HospitalInspections.org

Based on observation, the facility failed to ensure that all corridor walls in the sprinkled building could resist the passage of smoke in accordance with NFPA 101, 2000 Edition, Section 19.3.6.1. The deficiency affected one of four smoke compartments.

Findings include:

The room enclosing the autoclave was observed on 9/22/14 at 1:25 a.m. A conduit through the corridor wall was not sealed.¹

NFPA 101, 2000 Edition, Section 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.

Based on observation, the facility failed to ensure that all corridor doors latched properly in accordance with NFPA 101, 2000 Edition, Section 19.3.6.3.2., and that corridor doors released from their hold-open devices in accordance with NFPA 101, 2000 Edition, Section 19.3.6.3.3. The deficiency could affect two of ninety one corridor doors in the facility, and two of four smoke compartments.

Findings include:

1. The Laboratory corridor door was observed on 9/22/14 at 1:40 p.m., the door was chocked open with a wedge.¹ ²

2. The corridor door to the staff dining room was exercised on 9/22/14 at 4:10 p.m., the door failed to latch.

¹NFPA 101 Life Safety Code, 2000 Edition, Section 19.3.6.3.3; Hold-open devices that release when the door is pushed or pulled shall be permitted.

²NFPA 101, 2000 Edition, Annex A-19.3.6.3.3; Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation, the facility failed to maintain smoke barrier walls with at least a half hour fire resistance rating in accordance with NFPA 101, 2000 Edition, Section 8.3.6.1.¹ The deficiency could affect three of four smoke compartments.

Findings include:

1. The smoke barrier wall at the junction of the network Information Technology (IT) closet was observed at 2:10 p.m. on 9/22/14. A three inch conduit was not sealed properly in the smoke barrier wall.

2. The smoke barrier wall at room #1 of the hospital was observed on 9/23/14 at 9:45 a.m. There was one penetration near the top of the wall where a conduit was not properly sealed above the ceiling tile.

¹NFPA 101, 2000 Edition, Section 8.3.6.1; 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 as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation, the facility failed to enclose hazardous areas with smoke resisting partitions and doors in accordance with NFPA 101, 2000 Edition, Sections 8.2.4.4.1¹ and 19.3.2.1. The deficiencies could affect two of four smoke compartments.

Findings include:

1. The medical gas storage room was observed on 9/22/14 at noon. The self-closing device was disconnected from the corridor door.

2. The laundry room was observed on 9/22/14 at 12:50 p.m., there was one ceiling penetration behind dryer #2. A conduit extended through the wall and was not sealed properly.¹

3. The room housing the back of the autoclave was observed on 9/22/14 at 1:25 p.m., the wall separating the front and back of the autoclave boiler was not finished.¹

4. The the mechanical room for the Magnetic Resonance Imaging (MRI) system was observed on 9/22/14 at 2:20 p.m., there were three penetrations of the west wall where large conduits were not sealed. This room was larger than 50 square feet, and contained stored combustible items.¹

¹NFPA 101 Life Safety Code, 2000 Edition, Section 8.2.4.4.1, Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through smoke partitions shall be protected as follows:
(1) The space between the penetrating item and the smoke partition shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke partition, the sleeve shall be solidly set in the smoke partition, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of limiting the transfer of smoke.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibrations into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke partitions.
b. It shall be made by an approved device that is designed for the specific purpose.

Based on observation and interview, the facility failed to check all battery powered emergency light fixtures monthly for a duration of 30 seconds and annually for a duration of 90 minutes in accordance with NFPA 101, 2000 Edition, Section 7.9.3.¹ The deficiencies could affect all staff or patients who would use the lab, operating rooms, or kitchen.

Findings include:

1. The battery powered emergency light in the original Operating Room (OR) was tested on 9/22/14 at 1:20 p.m., the light failed to illuminate.

2. The two battery powered emergency light fixtures in the laboratory were tested on 9/22/14 at 1:32 p.m., the light fixtures failed to illuminate.

3. The battery powered emergency light fixture in the rear of the kitchen was tested on 9/22/14 at 4:00 p.m., the fixture failed to illuminate.

An interview was conducted with staff member B, maintenance supervisor on 9/23/14 at 8:30 a.m. He indicated that he had been testing the emergency light fixture in OR for one second monthly, and had performed a four hour test on the same fixture in May of 2014. He stated he did not know that the other emergency light fixtures were in the kitchen and lab.

¹NFPA 101 Life Safety Code, 2000 Edition, Section 7.9.3; A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, the facility failed to maintain exit signs fully illuminated in accordance with NFPA 101, 2000 Edition, Section 7.10.2¹ and 7.10.5.2.² The deficiencies could affect all staff, patients or visitors who utilize the business office, radiology, delivery, surgery or laundry areas.

Findings include:

1. The exit sign at the west exit for the business office was observed on 9/22/14 at 3:02 p.m., both bulbs had burnt out of the exit sign.

2. The exit sign located in the corridor near the double doors of the Radiology wing was observed on 9/23/14 at 9:45 a.m. The chevron indicator had been removed, indicating to exit before the double doors, which would put you into a ladies restroom instead of going through the double doors, around the corner to your right and then out the north exit.

¹NFPA 101, 2000 Edition, Section 7.10.2; 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.

²NFPA 101 Life Safety Code, 2000 Edition, Section 7.10.5.2; Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Based on record review and interview, the facility failed to have an annual fire alarm inspection completed per NFPA 72, 1999 Edition, Sections 2-8.2, 7-3.2 and Table 7.3.2 (6)(d)(1) & (3).These deficiencies could affect all residents, staff, and visitors in four of four smoke compartments.

Findings include:

1. The fire alarm records were reviewed on 9/22/14 at 11:25 a.m. There was no annual record for the testing of the fire alarm system. Staff member C, maintenance staff person, indicated that he could not locate the testing for the fire alarm system for 2012, 2013 or 2014.¹ The testing was to be performed by a service company annually. The records indicated that the load voltage test on the sealed lead-acid batteries for the fire alarm control panel had not been done since 2011. These tests must be conducted semi-annually.¹

2. The exit near laundry was observed on 9/22/14 at 1:00 p.m., a cardiac monitor had been placed directly in front of a pull station.²

3. On 9/23/14 at 10:30 a.m., the Fire Alarm Control Panel (FACP) was viewed with staff member C, superintendent of environmental services. He verified that the batteries in the FACP were sealed lead acid type. The date on both batteries indicated that they had been installed in November of 2009, and also indicated to replace them by November of 2013, some ten months ago. He also verified that the load voltage tests were conducted once, annually, by the service contractor, and were probably done last in 2011. Staff member C also verified that he did not conduct the load voltage tests.³

¹NFPA 72 National Fire Alarm Code, 1999 Edition, Section 7-3.2 Testing, Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

²NFPA 72, 1999 Edition, Section 2-8.2., Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

³NFPA 72, 1999 Edition, Table 7.3.2 (6)(d)(1) & (3), requires sealed lead-acid type batteries to be replaced every four years and have a "Load Voltage Test" upon initial installation and then semiannually thereafter.

Based on observation, the facility failed to provide complete coverage of a building of Type V (111) construction type by the automatic fire sprinkler system per NFPA 13, 1999 Edition, Section 5-13.8.1¹ and Section 5-5.5.2.2². This failure had the potential to affect all residents, staff and visitors in the facility.

Findings include:

The construction type for the building is Type V(III), and all exterior canopies must be sprinkled due to the combustible construction when building canopies exceed 48 inches in width.

1. The exterior canopies for the facility were observed on 9/22/14 at 2:25 p.m. The west exterior canopy measured sixty feet in length by five feet eight inches in width, the canopy exceeded the maximum allowance of 48 inches.¹

2. The exterior canopies for the administration office area and the business office area were observed on 9/22/14 at 2:41 p.m., the canopies measured five feet in width at both locations.¹

3. The laundry room was observed on 9/22/14 at 12:45 a.m. The wet and dry sprinkler standpipe is located in one corner of the room. The standpipe blocks a sprinkler head from providing complete coverage for an area of the room which is five feet in width by thirteen feet in length.²

¹NFPA 13 Standard for Installation for Sprinkler Systems, 1999 Edition, Section 5-13.8.1; Sprinklers shall be installed under exterior roofs or canopies exceeding 4 ft (1.2 m) in width. Exception: Sprinklers are permitted to be omitted where the canopy or roof is of noncombustible or limited combustible construction.

²NFPA 13, 1999 Edition, Section 5-5.5.2.2; Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.

Based on observation, the facility failed to ensure the automatic sprinkler system was maintained per NFPA 13, 1999 Edition, Section 5-1.1.¹ These deficiency could affect three of four smoke compartments.

Findings include:

1. The closet near the Operating Room (OR) was observed on 9/22/14 at 1:22 p.m., the escutcheon ring on the sprinkler was loose and dangling from the head.

2. Swing bed room 18 was observed on 9/22/14 at 3:00 p.m., an escutcheon ring was missing from the sprinkler head at the entrance to the room.

3. The Bio-hazard room near the kitchen was observed on 9/22/14 at 4:05 p.m., a ceiling tile was missing at the level of the sprinkler protection.

4. The walk-in-cooler in the kitchen was observed on 9/22/14 at 4:10 p.m., the lone sprinkler head had receded up inside the ceiling of the cooler box affecting spray pattern coverage for the walk-in-cooler.

¹NFPA 13 Standard for the Installation of Sprinkler Systems, 1999 Edition, Section 5-1.1, The requirements for spacing, location, and position of sprinklers shall be based on the following principles:
(1) Sprinklers installed throughout the premises
(2) Sprinklers located so as not to exceed maximum protection area per sprinkler
(3) Sprinklers positioned and located so as to provide satisfactory performance with respect to activation time and distribution
Exception No. 1: For locations permitting omission of sprinklers, see 5-13.1, 5-13.2, and 5-13.9.
Exception No. 2: When sprinklers are specifically tested and test results demonstrate that deviations from clearance requirements to structural members do not impair the ability of the sprinkler to control or suppress a fire, their positioning and locating in accordance with the test results shall be permitted.
Exception No. 3: Clearance between sprinklers and ceilings exceeding the maximum specified in 5-6.4.1, 5-7.4.1, 5-8.4.1, 5-9.4.1, 5-10.4.1, and 5-11.4.1 shall be permitted provided that tests or calculations demonstrate comparable sensitivity and performance of the sprinklers to those installed in conformance with these sections.

Based on observations, the facility failed to assure that portable fire extinguishers were inspected and maintained in accordance with the standards of NFPA 10, 1998 Edition, Section 4-4.3¹ and Table 5-2². The deficiency affected extinguishers in four of four smoke compartments.

Findings include:

1. The portable fire extinguisher in the corridor near the laundry was observed on 9/22/14 at 12:55 p.m. The extinguisher had received a 6-year service in 11/07 and then received the hydrostatic testing in 1/14. The hydrostatic testing should have been done by 11/2013.

2. The portable fire extinguisher in Delivery/Surgery was observed on 9/22/14 at 1:05 p.m. The extinguisher received the 6-year testing in 11/06 and the hydrostatic testing in 1/13. The hydrostatic testing should have been done by 12/12.

3. The water type K-fire extinguisher in the kitchen was observed on 9/22/14 at 3:25 p.m. The extinguisher was put in service in 2001, received a 5-year service in 9/07 and a hydrostatic test in 12/12. The 5-year service testing should have been completed in 2006 and the hydrostatic testing should have been completed in 2011. Stainless steel tanks are not on the same schedule as mild steel tanks for testing. The testing shifts to 5 year maintenance and 10 year hydrotest.

4. The 3-A-40-BC portable fire extinguisher in the rear of the kitchen was observed on 9/22/14 at 3:30 p.m. The service collar indicated that the fire extinguisher had received a 6-year service in 1/2010, but there was no sticker/label attesting that it had received service.

5. The 3-A-40-BC type portable fire extinguisher opposite the rear of the kitchen was observed on 9/22/14 at 4:02 p.m. A hydrostatic test on the cylinder had been done 8/05, a 6-year service had been done 8/12 which is 11 months past the latest month of the six year test of 9/11.

¹NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition, Section 4-4.3; Every six years, stored-pressure fire extinguishers that require a hydrostatic test shall be emptied and subjected to the applicable maintenance procedures.

²NFPA 10, 1998 Edition, Section 5-2; Fire extinguishers shall be hydrostatically tested at intervals not exceeding those specified in Table 5-2. The hydrostatic retest shall be conducted within the calendar year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date. Dry Chemical extinguishers with mild steel or aluminum shells shall be hydrostatically tested every 12 years. Extinguishers that pass the test shall have the maintenance information recorded on a label securely affixed to the shell showing month and year of the service, the name or initials of the person performing the work and the name of the agency performing the maintenance.

Table 5-2 Hydrostatic Test Interval for Extinguishers

Extinguisher Type Test Interval (Years)
Stored-pressure water,
loaded stream, and/or antifreeze 5
Wetting agent 5
AFFF (aqueous film-forming foam) 5
FFFP (film-forming fluoroprotein foam) 5
Dry chemical with stainless steel shells 5
Carbon dioxide 5
Wet chemical 5
Dry chemical, stored-pressure,
with mild steel shells, brazed brass
shells, or aluminum shells 12
Dry chemical, cartridge- or
cylinder-operated, with mild steel shells 12
Halogenated agents 12
Dry powder, stored-pressure,
cartridge- or cylinder-operated,
with mild steel shells 12

Note: Stored-pressure water extinguishers with fiberglass shells (pre-1976) are prohibited from hydrostatic testing due to manufacturer ' s recall.

Based on review of service records, the facility failed to assure that the kitchen hood exhaust system was inspected and/or cleaned on a semiannual basis in accordance with NFPA 96, 1998 Edition, Sections 8-2, 8-3.1 and 8-3.1.2. This deficiency could potentially affect all of patients/residents, staff, and visitors.

Findings include:

1. Service records for the kitchen hood cleaning were reviewed on 9/22/14 at 11:30 a.m. No documentation was available indicating the hood had been cleaned by a professional cleaning company or staff properly trained to do so at least semi-annually.¹ ² A professional cleaning company last cleaned the hood in January of 2014, another cleaning was due in July of 2014. Records indicated that the hood had only been cleaned annually in 2012 and 2013 instead of the required semi-annual cleaning.

2. The service records for the kitchen hood extinguishing system were reviewed on 9/22/14 at 11:30 a.m. No documentation was available to indicate that the extinguishing system had been serviced semi-annually by a service company.³ Reports were found indicating that service had been performed on 9/17/12 and 3/19/13, but there were no reports for 9/2013 or 3/2014.

¹NFPA 96, 1998 Edition, Section 8-3.1; 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 indicates that systems serving moderate-volume cooking operations (hospitals) are to be cleaned semiannually.

²NFPA 96, 1998 Edition, 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.

³NFPA 96, 1998 Edition, Section 8-2; An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Based on observation and interview, the facility failed to maintain exit access free of all obstructions or impediments to full instant use in case of fire or other emergency in accordance with NFPA 101, 2000 Edition, Section 7.1.10.¹ The deficiency affected one of ten exits for the building.

Findings include:

The north exit on the east side of laundry was observed on 9/22/14 at 12:40 p.m., a mobile X-Ray machine had been parked approximately four feet in front of the exit door and the battery on the X-Ray machine was dead and could not be moved as the machine had to be charged before it could be moved.

An interview was conducted with staff member A, Chief Operating Officer (CEO), on 9/22/14 at 12:45 a.m. She indicated that the piece of equipment was to be picked up soon and had only been parked in the corridor to get it out of the way. She was later able to move the X-Ray machine out of the exit way. She stated the facility staff didn't think about the exit.

¹NFPA 101, 2000 Edition, Section 7.1.10; Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Based on observation, the facility failed to meet the medical gas storage requirements in accordance with NFPA 99, 1999 Edition, Sections 4-3.1.1.1, 4.3.1.1.2 and NFPA 50, 1996 Edition, Section 4-2.1. The deficiency had the potential to affect everyone in the facility.

Findings include:

1. The medical gas storeroom on the east side of the hospital was observed on 9/22/14 at noon. The amount of stored oxygen would qualify the area as a bulk oxygen storage area as it exceeded 20,000 cubic feet of stored oxygen. The following deficiencies were noted:
a) There were two, unsecured E sized oxygen cylinders in the storeroom.¹
b) The electrical switch was not located above 60 inches from the floor.²
c) There were three penetrations in the wall above the door.³
(i) One was a wooden board which served as an access to the space above the ceiling tile in the corridor.
(ii) Another was around a wire.
(iii) The final one was an unsealed cable.

2. An interview with staff member B, maintenance director, revealed that he did not know that they were required to perform an annual report for the bulk oxygen storage area.4

¹NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 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.

²NFPA 99, 1999 Edition, Section 4-3.1.1.2 (a) (4); The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

³NFPA 99, 1999 Edition, Section 4-3.1.1.2 (b) (3); The walls, floors, and ceilings of locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) separating the supply system location from other occupancies in a building shall have a fire resistance rating of at least 1 hour.

4NFPA 50 Standard for Bulk Oxygen Systems at Consumer Sites, 1996 Edition, Section 4-2.1; Each bulk oxygen system installed on consumer premises shall be inspected annually and maintained by a qualified representative of the equipment owner.

Based on observations and staff interview, a smoke damper failed to closed upon activation of the fire alarm system in accordance with NFPA 90 A, 1999 Edition, Section 4-4.4.1¹ and NFPA 72, 1999 Edition, Section 3-9.5.2.² The deficiency could affect residents and staff in four of four smoke compartments.

The findings include:

1. An interview was conducted with staff member B, concerning a plan/map of where all the dampers were located, on 9/23/14 at 9:30 a.m. He stated they have never had to refer to a plan, as there are only three dampers on the main level and about three more in the attic.

After some exploration of the attic, ten smoke dampers were located with an additional three being on the main level. Maintenance staff did not know there were that many smoke dampers in the building.

On 9/23/14 at 9:55 a.m., the fire alarm was tested. Five of thirteen smoke dampers throughout the facility failed to close with the activation of the fire alarm.¹ ²
a) Damper just inside the door of the attic (small eight inch).
b) Damper on the left side of the attic corridor all the way to the end (large two foot by two foot).
c) Damper on north hall of care wing.
d) Two dampers on south hall of care wing.

¹NFPA 90 A Standard for the Installation of Air-Conditioning and Ventilating Systems,1999 Edition, Section 4-4.4.1, Smoke detectors shall be installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code®.

²NFPA 72 National Fire Alarm Code®, 1999 Edition, Section 3-9.5.2, If connected to the fire alarm system serving the protected premises, all detection devices used to cause the operation of Heating Ventilation and Air-Conditioning (HVAC) systems smoke dampers, fire dampers, fan control, smoke doors, and fire doors shall be monitored for integrity in accordance with 1-5.8.

Based on observation and interview, the facility failed to document a weekly inspection of the emergency generators per NFPA 110, 1999 Edition, Sections 6-3.1, 6-4.1 and NFPA 99, 1999 Edition, Section 3-4.4.2. This deficiency could affect all the occupants and four of four smoke compartments.

Findings include:

The generator test records were reviewed on 9/22/14. There was no documentation for weekly inspections or monthly load tests.¹ Staff member B, maintenance supervisor, confirmed at 9:00 a.m. on 9/23/14, he did not perform weekly inspections on the electrolyte levels in the batteries which serve to start the generator transfer switch connections for overheating and excessive contact erosion, dust, etc. He indicated that the two Generac generators ran weekly and were also set to run under load once per month, but that he had not documented it anywhere since the generators were installed in 2013. A weekly review and monthly load testing of the generator should be done and documented.¹ ² ³

¹NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition, Section 6-3.1, The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class. Annex A-6-3.1 The suggested maintenance procedure and frequency should follow those recommended by the manufacturer. In the absence of such recommendations, the Figures A-6-3.1(a) and (b) indicate alternate suggested procedures. [See Figures A-6-3.1(a) and (b).]

²NFPA 110, 1999 Edition, Section 6-4.1, Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

³NFPA 99 Standard for Health Care Facilities, 1999 Edition, Section 3-4.4.2 Recordkeeping, A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition, Articles 110-22, 110-13(a), Article 240-4(b)(3) and NFPA 99, 1999 Edition, Sections 7-5.1.2.6 and 7-6.2.1.5. The deficiency could affect three of four smoke compartments.

The findings include:

1. An electrical panel board located in the original Operating Room (OR) was examined on 9/22/14 at 1:15 p.m. Two spare breakers in the panel were in the on position and were not labeled.¹

2. Electrical panel board C-1 in the classroom did not have a service listing for breakers 22-30, when examined on 9/22/14 at 2:15 p.m.¹

3. Electrical panel board C in the imaging wing did not have a service listing for breakers 39-41, when examined on 9/22/14 at 2:40 p.m.¹

4. Electrical panel board H-1 in the business office area did not have a service listing for breaker 29, when examined on 9/22/14 at 3:05 p.m.¹

5. Electrical panel board H in the business office area did not have a service listing for breaker 34, when examined on 9/22/14 at 3:10 p.m.¹

6. Electrical panel board LAE5 in the business office area did not have a service listing for breakers 14, and a three phase breaker 20-24, when examined on 9/22/14 at 3:12 p.m.¹

7. The social services back office area was observed on 9/22/14 at 3:15 p.m., a white extension cord was in-use.²

8. The power cord to the aviary cabinet was plugged into a power strip which was dangling, and not properly supported as observed on 9/22/14 at 3:20 p.m.³

¹NFPA 70 National Electric Code, 1999 Edition, Article 110-22; Each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident.

²Extension cords (including power strips) or multiple adaptors used in health care shall be protected against overcurrent conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing power strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings per Article 240-4(b)(3) of NFPA 70 and 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99. The limited use of circuit breaker protected power strips is acceptable provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

³NFPA 70, 1999 Edition, Article 110-13(a), electrical equipment shall be firmly secured to the surface on which it is mounted (if not temporary in service).