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Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by The CEO, The Director of the Plant Operations, and The Chief Nursing Executive during the hours of the inspection from 9:30 AM to 12:00 PM on 05/26/2016 that there were the following issues.

A.) There were penetrations not sealed in the smoke barriers at the walls above the smoke barrier cross corridor doors.
B.) Some smoke barrier cross corridor doors were not fully closed.
C.) One set of control door on the magnetic locked was not released upon the fire alarm activation.

The inspector observed, while accompanied by The CEO, The Director of the Plant Operations, and The Chief Nursing Executive during the hours of the inspection from 9:30 AM to 12:00 PM on 05/26/2016 that there were the following issues. They were the following issues.

A.) Based on observation the medical gases cylinders were not individual chained. This does not comply with the following NFPA code. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Based on observation the facility failed to provide adequate receptacles and battery powered lighting units.

The inspector observed, while accompanied by The CEO, The Director of the Plant Operations, and The Chief Nursing Executive during the hours of the inspection from 9:30 AM to 12:00 PM on 05/26/2016 that there were the following issues. They were the following issues.

A.) There was a missing battery powered lighting units and a missing receptacle powered from life safety branch at the essential automatic transfer switch location.
B.) There was a missing receptacle powered from life safety branch at the generator set location.
C.) There were no label provided for the essential electrical panel and transfer switch panel. The label shall be easily identifiable as life safety, critical or equipment branch and in distinct color label.
D.) The electrical panel directory were not updated or provided in some electrical panels.
E.) The FCAP breaker was not identified as fire alarm control circuit control. Please provide label next to the FACP breaker.


" The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location " - NFPA 99, 1999: 3-4.2.2.2.(b)5.

Only those items listed in NFPA 70, 517.32 are allowed to be placed on the life safety branch of the essential electrical system - NFPA 70, 517.32.
The life safety branch of the essential electrical system shall supply power for the following: 1) illumination of means of egress, 2) exit signs and exit direction signs, 3) fire alarm and medical gas alarm, 4) hospital communication systems where used for emergency conditions, 5) generator set location that includes task illumination, battery charger for battery-powered lighting, and selected receptacles, 6) elevator cab lighting, control, communication, and signal systems, 7) automatic doors used for building egress, and 8) auxiliary functions of the fire alarm combination systems complying with NFPA 72. No other functions than those listed above shall be connected to the life safety branch, NFPA 99, 2002, 4.4.2.2.2.2.

The inspector observed, while accompanied by The CEO, The Director of the Plant Operations, and The Chief Nursing Executive during the hours of the inspection from 9:30 AM to 12:00 PM on 05/26/2016 that there were the following issues. They were the following issues.

A) The facility failed to provide a history of records for receptacle testing at inpatient care areas and the Line Isolation Monitor per NFPA 99: 3-3.3.3. in the patient care areas.

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

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

" NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984). "