnostic Lab located on the 4th Floor.
4) Two (2) refrigerators were plugged into a power strip located in the Stress Testing Room on the 2nd Floor.
5) Medical equipment was plugged into a power strip located in the 2nd Floor Vascular Outpatient storage room #C203D.
6) Storage located in front of electrical panels located in the Housekeeping Closet #C101C.
7) A refrigerator and microwave were plugged into a multi-plug extension cord located in the Staff Lounge Emergency Room 1st Floor.
8) An extension cord to lab equipment located in the 1st Floor Lab.

Interview, on 01/17/13 between 11:00 AM and 4:00 PM, with the Physical Plant Manager revealed he was not aware of the requirements for power strips and extension cords.

Interview, on 01/17/13 between 11:00 AM and 4:00 PM, with the Administrator revealed she was not aware of the proper use of power strips and extension cords.


Observations, on 01/18/13 between 9:00 AM and 11:00 AM, with the Physical Plant Manager and the Administrator revealed:

1) Two (2) power strips were plugged into a multi-plug adaptor located in room #B103C9.
2) A fountain drink machine pump was plugged into an extension cord located in the Retail Cafeteria.
3) A refrigerator, microwave, and coffee maker were plugged into a power strip located in room #C007F.

Interview, on 01/18/13 between 9:00 AM and 11:00 AM, with the Physical Plant Manager revealed he was not aware of the requirements for power strips and extension cords.

Interview, on 01/18/13 between 9:00 AM and 11:00 AM, with the Administrator revealed she was not aware of the proper use of power strips and extension cords.



Reference: NFPA 101 (2000 Edition)

9.1.2 Electric.
Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Reference: NFPA 70 400-8
( Extensions Cords) Uses Not Permitted.
Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces


Reference: NFPA 99 (1999 edition)

3-3.2.1.2 D

Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.



110-26. Spaces

About Electrical Equipment. Sufficient access and working space shall be provided and maintained around all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.