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Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all psych inpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/28/2014 at 2:05 pm, observation revealed on the 1st floor in the Acute Care Patient Unit & Support Spaces, of South Unit smoke compartment, that the separation wall was not constructed to have a 2-hour fire resistance rating because a large 18" diameter hole was present along with several smaller holes of 4" x 4" on two walls along the North side and West side of the Acute Psych Unit, where something was removed and not sealed, seams were not tapped, screws were not double mudded, penetrations by pipes, penetrations by electrical conduits and penetrations by sprinkler pipes not properly fire-sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.1.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with an exit sign when the egress path is not readily apparent. This deficiency occurred in 1 of the many smoke compartments, and had the potential to affect one staff member within this smoke compartment.

FINDINGS INCLUDE:

On 07/29/2014 at 10:50 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that the path of egress from the high hazardous space was not readily apparent and an exit sign was not provided near the exit door leading to the exterior. The other door lead to another hazardous room (Garage), not allowed to be the exit in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 ed.), section 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, and a smoke-tight room enclosure in a sprinkled smoke zone. This deficiency occurred in 1 of the many smoke compartments, and had the potential to affect one staff person within this smoke compartment.

FINDINGS INCLUDE:

1. On 07/29/2014 at 10:40 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that the fire barrier door could not be verified to have the required rating. The door to the emergency generator room should have been a 3-hour fire-rated door with a 'A' Label. The label was missing compared to other labeled doors in close proximity and the door was rusted from the exposed weathering. The door would not close and latch to the frame. The adjoining space was a garage with gasoline motors and other combustible elements within the space requiring this door to close. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

2. On 07/29/2014 at 10:44 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included one 1" diameter hole into the adjoining Garage and four 1" diameter holes into the adjoining Boiler Room. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).


______________________________________

Based on observation and interview, the facility did not provide egress paths at all times with level walking surfaces in the path of egress. This deficiency occurred in 1 of the smoke compartments, and had the potential to affect 1 staff member within this smoke compartment.

FINDINGS INCLUDE:

On 07/29/2014 at 10:45 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that a portion of the path of egress had an abrupt change in elevation of the exit discharge out of the Emergency Generator Room. The threshold dropped-off greater than 4 inches. An exit stoop was missing. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 7.1.6 and 7.1.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation, interview and a review of record documents, the facility did not maintain the fire alarm system according to NFPA 70 and NFPA 72 requirements with complete inspection documentation. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/28/2014 at 3:15 pm, observation revealed that during a review of the record documents it was discovered that the Quarterly Visual Inspections and Performance Tests of the fire alarm system, were not conducted as required by the code. The Quarterly Inspection Reports of the Fire Alarm System are missing. These reports were never completed. The primary issue is the Supervisory Devises & Control Valve Tampers were not recorded as being viewed per NFPA 72 (1999 ed.), section 7-3.1 and Tests of these devices were not recorded per NFPA 72 (1999 ed.), section 7-2.2 (#13h). This observed situation was not compliant with NFPA 101 (2000 ed.), section 9.6.1.7 and NFPA 72 (1999 ed.), section 7-5.2.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution. This deficiency occurred in 1 of the 2 smoke compartments at the South Acute Unit, and had the potential to affect all inpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 07/28/2014 at 1:05 pm, observation revealed on the 1st floor in the Exam Room, of South Acute Unit smoke compartment, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included the toilet door was in an open position and the door was 8'-0" in height, less than 6 inches of clearance between the top of the ceiling and top of the door, blocking the flow of water spray to all areas of the room. The door was missing signage to keep the door closed when not used. This observed situation was not compliant with NFPA 13 (1999 ed.), section 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation, interview and a review of record documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 (1998 ed.). The sprinkler system did not have all required sprinkler system inspections, intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/28/2014 at 2:45 pm, observation revealed that during a review of facility documents the annual wet sprinkler inspections were not performed as required by the code. The reference reviewed document is the Annual Inspection Report of Wet Sprinkler System. The hydraulic nameplate is required to be checked that it is attached to the sprinkler riser and is legible per NFPA 25 (1998 ed.), section 2-2.7. The Annual Report noted this information is not applicable. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

2. On 07/28/2014 at 1:55 pm, observation revealed on the 1st floor in the Acute Care Patient Unit & Support Spaces, of this Acute Unit smoke compartment, that the escutcheon rings on the sprinklers throughout the unit were not tight to the ceiling. These gaps may reduce the response time of the sprinklers in the rooms & corridors, and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

3. On 07/28/2014 at 1:27 pm, observation revealed on the 1st floor in the Housekeeping Closet, of South Acute Unit smoke compartment, that there was one or more unsealed holes near the ceiling. The holes included a ceiling panel that was open and was 2" x 24" in size. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 3rd party certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

4. On 07/28/2014 at 2:30 pm, observation revealed that during a review of facility documents the Monthly wet sprinkler inspections were not performed as required by the code. The facility was not doing Monthly Visual Inspections and recording them for 'gauges'; checking for condition and normal pressure per NFPA 25, section 2-2.4.1. Same for Monthly Visual Inspections and recording them for 'valves'; checking for normal position, accessibility, leaks, supervised and if the ID plate is present. These observed situations were not compliant with NFPA 25 (1998 ed.), section 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

5. On 07/28/2014 at 2:35 pm, observation revealed that during a review of facility documents the Quarterly wet Sprinkler Inspections were not performed as required by the code. The reference reviewed documents are the Quarterly Inspection Reports of Wet Sprinkler System. The hydraulic nameplate is required to be checked that it is attached to the sprinkler riser and is legible per NFPA 25 (1998 ed.), section 2-2.7. The Quarterly Reports noted this information is not applicable. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the many smoke compartments, and had the potential to affect one inpatient, and an unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 07/28/2014 at 1:35 pm, observation revealed on the 1st floor in the Restraint Toilet/Shower Room, of South Acute Unit smoke compartment, that a cubical curtain was installed that did not have a mesh top with 1/2" openings at least 18 inches down from the ceiling, and would restrict the proper flow of sprinkler water to the shower stall area. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.5.5 and NFPA 13 (1999 ed.) section 5-6.5.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).


______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, hospital grade outlets where medical device are used, and electrical panels with complete directories. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/28/2014 at 1:25 pm, observation revealed on the 1st floor in the Housekeeping Closet, of South Acute Unit smoke compartment, that access to electrical panel was less than 3'-0" clearance. The electrical panels were blocked by housekeeping buckets, mops, brooms, and paper supplies. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-26. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

2. On 07/28/2014 at 1:10 pm, observation revealed on the 1st floor in the Soiled Linen Room, of South Acute Unit smoke compartment, that a standard grade receptacle was used in lieu of a hospital grade receptacle. This observed situation was not compliant with NFPA 70 (1999 ed.), article 517-18(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

3. On 07/28/2014 at 1:29 pm, observation revealed on the 1st floor in the Open Nurses Station, of South Acute Unit smoke compartment, that a standard grade receptacle was used in lieu of a hospital grade receptacle. And the oscillating column shaped fan equipment was not properly grounded to the hospital electrical system. The oscillating fan equipment was missing a grounding plug, required for hospital use. This observed situation was not compliant with NFPA 70 (1999 ed.), article 517-18(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

4. On 07/28/2014 at 1:40 pm, observation revealed on the 1st floor in the Acute Care Patient Unit, that a standard grade receptacle was used in lieu of a hospital grade receptacle. Most electrical outlets throughout the acute care unit did not have the hospital grade outlets. This observed situation was not compliant with NFPA 70 (1999 ed.), article 517-18(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

5. On 07/28/2014 at 1:26 pm, observation revealed on the 1st floor in the Housekeeping Closet, of South Acute Unit smoke compartment, that a electrical panel breaker was not labeled to identify the loads it fed. Panel #N, breaker #57 was in the 'ON' position and was not identified what it served. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not provide a common separation wall with rated wall construction. This deficiency occurred in 2 of the 2 smoke compartments, and had the potential to affect all psych inpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/28/2014 at 2:05 pm, observation revealed on the 1st floor in the Acute Care Patient Unit & Support Spaces, of South Unit smoke compartment, that the separation wall was not constructed to have a 2-hour fire resistance rating because a large 18" diameter hole was present along with several smaller holes of 4" x 4" on two walls along the North side and West side of the Acute Psych Unit, where something was removed and not sealed, seams were not tapped, screws were not double mudded, penetrations by pipes, penetrations by electrical conduits and penetrations by sprinkler pipes not properly fire-sealed. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.1.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage with an exit sign when the egress path is not readily apparent. This deficiency occurred in 1 of the many smoke compartments, and had the potential to affect one staff member within this smoke compartment.

FINDINGS INCLUDE:

On 07/29/2014 at 10:50 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that the path of egress from the high hazardous space was not readily apparent and an exit sign was not provided near the exit door leading to the exterior. The other door lead to another hazardous room (Garage), not allowed to be the exit in the event of a fire. This observed situation was not compliant with NFPA 101 (2000 ed.), section 7.10.1.4. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not enclose hazardous rooms with rated doors, and a smoke-tight room enclosure in a sprinkled smoke zone. This deficiency occurred in 1 of the many smoke compartments, and had the potential to affect one staff person within this smoke compartment.

FINDINGS INCLUDE:

1. On 07/29/2014 at 10:40 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that the fire barrier door could not be verified to have the required rating. The door to the emergency generator room should have been a 3-hour fire-rated door with a 'A' Label. The label was missing compared to other labeled doors in close proximity and the door was rusted from the exposed weathering. The door would not close and latch to the frame. The adjoining space was a garage with gasoline motors and other combustible elements within the space requiring this door to close. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

2. On 07/29/2014 at 10:44 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that a hole in the enclosure did not resist the passage of smoke because of one or more unsealed holes. The holes included one 1" diameter hole into the adjoining Garage and four 1" diameter holes into the adjoining Boiler Room. The room was considered hazardous because it exceeded 50 square feet and contained a quantity of stored combustible materials considered hazardous. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.2.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).


______________________________________

Based on observation and interview, the facility did not provide egress paths at all times with level walking surfaces in the path of egress. This deficiency occurred in 1 of the smoke compartments, and had the potential to affect 1 staff member within this smoke compartment.

FINDINGS INCLUDE:

On 07/29/2014 at 10:45 am, observation revealed on the 1st floor in the Generator Room, of Central Utility Plant (C.U.P.) smoke compartment, that a portion of the path of egress had an abrupt change in elevation of the exit discharge out of the Emergency Generator Room. The threshold dropped-off greater than 4 inches. An exit stoop was missing. This observed situation was not compliant with NFPA 101 (2000 ed.), sections 7.1.6 and 7.1.7. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation, interview and a review of record documents, the facility did not maintain the fire alarm system according to NFPA 70 and NFPA 72 requirements with complete inspection documentation. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On 07/28/2014 at 3:15 pm, observation revealed that during a review of the record documents it was discovered that the Quarterly Visual Inspections and Performance Tests of the fire alarm system, were not conducted as required by the code. The Quarterly Inspection Reports of the Fire Alarm System are missing. These reports were never completed. The primary issue is the Supervisory Devises & Control Valve Tampers were not recorded as being viewed per NFPA 72 (1999 ed.), section 7-3.1 and Tests of these devices were not recorded per NFPA 72 (1999 ed.), section 7-2.2 (#13h). This observed situation was not compliant with NFPA 101 (2000 ed.), section 9.6.1.7 and NFPA 72 (1999 ed.), section 7-5.2.2. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation and interview, the facility did not provide a sprinkler system that complies with NFPA 13 (1999 edition) requirements, with unobstructed water distribution. This deficiency occurred in 1 of the 2 smoke compartments at the South Acute Unit, and had the potential to affect all inpatients, staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 07/28/2014 at 1:05 pm, observation revealed on the 1st floor in the Exam Room, of South Acute Unit smoke compartment, that the discharge of sprinkler water was prevented from reaching an unprotected area on the other side of the obstructing item. The obstruction included the toilet door was in an open position and the door was 8'-0" in height, less than 6 inches of clearance between the top of the ceiling and top of the door, blocking the flow of water spray to all areas of the room. The door was missing signage to keep the door closed when not used. This observed situation was not compliant with NFPA 13 (1999 ed.), section 5-6.5. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

______________________________________

Based on observation, interview and a review of record documents, the facility did not maintain the sprinkler system in a reliable operating condition that included a complete inspection program as required by NFPA 25 (1998 ed.). The sprinkler system did not have all required sprinkler system inspections, intact escutcheon rings, and ceilings sealed above the sprinklers to collect heat. This deficiency occurred in all of the smoke compartments, and had the potential to affect all inpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/28/2014 at 2:45 pm, observation revealed that during a review of facility documents the annual wet sprinkler inspections were not performed as required by the code. The reference reviewed document is the Annual Inspection Report of Wet Sprinkler System. The hydraulic nameplate is required to be checked that it is attached to the sprinkler riser and is legible per NFPA 25 (1998 ed.), section 2-2.7. The Annual Report noted this information is not applicable. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

2. On 07/28/2014 at 1:55 pm, observation revealed on the 1st floor in the Acute Care Patient Unit & Support Spaces, of this Acute Unit smoke compartment, that the escutcheon rings on the sprinklers throughout the unit were not tight to the ceiling. These gaps may reduce the response time of the sprinklers in the rooms & corridors, and did not duplicate the tight conditions that were used in the sprinkler escutcheon listed testing agency certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

3. On 07/28/2014 at 1:27 pm, observation revealed on the 1st floor in the Housekeeping Closet, of South Acute Unit smoke compartment, that there was one or more unsealed holes near the ceiling. The holes included a ceiling panel that was open and was 2" x 24" in size. This hole would reduce the response time of the sprinkler in the room and did not duplicate the tight conditions that were used in the sprinkler 3rd party certification test. This observed situation was not compliant with NFPA 25 (1998 ed.), section 1-11.1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

4. On 07/28/2014 at 2:30 pm, observation revealed that during a review of facility documents the Monthly wet sprinkler inspections were not performed as required by the code. The facility was not doing Monthly Visual Inspections and recording them for 'gauges'; checking for condition and normal pressure per NFPA 25, section 2-2.4.1. Same for Monthly Visual Inspections and recording them for 'valves'; checking for normal position, accessibility, leaks, supervised and if the ID plate is present. These observed situations were not compliant with NFPA 25 (1998 ed.), section 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

5. On 07/28/2014 at 2:35 pm, observation revealed that during a review of facility documents the Quarterly wet Sprinkler Inspections were not performed as required by the code. The reference reviewed documents are the Quarterly Inspection Reports of Wet Sprinkler System. The hydraulic nameplate is required to be checked that it is attached to the sprinkler riser and is legible per NFPA 25 (1998 ed.), section 2-2.7. The Quarterly Reports noted this information is not applicable. This observed situation was not compliant with NFPA 25 (1998 ed.), section 2-2 and Table 2-1. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff C (Environmental Srvs. Dir.).

______________________________________

Based on interview, and a review of facility flame spread documents, the facility did not provide hanging drapes or curtains that met code requirements, such as sprinkler obstruction with cubical curtains that permit the designed distribution of sprinkler water. This deficiency occurred in 1 of the many smoke compartments, and had the potential to affect one inpatient, and an unknown number of staff and visitors within this smoke compartment.

FINDINGS INCLUDE:

On 07/28/2014 at 1:35 pm, observation revealed on the 1st floor in the Restraint Toilet/Shower Room, of South Acute Unit smoke compartment, that a cubical curtain was installed that did not have a mesh top with 1/2" openings at least 18 inches down from the ceiling, and would restrict the proper flow of sprinkler water to the shower stall area. This observed situation was not compliant with NFPA 101 (2000 ed.), section 19.3.5.5 and NFPA 13 (1999 ed.) section 5-6.5.2.3. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).


______________________________________

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with working clearances at electrical panels, hospital grade outlets where medical device are used, and electrical panels with complete directories. This deficiency occurred in 1 of the 2 smoke compartments, and had the potential to affect all inpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On 07/28/2014 at 1:25 pm, observation revealed on the 1st floor in the Housekeeping Closet, of South Acute Unit smoke compartment, that access to electrical panel was less than 3'-0" clearance. The electrical panels were blocked by housekeeping buckets, mops, brooms, and paper supplies. This observed situation was not compliant with NFPA 70 (1999 ed.), article 110-26. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

2. On 07/28/2014 at 1:10 pm, observation revealed on the 1st floor in the Soiled Linen Room, of South Acute Unit smoke compartment, that a standard grade receptacle was used in lieu of a hospital grade receptacle. This observed situation was not compliant with NFPA 70 (1999 ed.), article 517-18(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

3. On 07/28/2014 at 1:29 pm, observation revealed on the 1st floor in the Open Nurses Station, of South Acute Unit smoke compartment, that a standard grade receptacle was used in lieu of a hospital grade receptacle. And the oscillating column shaped fan equipment was not properly grounded to the hospital electrical system. The oscillating fan equipment was missing a grounding plug, required for hospital use. This observed situation was not compliant with NFPA 70 (1999 ed.), article 517-18(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

4. On 07/28/2014 at 1:40 pm, observation revealed on the 1st floor in the Acute Care Patient Unit, that a standard grade receptacle was used in lieu of a hospital grade receptacle. Most electrical outlets throughout the acute care unit did not have the hospital grade outlets. This observed situation was not compliant with NFPA 70 (1999 ed.), article 517-18(b). This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

5. On 07/28/2014 at 1:26 pm, observation revealed on the 1st floor in the Housekeeping Closet, of South Acute Unit smoke compartment, that a electrical panel breaker was not labeled to identify the loads it fed. Panel #N, breaker #57 was in the 'ON' position and was not identified what it served. This observed situation was not compliant with NFPA 70 (1999 ed.), Article 110-22. This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director of Nursing) and staff C (Environmental Srvs. Dir.).

______________________________________