HospitalInspections.org

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) There was no light with battery backup and receptacle observed at generator set location.
B) Regarding the critical receptacle identification, the stick-on labels showed obvious sign of peeling throughout the critical care areas.
C) The labeling of the Type 1 Essential Electrical System panels was not meaningful or easily to follow.
D) At least one junction box was observed without a cover as required, exemplified but not limited to the Kitchen Janitor Closet containing the Life Safety and Critical electrical panels.

"Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2002: 4.4.2.2.2.2.(5).

"No function other than those listed in (a) through (f) 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 ....(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location. - NFPA 70, National Electric Code. U.S.A.: NFPA; 1999: 517-32(e)

"In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels. "

"All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. " - NFPA 70, 2002: 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable. "

Receptacle Testing in Patient Care Areas

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) The staff indicated the grounding system inpatient care areas testing was not made and records were not available for review.

"Testing Intervals. (a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General care areas - 12 months; critical care areas - 6 months; wet locations - 6 months. " - NFPA 99, 1999, 7-6.2.1.2

"Receptacle Testing in Patient Care Areas per NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz)."

Dietary

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) Based on observation the facility failed to provide adequate clearance between the deep fryer and the cooking top unit.

"All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames form adjacent cooking equipment. " NFPA 96, Standard For Ventilation Control And Fire Protection Of Commercial Cooking Operations. U.S.A.: NFPA; 2001: 12.1.2.4.

Disaster Drills Hospitals

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) Based on observation the facility failed to provide records of documentation of rehearsals for the last three years, in order to ensure that there was no lapse in disaster drills.

"Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 1999, 11-5.3.9.

Fire Drills Hospitals

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) Based on observation the facility failed to conduct acceptable fire drills such as having adequate number of participants.
B) Fire drill records did not contain names of staff members participating in fire drills.

"Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize the facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm (2100 hours) and 6:00 am (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. - NFPA 101, Life Safety Code. U.S.A.: NFPA; 2000: 19.7.1.2

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) There was no light with battery backup and receptacle observed at generator set location.
B) Regarding the critical receptacle identification, the stick-on labels showed obvious sign of peeling throughout the critical care areas.
C) The labeling of the Type 1 Essential Electrical System panels was not meaningful or easily to follow.
D) At least one junction box was observed without a cover as required, exemplified but not limited to the Kitchen Janitor Closet containing the Life Safety and Critical electrical panels.

"Generator Set Location: Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location and essential electrical system transfer switch locations. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2002: 4.4.2.2.2.2.(5).

"No function other than those listed in (a) through (f) 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 ....(e) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location. - NFPA 70, National Electric Code. U.S.A.: NFPA; 1999: 517-32(e)

"In critical care areas, emergency system receptacles must be labeled to indicate the panel board and circuit number supplying them in accordance with NFPA 70, 1999: 517-19(a). The identification label shall be permanent either by engraving the cover plates or permanent adhesive engraved laminated labels. "

"All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. " - NFPA 70, 2002: 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable. "

Receptacle Testing in Patient Care Areas

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) The staff indicated the grounding system inpatient care areas testing was not made and records were not available for review.

"Testing Intervals. (a) The facility shall establish policies and protocols for the type of test and intervals of testing for each appliance. (b) All appliances used in patient care areas shall be tested in accordance with 7-5.1.3 or 7-5.2.2.1 before being put into service for the first time and after repair or modification. Patient-care-related electrical appliances shall be retested at intervals determined by their normal location or area of normal use, but not exceeding the intervals listed below: General care areas - 12 months; critical care areas - 6 months; wet locations - 6 months. " - NFPA 99, 1999, 7-6.2.1.2

"Receptacle Testing in Patient Care Areas per NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz)."

Dietary

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) Based on observation the facility failed to provide adequate clearance between the deep fryer and the cooking top unit.

"All deep fat fryers shall be installed with at least a 16 inch space between the fryer and surface flames form adjacent cooking equipment. " NFPA 96, Standard For Ventilation Control And Fire Protection Of Commercial Cooking Operations. U.S.A.: NFPA; 2001: 12.1.2.4.

Disaster Drills Hospitals

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) Based on observation the facility failed to provide records of documentation of rehearsals for the last three years, in order to ensure that there was no lapse in disaster drills.

"Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least on semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both. " - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 1999, 11-5.3.9.

Fire Drills Hospitals

The inspector observed, while accompanied by the Director of Plant Operations, during the hours of the inspection from 1PM to 5PM on 02/04/2016 that there were the following issues:

A) Based on observation the facility failed to conduct acceptable fire drills such as having adequate number of participants.
B) Fire drill records did not contain names of staff members participating in fire drills.

"Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize the facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm (2100 hours) and 6:00 am (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. - NFPA 101, Life Safety Code. U.S.A.: NFPA; 2000: 19.7.1.2