HospitalInspections.org

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 6 (six) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility failed to ensure the outside emergency lights had two light sources at three (3) exits.

The findings include:

Observation, on 01/28/14 at 2:35 PM with the Director of Plant Operations, revealed the exterior exits at the business office exit, front stairwell exit, and the shop exit had a single light for illumination of the outside of the exit.

Interview, on 01/28/14 at 2:35 PM with the Director of Plant Operations, revealed he was unaware the lighting fixtures serving the exterior exits must include more than one bulb for illumination of the egress path.


Reference: NFPA 101 (2000 edition)
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 ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility failed to ensure (1) space heater was not located in the health care occupancy.

The findings include:

Observation, on 01/28/14 at 2:45 PM with the Director of Plant Operations, revealed a portable space heater located in the X-ray Director's Office with a heating element over 212 degrees and a jacket lying across the heater.

Interview, on 01/28/14 at 2:45 PM with the Director of Plant Operations, revealed he was not unaware the space heater was being used in the facility.


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 the emergency generator was maintained in accordance with NFPA standards. The deficiency had the potential to affect twenty-six (26) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility failed to check the two (2) generators for the month of June in 2013.

The findings include:

Observation, on 01/28/14 at 12:55 PM with the Director of Plant Operations, revealed the generator was not being maintained on a weekly basis as required. The generator was not checked during any week of June 2013.

Interview, on 01/28/14 at 12:55 PM with the Director of Plant Operations, revealed the employee that was in charge of checking the generator had left that month and the weekly generator checks were not performed for the month of June.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

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.

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 6 (six) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility failed to ensure the outside emergency lights had two light sources at three (3) exits.

The findings include:

Observation, on 01/28/14 at 2:35 PM with the Director of Plant Operations, revealed the exterior exits at the business office exit, front stairwell exit, and the shop exit had a single light for illumination of the outside of the exit.

Interview, on 01/28/14 at 2:35 PM with the Director of Plant Operations, revealed he was unaware the lighting fixtures serving the exterior exits must include more than one bulb for illumination of the egress path.


Reference: NFPA 101 (2000 edition)
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 ensure, portable space heaters used in the facility were in accordance with NFPA standards. The deficiency had the potential to affect one (1) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility failed to ensure (1) space heater was not located in the health care occupancy.

The findings include:

Observation, on 01/28/14 at 2:45 PM with the Director of Plant Operations, revealed a portable space heater located in the X-ray Director's Office with a heating element over 212 degrees and a jacket lying across the heater.

Interview, on 01/28/14 at 2:45 PM with the Director of Plant Operations, revealed he was not unaware the space heater was being used in the facility.


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 the emergency generator was maintained in accordance with NFPA standards. The deficiency had the potential to affect twenty-six (26) of twenty-six (26) smoke compartments, residents, staff and visitors. The facility failed to check the two (2) generators for the month of June in 2013.

The findings include:

Observation, on 01/28/14 at 12:55 PM with the Director of Plant Operations, revealed the generator was not being maintained on a weekly basis as required. The generator was not checked during any week of June 2013.

Interview, on 01/28/14 at 12:55 PM with the Director of Plant Operations, revealed the employee that was in charge of checking the generator had left that month and the weekly generator checks were not performed for the month of June.

Reference: NFPA 110 (1999 Edition).

6-1.1*
The routine maintenance and operational testing program shall be based on the manufacturer's recommendations, instruction manuals, and the minimum requirements of this chapter and the authority having jurisdiction

6-3.3
A written schedule for routine maintenance and operational testing of the EPSS shall be established

6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

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.