HospitalInspections.org

Based on review of facility documentation it was determined the hospital failed to inspect and test all components of the hospital fire alarm system annually in accordance with National Fire Protection Association (NFPA) 72. Findings include:

1. On 03/01/10 at approximately 1:00 p.m., the hospital annual fire alarm inspection report for the previous twelve (12) month period was reviewed. This report was prepared by Simplex Grinnell Company and dated 06/03/09. This report stated that the the following alarm initiating devices were not tested:

a. Device per zone test (four (4).
b. One (1) control/auxiliary device (power supply) located in maintenance/housekeeping.

This practice does not meet the requirement of annually (twelve (12) month interval) inspecting and testing of all components of the hospital fire alarm system.

National Fire Protection Association (NFPA) 110 - Standard for Emergency and Standby Power Systems
5-3 Lighting.
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.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain the facility generator in accordance with NFPA 110. Findings include:

1. On 03/02/10 at approximately 10:00 a.m., the generator transfer switch room was observed not to have any battery-powered emergency lighting installed. When installed, the battery-powered emergency lighting charging system shall be supplied from the load side of the transfer switch.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on staff interview it was determined the hospital failed to maintain all electrical wiring equipment in accordance with NFPA 99. Findings include:

1. On 03/02/10 at approximately 10:00 a.m., an interview with the maintenance supervisor revealed that there was no current certification (previous twelve (12) month period) documentation for the testing of the hospital LIM (line isolation monitor) circuit located in the operating room.

Based on review of facility documentation it was determined the hospital failed to inspect and test all components of the hospital fire alarm system annually in accordance with National Fire Protection Association (NFPA) 72. Findings include:

1. On 03/01/10 at approximately 1:00 p.m., the hospital annual fire alarm inspection report for the previous twelve (12) month period was reviewed. This report was prepared by Simplex Grinnell Company and dated 06/03/09. This report stated that the the following alarm initiating devices were not tested:

a. Device per zone test (four (4).
b. One (1) control/auxiliary device (power supply) located in maintenance/housekeeping.

This practice does not meet the requirement of annually (twelve (12) month interval) inspecting and testing of all components of the hospital fire alarm system.

National Fire Protection Association (NFPA) 110 - Standard for Emergency and Standby Power Systems
5-3 Lighting.
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.

This Standard is not met as evidenced by:

Based on observation it was determined the hospital failed to maintain the facility generator in accordance with NFPA 110. Findings include:

1. On 03/02/10 at approximately 10:00 a.m., the generator transfer switch room was observed not to have any battery-powered emergency lighting installed. When installed, the battery-powered emergency lighting charging system shall be supplied from the load side of the transfer switch.

National Fire Protection Association (NFPA) 99 Standard for Health Care Facilities
Chapter 3 Electrical Systems
3-3.3.4.2 Line Isolation Monitor Tests.
The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
Based on staff interview it was determined the hospital failed to maintain all electrical wiring and equipment in accordance with NFPA 99.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

This Standard is not met as evidenced by:

Based on staff interview it was determined the hospital failed to maintain all electrical wiring equipment in accordance with NFPA 99. Findings include:

1. On 03/02/10 at approximately 10:00 a.m., an interview with the maintenance supervisor revealed that there was no current certification (previous twelve (12) month period) documentation for the testing of the hospital LIM (line isolation monitor) circuit located in the operating room.