HospitalInspections.org

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other Code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate Interim Life Safety Measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on random observation during the survey walk-through the building emergency electrical system is not properly divided into Life Safety, Critical and Equipment branches in accordance with NFPA-99, and NFPA-70, Section 517. These deficiencies could affect all building occupants because emergency egress and the provision of services could be compromised by the loss of a single transfer switch.

Findings include:

A. Some of the critical panels were serving items other than those allowed on the critical power system. Critical panel EC-2 had a circuit feeding the fire alarm system NAC panel, and the critical panel in the outpatient area was serving the main fire alarm panel along with the med gas alarm panel (these items should be served from the life safety panel). This does not meet the requirements of NFPA-70, Section 517-32 and 33.

B. Some panels in the older portion of the building including EM-1B, EM00, and EMP served a mix of life safety, critical, and equipment loads which does not meet the requirements of NFPA-70, Sections 517-30 through 35.

C. Some panels such as EMP need new updated and typed directories to meet the requirements of NFPA-70, Section 110-22.

Based on random observation during the survey walk-through not all portions of the building systems are installed in accordance with NFPA 70 (1999).

Findings include:

A. Normal power receptacles were not provided in operating rooms, and procedure rooms as required by NFPA-70, Section 517-19, and NFPA-99, Section 3-3.2.1.2(a)1. In the event of a transfer switch failure upon return to normal power, these rooms could be left with no power.

B. Corrected 8/15/13

C. Corrected 8/15/13

D. Emergency receptacles in the ER, ICU, and other patient bed locations were not all identified as emergency receptacles. All receptacles or cover plates served by critical power shall have a distinctive color or marking so as to be readily identifiable in accordance with NFPA-99, Section 3-4.2.2.4(a)2, and NFPA-70, Section 517-19(a). This could cause confusion during a power outage trying to locate an emergency receptacle for critical care equipment.

E. Corrected 8/15/13

F. Electrical panel directories were observed that did not accurately or completely identify the use of all circuits to comply with NFPA 70-1999, 384-13. Example includes but is not limited to "Panel 52" located at the 1914 building 3rd floor OB north corridor.

UPDATE 4/2/13: The above noted panel was provided with a new updated directory but the original directory was still in-place. Review of electrical panels will be required to verify correction of K145 deficiencies.