HospitalInspections.org

Based on observation and interview, the facility failed to verity the glass in the fire rated door between the Parking Garage and the Hospital and failed to seal holes above the ceiling tiles to the adjacent business occupancy. This deficient practice would allow fire and smoke to migrate between the occupancies. The facility census was 11 patients.

Findings are:
1. Observations on 7-31-12 at 2:04 pm revealed the fire rated door between Parking Garage and the Hospital provided wire glass with no rating indicated on the glass.

During an interview on 7-31-12 at 2:04 pm, Director of Facilities confirmed the findings and failed to verify the fire rating for the door.

Observations on 8-1-12 between 8:42 pm and 9:42 pm above the ceiling tiles revealed:
2. An approximate 3 inch by 3 inch unsealed penetration in the 2 hour fire rated wall above the double doors leading to the MRI waiting area.
3. An approximate 2 inch unsealed penetration in the 2 hour fire rated wall above the fire rated doors in the MRI waiting area.
4. Unsealed penetration in the 2 hour fire rated wall in Consultation Room 1.

During an interview on 8-1-12 at each time of observation, Director of Facilities confirmed the findings.

NFPA Standard:
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. 2000, NFPA 101, 8.2.3.2.1.

Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for a door in a 2-hour fire barrier shall have a 1 1/2-hour fire protection rating. 2000, NFPA 101, 8.2.3.2.3.1 (1).

Based on observation and interview the facility failed to maintain the north corridor Kitchen door to close and latch within the door frame. This deficient practice would allow smoke to spread within the exit corridor and affected 11 patients on the second floor. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 11:08 am and 8-1-13 at 9:09 am revealed the north Kitchen door failed to engage the door frame.

During an interview on both dates and times of observations, Director of Facilities confirmed the door failed to latch and stated the hood fan was operating.

Based on observation and interview the facility failed to verify the glass in the North Stairwell door to be fire rated. This deficient practice would affect the integrity of the door and spread fire and smoke within the stair tower. Facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 12:40 pm revealed the glass in wood door in the north stair tower failed to provide fire rating.

During an interview on 7-31-12 at 12:40 pm, Director of Facilities confirmed the window failed to provide any type of fire rated markings.

Based on observations and interview the facility failed to maintain a smoke-tight barrier around the OR smoke compartment. This deficient practice affected all patients located within that smoke compartment and the adjacent areas, by allowing smoke to compromise exiting corridors. The facility census was 11 patients.

Findings are:
Observations on 8-1-12 between 8:40 am and 9:30 am above the ceiling tiles revealed:
1. Unsealed penetrations, unsealed cable tray above the Phase II doors.
2. Unsealed penetrations, unsealed duct work and cable tray above door to Recovery near CEO office.
3. Numerous unsealed penetration around various areas of the OR smoke compartment.

During an interview on 8-1-12 at each time of observation, Director of Facilities confirmed the openings within the walls, and failed to verify if the smoke compartment of this area was an actual suite.

Based on observations and interview the facility failed to provide self-closing devices on doors used as storage room and failed to maintain storage room doors to engage the frame. These deficient practices would allow smoke and fire to spread within the exit corridor and affected all occupants. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 11:08 am and 12:09 pm revealed:
1. Operating Room 6 was being used as a storage room, the doors failed to provide latching devices.
2. Storage room in the Pain Clinic failed to provide a self-closing device on the door.
3. Soiled Linen door in Pre-Op failed to engage the door frame.

During an interview 7-31-12 between 11:08 am and 12:09 pm, Director of Facilities confirmed all the findings.

Based on observation and interview the facility failed to restrict the storage of medical items and equipment in the corridors of the OR. The facility failed to disengage the locking mechanisms on exit doors or post egress signage instructions. These deficient practices affected all occupants as it would delay or impede egress. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 11:28 am and 12:19 pm revealed:
1. East OR corridor used for storage for medical supplies and equipment, including numerous storage carts.
2. Medical equipment stored in the west OR corridor.
3. East exit door was equipped with a thumb turn lock.
4. Front lobby doors were equipped with thumb turn lock.
5. Front lobby doors failed to provide egress signage instructions, the lever to release door was not marked.

During an interview on 7-31-12 at each time of observation, Director of Facilities confirmed the findings.

Based on observations and interview the facility failed to verify the amount of lighting provided at the exterior exit gates on the patio so that operation of hardware can be seen at night. This deficient practice would delay egress from the area during an emergency event. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 11:08 am revealed two exterior gates at the patio, with no exterior lighting within a distance that would illuminate the hardware.

During an interview on 7-31-12 at 11:08 am, Director of Facilities failed to verify the amount of light which would illuminate the egress gates.

Based on observation and interview, the facility failed to maintain emergency light in the Electrical Room, in accordance with NFPA 101, 7.9. The facility census was 11 Patients.

Findings are:
Observations on 7-31-12 at 1:38 pm revealed the emergency light in the Electrical Room failed to light when test button was depressed.

During an interview on 7-31-12 at 1:38 pm, Director of Facilities confirmed the emergency light failed to operate.

NFPA Standard:
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 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on observation and interview, the facility failed to provide exit signs to indicate the continuous path of egress on both sides of the second floor and signs on the exterior exit gates. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 10:51 am and 11:56 am revealed:
1. The facility failed to provide exit signs to indicate the second exit from the South Corridor.
2. The facility failed to provide exit sign to indicate the second exit from the North Corridor.
3. The facility failed to provide an exit sign on the exterior gate on the patio.

During an interview on 7-31-12 at each time of observations, Director of Facilities confirmed the lack of exit signs.

NFPA Standard:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different days during the month. This deficient practice has the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility was census 11 patients.

Findings are:
Documentation review on 7-31-12 revealed that 13 of 15 drills conducted were conducted within six days of the end of the month.

During an interview on 7-31-12 at 1:45 pm, Director of Facilities confirmed the findings.

NFPA Standard:
Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2

Based on documentation review and interview the facility failed to maintain the fire alarm system so that the smoke detectors were tested 100 percent annually and that the sensitivity test of the smoke detectors were current. This deficient practice affected all occupants of the facility. The facility census was 11 patients.

Findings are:
Documentation review of the facilities fire alarm test reports on 7-31-12 revealed, that the last smoke detector sensitivity test was conducted on 4-13-10.

Documentation review of the facilities fire alarm test reports on 7-31-12 revealed, that the facility failed to provide documentation of a 100 percent test done since the facility opened in 2008.

During an interview on 7-31-12 at 2:15 pm, Director of Facilities confirmed the lack of fire alarm testing.

NFPA Standard:
Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 1999 NFPA 72, 7-3.2.1

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. 1999 NFPA 72, 7-3.2 requires annual functional testing.

Based on observation and interview the facility failed to keep the rubber protective covers on the hood suppression nozzle and failed to maintain the gas burners on the stove. This deficient practice could allow smoke and fire to spread out of the kitchen and affect 11 patients on the second floor. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 10:34 am revealed:
1. The middle rubber cap on the hood suppression nozzles failed to be in place.
2. Front burner on the stove failed to ignite when tested.

During an interview on 7-31-12 at 10:34 am, Director of Facilities instructed the kitchen staff to place cap on the nozzle and confirmed the burner failed to ignite.

NFPA Standard:
All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge. 1998, NFPA 17A, 2-3.1.4

Based on documentation review and interview the facility failed to verify that the non-sleeping Operating Rooms, Pre-op and Post-op areas were less than 10,000 square feet to meet the Suite requirements of NFPA 101. Documents provided both gave square footage which would exceed the requirement. This deficient practice affected all patients in the area of the OR. The facility census was 11 patients

Findings are:
Documentation review on 7-31-12 revealed:
1. The information on the floor plan provided from the facility indicated the square footage of the OR " Smoke Compartment 2 " to be 16,574 square feet.
2. The documentation of the square footage provided from the facility of each area of the OR, Pre-op and Post-op to be 10,743 square feet.

During an interview on 8-1-12 at 11:30 am, Director of Facilities confirmed the documentation findings.

NFPA Standard:
Any suite of rooms that complies with the requirements of 19.2.5 shall be permitted to be subdivided with non-fire-rated, noncombustible, or limited-combustible partitions. 2000, NFPA 101, 19.2.5.4

Intervening rooms shall not be hazardous areas as defined by 19.3.2. 2000, NFPA 101, 19.2.5.5

Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2.
2000, NFPA 101, 19.2.5.7

Based on observation, documentation review and interview, the facility failed to provide a remote audible annunciator for the emergency generator at a work site readily observable by staff personnel at all times of the day or night. Facility verified that the offsite monitoring company failed to have the capability to identify the specific reason for the trouble signal being sent from the generator. Facility failed to document time to transfer during generator tests and failed to have a generator load bank test conducted every year. This deficient practice affected all patients and staff on 2 of 2 floors and all smoke zones as it would delay the response to maintain the generator in the event of failure. The facility census was 11 patients.

Findings are:
Observations on 8-1-12 at 9:23 am revealed that the facility failed to locate the annunciator panel for the generator in an attended location.

During an interview on 4-21-11 at 11:23 am, Director of Facilities confirmed the annunciator panel was located in an area which is not attended at all times. Director of Facilities also indicated that the offsite monitoring company only received a trouble signal and not the specific failure to the generator.

During documentation review on 7-31-12 facility failed to document the time to transfer from normal power to generator power during testing.

During documentation review on 7-31-12 facility provide only one year that they had conducted a load bank test since the facility opened in 2008.

During an interview on 7-31-12 at 2:35 pm, Director of Facilities confirmed the documentation and the lack of testing.

NFPA Standard
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2] 1999 NFPA 99, 3-4.1.1.15

Based on observations and interview the facility failed to prohibit the use of extension cords, power-strip cords and failed to cover electrical junction boxes. The facility failed to install electrical light switch in the Med-Gas storage room at 48 inches. These deficient practices affected all occupants in the facility by increasing the potential for electrical fires to occur. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 11:48 am to 1:15 pm revealed:
1. Crash cart located in the Pain Clinic failed to provide a hospital grade power strip.
2. Extension cord in the HR Manager Office.
3. Toaster in the Galley plugged into an extension cord.
4. Non-hospital grade power strip used in Post-op Room G.
5. The light switch in the Med-Gas storage room was located at 48 inches above finished floor.
Observations on 8-1-12 at 8:59 am revealed:
6. Open electrical junction box above the ceiling tile near the second floor elevators.

During an interview on both dates and each time of observations, Director of Facilities confirmed the findings.

NFPA Standard:
Electric installation in storage locations 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 5 ft above the floor as a precaution against their physical damage. 1999 NFPA 99, 4.3.1.1.2

Based on observation and interview the facility failed to have Alcohol Based Hand Rub (ABHR) dispenser in the Therapy Office and Beauty Shop, installed so that they were not adjacent to an ignition source. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 12:02 pm and 12:25 pm revealed:
1. ABHR was installed approximately 10 inches adjacent to an electrical light switch in Room 7.
2. ABHR was installed adjacent to an electrical light switch and outlet in Pre-Op Storage Room.

During an interview on 7-31-12 at 12:02 pm and 12:25 pm, Director of Facilities confirmed the alcohol based hand sanitizer installed immediately adjacent to an electrical source.

Regulation:
Nebraska State Fire Marshal Official Interpretation 05-04.

Based on observation and interview, the facility failed to verity the glass in the fire rated door between the Parking Garage and the Hospital and failed to seal holes above the ceiling tiles to the adjacent business occupancy. This deficient practice would allow fire and smoke to migrate between the occupancies. The facility census was 11 patients.

Findings are:
1. Observations on 7-31-12 at 2:04 pm revealed the fire rated door between Parking Garage and the Hospital provided wire glass with no rating indicated on the glass.

During an interview on 7-31-12 at 2:04 pm, Director of Facilities confirmed the findings and failed to verify the fire rating for the door.

Observations on 8-1-12 between 8:42 pm and 9:42 pm above the ceiling tiles revealed:
2. An approximate 3 inch by 3 inch unsealed penetration in the 2 hour fire rated wall above the double doors leading to the MRI waiting area.
3. An approximate 2 inch unsealed penetration in the 2 hour fire rated wall above the fire rated doors in the MRI waiting area.
4. Unsealed penetration in the 2 hour fire rated wall in Consultation Room 1.

During an interview on 8-1-12 at each time of observation, Director of Facilities confirmed the findings.

NFPA Standard:
Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies. 2000, NFPA 101, 8.2.3.2.1.

Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for a door in a 2-hour fire barrier shall have a 1 1/2-hour fire protection rating. 2000, NFPA 101, 8.2.3.2.3.1 (1).

Based on observation and interview the facility failed to maintain the north corridor Kitchen door to close and latch within the door frame. This deficient practice would allow smoke to spread within the exit corridor and affected 11 patients on the second floor. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 11:08 am and 8-1-13 at 9:09 am revealed the north Kitchen door failed to engage the door frame.

During an interview on both dates and times of observations, Director of Facilities confirmed the door failed to latch and stated the hood fan was operating.

Based on observation and interview the facility failed to verify the glass in the North Stairwell door to be fire rated. This deficient practice would affect the integrity of the door and spread fire and smoke within the stair tower. Facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 12:40 pm revealed the glass in wood door in the north stair tower failed to provide fire rating.

During an interview on 7-31-12 at 12:40 pm, Director of Facilities confirmed the window failed to provide any type of fire rated markings.

Based on observations and interview the facility failed to maintain a smoke-tight barrier around the OR smoke compartment. This deficient practice affected all patients located within that smoke compartment and the adjacent areas, by allowing smoke to compromise exiting corridors. The facility census was 11 patients.

Findings are:
Observations on 8-1-12 between 8:40 am and 9:30 am above the ceiling tiles revealed:
1. Unsealed penetrations, unsealed cable tray above the Phase II doors.
2. Unsealed penetrations, unsealed duct work and cable tray above door to Recovery near CEO office.
3. Numerous unsealed penetration around various areas of the OR smoke compartment.

During an interview on 8-1-12 at each time of observation, Director of Facilities confirmed the openings within the walls, and failed to verify if the smoke compartment of this area was an actual suite.

Based on observations and interview the facility failed to provide self-closing devices on doors used as storage room and failed to maintain storage room doors to engage the frame. These deficient practices would allow smoke and fire to spread within the exit corridor and affected all occupants. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 11:08 am and 12:09 pm revealed:
1. Operating Room 6 was being used as a storage room, the doors failed to provide latching devices.
2. Storage room in the Pain Clinic failed to provide a self-closing device on the door.
3. Soiled Linen door in Pre-Op failed to engage the door frame.

During an interview 7-31-12 between 11:08 am and 12:09 pm, Director of Facilities confirmed all the findings.

Based on observation and interview the facility failed to restrict the storage of medical items and equipment in the corridors of the OR. The facility failed to disengage the locking mechanisms on exit doors or post egress signage instructions. These deficient practices affected all occupants as it would delay or impede egress. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 11:28 am and 12:19 pm revealed:
1. East OR corridor used for storage for medical supplies and equipment, including numerous storage carts.
2. Medical equipment stored in the west OR corridor.
3. East exit door was equipped with a thumb turn lock.
4. Front lobby doors were equipped with thumb turn lock.
5. Front lobby doors failed to provide egress signage instructions, the lever to release door was not marked.

During an interview on 7-31-12 at each time of observation, Director of Facilities confirmed the findings.

Based on observations and interview the facility failed to verify the amount of lighting provided at the exterior exit gates on the patio so that operation of hardware can be seen at night. This deficient practice would delay egress from the area during an emergency event. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 11:08 am revealed two exterior gates at the patio, with no exterior lighting within a distance that would illuminate the hardware.

During an interview on 7-31-12 at 11:08 am, Director of Facilities failed to verify the amount of light which would illuminate the egress gates.

Based on observation and interview, the facility failed to maintain emergency light in the Electrical Room, in accordance with NFPA 101, 7.9. The facility census was 11 Patients.

Findings are:
Observations on 7-31-12 at 1:38 pm revealed the emergency light in the Electrical Room failed to light when test button was depressed.

During an interview on 7-31-12 at 1:38 pm, Director of Facilities confirmed the emergency light failed to operate.

NFPA Standard:
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 1 and 1/2 hours. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction. NFPA 101, 7.9.3

Based on observation and interview, the facility failed to provide exit signs to indicate the continuous path of egress on both sides of the second floor and signs on the exterior exit gates. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 10:51 am and 11:56 am revealed:
1. The facility failed to provide exit signs to indicate the second exit from the South Corridor.
2. The facility failed to provide exit sign to indicate the second exit from the North Corridor.
3. The facility failed to provide an exit sign on the exterior gate on the patio.

During an interview on 7-31-12 at each time of observations, Director of Facilities confirmed the lack of exit signs.

NFPA Standard:
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. 2000 NFPA 101, 7.10.1.2

Based upon record review and interview, the facility failed to hold fire drills under varied conditions at different days during the month. This deficient practice has the potential to affect staff preparation and experience in providing for the protection of all patients in the event of a fire. The facility was census 11 patients.

Findings are:
Documentation review on 7-31-12 revealed that 13 of 15 drills conducted were conducted within six days of the end of the month.

During an interview on 7-31-12 at 1:45 pm, Director of Facilities confirmed the findings.

NFPA Standard:
Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2

Based on documentation review and interview the facility failed to maintain the fire alarm system so that the smoke detectors were tested 100 percent annually and that the sensitivity test of the smoke detectors were current. This deficient practice affected all occupants of the facility. The facility census was 11 patients.

Findings are:
Documentation review of the facilities fire alarm test reports on 7-31-12 revealed, that the last smoke detector sensitivity test was conducted on 4-13-10.

Documentation review of the facilities fire alarm test reports on 7-31-12 revealed, that the facility failed to provide documentation of a 100 percent test done since the facility opened in 2008.

During an interview on 7-31-12 at 2:15 pm, Director of Facilities confirmed the lack of fire alarm testing.

NFPA Standard:
Smoke detector sensitivity shall be checked within one year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. 1999 NFPA 72, 7-3.2.1

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. 1999 NFPA 72, 7-3.2 requires annual functional testing.

Based on observation and interview the facility failed to keep the rubber protective covers on the hood suppression nozzle and failed to maintain the gas burners on the stove. This deficient practice could allow smoke and fire to spread out of the kitchen and affect 11 patients on the second floor. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 at 10:34 am revealed:
1. The middle rubber cap on the hood suppression nozzles failed to be in place.
2. Front burner on the stove failed to ignite when tested.

During an interview on 7-31-12 at 10:34 am, Director of Facilities instructed the kitchen staff to place cap on the nozzle and confirmed the burner failed to ignite.

NFPA Standard:
All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping. The protection device shall blow off, open, or blow out upon agent discharge. 1998, NFPA 17A, 2-3.1.4

Based on documentation review and interview the facility failed to verify that the non-sleeping Operating Rooms, Pre-op and Post-op areas were less than 10,000 square feet to meet the Suite requirements of NFPA 101. Documents provided both gave square footage which would exceed the requirement. This deficient practice affected all patients in the area of the OR. The facility census was 11 patients

Findings are:
Documentation review on 7-31-12 revealed:
1. The information on the floor plan provided from the facility indicated the square footage of the OR " Smoke Compartment 2 " to be 16,574 square feet.
2. The documentation of the square footage provided from the facility of each area of the OR, Pre-op and Post-op to be 10,743 square feet.

During an interview on 8-1-12 at 11:30 am, Director of Facilities confirmed the documentation findings.

NFPA Standard:
Any suite of rooms that complies with the requirements of 19.2.5 shall be permitted to be subdivided with non-fire-rated, noncombustible, or limited-combustible partitions. 2000, NFPA 101, 19.2.5.4

Intervening rooms shall not be hazardous areas as defined by 19.3.2. 2000, NFPA 101, 19.2.5.5

Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2.
2000, NFPA 101, 19.2.5.7

Based on observation, documentation review and interview, the facility failed to provide a remote audible annunciator for the emergency generator at a work site readily observable by staff personnel at all times of the day or night. Facility verified that the offsite monitoring company failed to have the capability to identify the specific reason for the trouble signal being sent from the generator. Facility failed to document time to transfer during generator tests and failed to have a generator load bank test conducted every year. This deficient practice affected all patients and staff on 2 of 2 floors and all smoke zones as it would delay the response to maintain the generator in the event of failure. The facility census was 11 patients.

Findings are:
Observations on 8-1-12 at 9:23 am revealed that the facility failed to locate the annunciator panel for the generator in an attended location.

During an interview on 4-21-11 at 11:23 am, Director of Facilities confirmed the annunciator panel was located in an area which is not attended at all times. Director of Facilities also indicated that the offsite monitoring company only received a trouble signal and not the specific failure to the generator.

During documentation review on 7-31-12 facility failed to document the time to transfer from normal power to generator power during testing.

During documentation review on 7-31-12 facility provide only one year that they had conducted a load bank test since the facility opened in 2008.

During an interview on 7-31-12 at 2:35 pm, Director of Facilities confirmed the documentation and the lack of testing.

NFPA Standard
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2] 1999 NFPA 99, 3-4.1.1.15

Based on observations and interview the facility failed to prohibit the use of extension cords, power-strip cords and failed to cover electrical junction boxes. The facility failed to install electrical light switch in the Med-Gas storage room at 48 inches. These deficient practices affected all occupants in the facility by increasing the potential for electrical fires to occur. The facility census was 11 patients.

Findings are:
Observations on 7-31-12 between 11:48 am to 1:15 pm revealed:
1. Crash cart located in the Pain Clinic failed to provide a hospital grade power strip.
2. Extension cord in the HR Manager Office.
3. Toaster in the Galley plugged into an extension cord.
4. Non-hospital grade power strip used in Post-op Room G.
5. The light switch in the Med-Gas storage room was located at 48 inches above finished floor.
Observations on 8-1-12 at 8:59 am revealed:
6. Open electrical junction box above the ceiling tile near the second floor elevators.

During an interview on both dates and each time of observations, Director of Facilities confirmed the findings.

NFPA Standard:
Electric installation in storage locations 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 5 ft above the floor as a precaution against their physical damage. 1999 NFPA 99, 4.3.1.1.2