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Based on observation, document review and interview, the facility failed to maintain their emergency lighting. This was evidenced by an emergency light that failed to illuminate when tested. This failure affected patients in the CT scan trailer.

NFPA 101 , Life Safety Code, 2000 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
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 test 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.


Findings:

During the facility tour with the Director of Facilities(DOF) on 5/2/16 through 5/3/16, the battery operated emergency lights were tested and maintenance documentation was reviewed.


At 9:15 a.m., the CT Scan trailer in the back of the facility was equipped with two battery powered lights. The light located in the CT scan room failed to illuminate when the DOF pressed the test button and the light located by the door illuminated but was hanging and not mounted in place. During interview, the DOF stated the lights were recently inspected and tested in April.

Based on observation and interview, the facility failed to maintain the oxygen storage as evidenced by oxygen cylinders stored less than five feet from combustibles and by the electrical light switch that was less than five feet from the floor. This failure could increase the risk of fire and affected 3 of 3 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4
Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 8 Gas Equipment
8-3-1.11.1 Storage Requirements
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft 3 (85 m3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (61.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the installations of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2. (a) 11d.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangements).
(a) Non flammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

Findings:

During the facility tour with the Director of Facilities (DOF) on 5/2/16 through 5/3/16, the oxygen storage was observed.

At 10:16 on 5/3/16, there were 10 oxygen cylinders stored with in 2 feet of medical equipment that was covered with plastic and the light switch was less than 5 feet above the floor. During interview, the DOF stated the cylinders were just recently moved into the room that was used as a clean storage room.
The room was located in unit one.

Based on document review and interview, the facility failed to conduct generator test in accordance with NFPA 110, 1999 Edition. This was evidenced by not doing the required duration for the annual load bank test . This had the potential for generator failure and affected 3 of 3 smoke compartments.

NFPA 99 Health Care Facilities, 199 Edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
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.

NFPA 110 Standard for Emergency and Standby Power Systems (1999) Edition
Chapter 6
6-4 Operational Inspection and Testing.
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.
6-4.2 Generators 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:
(a) Under operating temperatures 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.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review and interview with the Director of Facilities (DOF) on 5/2/16 through 5/3/16, the annual load bank test and the generator log was reviewed.

At 3:34 p.m., the DOF provided an annual load bank test dated 10/28/15 done by a vendor. The report documented the generator ran under load for one hour and not the required two hours. During interview, the DOF stated he was not aware the generator report indicated one hour.

Based on observation, the facility failed to maintain the electrical equipment in accordance with NFPA 70, 1999 Edition. This was evidenced by power strips plugged into power strips and the use of an extension cords. This could result in overloading the electrical system and increase the risk of an electrical fire. This affected 1 of 3 smoke compartments.

NFPA 101, Life Safety Code 2000 Edition
Section 9.1 Utilities
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.

NFPA 70, National Electrical Code, 1999 Edition.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the Director of Facilities(DOF) on 5/2/16 through 5/3/16, the electrical wiring and equipment were observed.

1. At 12:44 p.m. there was a power strip plugged into another power strip in the Director of Nursing office.

2. At 12:44 p.m., there was a power strip plugged into a power strip in the CRO/Administrator office.

3. At 12:49 p.m., the refrigerator in the laboratory managers office was plugged into a gray extension cord and not directly into the wall receptacle.