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Based on observation and interview, the facility failed to maintain the 2 hour rated fire wall, which separated the sprinkled Hospital from a non-sprinkled crawl space. This deficient practice would allow fire, gasses and smoke to migrate between the two separate occupancies. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 10:07 am revealed, the door separating the sprinkled area in the North Mechanical Room and the non-sprinkled crawl space failed to provide a fire rating.

During an interview on 11-8-16 at 10:07 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Where separated occupancies provisions are used in accordance with either 19.1.3.3 or 19.1.3.4, the most stringent construction type shall be provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type shall be determined as follows:
1) The construction type and supporting construction of the health care occupancy shall be based on the story on which it is located in the building in accordance with the provisions of 19.1.6 and Table 19.1.6.1.
2) The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters of this Code.
2012 NFPA 101, 19.1.3.5

Based on observation and interview, the facility failed to prohibit the use of more than one locking device on a door within a means of egress to allow for quick and reliable exiting to a public way (an area of safety) which had the potential to cause confusion and delay egress. This facility census was 11 patients.

Findings are:
Observation on 11-8-16 between 10:06 am and 10:56 am revealed:
1. The PACU door leading into the corridor was equipped with a thumb lock and lever hardware, requiring two motions to open the door if the thumb lock was engaged.
2. The Mammogram door was equipped with a thumb lock and lever hardware, requiring two motions to open the door if the thumb lock was engaged.
3. The Fluoroscopy door was equipped with a thumb lock and lever hardware, requiring two motions to open the door if the thumb lock was engaged.

During an interview on 11-8-16 between 10:06 am and 10:56, Plant Operations Staff A confirmed the findings.

NFPA Standard:
The releasing mechanism for any latch shall be located as follows:
1) Not less than 34 in. (865 mm) above the finished floor for other than existing installations
2) Not more than 48 in. (1220 mm) above the finished floor 7.2.1.5.10.2. The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.
2012 NFPA 101, 7.2.1.5.10.1

Based on observation and interview, the facility failed to maintain doors and ceilings in hazardous areas so they would be smoke tight. This deficient practice would allow fire and smoke to migrate out of the hazard area into exit corridors. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 10:48 am and 11:38 am revealed:
1. There were unsealed penetrations in the ceiling of the Boiler Room.
2. The double doors into the basement Pump Room next to the elevator, failed to close and latch.

During an interview on 11-8-16 at 10:48 am and 11:38 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012 NFPA 101, 19.3.2.1.2

Based on observation and staff interview the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building, and in lieu of complete sprinkler coverage, failed to provide a 2-hour fire separation between sprinkled and unsprinkled portions of the building. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 between 10:12 am and 11:40 am revealed:
1. The facility failed to verify the area above the " Old Vault " provided sprinkler protection and could not verify there was a 2-hour fire separation for the area.
2. The facility failed to provide sprinkler protection under the duct work which was greater than 4 foot wide in the basement North Mechanical Room.
3. No sprinkler protection was provided in the new Electrical Room next to the "Old Finance Office" and the facility could not verify there was a 2-hour fire separation for the room.

During an interview on 11-8-16 between 10:12 am and 11:40 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101, 19.3.5.3

NFPA Standard:
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. 2010 NFPA 13, 8.5.5.3.1

Based on observation and interview the facility failed to provide the correct type of sprinkler head in rooms that provided no ceilings. This deficient practice would not allow the sprinkler head to activate as designed. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 9:40 and 10:10 am revealed:
1. No ceiling was provided in the "Old Finance Office". The sprinkler head in the room was not an upright type but was a type that required an intact ceiling to function as designed.
2. No ceiling was provided in the Payroll Office closet. The sprinkler head in the room was not an upright type but was a type that required an intact ceiling to function as designed.

During an interview on 11-8-16 at 9:40 and 10:10 am, Plant Operations Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide corridor doors with a suitable means of keeping the door closed. The deficient practice would allow smoke to migrate into the exit corridors. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 10:29 am revealed, the PACU door leading into the Surgery corridor failed to latch.

During an interview on 11-8-16 at 10:29 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
2012 NFPA 101, 19.3.6.3.5

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch and the Equipment System. This deficient practice had the potential to affect all residents of the facility by affecting the egress lighting and emergency systems of the facility. The facility census was 11 patients.

Findings are:
Observation on 11-8-16 at 9:20 am and 11:48 am revealed:
1. Electrical panel CLRIC critical branch, in the ER Electrical Room contained Elevator Lights.(LS)
2. Electrical panel CLRIC critical branch, in the ER Electrical Room contained ER egress door.(LS)

During an interview on 11-8-16 at 9:20 am and 11:48 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
2011 NFPA 70, 517.30
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure Facilities (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to prevent the use of power strip cords in lieu of permanent wiring. This deficient would practice increase the probability of electrical wiring to cause an electrical shock or fire. Facility census was 11 patients.

Findings are:
Observation on 11-8-16 at 9:20 am and 9:48 am revealed:
1. A refrigerator was plugged into a power strip in the Clinical Analyst Office.
2. A refrigerator was plugged into a power strip in the Lab, located next to the copier.

During an interview on 11-8-16 at 9:20 am and 9:48 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Unless specifically permitted in 400.7, flexible cords 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
Exception to (4): Flexible cord and cable shall be permitted
to be attached to building surfaces in accordance with the
provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped
ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
2011 NFPA 70, 400.8

Based on observation and interview the facility failed to segregate full oxygen cylinders from empty ones which would increase the potential that staff would inadvertently choose an empty oxygen cylinder in an emergency when a full one was needed. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 between 10:35 am and 11:26 am revealed:
1. The West Equipment Storage room contained empty oxygen cylinders intermixed with full ones.
2. The Main Oxygen Storage room contained empty oxygen cylinders intermixed with full ones.
3. The RT Oxygen Storage room contained empty oxygen cylinders intermixed with full ones.

During an interview on 11-8-16 between 10:35 am and 11:26 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA 99, 11.6.5.2

Based on observation and interview, the facility failed to maintain the 2 hour rated fire wall, which separated the sprinkled Hospital from a non-sprinkled crawl space. This deficient practice would allow fire, gasses and smoke to migrate between the two separate occupancies. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 10:07 am revealed, the door separating the sprinkled area in the North Mechanical Room and the non-sprinkled crawl space failed to provide a fire rating.

During an interview on 11-8-16 at 10:07 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Where separated occupancies provisions are used in accordance with either 19.1.3.3 or 19.1.3.4, the most stringent construction type shall be provided throughout the building, unless a 2-hour separation is provided in accordance with 8.2.1.3, in which case the construction type shall be determined as follows:
1) The construction type and supporting construction of the health care occupancy shall be based on the story on which it is located in the building in accordance with the provisions of 19.1.6 and Table 19.1.6.1.
2) The construction type of the areas of the building enclosing the other occupancies shall be based on the applicable occupancy chapters of this Code.
2012 NFPA 101, 19.1.3.5

Based on observation and interview, the facility failed to prohibit the use of more than one locking device on a door within a means of egress to allow for quick and reliable exiting to a public way (an area of safety) which had the potential to cause confusion and delay egress. This facility census was 11 patients.

Findings are:
Observation on 11-8-16 between 10:06 am and 10:56 am revealed:
1. The PACU door leading into the corridor was equipped with a thumb lock and lever hardware, requiring two motions to open the door if the thumb lock was engaged.
2. The Mammogram door was equipped with a thumb lock and lever hardware, requiring two motions to open the door if the thumb lock was engaged.
3. The Fluoroscopy door was equipped with a thumb lock and lever hardware, requiring two motions to open the door if the thumb lock was engaged.

During an interview on 11-8-16 between 10:06 am and 10:56, Plant Operations Staff A confirmed the findings.

NFPA Standard:
The releasing mechanism for any latch shall be located as follows:
1) Not less than 34 in. (865 mm) above the finished floor for other than existing installations
2) Not more than 48 in. (1220 mm) above the finished floor 7.2.1.5.10.2. The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.
2012 NFPA 101, 7.2.1.5.10.1

Based on observation and interview, the facility failed to maintain doors and ceilings in hazardous areas so they would be smoke tight. This deficient practice would allow fire and smoke to migrate out of the hazard area into exit corridors. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 10:48 am and 11:38 am revealed:
1. There were unsealed penetrations in the ceiling of the Boiler Room.
2. The double doors into the basement Pump Room next to the elevator, failed to close and latch.

During an interview on 11-8-16 at 10:48 am and 11:38 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.7.1. 2012 NFPA 101, 19.3.2.1

Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. 2012 NFPA 101, 19.3.2.1.2

Based on observation and staff interview the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building, and in lieu of complete sprinkler coverage, failed to provide a 2-hour fire separation between sprinkled and unsprinkled portions of the building. This deficient practice affected all patients, staff, and visitors of the facility. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 between 10:12 am and 11:40 am revealed:
1. The facility failed to verify the area above the " Old Vault " provided sprinkler protection and could not verify there was a 2-hour fire separation for the area.
2. The facility failed to provide sprinkler protection under the duct work which was greater than 4 foot wide in the basement North Mechanical Room.
3. No sprinkler protection was provided in the new Electrical Room next to the "Old Finance Office" and the facility could not verify there was a 2-hour fire separation for the room.

During an interview on 11-8-16 between 10:12 am and 11:40 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101, 19.3.5.3

NFPA Standard:
Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. 2010 NFPA 13, 8.5.5.3.1

Based on observation and interview the facility failed to provide the correct type of sprinkler head in rooms that provided no ceilings. This deficient practice would not allow the sprinkler head to activate as designed. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 9:40 and 10:10 am revealed:
1. No ceiling was provided in the "Old Finance Office". The sprinkler head in the room was not an upright type but was a type that required an intact ceiling to function as designed.
2. No ceiling was provided in the Payroll Office closet. The sprinkler head in the room was not an upright type but was a type that required an intact ceiling to function as designed.

During an interview on 11-8-16 at 9:40 and 10:10 am, Plant Operations Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide corridor doors with a suitable means of keeping the door closed. The deficient practice would allow smoke to migrate into the exit corridors. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 at 10:29 am revealed, the PACU door leading into the Surgery corridor failed to latch.

During an interview on 11-8-16 at 10:29 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.
2012 NFPA 101, 19.3.6.3.5

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch and the Equipment System. This deficient practice had the potential to affect all residents of the facility by affecting the egress lighting and emergency systems of the facility. The facility census was 11 patients.

Findings are:
Observation on 11-8-16 at 9:20 am and 11:48 am revealed:
1. Electrical panel CLRIC critical branch, in the ER Electrical Room contained Elevator Lights.(LS)
2. Electrical panel CLRIC critical branch, in the ER Electrical Room contained ER egress door.(LS)

During an interview on 11-8-16 at 9:20 am and 11:48 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
2011 NFPA 70, 517.30
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure Facilities (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to prevent the use of power strip cords in lieu of permanent wiring. This deficient would practice increase the probability of electrical wiring to cause an electrical shock or fire. Facility census was 11 patients.

Findings are:
Observation on 11-8-16 at 9:20 am and 9:48 am revealed:
1. A refrigerator was plugged into a power strip in the Clinical Analyst Office.
2. A refrigerator was plugged into a power strip in the Lab, located next to the copier.

During an interview on 11-8-16 at 9:20 am and 9:48 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
Unless specifically permitted in 400.7, flexible cords 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
Exception to (4): Flexible cord and cable shall be permitted
to be attached to building surfaces in accordance with the
provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped
ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
2011 NFPA 70, 400.8

Based on observation and interview the facility failed to segregate full oxygen cylinders from empty ones which would increase the potential that staff would inadvertently choose an empty oxygen cylinder in an emergency when a full one was needed. The facility census was 11 patients.

Findings are:
Observations on 11-8-16 between 10:35 am and 11:26 am revealed:
1. The West Equipment Storage room contained empty oxygen cylinders intermixed with full ones.
2. The Main Oxygen Storage room contained empty oxygen cylinders intermixed with full ones.
3. The RT Oxygen Storage room contained empty oxygen cylinders intermixed with full ones.

During an interview on 11-8-16 between 10:35 am and 11:26 am, Plant Operations Staff A confirmed the findings.

NFPA Standard:
If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 2012 NFPA 99, 11.6.5.2