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Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...."

Findings Include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, observed and tested the following corridor doors:

1. PACU, door tested three of three times will not positively latch.
2. Clean utility and storage room doors taped in the open position, two of two doors will not positively latch.
3. Kitchen double doors tested three of three times will not positively latch.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3: "...Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles...."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, observed the astragal was removed from the corridor smoke/fire doors to MRI. When closed there was a gap greater than 1/8 inch gap between the doors.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation and interview it was determined the facility did not maintain the integrity, and smoke resistance of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors...."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, observed the following hazardous area doors:

1. ED/Trauma storage room contains combustibles. The room has two of two doors with no closing device.
2. The lab storage room containing 10 gallons of hazardous flammable waste does not have a self closing device.
3. The lab storage room with large quantities of hazardous chemicals has the door removed.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation, document review, and staff interview it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.
Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 3, Section 3-2.6.1 and 3-2.6.2, "Listed corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler...."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, reviewed the sprinkler quarterly documentation. The documentation dates of inspection were; 12/4/14; 02/12/15; 06/15/15(LATE); and 08/11/15. The quarterly inspection from 02/12/15 to 05/15/15 was one month late.
The walk in refrigerator and the walk in freezer have one each corroded sprinkler heads for a total of two.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation, document review, and staff interview it was determined the facility did not clean the Kitchen Hood semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations....Chapter 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually" Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3." Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, reviewed the kitchen hood cleaning documentation. The facility had documentation that the kitchen hood had been cleaned one time a year, and not two times or every six months, as required in accordance with NFPA 96.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

Based on observation, document review and staff interview it was determined the facility failed to store flammable liquids in an approved flammable/combustible liquid cabinet, and limit the working supplies of flammable or combustible liquids.

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.3.2 "Protection from Hazards,"
18.3.2.2 "Laboratories," and Table 19.3.2.1 "Physical plant maintenance shops," and "Storage Rooms"
or Chapter 19, Section, 19.3.2.1 "Hazardous Areas" "(4) Repair shops," "(7) Storage rooms," and (8) " Laboratories."

Chapter 19.3.2.2* Laboratories: "... Laboratories employing quantities of flammable, combustible or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities...."

NFPA 99 Health Care Facilities, 1999 Chapter 10, Section 10-7-2* Storage and Use: "... Established laboratory practice shall limit working supplies of flammable or combustible liquid. The total volume of Class l, 11, and 111A, liquids outside of an approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class 1, 11, and 111A liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal...."

Finding include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager, Regulatory Consultant and the Laboratory Manager reviewed the facilities Fire Life Safety plan. It was determined the laboratory walls are one hour walls with a twenty minute door.

The quantity of flammable hazardous waste at the time of survey was two five gallon plastic containers equaling a total of ten gallons. The only document presented to the surveyor stated one of the materials within the ten gallons is Acetone a highly volatile liquid. The flash point is 15 degrees F(-9 degrees C).

The surveyor requested the MSDS sheets for the various chemicals used in the lab. The surveyor never received the MSDS as the manger of the lab could not locate them on the computer.

The surveyor requested the excess nine gallons of flammable waste be removed from the lab. Staff stated it would be removed at the end of the day.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to store flammable and combustible liquids properly may create a spill hazard, and will contribute to a fire, which will cause harm to patients and staff.

Based on observation, document review, and staff interview it was determined the facility allowed the use of a multiple outlet adapter/extension cords. The facility failed to provide battery operated emergency lighting in the operating rooms,and anesthetizing locations. The facility failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1: "... The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters...."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e)...."

NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 "The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (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 that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, requested the documentation for the Battery back up lights in the Operating Rooms and the documentation of the Isolated Electrical Panels.

The staff stated the Operating rooms do not have battery back up lights and the facility does not test the Isolated Electrical panels.

The Materials Management office has a microwave and a refrigerator plugged into a power strip. The Gift shop has a display case plugged into an extension cord.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.
The use of multiple outlet adapters and extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.

Based on observation it was determined the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke...."

Findings Include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, observed and tested the following corridor doors:

1. PACU, door tested three of three times will not positively latch.
2. Clean utility and storage room doors taped in the open position, two of two doors will not positively latch.
3. Kitchen double doors tested three of three times will not positively latch.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility failed to maintain self closing doors in a smoke barrier.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.7.3: "...Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than I hour. (1/2 hour for existing) Section 8.3.4.1, " Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles...."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, observed the astragal was removed from the corridor smoke/fire doors to MRI. When closed there was a gap greater than 1/8 inch gap between the doors.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

This installation will allow smoke to contaminate smoke zones not directly effected by the fire, which will cause harm to patients.

Based on observation and interview it was determined the facility did not maintain the integrity, and smoke resistance of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors...."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, observed the following hazardous area doors:

1. ED/Trauma storage room contains combustibles. The room has two of two doors with no closing device.
2. The lab storage room containing 10 gallons of hazardous flammable waste does not have a self closing device.
3. The lab storage room with large quantities of hazardous chemicals has the door removed.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation, document review, and staff interview it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.
Section 9.7." Section 9.7.1.1 "Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems." Chapter 3, Section 3-2.6.1 and 3-2.6.2, "Listed corrosion resistant sprinklers shall be installed in locations where chemicals, moisture, or other corrosive vapors sufficient to cause corrosion of such devices exist. Corrosion -resistant coatings shall be applied only by manufacturer of the sprinkler...."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, reviewed the sprinkler quarterly documentation. The documentation dates of inspection were; 12/4/14; 02/12/15; 06/15/15(LATE); and 08/11/15. The quarterly inspection from 02/12/15 to 05/15/15 was one month late.
The walk in refrigerator and the walk in freezer have one each corroded sprinkler heads for a total of two.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Based on observation, document review, and staff interview it was determined the facility did not clean the Kitchen Hood semi-annually in accordance with NFPA 96.

NFPA 101 Life Safety Code, 2000 Edition, Chapter 19, Section 19.3.2.6, "Cooking Facilities." "Cooking facilities shall be protected in accordance with 9.2.3." Section 9.2.3, "Commercial Cooking Equipment" "Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations....Chapter 8, Section 8-3 "Cleaning" "Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1." Table 8-3.1, Exhaust System Inspection Schedule "Type or Volume of Cooking Frequency" "Systems serving moderate-volume cooking operations." Frequency is Semiannually" Section 8-3.1.1 "Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 8-3." Section 8-3.1.2 "When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned."

Findings Include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, reviewed the kitchen hood cleaning documentation. The facility had documentation that the kitchen hood had been cleaned one time a year, and not two times or every six months, as required in accordance with NFPA 96.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to inspect and clean the kitchen hood and vents will allow a build-up of grease and provide fuel for a fire. A fire in the kitchen may cause harm to patients and staff.

Based on observation, document review and staff interview it was determined the facility failed to store flammable liquids in an approved flammable/combustible liquid cabinet, and limit the working supplies of flammable or combustible liquids.

NFPA 101 Life Safety Code, 2000 Chapter 19, Section 19.3.2 "Protection from Hazards,"
18.3.2.2 "Laboratories," and Table 19.3.2.1 "Physical plant maintenance shops," and "Storage Rooms"
or Chapter 19, Section, 19.3.2.1 "Hazardous Areas" "(4) Repair shops," "(7) Storage rooms," and (8) " Laboratories."

Chapter 19.3.2.2* Laboratories: "... Laboratories employing quantities of flammable, combustible or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities...."

NFPA 99 Health Care Facilities, 1999 Chapter 10, Section 10-7-2* Storage and Use: "... Established laboratory practice shall limit working supplies of flammable or combustible liquid. The total volume of Class l, 11, and 111A, liquids outside of an approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class 1, 11, and 111A liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal...."

Finding include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager, Regulatory Consultant and the Laboratory Manager reviewed the facilities Fire Life Safety plan. It was determined the laboratory walls are one hour walls with a twenty minute door.

The quantity of flammable hazardous waste at the time of survey was two five gallon plastic containers equaling a total of ten gallons. The only document presented to the surveyor stated one of the materials within the ten gallons is Acetone a highly volatile liquid. The flash point is 15 degrees F(-9 degrees C).

The surveyor requested the MSDS sheets for the various chemicals used in the lab. The surveyor never received the MSDS as the manger of the lab could not locate them on the computer.

The surveyor requested the excess nine gallons of flammable waste be removed from the lab. Staff stated it would be removed at the end of the day.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to store flammable and combustible liquids properly may create a spill hazard, and will contribute to a fire, which will cause harm to patients and staff.

Based on observation, document review, and staff interview it was determined the facility allowed the use of a multiple outlet adapter/extension cords. The facility failed to provide battery operated emergency lighting in the operating rooms,and anesthetizing locations. The facility failed to test and document the monthly testing of the Line Isolation Monitor tests/Isolated Electrical Panels.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1: "... The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities, " 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters...."

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1 "Utilities shall comply with the provisions of Section 9.1. Section 9.1.2 "Electric wiring and equipment shall be in accordance with NFPA 70 National Electrical Code... Article 517 Health Care Facilities, Section 517-63 Grounded Power systems in Anesthetizing Locations. 517-63(a), 'Battery-Powered Emergency Lighting Units." "One or more battery-powered emergency lighting units shall be provided in accordance with Section 700-12(e)." NFPA 99, Health Care Facilities, Chapter 3, Section 3-3.2.1.2, (5) Wiring in Anesthetizing Locations. (e) Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, Section 700-12 (e)...."

NFPA 101, Life Safety Code, 2000 Edition, Maintenance and Testing (See 4.6.12) "Maintenance and Testing "Section 4.6.12.1, "Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction."

"NFPA 99 1999 Edition, Health Care Facilities Section 3-3.3.4.2 "The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following: (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 that 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators."

Findings include:

On August 1st and 2nd 2015, the surveyor, accompanied by the Facilities Manager and the Regulatory Consultant, requested the documentation for the Battery back up lights in the Operating Rooms and the documentation of the Isolated Electrical Panels.

The staff stated the Operating rooms do not have battery back up lights and the facility does not test the Isolated Electrical panels.

The Materials Management office has a microwave and a refrigerator plugged into a power strip. The Gift shop has a display case plugged into an extension cord.

During the Exit conference on August 2, 2015, the above findings were again acknowledged by the CEO; CHRO; Facilities Manager and the Regulatory Consultant.

Failing to provide battery-powered emergency lighting in the operating rooms will harm patients during a power outage and failure of the emergency generator.

Failing to test and maintain documentation on the Line Isolation Tests/Isolated Electrical Panels could cause harm to the patients in an emergency or power outage.
The use of multiple outlet adapters and extension cords could create an overload of the electrical system and could cause a fire or an electrical hazard. A fire could cause harm to the patients.