HospitalInspections.org

Bringing transparency to federal inspections

3100 CHANNING WAY

IDAHO FALLS, ID 83404

No Description Available

Tag No.: K0015

Based on observation and interview the facility failed to construct a healthcare building for use by residents with a class of interior finish required for construction of structures to be used or occupied by health care residents. The deficient practice affects one of three smoke compartments, staff, and all patients who may use the building. The facility has 28 beds and at the time of the survey the census was four.

Findings include:

Observation on 08/07/13 at 1:49 p.m. revealed the facility calm room that is open to the corridor has walls that are covered in a carpet material. The facility was unable to provide a flame spread or fire rating for the carpet material. Studies of past fires have revealed that such materials can contribute to a very rapid spread of fire. Interview on 08/07/13 at 1:49 p.m., with facility the Director of Plant Operations revealed the facility was not aware that the interior finish had to have a flame spread rating.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard: NFPA 101, 19.3.3.2 Interior Wall and Ceiling Finish.
Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.
(2) Newly installed materials - Class A
Exception No. 1: Newly installed walls and ceilings shall be permitted to have Class A or Class B interior finish in individual rooms having a capacity not exceeding four persons.
Exception No. 2: Newly installed corridor wall finish not exceeding 4 ft (1.2 m) in height that is restricted to the lower half of the wall shall be permitted to be Class A or Class B.

No Description Available

Tag No.: K0017

Based on observation and staff interview during a tour of the facility on 08/07/13, the facility failed provide early detection to protect corridors and expedite resident movement to a safe area. This potentially exposed residents to a smoke or fire environment. The deficient practice would affect all patients, visitors, and staff in one of three compartments. The facility has the capacity for 28 beds with a census of four on the day of the survey.

Findings include:

Observation on 08/07/13 at 1:38 p.m., revealed there was no fire alarm system smoke detection device in the calm room that is open to the corridor. Interview with the Director of Plant Operations on 08/07/13 at 1:38 p.m., revealed that the facility was not aware that smoke detection devices were required in spaces open to the corridor.

The findings were acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA standard(s):
19.3.6.1
Corridors shall be separated from all other areas by partitions complying with 19.3.6.2 through 19.3.6.5. (See also 19.2.5.9.)
Exception No. 1: Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 shall be permitted to have spaces that are unlimited in size open to the corridor, provided that the following criteria are met:
(a) The spaces are not used for patient sleeping rooms, treatment rooms, or hazardous areas.
(b) The corridors onto which the spaces open in the same smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the smoke compartment in which the space is located is protected throughout by quick-response sprinklers.
(c) The open space is protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the entire space is arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(d) The space does not obstruct access to required exits

No Description Available

Tag No.: K0022

Based on observation and interview, the facility failed to provide directional exit signs for one of four smoke compartments. The deficient practice affected one of four smoke compartments, staff and 17 residents. The facility has the capacity for 292 beds with a census of 196 the day of survey.

Findings include:

1.) Observation on 08/06/13 at 11:05 a.m., revealed that the E.I.R.M.C. simulation lab corridor did not have an illuminated directional exit signs to direct occupants to the exit corridor in case of emergency. Interview with the Director of Plant Operations on 08/06/13 at 11:05 a.m., revealed that the facility was not aware directional signage was needed at this location.

2.) Observation on 08/06/13 at 2:00 p.m., revealed that the exit sign in on the wall by the Infusion Center electrical equipment closet was obstructed. Interview with the Director of Plant Operations on 08/06/13 at 2:00 p.m., revealed that the facility was not aware the exit sign was not visible at this location.

3.) Observation on 08/07/13 at 11:05 a.m., revealed that the exit sign from the main corridor of the Idaho Heart Institute into the Pain Clinic was missing the directional arrow directing occupants to the exit door to the exterior located adjacent to the door to the Pain Clinic. Interview on 08/07/13 at 11:05 a.m., with the Director of Plant Operations revealed the facility was not aware the exit sign was missing the directional arrow.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard(s):

Item 1.) 7.10.2 Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Item 2.) 7.10.1.7 Visibility.
Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations, interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

No Description Available

Tag No.: K0025

Based on observation and interview, the facility failed to maintain the smoke resistive properties of a smoke barrier ceiling. This potentially exposed residents to a smoke or fire environment. The facility is licensed for 292 beds and had a census of 196 on the day of survey.

Findings include:

Observation and interview between 08/06/13 and 08/07/13 revealed open ceiling penetrations in the following E.I.R.M.C.locations: 5th floor corridor outside of the telephone equipment room, 3rd floor storage room opposite the nurses' station, and the x-ray/angio storage room. Interview on 08/07/13 at 03:36 p.m., with the Director of Plant Operations revealed that the facility was not aware of the unsealed penetrations in the smoke barrier ceilings.

The findings were acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard: NFPA 101, 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 1/2 hour.

Actual NFPA Standard: NFPA 101, 8.3.6.1 (1) a. and b. Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

No Description Available

Tag No.: K0025

Based on observation and interview, the facility failed to maintain the smoke resistive properties of a smoke barrier wall. The deficient practice affected two of three smoke compartments, staff, and four patients. The facility has the capacity for 28 beds with a census of four the day of survey.

Findings include:

On 08/07/13 at 2:07 p.m., a three inch unsealed space around a three inch pipe and a three inch circular hole was observed in the smoke barrier wall in the attic. Interview on 08/07/13 at 2:07 p.m., with the Director of Plant Operations revealed that the facility was not aware of the unsealed penetrations in the smoke barrier wall.

The finding was acknowledged by the Administrator and verified by the facility Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard: NFPA 101, 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 1/2 hour.

Actual NFPA Standard: NFPA 101, 8.3.6.1 (1) a. and b. Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected by filling the space between the penetrating item and the smoke barrier with a material that is capable of maintaining the smoke resistance of the smoke barrier or it shall be protected by an approved device that is designed for the specific purpose.

No Description Available

Tag No.: K0029

Based on observation and interview it was determined that the facility did not ensure that hazardous areas are equipped with self-closing doors. Hazardous area doors that do not self-close can allow smoke and fire gasses to enter the corridor or other areas of the facility in the event of a fire.

Findings include:

During the tour of the Pain Institute on 08/07/13 at 11:14 a.m., observation of the soiled linen room revealed that the door was not equipped with a self-closing device. Interview with the Director of Plant Operations on 08/07/13 at 11:14 a.m., revealed he was unaware the door was not equipped with a closing device.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.


Actual NFPA Standard:

19.3.2 Protection from Hazards.
19.3.2.1 Hazardous Areas.
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

No Description Available

Tag No.: K0038

Based on observation and interview, the facility failed to provide exit access from the building that could be kept clear and provide a hard surface during all weather conditions that would be readily accessible at all times. The deficient practice affected one of three smoke compartments, staff and four patients. The facility has the capacity for 28 beds with a census of four the day of survey.

Findings include:

Observation on 08/07/13 at 2:21 p.m., revealed that the south exit discharged out of the building onto a river stone and grass surfaced area for a distance of approximately 50 feet before terminating at the public way. Interview with the Director of Plant Operations on 08/07/13 at 2:21 p.m., revealed that the exit had been that way when they acquired the building.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard: NFPA 101, 7.5.1.1. Exit access shall be arranged that exits are readily accessible at all times.
Actual NFPA Standard: NFPA 101, 7.1.10.1. The means of egress shall be continuously maintained free of all obstructions or impediments to full and instant use in the case of fire or emergency.

No Description Available

Tag No.: K0038

Based on observation, operational testing, and staff interview, it was determined that the facility had not ensured exit doors are arranged to be opened readily from the egress side. These deficiencies can entrap people and prevent egress from the identified exits. The facility has the capacity for 292 beds with a census of 196 the day of survey. Findings include:

1.) During operational testing of the doors labeled "EXIT" on the third floor E.I.R.M.C. pediatric unit fire stair exit door and the cross corridor door from the pediatric unit to elevator lobby 08/06/13 at 10:04 a.m., disclosed that the magnetic door lock would not open without the use of an access control card swipe mechanism. Interview with the Director of Plant Operations on 08/06/13 at 10.04 a.m., indicated the facility was not aware that the locking arrangements were not code compliant.

2.) During operational testing of the doors labeled "EXIT" on the second floor E.I.R.M.C. pediatric intensive care unit (PICU) fire stair exit door, the cross corridor door between the intensive care unit ICU-C and the PICU and the main PICU door 08/06/13 at 11:01 a.m., disclosed that the magnetic door lock would not open without the use of an access control card swipe mechanism. Interview with the Director of Plant Operations on 08/06/13 at 11:01 a.m., indicated the facility was not aware that the locking arrangements were not code compliant.

3.) During operational testing of the doors labeled "EXIT" on the second floor E.I.R.M.C. cross corridor door between the catheter handling and the nurse training/skills lab on 08/06/13 at 11:15 a.m., disclosed that the magnetic door lock would not open without the use of an access control card swipe mechanism. Interview with the Director of Plant Operations on 08/06/13 at 11:15 a.m., indicated the facility was not aware that the locking arrangements were not code compliant.

4.) During operational testing of the doors labeled "EXIT" on the second floor E.I.R.M.C. operating room (OR) cross corridor door in the rear of the OR and the OR door to surgery from the staff elevator 08/06/13 at 2:30 p.m., disclosed that the magnetic door lock would not open without the use of an access control card swipe mechanism. Interview with the Director of Plant Operations on 08/06/13 at 2:30 p.m., indicated the facility was not aware that the locking arrangements were not code compliant.

5.) During operational testing of the doors labeled "EXIT" on the first floor E.I.R.M.C. cross corridor door between the emergency department and the x-ray department on 08/07/13 at 8:45 a.m., disclosed that the magnetic door lock would not open without the use of an access control card swipe mechanism. Interview with the Director of Plant Operations on 08/07/13 at 8:45 a.m., indicated the facility was not aware that the locking arrangements were not code compliant.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standards:

NFPA 101? Life Safety Code ? 2000 Edition
Chapter 19 Existing Health Care Occupancies
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

No Description Available

Tag No.: K0062

Based on observation, interview, and record review, the facility failed to properly maintain the water based fire protection systems. The deficient practice affected four of 28 smoke compartments, staff, and all patients. The facility has the capacity for 292 beds with a census of 196 the day of survey. Findings include:

1.) Based on observation, interview, and record review of the sprinkler testing reports for the last 12 month period on 08/05/13 at 4:30 p.m., documentation indicated that the sprinkler system had been inspected on 11/19/12. The inspection report noted the following deficiency: "There is a sprinkler head in the elevator penthouse electrical room that is too close to the wall. NFPA 13 requires a min (sp.) of 0-4" off the wall". The facility was unable to provide any documentation the deficiency had been corrected. Interview with the Director of Plant Operations on 08/06/13 at 8:30 a.m., revealed the facility was in the process of having the deficiency corrected.

2.) Based on observation and interview on 08/06/13 between 11:16 a.m. and 4:34 p.m., revealed the escutcheon ring was missing from a sprinkler head in the central supply trash collection room and the Backdoor Cafe corridor to NICU in the E.I.R.M.C. building. Interview with the Director of Plant Operations between 11:16 a.m. and 4:34 p.m., revealed the facility was not aware of the missing sprinkler escutcheon rings.

3.) Based on observation and interview on 08/07/13 at 8:57 a.m., revealed that a light fixture support chain was attached to the sprinkler system piping in the E.I.R.M.C. boiler room. Interview on 08/07/13 at 8:57 a.m., with the Director of Plant Operations revealed that the facility was not aware that the chain was attached to the sprinkler system piping.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standards:

Item 1.) NFPA 25, 1-4.4
The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

Item 2.) NFPA 13, 3-2.7.2
Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly.

Item 3.) NFPA 13, NFPA 13, 6-1.1.5
Sprinkler piping or hangers shall not be used to support nonsystem components.

No Description Available

Tag No.: K0074

Based on observation and interview, the facility failed to ensure that curtains were treated with inherently flame retardant coatings. This has the potential to expose patients to a fire or smoke environment. Loosely hanging fabrics would contribute to the rapid growth and spread of fire. The deficient practice affected all smoke compartments, staff, and all patients. The facility has the capacity for 28 beds with a census of four the day of survey.

Findings include:

During observation on 08/07/13 at 1:51 p.m. disclosed that the curtain panels in all of the corridors and patient rooms had no identification tags or proof indicating that these were treated with inherently flame retardant qualities. Interview with the Director of Plant Operations on 08/07/13 at 1:51 p.m., indicated the facility was not aware the curtains were not treated with flame retardant.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13

Actual NFPA standards:

NFPA 101 18.7.5.1
Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1.

10.3.1
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

No Description Available

Tag No.: K0076

Based on observation and interview, the facility failed to provide the required protective features for storage of compressed gas cylinders. This has the potential for a fire and explosive hazard exposure to the staff. The deficient practice affected one of twenty eight smoke compartments, staff, and no patients. The facility has the capacity for 292 beds with a census of 196 the day of survey.

Findings include:

1.) On 08/07/13 at 9:36 a.m., it was observed that the storage of "K" type oxygen cylinders and "K" type carbon dioxide cylinders in the E.I.R.M.C. compressed gas storage room, were not individually secured and located to prevent falling or being knocked over. Interview with the Director of Plant Operations on 08/07/13 at 9:36 a.m., revealed the facility was not aware of the requirement that cylinders were to be individually secured and located to prevent falling or being knocked over.

2.) On 08/07/13 10:55 a.m., it was observed that the storage of "K" type oxygen cylinders in the Cancer Resource Center compressed gas storage room, were not individually secured and located to prevent falling or being knocked over. Interview with the Director of Plant Operations on 08/07/13 at 10:55 a.m., revealed the facility was not aware of the requirement that cylinders were to be individually secured and located to prevent falling or being knocked over.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard: NFPA 99, 4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

No Description Available

Tag No.: K0144

Based on observation and interview, the facility failed to provide a remote emergency stop station and emergency lighting for the emergency generator system. The deficient practice affected one of twenty eight smoke compartments, staff, and all patients. The facility has the capacity for 292 beds with a census of 196 the day of survey.

Findings include:
1.) Observation on 08/07/13 at 9:15 a.m., of the E.I.R.M.C. generators revealed they did not have the required remote manual stop station. Failure to provide a remote shutdown could result in staff injury in the event of a generator malfunction. Interview with the Director of Plant Operations 08/07/13 at 9:15 a.m., revealed the facility was not aware of the requirement.

2.) Observation on 08/07/13 at 9:20 a.m., revealed of the E.I.R.M.C. generator room revealed that the emergency generator room did not have battery back-up task illumination. Failure to provide emergency lighting could leave the generator room in total darkness in the event of a power outtage. Interview with the Director of Plant Operations on 08/07/13 at 9:20 a.m., revealed the facility was recently made aware of the requirement for battery back-up task illumination for an emergency generator located inside a room or building enclosure.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard(s):
Item 1.) NFPA 110 3-5.5.5; All Level 1 installations shall have a remote manual stop station of a type similar to a break glass station located outside the room housing the prime mover (when so installed) or elsewhere on the premises when the prime mover is located outside the building.

Item 2.) NFPA 110, 5-3.1. 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.
Exception: This requirement shall not apply to units housed outdoors.

No Description Available

Tag No.: K0147

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. This deficient practice affected all smoke compartments, staff, and patients on the dates of the survey. The facility has the capacity for 28 beds with a census of four the day of survey.

Findings include:

Based on observation and interview on 08/07/13 at 1:26 p.m., observation revealed electric circuit breakers were not labeled in the breaker panel labeled P4 as to what they control. Interview with the Director of Plant Operations on 08/07/13 at 1:26 p.m., revealed that the facility was not aware the circuits were not properly labeled.

The finding was acknowledged by the Administrator and verified by theDirector of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard(s):

Item #1

NFPA 70, 110-22 Identification of Disconnecting Means
Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

No Description Available

Tag No.: K0147

Based on observation and interview, the facility failed to ensure electrical wiring was in accordance with the National Electrical Code. This deficient practice affected all smoke compartments, staff, and patients on the dates of the survey.

Findings include:

1. Observation and interview between 08/06/13 and 08/07/13 revealed electric circuit breakers were not labeled in breaker panels labeled 4AN1, 4ACI, 4AHN1, and 2BC as to what they control in the E.I.R.M.C. Interview with the Director of Plant Operations on 08/06/13 revealed that the facility was not aware the circuits were not properly labeled.

2. Observation and interview on 08/07/13 at 8:37 a.m. revealed the facility failed to prohibit storage from obstructing access to the electric breaker panel in the 1st floor IT server room. The IT server room was cluttered with storage that blocked access to the electric breaker panel and prohibited the ability to open the breaker panel door. Interview with the Director of Plant Operations on 08/07/13 at 8:37 a.m. indicated the facility was not aware of the stored items obstructing the breaker panel.

3. Observation and interview on 08/07/13 at 8:42 a.m. revealed multiple servers plugged into a power strip supplying power to another power strip that was plugged into a wall outlet in the 1st floor IT server room. Interview with the Director of Plant Operations on 08/07/13 at 8:42 a.m. indicated the facility was not aware the power strip was plugged into another power strip.

4. Observation and interview on 08/07/13 at 2:55 p.m. revealed a relocatable power tap (power strip) was observed to not be used in accordance with the listing and labeling of said equipment (computer, AV equipment and peripherals) on anesthesia machine in operating room 6. Interview with the Director of Plant Operations on 08/07/13 at 2:55 p.m. indicated the facility was not aware the power tap was being utilized.

5. Observation and interview on 08/07/13 between 2:30 p.m. and 4:00 p.m., unlabeled, facility built ceiling mounted corded eight outlet gang boxes were identified in the following locations; operating rooms 1 through 7 and 10 through 12, and labor delivery rooms 1 & 2. This finding was witnessed and acknowledged by the Director of Plant Operations .

The findings were acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.

Actual NFPA Standard(s):

Item #1

NFPA 70, 110-22 Identification of Disconnecting Means
Each disconnecting means required by this Code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

Item #2

NFPA 70 110.26 Spaces about Electrical Equipment.

Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 750 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

Item #3, #4, and #5
NFPA 70,110-3. Examination, Identification, Installation, and Use of Equipment
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
1. Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
2. Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
3. Wire-bending and connection space
4. Electrical insulation
5. Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
6. Arcing effects
7. Classification by type, size, voltage, current capacity, and specific use
8. Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Means of Egress - General

Tag No.: K0211

Based on observation and interview, the facility failed to assure that Alcohol Based Hand Rub (ABHR) dispensers were installed as required. Failure to keep an ABHR away from an ignition source could result in a dispenser fire. This deficient practice affected one of four smoke compartments on the 5th floor, staff, and 12 patients on the dates of the survey. The facility has the capacity for 292 nursing beds with a census of 196 the day of survey.

Findings include:

Observation on 08/06/13 at 9:45 a.m., revealed that an ABHR dispenser was adjacent to an ignition source (light switch) in the E.I.R.M.C. 5th floor nourishment room. Interview with the Director of Plant Operations on 08/06/13 at 9:45 a.m., revealed that the facility was not aware that the ABHR dispenser was located next to an ignition source in this room.

The finding was acknowledged by the Administrator and verified by the Director of Plant Operations at the exit interview on 08/07/13.