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A. Interim Life Safety Measures: Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.


Findings include:

A. Life safety panels 5LS2, B2LS1and other life safety panels throughout the older portion of the main building are serving loads other than those specifically allowed by NFPA70, Section 517-32.

B. Critical panels F5CR5, 4CR7-A1, F3CR5, BB2CR1, B2CR1, and B2CR2 were serving loads other than those allowed on the critical power system. Critical panel F5CR5 had a circuit feeding the fire alarm system, 4CR7 and F3CR5 were serving med gas alarms (which should be on the life safety panel). This does not meet the requirements of NFPA70, Section 517-33.

C. The fire alarm circuit breaker in the panel F2LS1 as well as any othe breakers serving fire alarm panels or NAC are required to be marked red and have a locking device on the breakers to comply with NFPA-72, Section 1-5.2.5.

D. Panels PPENPH, EMBR1, EMBR2, CLP1, CLP2, EAG, EMBW1, E1, ESB2 and other emergency panels are not separated into life safety, critical and equipments branches in accordance with the 1999 Edition of NFPA-70, Section 30 through 35.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms, and rooms 1, 2, 17, and 19 in the ER as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power which could endanger any patient being treated at the time.

B. Electrical room A414A housed 4160 Volt, 2000 Amp switchgear and did not have access and exiting meeting the requirements of NFPA-70, Section 110-33, and Table 110-34(a). This sutuation could endanger the life of anyone working in the electrical room if a fault occured on the equipment.

C. The car lighting disconnects for the oaks elevators, and elevators 3, 4, and 5 did not meet the requirements of NFPA-70, Section 620-53.

D. Corrected 06/25/13.

E. Several panel schedules in the older part of the hospital were hand written and not current and did not meet the requirements of NFPA-70, Section 110-22.