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Based on observation, the facility failed to maintain the fire resistant rating of its walls. This was evidenced by penetrations in the fire rated walls. This affected two of two floors, and could result in the spread of fire and smoke to nearby smoke compartments.

Findings:

During a tour of the facility with Plant Operation Staff, the fire resistive barrier walls were observed.

During a tour of the facility with Plant Operation Staff, the fire resistive walls were observed.

1. At 10:40 a.m., the one hour fire resistive north corridor wall above the drop down ceiling had two approximately two inch penetrations caused by two 3/4 inch pipes (yellow and green) traveling through the wall near the Time Clock. The one hour fire resistive south corridor wall above the drop ceiling had five approximately two inch penetrations caused by five 3/4 inch pipes (yellow, green, and red) traveling through the wall near Exit Sign 7. The yellow pipe was for the Life Safety Branch, the green pipe was for the electrical equipment, and red pipe was for the fire equipment.

2. On 11/30/15 at 10:55 a.m., on the first floor, there were two approximately 1/4 inch penetrations above the drop down ceiling in the one hour fire rated wall near fire door 0-53.

3. On 12/1/15 at 10:50 a.m., on the second floor, there were four approximately 1/4 inch penetrations above the drop down ceiling in the one hour fire rated occupancy separation wall near fire door 0-91.

Based on observation and interview, the facility failed to provide emergency lighting. This was evidenced by no battery powered emergency light in an anesthetizing location. This affected one of two floors, and could result in a loss of lighting during surgical procedures, within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages or longer if the generator fails to start.

NFPA 101, 2000 edition
18.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 edition
3-3.2.1.2, All Patient Care Areas
(5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

Findings:

During a tour of the facility and interview with Plant Operations Staff, the emergency lights were observed.

On 11/30/15 at 9:50 a.m., there was no battery back-up emergency light provided in Procedure Room 1B22 on the first floor. During an interview at 9:55 a.m., Plant Operation Staff stated that the Procedure Room surgeries used conscious sedation and that the Room had not been used for four months.

Based on observation, document review, and interview, the facility failed to maintain its emergency exit signs. This was evidenced by the failure to test the emergency exit signs monthly. This affected two of two floors, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000 edition
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 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.

Findings:

During a tour of the facility, document review, and interview with Plant Operation Staff, the emergency exit signs were observed and documents were reviewed.

On 12/1/15 at 1:46 p.m., the facility was observed with emergency exit signs with a test button on the side. A review of the emergency exit sign testing log indicated that the exit signs were tested quarterly instead of monthly. The exit signs were tested on 12/4/14, 9/30/15, 6/5/15, and 3/22/15. During an interview at 2 p.m., Plant Operation Staff confirmed the finding.

Based on document review and interview, the facility failed to maintain its fire/smoke dampers. This was evidenced by two dampers that fail during an inspection that was not repaired and by the failure to test its dampers every four years. This affected two of two floors, and could result in the spread of smoke and/or fire to other locations of the facility due to a malfunctioning smoke/fire damper.

NFPA 101, 2000 edition
18.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacturer's specifications.
9.2.1 Air conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, 1999 edition
Section 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


Findings:

During document review and interview with Plant Operation Staff, the fire/smoke damper reports were reviewed.

1. On 12/1/15 at 2:15 p.m., the facility has approximately 271 dampers. Documentation for damper testing dated 2/23/10, indicated that two of 271 dampers failed. The failed dampers were located in Room 1B10. During an interview at 2:30 p.m., Plant Operation Staff confirmed there was no repair report for the dampers located in Room 1B10.

2. On 12/2/15 at 10 a.m., documentation provide for the facility damper testing was dated 2/23/10. The facility did not notify the survey team that it had elected to operate under the categorical waiver referenced in CMS issued S&C letter 10-04 extending the damper testing from a four year to a six year testing interval. During an interview at 10:02 a.m., Plant Operation Staff stated that they were unaware of the categorical waiver for damper testing.

Based on document review and interview, the facility failed to maintain the relative humidity (RH). This was evidenced by the failure to maintain the relative humidity equal to or greater than 35 percent in its anesthetizing locations. This affected one of two floors, and could result in the increased risk of fire.


Findings:

During document review and interview with Plant Operation Staff, the RH policy and log documentation was requested and reviewed.

1. On 12/1/15 at 2:11 p.m., a review of the facility's RH policy indicated that the RH range was ideally between 30 and 60 percent and that if the temperature or humidity were out of range, the following steps would be taken:
(A) report variance to department manager/designee
(B) repeat the reading in one hour
(C) if the readings are still out of range, report the variance to the department manager/designee who will contact PAMP facilities
(D) Facilities will take necessary measures to correct the problem and will make contact with the department to keep informed of actions taken or issues, if any, will return the room to range. These actions taken and the completion of work will be reported back to operation room (OR) Manager.

The documentation titled, "OR Temperature Log Sheet," noted that the humidity would be between 30 and 60 percent.
A review of the log sheet indicated that the RH during the following days was below 30 percent:

(A) OR 2 on 8/17/15 and 8/31/15, the RH was at 29%.
(B) OR 2 on 5/7/15, 5/8/15, and 5/13/15, the RH was between 27% and 29%.
(C) OR 1 on 4/1/15, 4/2/15, 4/3/15, 4/14/15, 4/15/15, and 4/16/15, the RH was between 21% and 29%.
(D) OR 2 on 4/1/15, 4/2/15, 4/3/15, 4/6/15, 4/7/15, 4/8/15, 4/9/15, 4/10/15, 4/14/15, 4/15/15, 4/16/15, 4/17/15, and 4/30/15, the RH was between 14%and 28%.
(E) OR 3 on 4/1/15, 4/2/15, 4/3/15, 4/14/15, 4/15/15, and 4/16/15, the RH was between 21% and 27%.
(F) OR 2 on 3/2/15, 3/3/15, 3/4/15, 3/5/15, 3/6/15, and 3/18/15, the RH was between 20% and 28%.
(G) OR 1 on 2/23/15, 2/24/15, and 2/25/15, the RH was between 14% and 27%.
(H) OR 2 on 2/11/15, 2/23/15, 2/24/15, 2/25/15, 2/26/15, and 2/27/15, the RH was between 14% and 29%.
(I) OR 3 on 2/23/15 and 2/24/15, the RH was between 14% and 15%.
(J) OR 1 on 1/2/15, the RH was at 27%.
(K) OR 2 on 1/2/15, 1/5/15, 1/6/15, 1/7/15, 1/13/15, 1/14/15, 1/15/15, 1/16/15, 1/21/15, 1/22/15, 1/23/15, 1/26/15, 1/29/15, and 1/30/15, the RH was between 21% and 27%.
(L) OR 3 on 1/2/15, the RH was 29%.

On these dates no actions were documented as being taken. During an interview at 2:25 p.m., Plant Operation Staff confirmed the findings.

2. On 12/2/15 at 10:30 a.m., the facility did not notify the survey team or provide written documentation electing to use the categorical waiver referenced in the CMS issued S&C letter 13-25 to maintain the RH equal to or greater than 20 percent. During an interview at 10:32 a.m., Plant Operation Staff stated that they were not aware of a categorical waiver for RH level.

Based on observation, the facility failed to maintain the electrical wiring and connections. This was evidenced by electrical panels that did not have the circuits properly labeled and by the use of a power strip for medical equipment. This affected two of two floors, and could result in an increased risk of an electrical fire resulting in potential harm to the residents.

NFPA 101, 2000 edition
18.5.1.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, 1999 edition
110-12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
384-13 General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufactured with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer name or trademark in such a manner so as to visible after installation, without disturbing the interior parts of wiring. All panelboard circuits and circuit modification shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit
and circuit modification shall be legibly identified as to
its clear, evident, and specific purpose or use. The identification
shall include sufficient detail to allow each circuit to
be distinguished from all others. Spare positions that contain
unused overcurrent devices or switches shall be described
accordingly. The identification shall be included in
a circuit directory that is located on the face or inside of the
panel door in the case of a panelboard, and located at each
switch or circuit breaker in a switchboard. No circuit shall
be described in a manner that depends on transient conditions
of occupancy.

Findings:

During a tour of the facility with the Plant Operation Staff, the electrical wiring and connections were observed.

1. On 11/30/15 at 9:41 a.m., electrical panel LN1A1 had circuit breaker switch 25 in the off position but it was labeled for Film Processor under the circuit directory list, in Electrical Panel Room 1A21 on the first floor.

2. On 11/30/15 at 9:58 a.m., in Electrical Panel Transfer Switch Room 1C30 on the first floor, electrical panel LCR1B1 had circuit breaker switches 60, 62, 66, and 68 in off positions but it were labeled for operation rooms (OR) 4, 3, 2, 1 for Surgical Lights. Circuit breaker switch 70 was in off position but it was labeled for Time Clock, under the circuit directory list.

3. On 11/30/15 at 10:03 a.m., in the Electrical Panel Main Room 1C26 on the first floor, electrical panel HN1B1 had circuit breaker switches 25, 27, and 29 in the on position but were labeled as Spare. Circuit breaker switches 8, 10, and 12 were in off positions but were labeled for Steris Washer, in the circuit directory list .

4. On 11/30/15 at 10:04 a.m., in the Electrical Panel Main Room 1C26 on the first floor, electrical panel LN1B1 had circuit breaker switch 15 that was blank but was labeled for Sonic Cleaner 1C21. Circuit breaker switch 17 was in off position but was labeled for Sonic Cleaner 1C21, under the circuit directory list.

5. On 11/30/15 at 10:23 a.m., electrical panel LCR2A1 had circuit breaker switches 16 and 18 that were in off position but were labeled for Card Readers. Circuit breaker switch 5 was in on position but was labeled for a Spare, under the circuit directory list in the Electrical Panel Room 2A14 on the second floor.

6. On 11/30/15 at 10:35 a.m., electrical panel LN2B2 had circuit breaker 9 in off position but it was labeled for Hot Food Table, under the circuit directory list in the Electrical Panel Room 2C06 on the second floor.

7. On 12/1/15 at 9:15 a.m., in OR 4, a syringe pump, an otoscope, and an anesthesia light were plugged into a power strip that was attached by Velcro to an anesthesia cart.

Based on observation, the facility failed to maintain the fire resistant rating of its walls. This was evidenced by penetrations in the fire rated walls. This affected two of two floors, and could result in the spread of fire and smoke to nearby smoke compartments.

Findings:

During a tour of the facility with Plant Operation Staff, the fire resistive barrier walls were observed.

During a tour of the facility with Plant Operation Staff, the fire resistive walls were observed.

1. At 10:40 a.m., the one hour fire resistive north corridor wall above the drop down ceiling had two approximately two inch penetrations caused by two 3/4 inch pipes (yellow and green) traveling through the wall near the Time Clock. The one hour fire resistive south corridor wall above the drop ceiling had five approximately two inch penetrations caused by five 3/4 inch pipes (yellow, green, and red) traveling through the wall near Exit Sign 7. The yellow pipe was for the Life Safety Branch, the green pipe was for the electrical equipment, and red pipe was for the fire equipment.

2. On 11/30/15 at 10:55 a.m., on the first floor, there were two approximately 1/4 inch penetrations above the drop down ceiling in the one hour fire rated wall near fire door 0-53.

3. On 12/1/15 at 10:50 a.m., on the second floor, there were four approximately 1/4 inch penetrations above the drop down ceiling in the one hour fire rated occupancy separation wall near fire door 0-91.

Based on observation and interview, the facility failed to provide emergency lighting. This was evidenced by no battery powered emergency light in an anesthetizing location. This affected one of two floors, and could result in a loss of lighting during surgical procedures, within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages or longer if the generator fails to start.

NFPA 101, 2000 edition
18.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 edition
3-3.2.1.2, All Patient Care Areas
(5) Wiring in Anesthetizing Locations
(e) Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

Findings:

During a tour of the facility and interview with Plant Operations Staff, the emergency lights were observed.

On 11/30/15 at 9:50 a.m., there was no battery back-up emergency light provided in Procedure Room 1B22 on the first floor. During an interview at 9:55 a.m., Plant Operation Staff stated that the Procedure Room surgeries used conscious sedation and that the Room had not been used for four months.

Based on observation, document review, and interview, the facility failed to maintain its emergency exit signs. This was evidenced by the failure to test the emergency exit signs monthly. This affected two of two floors, and could result in a delay in evacuation in the event of a power outage.

NFPA 101, 2000 edition
18.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 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.

Findings:

During a tour of the facility, document review, and interview with Plant Operation Staff, the emergency exit signs were observed and documents were reviewed.

On 12/1/15 at 1:46 p.m., the facility was observed with emergency exit signs with a test button on the side. A review of the emergency exit sign testing log indicated that the exit signs were tested quarterly instead of monthly. The exit signs were tested on 12/4/14, 9/30/15, 6/5/15, and 3/22/15. During an interview at 2 p.m., Plant Operation Staff confirmed the finding.

Based on document review and interview, the facility failed to maintain its fire/smoke dampers. This was evidenced by two dampers that fail during an inspection that was not repaired and by the failure to test its dampers every four years. This affected two of two floors, and could result in the spread of smoke and/or fire to other locations of the facility due to a malfunctioning smoke/fire damper.

NFPA 101, 2000 edition
18.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of section 9.2 and shall be installed in accordance with the manufacturer's specifications.
9.2.1 Air conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, 1999 edition
Section 3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.


Findings:

During document review and interview with Plant Operation Staff, the fire/smoke damper reports were reviewed.

1. On 12/1/15 at 2:15 p.m., the facility has approximately 271 dampers. Documentation for damper testing dated 2/23/10, indicated that two of 271 dampers failed. The failed dampers were located in Room 1B10. During an interview at 2:30 p.m., Plant Operation Staff confirmed there was no repair report for the dampers located in Room 1B10.

2. On 12/2/15 at 10 a.m., documentation provide for the facility damper testing was dated 2/23/10. The facility did not notify the survey team that it had elected to operate under the categorical waiver referenced in CMS issued S&C letter 10-04 extending the damper testing from a four year to a six year testing interval. During an interview at 10:02 a.m., Plant Operation Staff stated that they were unaware of the categorical waiver for damper testing.

Based on document review and interview, the facility failed to maintain the relative humidity (RH). This was evidenced by the failure to maintain the relative humidity equal to or greater than 35 percent in its anesthetizing locations. This affected one of two floors, and could result in the increased risk of fire.


Findings:

During document review and interview with Plant Operation Staff, the RH policy and log documentation was requested and reviewed.

1. On 12/1/15 at 2:11 p.m., a review of the facility's RH policy indicated that the RH range was ideally between 30 and 60 percent and that if the temperature or humidity were out of range, the following steps would be taken:
(A) report variance to department manager/designee
(B) repeat the reading in one hour
(C) if the readings are still out of range, report the variance to the department manager/designee who will contact PAMP facilities
(D) Facilities will take necessary measures to correct the problem and will make contact with the department to keep informed of actions taken or issues, if any, will return the room to range. These actions taken and the completion of work will be reported back to operation room (OR) Manager.

The documentation titled, "OR Temperature Log Sheet," noted that the humidity would be between 30 and 60 percent.
A review of the log sheet indicated that the RH during the following days was below 30 percent:

(A) OR 2 on 8/17/15 and 8/31/15, the RH was at 29%.
(B) OR 2 on 5/7/15, 5/8/15, and 5/13/15, the RH was between 27% and 29%.
(C) OR 1 on 4/1/15, 4/2/15, 4/3/15, 4/14/15, 4/15/15, and 4/16/15, the RH was between 21% and 29%.
(D) OR 2 on 4/1/15, 4/2/15, 4/3/15, 4/6/15, 4/7/15, 4/8/15, 4/9/15, 4/10/15, 4/14/15, 4/15/15, 4/16/15, 4/17/15, and 4/30/15, the RH was between 14%and 28%.
(E) OR 3 on 4/1/15, 4/2/15, 4/3/15, 4/14/15, 4/15/15, and 4/16/15, the RH was between 21% and 27%.
(F) OR 2 on 3/2/15, 3/3/15, 3/4/15, 3/5/15, 3/6/15, and 3/18/15, the RH was between 20% and 28%.
(G) OR 1 on 2/23/15, 2/24/15, and 2/25/15, the RH was between 14% and 27%.
(H) OR 2 on 2/11/15, 2/23/15, 2/24/15, 2/25/15, 2/26/15, and 2/27/15, the RH was between 14% and 29%.
(I) OR 3 on 2/23/15 and 2/24/15, the RH was between 14% and 15%.
(J) OR 1 on 1/2/15, the RH was at 27%.
(K) OR 2 on 1/2/15, 1/5/15, 1/6/15, 1/7/15, 1/13/15, 1/14/15, 1/15/15, 1/16/15, 1/21/15, 1/22/15, 1/23/15, 1/26/15, 1/29/15, and 1/30/15, the RH was between 21% and 27%.
(L) OR 3 on 1/2/15, the RH was 29%.

On these dates no actions were documented as being taken. During an interview at 2:25 p.m., Plant Operation Staff confirmed the findings.

2. On 12/2/15 at 10:30 a.m., the facility did not notify the survey team or provide written documentation electing to use the categorical waiver referenced in the CMS issued S&C letter 13-25 to maintain the RH equal to or greater than 20 percent. During an interview at 10:32 a.m., Plant Operation Staff stated that they were not aware of a categorical waiver for RH level.

Based on observation, the facility failed to maintain the electrical wiring and connections. This was evidenced by electrical panels that did not have the circuits properly labeled and by the use of a power strip for medical equipment. This affected two of two floors, and could result in an increased risk of an electrical fire resulting in potential harm to the residents.

NFPA 101, 2000 edition
18.5.1.1 Utilities. Utilities shall comply with the provisions of section 9.1
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, 1999 edition
110-12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.
384-13 General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufactured with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer name or trademark in such a manner so as to visible after installation, without disturbing the interior parts of wiring. All panelboard circuits and circuit modification shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit
and circuit modification shall be legibly identified as to
its clear, evident, and specific purpose or use. The identification
shall include sufficient detail to allow each circuit to
be distinguished from all others. Spare positions that contain
unused overcurrent devices or switches shall be described
accordingly. The identification shall be included in
a circuit directory that is located on the face or inside of the
panel door in the case of a panelboard, and located at each
switch or circuit breaker in a switchboard. No circuit shall
be described in a manner that depends on transient conditions
of occupancy.

Findings:

During a tour of the facility with the Plant Operation Staff, the electrical wiring and connections were observed.

1. On 11/30/15 at 9:41 a.m., electrical panel LN1A1 had circuit breaker switch 25 in the off position but it was labeled for Film Processor under the circuit directory list, in Electrical Panel Room 1A21 on the first floor.

2. On 11/30/15 at 9:58 a.m., in Electrical Panel Transfer Switch Room 1C30 on the first floor, electrical panel LCR1B1 had circuit breaker switches 60, 62, 66, and 68 in off positions but it were labeled for operation rooms (OR) 4, 3, 2, 1 for Surgical Lights. Circuit breaker switch 70 was in off position but it was labeled for Time Clock, under the circuit directory list.

3. On 11/30/15 at 10:03 a.m., in the Electrical Panel Main Room 1C26 on the first floor, electrical panel HN1B1 had circuit breaker switches 25, 27, and 29 in the on position but were labeled as Spare. Circuit breaker switches 8, 10, and 12 were in off positions but were labeled for Steris Washer, in the circuit directory list .

4. On 11/30/15 at 10:04 a.m., in the Electrical Panel Main Room 1C26 on the first floor, electrical panel LN1B1 had circuit breaker switch 15 that was blank but was labeled for Sonic Cleaner 1C21. Circuit breaker switch 17 was in off position but was labeled for Sonic Cleaner 1C21, under the circuit directory list.

5. On 11/30/15 at 10:23 a.m., electrical panel LCR2A1 had circuit breaker switches 16 and 18 that were in off position but were labeled for Card Readers. Circuit breaker switch 5 was in on position but was labeled for a Spare, under the circuit directory list in the Electrical Panel Room 2A14 on the second floor.

6. On 11/30/15 at 10:35 a.m., electrical panel LN2B2 had circuit breaker 9 in off position but it was labeled for Hot Food Table, under the circuit directory list in the Electrical Panel Room 2C06 on the second floor.

7. On 12/1/15 at 9:15 a.m., in OR 4, a syringe pump, an otoscope, and an anesthesia light were plugged into a power strip that was attached by Velcro to an anesthesia cart.