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Based on observation and interview, the facility failed to maintain two hour rated fire doors, which separated the Health Care facility from the Business Occupancy. This deficiency had the potential to allow a fire to spread beyond the compartment of origin. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 between 11:40 am and 2:47 pm revealed:
1. The 2 hour fire rated separation at the Education Coordinator Office failed to provide a rated door.
2. The 2 hour fire rated doors into the 1730 Building at Same Day South failed to close and latch. The door appeared to be warped.
3. The gap between the 2 hour fire rated doors at Materials Area was greater than 1/8 inch.

During an interview on 1-18-17 at 11:40 am and 2:47 pm, Maintenance Staff A confirmed the 2 hour rated fire doors were not maintained.

Based on observation and interview, the facility failed to provide a means to prevent egress to lower levels of the facility which were not an exit. This deficient practice would cause confusion and delay exiting from two stairwells used as an exit. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 1:02 pm and 4:40 pm revealed two stairwells which are used as exits failed to provide measures to prevent occupants from traveling into levels that were below the level of the exit.

During an interview on 1-18-17 at 1:02 pm and 4:40 pm, Maintenance Staff A confirmed that there was nothing preventing occupant from traveling to a level below the exit discharge.

NFPA Standard:
NFPA 101 2012, 7.7.3.3
Stairs and ramps shall be arranged so as to make clear the direction of egress travel from the exit discharge to a public way.

7.7.3.4*
Stairs and ramps that continue more than one-half story beyond the level of discharge shall be provided with an approved means to prevent or dissuade occupants from traveling past the level of discharge during emergency building evacuation.
A.7.7.3.4
Examples include partitions and gates. The design should not obstruct the normal movement of occupants to the exit discharge. Signs, graphics, or pictograms, including tactile types, might be permitted for existing exit enclosures where partitions or gates would obstruct the normal movement of occupants to the exit discharge.

Based on observation and interview, the facility failed to maintain means of egress free of obstructions for full instant use in an emergency. The deficient practice would delay egress during an emergency. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 between 11:40 am and 2:18 pm revealed:
1. An unattended empty rolling cart was located in the corridor on 1st floor near the stairwell.
2. An unattended Pharmacy rolling cart was located in the corridor near the Nurses Station.
3. An electric rolling shade covered and obstructed the egress door in the Conference Room when in the down position.

During an interview on 1-18-17 between 11:40 am and 2:18 pm, Maintenance Staff A confirmed the obstructions.

Based on observation and interview, the facility allowed a horizotal sliding door to be used as an exit door in an area with an occupant load over 50 . The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 2:20 pm revealed:
1. A glass horizontal sliding door was used as a required exit from the Cafeteria. The occupant capacity of the cafeteria was over 50 persons. The door did not have an emergency breakaway feature that would allow the door to open pependicular to the wall.
2. The glass sliding door at the Cafeteria was equipped with only a locking device, and no latching device.


During an interview on 1-18-17 at 2:20 pm, Maintenance Staff A confirmed the use of the sliding glass door which is required to be side hinged and confirmed the door had only a lock and no latching device.

NFPA Standard:
2012 NFPA 101, 7.2.1.14
Horizontal sliding door assemblies shall be permitted in means of egress, provided that all of the following criteria are met:
(1) The door leaf is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door leaf is not more than 15 lbf (67 N).
(3) The force required to operate the door leaf in the direction of travel is not more than 30 lbf (133 N) to set the leaf in motion and is not more than 15 lbf (67 N) to close the leaf or open it to the minimum required width.
(4) The door leaf is operable using a force of not more than 50 lbf (222 N) when a force of 250 lbf (1100 N) is applied perpendicularly to the leaf adjacent to the operating device, unless the door opening is an existing horizontal sliding exit access door assembly serving an area with an
occupant load of fewer than 50.
(5) The door assembly complies with the fire protection rating, if required, and, where rated, is self-closing or automatic closing by means of smoke detection in accordance with
7.2.1.8 and is installed in accordance with NFPA80, Standard for Fire Doors and Other Opening Protectives.

Based on observation and interview, the facility failed to prohibit storage in an exit stair well. This deficient practice would delay egress during an emergency. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 10:59 am revealed, five walkers, two pair of crutches and a cane stored in the East PSC stairwell.

During an interview on 1-18-17 at 10:59 am, Maintenance Staff A confirmed the items stored in the stairwell.

NFPA Standard:
NFPA 101 2012, 7.2.2.5.3*
Enclosed, usable spaces within exit enclosures shall be prohibited, including under stairs, unless otherwise permitted by 7.2.2.5.3.2.

7.2.2.5.3.1
Open space within the exit enclosure shall not be used for any purpose that has the potential to interfere with egress.

Based on observation and interview, the facility failed to maintain all emergency lights in the facility. This deficient practice would delay a response for an electrical issue. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 2:33pm revealed, the emergency light in the Transfer Switch Room failed to illuminate when the test button was depressed.

During an interview on 1-18-17 at 2:33 pm, Maintenance Staff A confirmed the emergency light failed to operate when test button was depressed.

Based on observation and interview, the facility failed to mark exits with readily visible signs that directed occupants out of the facility and failed to provide "No Exit" sign on the exterior door leading into the underground parking garage. These deficient practices have the potential to delay exiting in an emergency and would allow occupants to mistakenly enter an area that was not an exit passage from the building. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 between 12:07 pm and 2:48 pm revealed:
1. While standing outside Room 222 looking east, no exit sign was visible for the second required exit.
2. The facility failed to provide an exit sign above the double doors in OR to Eyes.
3. The second required exit sign in the northeast corner of the Cafeteria failed to be visible.
4. The door in the leading into the underground parking garage failed to be identified by a "NO Exit" sign.

During an interview on 1-18-17 between 12:07 pm and 2:48 pm, Maintenance Staff A confirmed the lack of signage.

NFPA Standard:
2012 NFPA 101, 7.10.8.3
Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO EXIT
Such sign shall have the word NO in letters 2 in. high with a stroke width of 3/8 in. and the word EXIT in letters 1 in. high, with the word EXIT below the word NO.

Based on observation and interview, the facility failed to provide a smoke resistant partition around hazardous areas to separate them from the rest of the building and failed to provide doors to hazardous areas with a means of keeping the door closed. The deficient practice would allow smoke and fire to migrate into the exit corridors. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 10:56 am and 3:05 pm revealed:
1. A rubber door stop was holding 2nd floor Storage Room door in the open position.
2. There was an unsealed penetration around conduit in the Mechanical Room next to Room 318.
3. The Mechanical/Storage room door next to Room 319 failed to latch within the door frame.
4. The gap between the doors to the Mechanical Room next to Room 214 was greater than 1/8 inch.
5. The gap between the doors to the Mechanical Room next to Room 219 was greater than 1/8 inch.
6. The door to the South Same Day Mechanical Room failed to provide latching device. Only a deadbolt lock was provided.
7. There were two unsealed penetrations in the Mechanical Room in the OR corridor.
8. The Same Day Storage Room door near the Nurses station was being held open with a scale.
9. The gap between the doors to the North Same Day Mechanical Room was greater than 1/8 inch.
10. The Storage Room in PACU measured 90 square feet and was not provided with a door.
11. The East Same Day Mechanical Room had numerous unsealed penetrations.
12. There were numerous unsealed penetrations in the east and west walls of the Ships Ladder Mechanical Room.
13. The East Same Day Electrical Room had unsealed penetrations.
14. The Auto-clave 1-6 Room had unsealed penetrations on the east wall.
15. The " Pegg " Room measured 200 square feet and the door was not provided with a self-closing device.
16. The Orthopedic Instrument Storage Room measured 135 square feet and the door was not provided with a self-closing device.
17. The door to the Orthopedic Instrument Storage Room was obstructed by a cart that would not allow the door to close.
18. There were unsealed penetrations in the South Main Floor Mechanical Room/Water Service Room.
19. Ceiling tile was out of the grid in the PSU1 water machine room.
20. The PSU1 East Mechanical Room door failed to latch.
21. The Medical Records double doors failed to latch.
22. The Dictation paper storage room door failed to latch.
23. The OSR North Mechanical room door failed to latch.
24. The Sub-basement Housekeeping door failed to latch.
25. The OSR Main Mechanical Room doors failed to latch.
26. The door to the Main Elevator Equipment Room in the Materials Storage Room failed to close and latch within the door frame.
27. There were unsealed penetrations in the Main Elevator Equipment Room.
28. The double doors to Mechanical Room 6-7-8 failed to close and latch.
29. There were unsealed penetrations in the Mechanical Room 6-7-8.
30. The double doors to the Materials Supply room failed to close in sequence and doors failed to latch.
31. There were unsealed penetrations in the Dock Elevator/Mechanical Room.
32. There were unsealed penetrations in the Sub-basement Electrical Room.

During an interview on 1-18-17 at 10:56 am and 3:05 pm, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to use materials in accordance with the interior finish requirements for walls in healthcare occupancies.The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 2:38 pm revealed, untreated wood installed on the wall of the OSR Main Mechanical Room. The facility failed to provide documentation for the flame spread rating of the wood on the wall.

During an interview on 1-18-17 at 2:38 pm, Maintenance Staff A confirmed the wood on the wall.

Based on record review and interview, the facility failed to provide all required documentation for the annual fire alarm system inspection. This deficient practice did not ensure that all fire alarm devices were inspected and increased the potential that the fire alarm would fail to operate as designed during a fire. The facility census was 19 patients.

Findings are:
Record review of the facility's annual fire alarm inspection report on 1-19-17 at 12:20 pm, revealed the current fire alarm report did not include inspection of fire dampers.

During an interview on 1-19-17 at 12:20 pm, Maintenance Staff A confirmed the findings of the documentation review.

NFPA Standard:
2010 NFPA 72, 14.6.2.4*
A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Based on observation and interview the facility failed to install an 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. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 2:14 pm revealed, no sprinkler protection was provided in the Eyes Elevator Equipment rooms.

During an interview on 11-8-16 at 2:14 pm, Maintenance Staff A confirmed the lack of sprinklers within the two rooms, and stated the two hour wall was located on the back side of the room.

NFPA Standard:
2012 NFPA 101, 19.3.5.3
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.

Based on observation, documentation review and interview, the facility failed to prohibit non-sprinkler related items to be attached to sprinkler pipe, failed to have a 5 year internal pipe inspection conducted, and provide a spare head box for the main floor sprinkler riser. These deficient practices could impact the response and effectiveness of the sprinkler head and a larger fire could spread outside of the room into the exit corridor, and could cause damage to sprinkler piping leading to failure of the sprinkler system. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 12:43 pm and 2:20 pm revealed:
1. Blue wire was attached to the sprinkler pipe in the Ships Ladder Mechanical Room.
2. The facility failed to provide a spare sprinkler head box and wrench in the Water Service Room on the main floor.

During an interview on 1-18-17 at 12:43 pm, Maintenance Staff A confirmed the wire and removed it and confirmed the lack of a spare sprinkler head box.

Documentation review on 1-19-17 at 12:43 pm revealed that no 5 year internal pipe examination and no gauge calibration test had been completed.

During an interview on 1-19-17 at 12:43 pm, Maintenance Staff A was unaware of the requirements.

Based on observation and interview, the facility allowed a bench to obstruct access to the fire extinguisher. This deficient practice not allow unrstricted accee to the fire extinguisher could delay the extinguishment of a fire. Facility census was 19 patients.

Findings are:
Observation on 1-18-17 at 11:25 am revealed bench on second floor near the elevator which blocked access to the fire extinguisher.

During an interview on 1-18-17 at 11:25 am, Maintenance Staff A confirmed the bench blocked the fire extinguisher.

NFPA Standard:
NFPA 10 2010, 6.1.3.1
Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. The facility census was 19 patients.

Findings are:
Observation on 1-18-17 between 11:05 am and 2:23 pm revealed:
1. The gap between the double doors to the 2nd floor Mechanical Rooms were greater than 1/8 inch.
2. Patient Door 306 failed to latch within the door frame.
3. Patient Door 309 failed to latch within the door frame.
4. The gap between the double doors to the Electrical Room across from 2nd floor Nurses station was greater than 1/8 inch.
5. Patient Door 218 failed to latch within the door frame.
6. The east Same Day Electrical room doors failed to have the manual latch locked within the door frame.
7. The Doctor's Lounge door from Cafeteria failed to latch within the door frame.
8. The Mother's Room door failed to latch within the door frame.

During an interview on 1-18-17 between 10:05 am and 2:23 pm, Maintenance Staff A confirmed the gaps between the double doors and doors which failed to latch.

Based on observation and interview, the facility did not ensure that smoke barrier doors resisted the passage of smoke from one smoke compartment to another. This deficient practice would not prevent the spread of fire and smoke between smoke compartments. The facility census was 19 patients.

Findings are:
Observation on 1-18-17 at 1:37 pm revealed, the smoke door outside X-ray room in the OR had a gap between the doors greater than 1/8 inch.

During an interview on 1-18-17 at 1:37 pm, Maintenance Staff A confirmed the gap between the doors was greater than 1/8 inch.

Based on observation, interview and documentation review, the facility failed to provide windows in rooms occupied by patients for 24 hours or more. The deficinet practice did not provide for rescue of patients in the event the area could not be entered. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 1:22pm revealed four interior patient rooms without windows.

During an interview on 1-18-17 at 1:22 pm, Maintenance Staff A stated that the four interior patient rooms were not for 24 hour stay patients.

During documentation review on 1-18-17 at 4:43 pm, the facility allowed 73 of 88 patients in a 6 month period to stay in the rooms without windows for a timeframe longer than 24 hours, based on their arrival time. 13 of 88 patients were in the room longer than 24 hours based on the check-in time to the room.

During an interview on 1-18-17 at 4:43 pm, Maintenance Staff A stated they were unaware of the patient times within the rooms and was instructed that those rooms were for less than 24 hour stay.

CMS Federal Register Regulation:
42 CFR 403, 418, 460, 482, 483, and 485
Every patient sleeping room has an outside window or outside door. In new occupancies, sill height does not exceed 36 inches above the floor. Windows in atrium walls are considered outside windows. Newborn nurseries and rooms intended for occupancy less than 24 hours have no outside window or door requirements. Window sills in special nursing care areas (e.g., ICU, CCU, hemodialysis, neonatal) do not exceed 60 inches above the floor.

Based on observation and interview, the facility failed to install the suspended heating units so that it was out of reach. This deficient practice would increase the potential for harm to staff. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 2:43 pm revealed the suspending heating units installed in the OSR Fluid Cooler room were low enough to be touched by the room's occupants.

During an interview on 1-18-17 at 2:43 pm, Maintenance Staff A confirmed the heating units were installed so that it was in reach.

NFPA Standard:
2012 NFPA 101, 18.5.2.3(1), 19.5.2.3(1)
Suspended unit heaters are permitted provided the following are met:
Not located in means of egress or in patient rooms.
Located high enough to be out of reach of people in the area.
Has a safety feature to stop fuel and shut down equipment if there is excessive temperature or ignition failure. 18.5.2.3(1), 19.5.2.3(1)

Based on documentation review and interview, the facility failed to hold fire drills under varied conditions during 12 hour shifts for five of five quarters reviewed and failed to transmit the alarm when the drill was conducted after 9:00 pm. This condition failed to provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect fire procedure response. The facility census was 19 patients.

Findings are:
Fire drill documentation review on 1-19-17 at 12:20 pm revealed, the facility had two 12 hour shifts.
1. The First 12 hour shift fire drills were conducted at 11:30am, 11:20am, 12:55pm, 1:06pm, 2:00pm, 2:35pm.
2. The Second 12 hour shift fire drills were conducted at 8:49pm, 9:05 pm, 9:14pm, 9:24pm, 9:34pm, 9:40pm, 10:10pm, 10:21pm.
3. 9 of 15 fire drills reviewed were conducted between the 27th day and the 30th day of the month.
4. There was no documentation that the fire alarm signals for drills conducted after 9:00pm were transmitted to the receiving station.

During an interview on 1-19-17 at 12:20 pm, Maintenance Staff A confirmed the lack of random drills and stated that transmission of the alarm for the night shift drills had not been done.

NFPA Standard:
2012 NFPA 101, 19.7.1.6
Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
19.7.1.7
When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
19.7.1.4*
Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

Based on observation and interview, the facility failed to store a trash collection container, which was over 32 gallons, in a room protected as a hazardous area. This deficient practice would increase the potential for the delay of exiting during an emergency and added fire load to the exit corridor. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 12:39 pm revealed, a 50 gallon unattended trash receptacle in the East Same day corridor in front of the Ship Ladder Mechanical Room.

During an interview on 1-18-17 at 12:39 pm, Maintenance Staff A confirmed the 50 gallon trash receptacle's location and stated that their department did not purchase it.

NFPA Standard:
2012 NFPA 101, 18/19.7.5.7
Soiled linen or trash collection receptacles shall not exceed 32 gallons in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons shall not be exceeded within any 64 square feet area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gallons shall be located in a room protected as a hazardous area when not attended.
Containers used solely for recycling are permitted to be excluded from the above requirements where each container is less than or equal to 96 gallons unless attended, and containers for combustibles are labeled and listed as meeting FM Approval Standard 6921 or equivalent.

Based on observation and interview, the facility allowed the use of portable electric space heaters and failed to provide documentation the heating element of the device did not exceed 212 degrees Fahrenheit. This deficient practice increased the potential of a fire throughout the facility. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 between 2:29 am and 3:20 pm revealed:
1. A portable space heater was located in the Care Management office.
2. A portable space heater was located in the Transcription office.
3. A portable space heater was located in the Materials Management office.

During an interview on 1-18-17 between 2:29 am and 3:20 pm, Maintenance Staff A stated that they unaware that the space heaters were in the rooms and stated the facility did not have the manufactures specification for the heaters and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit.

NFPA Standard:
2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on observation and interview, the facility failed to provide a remote manual stop switch for the Level 1 emergency generator in a location outside the area of the generator. The deficient practice could delay shutdown of the generator during a malfunction which could cause damage to the generator resulting in loss of emergency power. Facility census was 19 patients.

Findings are:
Observation on 1-19-17 at 12:45 pm revealed, the facility failed to provide remote manual shutdown switch for the emergency generator.

During an interview on 1-19-17 at 12:45 pm, Maintenance Staff A confirmed the lack of a remote stop for the generator.

NFPA Standard:
2010 NFPA 110, 5.6.5.6*
All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

2010 NFPA 110, 5.6.5.6.1
The remote manual stop station shall be labeled.

Based on record review and interview, the facility failed to conduct retention tests on non-hospital grade receptacles at patient bed locations or where anesthesia was administered. The facility failed to provide testing documentation for the line isolation monitor "LIM". These deficient practices have the potential to affect how equipment operates which could result in an electrical fire and harm to the patient. The facility census was 19 patients.

Findings are:
Documentation review on 1-19-17 at 2:48 pm revealed,
1. No retention testing had been conducted on the non-hospital grade receptacles at patient care areas.
2. The facility only provided documentation for two months of the past year for the testing of the LIM ' s in the OR ' s.

During an interview on 1-19-17 at 2:48 pm, Maintenance Staff A confirmed the lack of documentation for LIM testing and stated that they were unaware of the retention testing requirements.

NFPA Standard:
2012 NFPA 99
6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.

Based on observation and interview, the facility failed to provide a separate Life Safety Branch, Critical Branch and Equipment Branch for the Type I essential electrical system. The deficient practice could cause failure of life safety or critical equipment caused by malfunction of a non critical or non life safety circuit. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 between 10:20 am and 4:30 pm revealed:
The electrical panel boxes throughout the facility had Critical Branch circuits, Life Safety Branch circuits and Equipment Branch circuits intermixed within the panels throughout the facility.
1. Panel box E, which the facility identified as Equipment Branch contained: circuit 2- Exit Emergency Combo Lt, circuit 3-emergency Lt, circuit 6-Em Lts, circuit 28-exit signs which are required to be on the Life Safety Branch.
2. Panel box E, which the facility identified as Equipment Branch contained: circuits 14, 16, 20 ,22-OR1 and OR2 isolation panel, circuit 29-medical refrig, which are required to be on the Critical Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
3. Panel box H, which the facility failed to identify as to what branch the circuits were fed from contained: circuit 7- north stairs, exit, emergency lt, circuit 37- door opener, which are required to be on the Life Safety Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
4. Panel box EE6, which facility the identified as Equipment Branch contained: circuit 39-aut5o door opener, circuit 40 auto door opener, if these doors are in the path of egress they are required to be on the Life Safety Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
5. Panel box EDE-Sec 2, which the facility failed to identify as to what branch the circuits were fed from and contained: circuit 8-front door, circuit 10-front door, if these doors are in the path of egress they are required to be on the Life Safety Branch.
6. Panel box EDE-Sec 2, which the facility failed to identify as to what branch the circuits were fed from and contained: circuit 18- med refrig, which is required to be on the Critical Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
7. Panel box EE7, which the facility identified as Equipment Branch contained: circuit 34-med gas panels, which is required to be on the Critical Branch.
8. Panel box A6, which the facility identified as Normal Power contained: circuit 38- crash cart power, which is required to be on the Critical Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
9. Panel box EC3, which the facility identified as Critical Branch, contained circuits within the panel that failed to be identified to what the functions were and could be required to be relocated.
10. Panel box EL, which the facility failed to identify as to what branch the circuits were fed from and contained: circuit 8-fire alarm panel, circuit 27-FA second floor, circuit 28- FA 1st floor, circuit 29-FA smoke dampers. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
11. Panel box EC SEC 2, which the facility identified as Critical Branch contained: circuit 47- door motor, circuit 49-door motor, auto door same day surgery, circuit 52-door control, which are required to be on the Life Safety Branch which facility failed to identify as egress doors. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
12. Panel box EC Sec 1, which the facility identified as Critical Branch, contained circuits within the panel that failed to be identified to what the functions were and could be required to be relocated.
13. Panel box Equipment Panel Schedule EE, which the facility identified as Equipment Branch contained: circuit 40- dampers, circuit 42-med gas alarm, circuit 50-damper OR 9, these items are required to be on the Life Safety Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
14. Panel box L1, which the facility identified as Normal Power contained: circuit 7-blanket warmer recp (2), circuit 24-crash cart, these items are required to be on the Critical Branch. Circuit 16- emergency ltg, which is required to be on the Life Safety Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
15. Panel box ECR, which the facility identified as Critical Branch contained: circuit 2-MED gas alarm, circuit 18-emerg lighting, circuit 20-emerg lighting, circuit 25-dampers, which are required to be on the Life Safety Branch. Other circuits within the panel failed to be identified to what the functions were and could be required to be relocated.
16. Panel box EC2 fed from EC1, which the facility identified as Critical Branch contained: circuit 5- Med Gas Alarm, which is required to be on the Life Safety Branch.
17. Panel box L2, contained circuits within the panel that failed to be identified to what the functions were and could be required to be relocated.
18. Facility provided 20 transfer switches; some of them did not operate equipment that served the hospital. The facility failed to confirm what branch each transfer switch was fed from.
During an interview on 1-18-17 between 10:20 am and 4:30 pm, Maintenance Staff A confirmed that the electrical panels throughout the facility had items intermixed in the panels and failed to confirm the identification of circuits to their function.

NFPA Standard:
NFPA 99 2012 6.4.2.2.3 Life Safety Branch.
6.4.2.2.3.1 The life safety branch shall be limited to circuits essential to life safety.
6.4.2.2.3.2 The life safety branch shall supply power for lighting, receptacles, and equipment as follows:
(1) Illumination of means of egress in accordance with NFPA 101, Life Safety Code
(2) Exit signs and exit directional signs in accordance with NFPA 101, Life Safety Code
(3)*Hospital communications systems, where used for issuing instruction during emergency conditions
(4) Generator set location as follows:
(a) Task illumination
(b) Battery charger for emergency battery-powered lighting unit(s)
(c) Select receptacles at the generator set location and essential electrical system transfer switch locations
(5) Elevator cab lighting, control, communications, and signal systems
(6) Electrically powered doors used for building egress
(7) Fire alarms and auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm and Signaling Code
6.4.2.2.3.3 Alarm and alerting systems (other than fire alarm systems) shall be connected to the life safety branch or critical branch.
6.4.2.2.3.4 Loads dedicated to a specific generator, including the fuel transfer pump(s), ventilation fans, electrically operated louvers, controls, cooling system, and other generator accessories essential for generator operation, shall be connected to the life safety branch or the output terminals of the generator with overcurrent protective devices.
6.4.2.2.3.5
No functions other than those in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.4.2.2.3.
6.4.2.2.4* Critical Branch.
6.4.2.2.4.1 The critical branch shall be permitted to be subdivided into two or more branches.
6.4.2.2.4.2 The critical branch shall supply power for task illumination, fixed equipment, select receptacles, and select power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases, task illumination, select receptacles, and fixed equipment
(2) Isolated power systems in special environments
(3) Task illumination and select receptacles in the following:
(a) Patient care rooms, including infant nurseries, selected acute nursing areas, psychiatric bed areas (omit receptacles), and ward treatment rooms
(b) Medication preparation areas
(c) Pharmacy dispensing areas
(d) 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, select receptacles, and select power circuits for the following areas:
(a) General care beds with at least one duplex receptacle per patient bedroom, and task illumination as required by the governing body of the health care facility
(b) Angiographic labs
(c) Cardiac catheterization labs
(d) Coronary care units
(e) Hemodialysis rooms or areas
(f) Emergency room treatment areas (select)
(g) Human physiology labs
(h) Intensive care units
(i) Postoperative recovery rooms (select)
(9) Additional task illumination, receptacles, and select power circuits needed for effective facility operation, including single-phase fractional horsepower motors, which are permitted to be connected to the critical branch

6.4.2.2.5 Equipment Branch.
6.4.2.2.5.1 General. The equipment branch shall be connected to equipment described in 6.4.2.2.5.3 through 6.4.2.2.5.4.
6.4.2.2.5.2 Connection to Alternate Power Source.
(A) The equipment branch shall be installed and connected to the alternate power source, such that equipment described in 6.4.2.2.5.3 is automatically restored to operation at appropriate time-lag intervals following the energizing of the life safety and critical branches.
(B) The arrangement of the connection to the alternate power source shall also provide for the subsequent connection of equipment described in 6.4.2.2.5.4.
6.4.2.2.5.3* Equipment for Delayed-Automatic Connection.
(A) The following equipment shall be permitted to be arranged for delayed-automatic connection to the alternate power source:
(1) Central suction systems serving medical and surgical functions, including controls, with such suction systems permitted to be placed 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, with such air systems permitted to be placed on the critical branch
(4) Smoke control and stair pressurization systems
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood
(6) Supply, return, and exhaust ventilating systems for the following:
(a) Airborne infectious/isolation rooms
(b) Protective environment rooms
(c) Exhaust fans for laboratory fume hoods
(d) Nuclear medicine areas where radioactive material is used
(e) Ethylene oxide evacuation
(f) Anesthetic evacuation
(B) Where delayed-automatic connection is not appropriate, the ventilation systems specified in 6.4.2.2.5.3(A)(6) shall be permitted to be placed on the critical branch.
6.4.2.2.5.4* Equipment for Delayed-Automatic or Manual Connection.
The following equipment shall be permitted to be arranged for either delayed-automatic or manual connection to the alternate power source (also see A.6.4.2.2.5.3):
(1) Heating equipment used 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 maintenance (jockey or make-up) pump(s) for water-based fire protection systems
(2)*Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) Outside design temperature is higher than -6.7°C
(+20°F) (b) Outside design temperature is lower than -6.7°C (+20°F), where a selected room(s) is provided for the needs of all confined patients [then only such room(s) need be heated].
(3) Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power
(4) Supply, return, and exhaust ventilating systems for surgical and obstetrical delivery suites, intensive care, coronary care, nurseries, and emergency treatment spaces
(5) Hyperbaric facilities
(6) Hypobaric facilities
(7) Autoclaving equipment, which is permitted to be arranged for either automatic or manual connection to the alternate source
(8) Controls for equipment listed in 6.4.2.2.4
(9)*Other selected equipment

6.4.2.2.6 Wiring Requirements.
6.4.2.2.6.1* Separation from Other Circuits.
The life safety branch and critical branch shall be kept independent of all other wiring and equipment.

Based on documentation review and interview, the facility failed to conduct all required inspections of the emergency generator in accordance with the National Fire Protection Association (NFPA), 110. The facility failed to document time to transfer from normal to emergency power, and failed to run the generator at the required 30 percent load. These deficient practices increased the potential that the generator would fail to run during loss of power. Facility census was 19 patients.

Findings are:
Documentation review on 1-19-16 at 12:46 pm of the provided emergency generator maintenance log revealed, the documentation failed to exhibit the following required information for weekly/monthly testing in accordance with NFPA 110:

1. The lubrication system failed to be inspected weekly.
2. The exhaust system failed to be inspected weekly.
3. The electrical system failed to be inspected weekly.
4. The belts and hoses failed to be inspected weekly.
5. The battery failed to be inspected weekly.
6. The oil level failed to be inspected weekly.
7. Documentation that the generator picked up the emergency system load within 10 seconds after loss of normal power failed to be recorded monthly.
8. Failed to run generator to the required 30 percent for 3 of 12 months and record cool down period.
.

During an interview on 1-19-17 at 12:46 pm, Maintenance Staff A confirmed that the generator testing documentation failed to provide all required information.

NFPA Standard:
2010 NFPA 110, 8.4.2*
Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating

Based on observation and interview the facility failed to provide covers for electrical junction boxes and allowed electrical cords to be run under door openings. These deficient practices would allow an electrical fire to spread outside of the junction box and cause the electrical cord to be damaged increasing the potential for an electrical fire. The facility census was 19 patients.

Findings are:
Based on observation on 1-18-17 between 10:59 am to 2:20 pm revealed:
1. The electrical cord for an IV pump in Patient Room 302 was run under the cabinet door.
2. The electrical cord for a Vitals Machine in Patient Room 309 was run under the cabinet door.
3. The electrical junction box on the north wall in main floor Mechanical Room did not have a cover installed.

During an interview on 1-18-17 between 10:59 am to 2:20 pm, Maintenance Staff A confirmed the electrical cords were ran through a door opening and that there was a cover missing for a junction box.

NFPA Standard:
2011 NFPA 70, 400.8
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, 314.28
Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E).
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Based on observation and interview, the facility failed to prohibit power taps to be plugged into each other or " piggybacked " . This deficient practice would increase the potential for an electrical fire. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 3:34 pm revealed, power taps in the Materials Management Office piggy backed to each other.

During an interview on 1-18-17 at 3:34 pm, Maintenance Staff A confirmed multiple power taps plugged into each other.

UL Standard:
Relocatable power taps are not intended to be piggybacked or daisy chained. UL 1363 User Guide for Relocatable Power Taps

Based on observation and interview, the facility failed to segregate full oxygen cylinders from empty ones, and failed to provide labels identifying whether the oxygen cylinders were full or empty. This deficient practice occurred in the Oxygen Storage Room which increased the potential that staff would inadvertently choose an empty oxygen cylinder in an emergency when a full one was needed. The facility census was 19 patients.

Findings are:
Observations on 1-18-17 at 11:51 am revealed, 14 full oxygen cylinders and 1 empty stored in the same rack in Oxygen Storage room and no signage to indicate which tanks were full or empty.

During an interview on 1-18-17 at 11:51 am, Maintenance Staff A confirmed that an empty oxygen cylinder was intermixed and full cylinders and no signage was provided.

NFPA Standard:
2012 NFPA 99, 11.6.5.1
Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.