HospitalInspections.org

Based on observation and interview, the facility failed to ensure that corridor doors would resist the passage of smoke. This deficient practice had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-14-15 between 1:40 P.M. and 2:22 P.M. revealed:
1. The double doors by OR #3 had a 3/8 " gap between the doors.
2. The double for Endoscopy/Minor room #1269 had a ¼ " gap between the doors.

During an interview on 12-14-15 between 1:40 P.M. and 2:22 P.M., Maintenance A confirmed all the findings.

Based on observation and staff interview, the facility failed to provide smoke resistant doors to hazardous areas. This deficient practice had the potential to allow smoke or fire to migrate out of the hazardous areas into exit corridors. The facility census was 5 patients.

Findings are:
Observations on 12-14-15 at 1:48 P.M. in the storage room between OR #2 and OR #3 revealed that two of the doors failed to latch when closed.

During an interview on 12-14-15 at 1:48 P.M., observations were acknowledged and verified by Maintenance A.
Observations on 12-15-15 at 10:34 A.M. revealed that the decontamination room was measured to be 100 ft2 and was used for storage. The door for the decontamination room failed to be self-closing.

During an interview on 12-15-15 at 10:34 A.M., observations were acknowledged and verified by Maintenance A.

Based on observation and staff interview, the facility failed to maintain the doors in the path of egress so the exit hardware would release with the application of not more than 15 pounds of pressure. Also, the facility allowed the means of egress to become obstructed. These deficient practices had the potential to prevent occupants from exiting the facility during an emergency. Facility census was 5 residents.

Findings are:
Observation on 12/14/15 between 1:30 P.M. and 3:24 P.M. revealed:
1. While using a door pressure gauge to release the panic hardware for the double smoke doors next to OR #5, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
2. Two curtains in OR recovery were used to pull across the hallway obstructing the view and access to the exit.
3. While using a door pressure gauge to release the panic hardware for the double smoke doors next to data room #447, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
4. While using a door pressure gauge to release the panic hardware for the exit next to CT equipment storage room, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.

During an interview on 12/14/15 between 1:30 P.M. and 3:24 P.M., observations were acknowledged and verified by Maintenance A.
Observation on 12/15/15 between 10:30 A.M. and 11:14 P.M. revealed:
1. While using a door pressure gauge to release the panic hardware for the double fire doors next to room #1676, it took 25 pounds to release the panic hardware.
2. While using a door pressure gauge to release the panic hardware for the double smoke door next to room #1348, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.

During an interview on 12/15/15 between 10:30 A.M. and 11:14 P.M., observations were acknowledged and verified by Maintenance A.
NFPA Standard:

2000 ed. NFPA 1017.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Based on observation and interview, the facility failed to maintain all sprinkler heads throughout the facility in accordance with their llisting and failed to ensure all upright sprinkler heads located near the ceilings were installed within the required clearance range. This condition could prevent a fire from being suppressed by the sprinkler system. The facility census was 5 patients.

Findings are:
Observations on 12-14-15 at 2:30 P.M. revealed that some of upright sprinkler heads in chiller room were located more than 12 inches from the ceiling.

During an interview on 12-14-15 at 2:30 P.M., Maintenance A confirmed the findings.

NFPA Standard:

Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing. NFPA 13 1999, 5-6.4.1.1

Based on observation and staff interview, the facility failed to ensure an approved single-station smoke alarm was installed in staff sleeping room. This deficient practice would delay the detection of a fire in the staff sleeping room. The facility census was 5 patients.
Observation on 12-14-15 at 3:15 P.M. revealed that the ED on call which is used for staff sleeping did not have an approved smoke alarm.
During an interview on 12-14-15 at 3:15 P.M., Maintenance A confirmed the findings.

NFPA 101, 2000ed., 26.3.3.5 Smoke Alarms. Approved single-station smoke alarms shall be installed in accordance with 9.6.2.10 in every sleeping room. Such smoke alarms shall not be required to be interconnected.

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice had the potential to affect all patients, staff and visitors of the facility. The facility census is 5 patients.

Findings are:
Observations on 12-14-15 between 10:31 am and 1:30 pm revealed:
1. The following non-Critical loads were located in the Critical branch panel FCL2 in Room 1441; (14) Security 1431 outlet, (18) Manage Office 1422, 1438 outlets, (19) Management A 1442, 1441, 1439A outlets, (21) Management A 1442, 1444 outlets, (23) On Call 1439 outlets.
2. The following non-Life Safety loads were located in the Life Safety branch panel ALH1 in Room 1112; (12) Spare to Material Mat.
3. The following non-Critical loads were located in the Critical branch panel DCL1 in Room 1265; (57) Business Office 1277 outlets, (61) Business Lights 1271A, 1277.
4. The following non-Critical loads were located in the Critical branch panel GCL1 in Room 1609; (85) West Hall Lights.
5. The following non-Critical loads were located in the Critical branch panel BCL1 located outside pool area; (2) Boardroom 1323 lights, (6) (8) (10)Boardroom 1352 outlets.
6. The following non-Critical loads were located in the Critical branch panel GCL1 in Room 1609; (2)1601 recpts CNO/ASS. ADM Office, (3) 1675 recepts on call (4)1601 recpts CNO office, (5) 1676 recpts hospitalist, (6)1669 rectps staff lounge, (9) recepts storage (10)(12) 1662 recpts corridor (13) 1661 recpts ASE, FAC, House (15) 1664 recpts manage office, (17) 1665 recpts manage office, (26) 1638 recpts equip. rm.
7. The following non-Critical loads were located in the Critical branch panel GCL1 in Room 1609; (28) south hall recpts,(29) east hall recpts, (31) 1650 recpts equip, (35) west hall recpts.

During an interview on 12-4-15 between 10:31 am and 1:30 pm, Maintenance A confirmed the findings.

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 observation and staff interview, the facility allowed storage to be place in front of the electrical panel. This deficient practice would prevent access the electrical panel in the event of an emergency. Facility census was 5.

Observation 12-14-15 between 1:38 P.M. and 2:57 P.M revealed:
1. OR equipment in front of electrical panel in OR #4.
2. OR equipment in front of electrical panel in OR #3.
3. OR equipment in front of electrical panel in OR #1.
4. A table in front of electrical panel in the fire alarm panel room.
During an interview on 12-14-15 between 1:38 P.M. and 2:57 P.M, observations were acknowledged and verified by Maintenance A.

Based on observation and interview, the facility failed to ensure that corridor doors would resist the passage of smoke. This deficient practice had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 48 patients.

Findings are:
Observations on 12-14-15 between 1:40 P.M. and 2:22 P.M. revealed:
1. The double doors by OR #3 had a 3/8 " gap between the doors.
2. The double for Endoscopy/Minor room #1269 had a ¼ " gap between the doors.

During an interview on 12-14-15 between 1:40 P.M. and 2:22 P.M., Maintenance A confirmed all the findings.

Based on observation and staff interview, the facility failed to provide smoke resistant doors to hazardous areas. This deficient practice had the potential to allow smoke or fire to migrate out of the hazardous areas into exit corridors. The facility census was 5 patients.

Findings are:
Observations on 12-14-15 at 1:48 P.M. in the storage room between OR #2 and OR #3 revealed that two of the doors failed to latch when closed.

During an interview on 12-14-15 at 1:48 P.M., observations were acknowledged and verified by Maintenance A.
Observations on 12-15-15 at 10:34 A.M. revealed that the decontamination room was measured to be 100 ft2 and was used for storage. The door for the decontamination room failed to be self-closing.

During an interview on 12-15-15 at 10:34 A.M., observations were acknowledged and verified by Maintenance A.

Based on observation and staff interview, the facility failed to maintain the doors in the path of egress so the exit hardware would release with the application of not more than 15 pounds of pressure. Also, the facility allowed the means of egress to become obstructed. These deficient practices had the potential to prevent occupants from exiting the facility during an emergency. Facility census was 5 residents.

Findings are:
Observation on 12/14/15 between 1:30 P.M. and 3:24 P.M. revealed:
1. While using a door pressure gauge to release the panic hardware for the double smoke doors next to OR #5, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
2. Two curtains in OR recovery were used to pull across the hallway obstructing the view and access to the exit.
3. While using a door pressure gauge to release the panic hardware for the double smoke doors next to data room #447, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.
4. While using a door pressure gauge to release the panic hardware for the exit next to CT equipment storage room, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.

During an interview on 12/14/15 between 1:30 P.M. and 3:24 P.M., observations were acknowledged and verified by Maintenance A.
Observation on 12/15/15 between 10:30 A.M. and 11:14 P.M. revealed:
1. While using a door pressure gauge to release the panic hardware for the double fire doors next to room #1676, it took 25 pounds to release the panic hardware.
2. While using a door pressure gauge to release the panic hardware for the double smoke door next to room #1348, it exceeded the maximum 35 pounds limit of the gauge to release the panic hardware.

During an interview on 12/15/15 between 10:30 A.M. and 11:14 P.M., observations were acknowledged and verified by Maintenance A.
NFPA Standard:

2000 ed. NFPA 1017.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.

Based on observation and interview, the facility failed to maintain all sprinkler heads throughout the facility in accordance with their llisting and failed to ensure all upright sprinkler heads located near the ceilings were installed within the required clearance range. This condition could prevent a fire from being suppressed by the sprinkler system. The facility census was 5 patients.

Findings are:
Observations on 12-14-15 at 2:30 P.M. revealed that some of upright sprinkler heads in chiller room were located more than 12 inches from the ceiling.

During an interview on 12-14-15 at 2:30 P.M., Maintenance A confirmed the findings.

NFPA Standard:

Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm).
Exception: Ceiling-type sprinklers (concealed, recessed, and flush types) shall be permitted to have the operating element above the ceiling and the deflector located nearer to the ceiling where installed in accordance with their listing. NFPA 13 1999, 5-6.4.1.1

Based on observation and staff interview, the facility failed to ensure an approved single-station smoke alarm was installed in staff sleeping room. This deficient practice would delay the detection of a fire in the staff sleeping room. The facility census was 5 patients.
Observation on 12-14-15 at 3:15 P.M. revealed that the ED on call which is used for staff sleeping did not have an approved smoke alarm.
During an interview on 12-14-15 at 3:15 P.M., Maintenance A confirmed the findings.

NFPA 101, 2000ed., 26.3.3.5 Smoke Alarms. Approved single-station smoke alarms shall be installed in accordance with 9.6.2.10 in every sleeping room. Such smoke alarms shall not be required to be interconnected.

Based on observation and interview, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, the Critical Branch, and the Equipment System. This deficient practice had the potential to affect all patients, staff and visitors of the facility. The facility census is 5 patients.

Findings are:
Observations on 12-14-15 between 10:31 am and 1:30 pm revealed:
1. The following non-Critical loads were located in the Critical branch panel FCL2 in Room 1441; (14) Security 1431 outlet, (18) Manage Office 1422, 1438 outlets, (19) Management A 1442, 1441, 1439A outlets, (21) Management A 1442, 1444 outlets, (23) On Call 1439 outlets.
2. The following non-Life Safety loads were located in the Life Safety branch panel ALH1 in Room 1112; (12) Spare to Material Mat.
3. The following non-Critical loads were located in the Critical branch panel DCL1 in Room 1265; (57) Business Office 1277 outlets, (61) Business Lights 1271A, 1277.
4. The following non-Critical loads were located in the Critical branch panel GCL1 in Room 1609; (85) West Hall Lights.
5. The following non-Critical loads were located in the Critical branch panel BCL1 located outside pool area; (2) Boardroom 1323 lights, (6) (8) (10)Boardroom 1352 outlets.
6. The following non-Critical loads were located in the Critical branch panel GCL1 in Room 1609; (2)1601 recpts CNO/ASS. ADM Office, (3) 1675 recepts on call (4)1601 recpts CNO office, (5) 1676 recpts hospitalist, (6)1669 rectps staff lounge, (9) recepts storage (10)(12) 1662 recpts corridor (13) 1661 recpts ASE, FAC, House (15) 1664 recpts manage office, (17) 1665 recpts manage office, (26) 1638 recpts equip. rm.
7. The following non-Critical loads were located in the Critical branch panel GCL1 in Room 1609; (28) south hall recpts,(29) east hall recpts, (31) 1650 recpts equip, (35) west hall recpts.

During an interview on 12-4-15 between 10:31 am and 1:30 pm, Maintenance A confirmed the findings.

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 observation and staff interview, the facility allowed storage to be place in front of the electrical panel. This deficient practice would prevent access the electrical panel in the event of an emergency. Facility census was 5.

Observation 12-14-15 between 1:38 P.M. and 2:57 P.M revealed:
1. OR equipment in front of electrical panel in OR #4.
2. OR equipment in front of electrical panel in OR #3.
3. OR equipment in front of electrical panel in OR #1.
4. A table in front of electrical panel in the fire alarm panel room.
During an interview on 12-14-15 between 1:38 P.M. and 2:57 P.M, observations were acknowledged and verified by Maintenance A.