HospitalInspections.org

Based on observations of 7/20/2010, the surveyor determined that the health care occupancies of the hospital are required to be separated from business occupancies by at least 2 hour construction. At the time of the survey, this construction requirement could not be thoroughly maintained.

Findings include:

On 7/20/2010 at 11:22 a.m., the wall was examined which separates the 2nd floor of the business occupancy from the patient tower (health care occupancy). The door which opened into the business occupancy is a 1 1/2 rated door. This door was not equipped with self- closing hardware which was needed to ensure that the rated door was closed at all times.

Based on observations between 7/19/2010 through 7/22/2010, the facility failed to maintain the fire and smoke resistance rating of wall and ceiling assemblies.

Findings include:

In accordance with Section 19.1.6.1 of NFPA 101, 2000 Edition, building construction type and height shall meet one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1.

The building is of Type II (111) non-combustible construction which requires that the facility be protected throughout by an automatic sprinkler system that meets NFPA 13 standards, or be totally non-combustible type construction.

1. On 7/20/2010 at 4:05 p.m. in the basement, the north phone room ceiling tile was removed from it's track exposing an area measuring approximately 3 feet by 1 foot space above it.

2. On 7/21/2010 at 11:41 p.m., the ceiling tile around a ceiling drain pipe, in the main basement elevator equipment room, was damaged and needed to be replaced.




27244

3. The Emergency Room west side canopy was reviewed on 7/20/2010 at 9:45 a.m. An approximately two inch by four inch hole was cut into the canopy. This hole compromises the ability of the canopy sprinkler system from fully protecting the combustible portions of the canopy.

4. The CATH Lab Electrical Room was reviewed on 7/20/2010 at 2:23 p.m. The suspended ceiling grid had at least two ceiling tiles out of place. Note: The ceiling tiles were replaced by staff after the deficiency was noted.

5. The CATH Lab Film Storage area was reviewed on 7/20/2010 at 2:46 p.m. The suspended ceiling grid had two tiles removed.

6. The Old Imaging Mammography area was reviewed on 7/20/2010 at 3:39 p.m. The suspended ceiling grid was missing five tiles in the room. Note: The ceiling tiles were replaced by the facility staff at the time of survey.

Surveyors made observations between 7/19/2010 and 7/22/2010, throughout the main building of the hospital. At that time, not all corridor doors were properly maintained in order to allow such doors to close to positive latching.

Findings include:

1. At 3:52 p.m. on 7/20/2010 on the patient tower second floor, the corridor door to the patient nourishment room did not close to positive latching when the door was closed.

2. The Cath Lab Library Conference Room door was observed at 2:25 p.m. on 7/20/2010. The door failed to costively latch when exercised.



27244

3. The Imaging Suite was reviewed on 7/20/2010 at 3:47 p.m. The corridor door for the room containing a treadmill would not close to positive latching after three attempts to close the door.

Based on observations made on 7/19/2010, the facility failed to ensure that all exit corridors doors' latched properly when exercised.

Findings include:

The exit corridor door to the medical director's office did not close on 7/19/2010 at 3:35 p.m. The latching hardware on this door did not engage to keep the door closed.

Based on observations from 7/19/2010 to 7/22/2010, the facility failed to ensure that all doors enclosing hazardous areas, which are a part of a fire barrier separation, and/or which serve smoke barriers; were equipped with self closing hardware to allow the doors to automatically close to positive latching. Additionally, the facility did not ensure fire rating labels of all fire rated doors were legible and distinguishable.

Findings include:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 Edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 Edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

1. On 7/20/2010 at 10:22 a.m., a pair of smoke barrier doors were exercised by the surveyor at the nursing station of the patient tower on the second floor. When both doors were released from their magnetic hold open devices, one of the two doors did not fully close. A vertical opening of one to two inches remained between the edges of both doors. The doors were tested two more times with the same results.

2. On 7/20/2010 at 4:49 p.m., the wall which separating the 2nd floor of the Business occupancy from the patient tower (Health Care Occupancy) was examined. The door in this wall opened into the Business occupancy was a 1 1/2 rated door. This door was not equipped with self closing hardware.


18076


3. On 7/20/2010 at 4:26 p.m., the fire rating labels of the 3-hour doors located in the 4-hour barrier between G1 and M1 were painted over. The surveyor could not distinguish the rating of the doors until the supervisor of the plant operations scraped paint off.

4. On 7/21/2010 at 10:52 a.m., the vestibule doors (in the exit corridor) to the patient tower elevators at the basement level did not latch when they were released from the magnetic hold devices.

5. On 7/21/2010 at 10:54 a.m., the stairwell gate with a magnetic hold (indicating the gate closure was interfaced with the fire alarm), is used to prevent occupant access to the basement from the patient tower lobby. The stairway gate did not self close when released from the magnetic hold device.

6. On 7/21/2010 at 11:05 a.m., the 1.5 hour rated exit corridor door to the Bass Center mechanical room in the basement did not latch. The door had a self closure device.

7. On 7/21/2010 at 11:10 a.m., it was noted in the basement of the patient tower that there is an exit corridor door to the equipment storage room which is next to clinical engineering. The door was held open with a card board box full of plastic tubing. The door had a self closure device.

8. On 7/21/2010 at 11:11 a.m., the communications exit corridor door with a self closure device did not latch in the basement.

9. On 7/21/2010 at 11:13 a.m., the exit corridor door to the air handling room (in the basement of the patient tower) was held open with an oversized wooden wedge. The supervisor of the plant operations stated they were trying to accommodate air flow by keeping the door open because air handler three return side fan motor quit working three days ago. The door had a self closure device.

10. On 7/21/2010 at 11:26 a.m., the stairwell gate with a magnetic hold device was used to prevent occupant access to the basement. In the northwest stairwell at the admitting lobby level, the stairwell gate did not self close when released from the magnetic hold.

11. On 7/21/2010 at 11:35 a.m., the exit corridor door to the main electrical room (patient tower) in the basement was held open with a flashlight.

12. On 7/21/2010 at 11:48 a.m., the door with a magnetic hold device to the Big Mountain room in Education did not self close when released from the magnetic-hold device.

13. On 7/21/2010 at 12:06 p.m., the supply room door (next to Mission Room) in Education did not self close. The door had a self closure device.



27244

14. The Medical Tower 3rd Floor was observed on 7/19/2010 at 4:37 p.m. A rolling cart/shelf was being used to hold open the dictation room which is west of the west nurses station. This door had a self closure device in place.

15. The Office Tower 3rd Floor was observed on 7/20/2010 at 8:25 a. m. A garbage can was used to hold open the door to the breakroom.

16. The Office Tower 3rd Floor was observed on 7/20/2010 at 8:25 a. m. Three wedges were used on three separate doors to hold open doors which had automatic closers installed on them.

17. The Family Support of the Emergency Room was observed on 7/20/2010 at 9:35 a.m. The door to the room which had a self closure was being held open with a chair. Note: The chair was removed at the time of survey.

18. The 1st Floor Patient Tower center stairway was observed on 7/20/2010 at 12:35 p.m. The door would not close to positive latching when exercised on there different occasions.

Based on observations made on 7/20/2010, the facility failed to ensure that all exit corridors doors' latched properly when exercised in order to prevent passage of smoke.

Findings include:

Hold-open devices that release when the corridor door is pushed or pulled shall be permitted per Section 19.3.6.3.3 of NFPA 101 LSC, (2000 Edition). However, a hold-open device can not be used on doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, fire barrier or hazardous area enclosure unless they conform with Section 7.2.1.8.2 of NFPA 101 LSC, (2000 Edition). Doors cannot be blocked open by furniture, door stops, chocks, wedges, or devices that necessitate manual releasing action to close the door.

1. On 7/20/2010 between 12:34 p.m. to 1:40 p.m., several exit corridor doors were exercised during the tour of the Pathways Treatment Center. The following exit corridor doors with self closure devices did not latch when exercised:

a. The conference room door near the administrative entrance,
b. The office door of the chemical dependance medical director,
c. The office door of the clinical supervisor, and
d. The door to the adult day room

Based on observations which were made from 7/19/2010 through 7/22/2010, the surveyor determined that not all exit locations are clearly marked by exit signs in order to ensure the proper door or exit doors are used.

Findings include:

There is an open area at the main entrance which is appropriately 4,000 sq. ft. Although there is an exit sign which clearly shows exiting through the main entrance is possible, no other means of egress are identified from this lobby area at the main entrance.

Based on observations made on 7/21/2010, the facility did not have exit signs displayed to show direction of the emergency exiting.

Findings include:

Section 7.10.1.4 Exit Access of NFPA 101 indicates that "access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs."

During the tour of the building at approximately 11:00 am, it was observed that there were no exit signs installed in the clinic building.

Based on observations made on 7/21/2010, the facility did not have exit signs in place for patients and staff to identify exit routes.

Findings include:

Section 7.10.1.4 Exit Access of NFPA 101 indicates that "access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs."

While touring the newly remodeled outpatient area on 7/21/2010, it was observed that there were no exiting signs in the corridors indicating direction to the means of egress. The maintenance staff indicated that they were being installed shortly, but had not been installed.

Based on observations from 7/19/2010 to 7/22/2010, the facility failed to maintain the smoke resistance of smoke barriers at all locations.

Findings include:

On 7/21/2010 at approximately 3:15 p.m., there was an open penetration caused by wiring at a smoke barrier above the ceiling located in Surgery across from "OR 7". Note: Staff repaired the penetration before the end of the day.

Based on observation made on 7/20/2010, the facility failed to maintain the smoke resistance rating of the observed smoke barriers.

Finding include:

In accordance with Section 8.3 of NFPA 101 LSC, 2000 Edition; smoke barriers shall be constructed to provide at least a one half hour fire resistance rating. Smoke barriers may terminate at an atrium wall. Windows are protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments are provided on each floor. Dampers are not required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems in accordance with Sections 19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4 of NFPA 101, LSC (2000 Edition).

On 7/20/2010 at 1:30 p.m., there was an unsealed penetration where three blue communication cables extended through the fire/smoke barrier wall above the double doors as viewed from the attic in the Pathways Treatment Center. This was the only fire/smoke barrier wall in the building.

Based on observations which were made on 7/21/2010 in the basement, it was determined the facility failed to maintain a fire separation between the basement and the floor above.

Findings include :

In accordance with Section 8.4.1.1 Special Hazard Protection under NFPA 101 2000 Edition, Chapter 39 Existing Business Occupancies, the facility is required to keep combustible hazards separated from the remainder of the building.

The basement is not separated from the upstairs with fire rated construction. Above the electrical panel is a gaping hole through which wiring passes. The gap in the ceiling has not been sealed with an acceptable fire stop material.

Based on observations made on 7/20/2010, the facility failed to maintain or establish the fire rated protection for hazardous areas.

Findings include:

In accordance with Section 8.4 of NFPA 101, LSC, 2000 Edition; hazardous areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows. Doors to hazardous areas shall be self-closing or automatic closing in accordance with Section 7.2.1.8 and Section 19.3.2.1 of NFPA 101 LSC.

1. On 7/20/2010 at 3:56 p.m., the fire rated door, with a self closure device, to the elevator mechanical room in G1 did not latch and close.



27244

2. The Old Imaging Mammography room was reviewed on 7/20/2010 at 3:41 p.m. There were at least 30 empty computer boxes being stored in this room. The room lacked a self closure on the door as required for hazardous areas. Note: The boxes were removed from the room and confirmed by the surveyor while on site.

Based on observations made on 7/20/2010, the facility failed to assure that vertical openings between floors were sealed and/or enclosed by fire resistive construction.

Findings include:

According to Section 8.2.5.2 of NFPA 101, openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

On 7/20/2010 at 1:29 p.m. in the 1st floor Medical Storage which has access to the Ancillary Penthouse, it was observed that a fire rated door into the penthouse was not closed and could not have been closed because a 1/2 inch rope was hanging through the ladder opening.

Based on observations made on 7/20/2010, the surveyor determined that not all means of egress in stairwells were being maintained to provide for unhindered exiting from the building.

In accordance with 3.3.121 as defined in the LSC, a portion of a "means of egress" that leads to an exit was not maintained.

Findings include:

At 1:36 p.m. after entering the hospital's north entrance by the LAB, observations were made in the stairwell. In this stairwell, a bicycle had been chained to a handrail. The bicycle partially blocked the path to a direct exit from the exit stairwell.

The surveyor observed on 7/21/2010 that not all means of exiting from exit doors to a common way were being maintained to expedite rapid removal of the occupants to the public way.

Findings include:

At 2:37 p.m., the lower level of the building was inspected. There is an outpatient "rehab" clinic on this level and has at least two means of exiting the clinic. The back exit discharge does not provide for a hardened path to a common way . The concrete pad extends approximately 10 feet from the exit door. The remainder of the exit discharge to a common way is comprised of grass which is not acceptable for a hardened path.

Based on observations made on 7/21/2010, the facility failed to provide emergency lighting for the newly occupied building.

Findings include:

In accordance with Section 39.2.9.1 of NFPA 101, emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is two or more stories in height above the level of exit discharge.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

The facility was reviewed on 7/21/2010 at 3:45 p.m. for emergency lighting. There was no emergency lighting provided as required per 39.2.9.1. The facility maintenance staff stated that a bid had been accepted for installation of emergency lighting.

Based on observations on 7/21/2010, the facility failed to ensure that all exit and directional signs were continuously illuminated.

Findings include:

Section 39.2.10 Marking of Means states that means of egress shall have signs in accordance with Section 7.10.

Section 7.10.5.2 Continuous Illumination states that 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.

1. The patient and public waiting area was reviewed at 10:57 a.m. on 7/21/2010. The exit light did not illuminate.

2. The CT SIM Room was reviewed on 7/21/2010 at 11:27 a.m. An exit sign from the room was not illuminated.

Based on record review and staff interview on 7/21/2010, the facility failed to ensure simulated fire drills were held at unexpected times under varying conditions for each shift in accordance with NFPA 101 Life Safety Code, Chapter 39, section 39.7.1 and in accordance with 4.7.2 of chapter 4.

Findings include:

On 7/21/2010 at 2:25 p.m., the fire drill logs indicated that no drills were conducted for the 7 p.m. to 7 a.m. shift for the sleep center staff members.

Based on observations from 7/19/2010 through 7/22/2010, the facility failed to provide for complete automatic sprinkler protection of all portions or areas of the building.

Findings include:

1. The surveyors entered the facility on 7/19/2010 at approximately 1:00 p.m. by way of the emergency room entrance. There is at the north side of this entrance a wooden combustible canopy which was not protected by the sprinkler system.

2. On 7/20/2010 at 1:29 p.m., a surveyor observed that the ancillary penthouse did not have sprinkler coverage.

3. During the course of the survey on 7/20/2010 at 9:40 a.m., it was observed that the security office located next to the emergency room entrance lacked sprinkler protection.

Based on observation made on 7/20/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

Findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 Edition.

An escutcheon ring was missing from a ceiling sprinkler in the wheelchair storage closet located in the main entrance at 12:56 p.m. on 7/20/2010.

Based on an observation made on 7/21/2010, the facility failed to maintain the sprinkler system in accordance with the standards of NFPA 13.

Findings include:

Escutcheon plates used with a recessed or flush-type sprinkler shall be part of a listed sprinkler assembly per Section 3-2.7.2 of NFPA 13, 1999 Edition.

An escutcheon ring was missing from a ceiling sprinkler in the GYN Exam Room at 11:10 a.m. on 7/21/2010.

Based on observations made on 7/20/2010, the facility failed to maintain fire extinguishers in accordance with the standards of NFPA 10, 1998 Edition.

Findings include:

In accordance with 1-6.7 and 1-6.10 of NFPA 10 portable extinguishers other than wheeled types shall be securely installed on the hanger or bracket supplied with them or placed in cabinets or wall recesses. In no case shall the clearance between the bottom of the supported extinguisher and the floor be less than 4 inches. Extinguishers weighing less than or equal to 40 lb shall be installed so that the top of the extinguisher is not more than 5 feet above the floor. Those extinguishers with a weight more than 40 lb shall be installed so that the top of the extinguisher is not more than 3 1/2 feet above the floor.

On 7/20/2010 at 1:20 p.m., a fire extinguisher was observed hanging in the main nurses' station above the handwashing sink in Pathways Treatment Center. The top of the extinguisher measured at approximately six feet (72 inches) from the floor. The unit weighed approximately 8 pounds.

Based on observation, record review, and staff interview on 7/22/2010; the facility failed to ensure that all vertical openings met the 1-hour fire/smoke rating. The laundry chute that was accessed from the surgical suite and discharges outside of the Central Supply in the basement is not fully separated as required.

Findings include:

The laundry chute that extends from the surgical suite to the basement Central Supply has not been altered since the last survey of January 2009. The lower door on the laundry chute has a fusible link but is not rated for installation in a horizonal plane as it was installed.

Based on observations made on 7/20 to 7/21/2010, the facility failed to ensure that all non-flammable gas cylinders were properly secured from falling over or being knocked down.

Findings include:

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down in accordance with Sections 8-3.1.11.2(h) and 4-3.5.2.1(b) 27 of NFPA 99, 1999 Edition).

1. On 7/21/2010 at 11:11 a.m., a C size cylinder of Argon gas was free standing on the floor in the equipment storage room, next to Clinical Engineering, in the basement.

2. On 7/21/2010 at 11:58 a.m., two K size air cylinders were observed free standing in Central Sterile. The chain was hanging down from the wall near the cylinders.



27244

3. A "PEPSI Cola" carbon dioxide compressed gas cylinder was free standing in the 3rd Floor supply storage area on 7/20/2010 at 8:32 a.m.

4. Several E size and smaller oxygen and non flammable compressed gas containers were found free standing or laying on their sides inside the Emergency Room Ambulance Bay as observed at 9:30 a.m. on 7/20/2010.

Based on observations made on 7/20/2010, the staff of the helicopter hanger were not storing oxygen cylinders.

Freestanding cylinders of nonflammable gases such as oxygen, shall be properly chained or supported in a cylinder cart or stand or by means of racks or fastenings to protect them from falling over or being knocked down in accordance with Sections 8-3.1.11.2(h) and 4-3.5.2.1(b) 27 of NFPA 99, 1999 Edition).

Findings include:

The helicopter hanger was reviewed on 7/20/2010 at 9:30 a.m. A free standing E cylinder of oxygen was found. Note: The cylinder was removed at the time of survey and placed in the oxygen storage area.

Based on observations made on 7/19/2010 and 7/22/2010, the facility failed to ensure all smoke dampers closed completely or would operate upon the activation of smoke detectors interconnected to the fire alarm system.

Findings include:

1. A 3rd Floor smoke barrier was reviewed on 7/19/2010 at 4:13 pm. The smoke damper was electrically disconnected from the power source to operate the smoke damper. Note: Facility staff reconnected the damper at the time of survey.

2. Between approximately 8:00 a.m. and 9:00 a.m. on 7/22/2010, the expected movement of smoke dampers was observed when the fire alarm system was activated by a pull station. Two smoke dampers did not operate when the fire alarm system was activated.

a) One damper at the smoke barrier between "Cath" Lab and Radiology did not close during alarm testing.

b) A second damper at the smoke barrier near the OB Nurses Station and the soiled utility room was observed during the fire drill. The damper did not close when the fire alarm was initiated.

Based on observations on 7/21/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition; NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Extension 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 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS 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.

An extension cord was in use in the basement of the building below the electrical panel at 10:55 a.m.

Based on observations made 7/19/2010 through 7/22/2010, the surveyor determined that the facility failed to fully maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition; NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Extension 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 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS 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.

1. On 7/21/2010 at 12:09 p.m., a microwave and a refrigerator were plugged into a surge protector in the basement house keeping breakroom.

2. On 7/21/2010 at 12:20 p.m., two areas were noted that appliances were plugged into surge protectors.

a) One microwave was plugged into a surge protector in the materials management area, and

b) there were two refrigerators plugged into a surge protector on the north wall side of the materials management.

3. The HIM Medical Records Office was reviewed on 7/21/2010 at 12:51 p.m. Desk area HIM 21 was reviewed and a white extension cord was in use.

4. The HIM Conference Room was observed on 7/21/2010 at 12:52 pm. A computer located on the conference table was plugged into a surge protector that was hooked in series with another surge protector.

5. The HIM Medical Records Office was reviewed on 7/21/2010 at 12:55 p.m. Computer station "HIM Softmed Test Station" was plugged into a surge protector that was hooked in series into another surge protector.

6. The Financial Counselors Office was observed on 7/20/2010 at 3:30 p.m. A yellow extension cord was in use in the office.


27244


In accordance with Article 110-13(a) of NFPA 70 (1999 Edition) electrical equipment shall be firmly secured to the surface on which it is mounted.

7. The 3rd Floor equipment holding area was inspected on 7/19/2010 at 4:00 p.m. A surge protector was utilized to plug at least two of the pieces of equipment. The surge protector cord was hung off a bumper rail and thus supporting its own weight by the cord.

In accordance with Article 110-26 of NFPA 70 (1999 Edition) 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. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

8. The Paint Brush Conference Room was reviewed on 7/20/2010 at approximately 11:00 a.m. Storage Room B in the conference room contains electrical panel H1LN 485 which was blocked with storage.

9. The MASH Office was reviewed on 7/20/2010 at 1:10 p.m. One of the two computer stations in the room had two surge protectors hooked in series.

10. On 7/20/2010 at approximately 10:00 a.m., the second floor of the Office Tower was inspected. When the electrical room by the elevator shaft was entered, it was noticed it was difficult to gain access to the electrical panels since a folding chair and other equipment were blocking access to at least two electrical panels.

Based on observations made on 7/20/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL per sections 1-5.2.5.2 of NFPA 72, 1999 Edition.

Extension 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 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS 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.

1. There was no red marking on breaker #4 in electrical panel LY located in the fire alarm panel room identifying it as the disconnect means for the fire alarm panel at 1:03 p.m. on 7/20/2010.

2. A microwave, a small refrigerator and a single pot coffee maker were plugged into a surge protector in the staff lounge at 1:54 p.m. on 7/20/2010.

Based on observations made on 7/21/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 edition; NFPA 99, 1999 edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with Article 110-26 of NFPA 70 (1999 edition) 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. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

On 7/21/2010 at 2:15 p.m., there was a large linen cart (3 feet by 3.5 feet by 3 feet) parked in front of the electrical panels G and HS in the sleep center storage room.

Based on observations made on 7/21/2010, the facility failed to maintain electrical components as required by NFPA 70 National Electric Code (NEC), 1999 edition. An electrical panel schedule was not current and items were stacked in front of the electrical panel.

Findings include:

1. 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 per Article 110-22 of NFPA 70.

The electrical panel schedule in the doctor office was reviewed at 3:40 p.m. on 7/21/2010. Breakers were in the on position and were not labeled.

2. In accordance with Article 110-26 of NFPA 70 (1999 edition) 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. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

The area in front of the electrical panel in the doctor's office was reviewed at 3:40 p.m. on 7/21/2010. Several brown boxes full of office items were stacked in front of the electrical panel.
Note: These items were moved at the time of survey by facility staff.

















04698

Based on observations made on 7/21/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Findings include:

In accordance with Article 110-26 of NFPA 70 (1999 Edition) 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. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

1. The electrical sprinkler riser room was reviewed on 7/21/2010 at 11:23 a.m. Several cardboard boxes were stacked in front an electrical panel.

Extension 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 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS 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.

2. Two microwaves were plugged into a surge protector in the staff kitchen as observed at 11:23 a.m. on 7/21/2010.

Based on observations on 7/20/2010, the facility failed to maintain the electrical system and/or its components in accordance with the standards of NFPA 70, 1999 Edition; NFPA 99, 1999 Edition; or interpretations from the Centers for Medicare and Medicaid Services (CMS).

Extension 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 of NFPA 70; and Sections 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99; and previous interpretations from CMS. The limited use of circuit breaker protected power strips is acceptable by CMS 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.

1. A computer station in the helicopter hanger was reviewed on 7/20/2010 at 9:30 a.m. Two electrical deficiencies were identified as follows:
a) A white extension cord was in use, and
b) a multi-plug adaptor was in use.

Based on observations made on 7/19/2010, the facility failed to prevent Alcohol Based Hand Rub (ABHR) dispensers from being installed near an ignition source.

Findings include:

Guidance issued by the Centers for Medicare & Medicaid Services (CMS) in Survey and Certification Letter (S&C 05-33) issued in June 9, 2005 indicates that "dispensers shall not be installed over or directly adjacent to an ignition source." Directly adjacent has been interpreted to be one inch.

The "Purell" ABHR dispenser in the housekeeping closet of the rehabilitation side of the second floor was installed right next to the an electrical switch as observed at 3:54 p.m. on 7/19/2010. The dispenser was confirmed to contain an alcohol based hand rub solution.