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Based on record review and staff interview, the facility failed to inspect all emergency electrical system (EES) circuit breakers annually, and to exercise the circuit breakers periodically associated for the emergency generator. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 1/17/23, at 11:34 am revealed documentation was not provided to verify emergency electrical system (EES) circuit breakers were inspected annually, and exercised periodically.

In an interview on 1/17/23, at 11:34 am, Administration A confirmed the testing was not conducted, so documentation was not available.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

Based on observation, record review and staff interview, the facility failed to provide approved installation and testing documentation to verify emergency lights would function during a power outage. This condition increased the probability occupants would be left in darkness during an emergency.

Findings are:
Record review on 1/17/23, at 11:39 am revealed documentation was not provided to verify that battery backup emergency lights in various areas of the facility, such as the Electrical Closet, CT Room and the Pharmacy were tested monthly and annually.

Observation on 1/17/23, at 1:33 pm revealed the Pharmacy battery backup emergency light was not installed in a way that would ensure operation during loss of power. The light was wired into an electrical junction box that sat on a filing cabinet and was then plugged into a wall outlet by a flexible cord.

In an interview on 1/17/23, from 11:39 am to 1:33 pm, Administration A confirmed testing documentation was not available for review and acknowledged the lack of reliability of the Pharmacy battery backup light.

NFPA 101, 2012, 7.8.2 Sources of Illumination. 7.8.2.1* Illumination of means of egress shall be from a source considered reliable by the authority having jurisdiction. 7.8.2.2 Battery-operated electric lights and other types of portable lamps or lanterns shall not be used for primary illumination of means of egress. Battery-operated electric lights shall be permitted to be used as an emergency source to the extent permitted under Section 7.9.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in
accordance with one of the three options offered by 7.9.3.1.1,
7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a
minimum of 3 weeks and a maximum of 5 weeks between
tests, for not less than 30 seconds, except as otherwise
permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond
30 days with the approval of the authority having
jurisdiction.
(3) Functional testing shall be conducted annually for a minimum
of 11?2 hours if the emergency lighting system is battery
powered.
(4) The emergency lighting equipment shall be fully operational
for the duration of the tests required by 7.9.3.1.1(1)
and (3).
(5) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

Based on record review and staff interview, the facility failed to have electrical appliances under the Kitchen range hood suppression system shut down power with the activation of the suppression system. This condition would affect the suppression of a fire under the range hood.

Findings are:
Record review on 1/17/23, at 11:12 am revealed the 10/19/22 range hood suppression inspection report stated that the electrical to appliances under the hood were not shutting down when the system was trip-tested. Documentation of correction was not provided for review.

In an interview on 1/17/23, at 11:12 am, Administration A acknowledged the findings of the inspection report, and that the deficiency had not yet been addressed.

NFPA 17A, 2009, 4.4.3 Shutoff Devices. 4.4.3.1 On activation of any cooking equipment fire extinguishing system, all sources of fuel and electric power that produce heat to all equipment protected by the system shall be shut down.

Based on record review and staff interview, the facility failed to inspect all emergency electrical system (EES) circuit breakers annually, and to exercise the circuit breakers periodically associated for the emergency generator. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 1/17/23, at 11:34 am revealed documentation was not provided to verify emergency electrical system (EES) circuit breakers were inspected annually, and exercised periodically.

In an interview on 1/17/23, at 11:34 am, Administration A confirmed the testing was not conducted, so documentation was not available.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

Based on observation and staff interview, the facility failed to use electrical equipment in accordance with device listings, which increased the potential to cause a fire.

Findings are:
Observation on 1/17/23, from 1:47 pm to 2:06 pm revealed:
1. An APC-brand 6-outlet surge protector that served the patient care vicinity was observed next to the exam tables in the Procedure Room and in the ER.
2. Appliances were plugged into a power strip in the OR Breakroom, and not into a hardwired outlet.
3. A power strip that served the patient care vicinity on the floor next to the OR operating table was observed.

Record review of the power strip listings on 1/17/23, from 1:47 pm to 2:06 pm revealed an unidentified listing of the APC-brand surge protectors, and the OR power strip UL Listing 58M7. Documentation was not provided to verify the devices for met UL 1363A or UL 60601-1 in the patient care vicinities.

In an interview on 1/17/23, from 1:47 pm to 2:06 pm, Administration A acknowledged the electrical hazard in the Breakroom, and that it could not be verified that the power strips met the approved listings for use in patient care vicinity.

NFPA 70, 2011, 210.23 Permissible Loads. In no case shall the load exceed
the branch-circuit ampere rating. An individual branch
circuit shall be permitted to supply any load for which it is
rated. A branch circuit supplying two or more outlets or
receptacles shall supply only the loads specified according
to its size specified in 210.23(A) through (D) and as summarized
in 210.24 and table 210.24.