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Based on observation the facility failed to keep the fire door to the generator room closed.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 8:00 am to 9:45 am on 7/24/2012 that the fire doors going into the generator room had the closers removed and the doors were propped open. The doors must be self-closing. If the facility requires the doors to be open, they must be placed on hold opens that will release with activation of the fire alarm.

The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 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, 1999, 3-4.3.1

Based on observation the facility failed to properly maintain the emergency power system.

The inspector observed, while reviewing the generator documentation, with the Manager of Facility Services, the Chief Operating Officer, and the Manager Plant Operation during the hours of the inspection from 8:00 am to 9:45 am on 7/24/2012 that the following sequence of events had occurred.

1) On 6/12/2012 the monthly load test showed that the power from the generator was not transferring within the time period specified by the Code.

2) On 7/10/2012, the next monthly load test, the problem was still present.

3) On 7/13/2012 a Contractor was called to evaluate the problem. The Service Order showed that there was a bad AVR, automatic voltage regulator, and a new AVR was ordered.

4) On 7/15/2012, between approximately 5:15 and 7:00 pm the power from the electric utility failed, and the hospital had no emergency power because the AVR had completely failed.

5) On 7/16/2012 the AVR was replaced. The emergency power system was then tested and found to be in good working order.

Based on observation the facility failed to keep the fire door to the generator room closed.

The inspector observed, while accompanied by the Plant Manager during the hours of the inspection from 8:00 am to 9:45 am on 7/24/2012 that the fire doors going into the generator room had the closers removed and the doors were propped open. The doors must be self-closing. If the facility requires the doors to be open, they must be placed on hold opens that will release with activation of the fire alarm.

The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 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, 1999, 3-4.3.1

Based on observation the facility failed to properly maintain the emergency power system.

The inspector observed, while reviewing the generator documentation, with the Manager of Facility Services, the Chief Operating Officer, and the Manager Plant Operation during the hours of the inspection from 8:00 am to 9:45 am on 7/24/2012 that the following sequence of events had occurred.

1) On 6/12/2012 the monthly load test showed that the power from the generator was not transferring within the time period specified by the Code.

2) On 7/10/2012, the next monthly load test, the problem was still present.

3) On 7/13/2012 a Contractor was called to evaluate the problem. The Service Order showed that there was a bad AVR, automatic voltage regulator, and a new AVR was ordered.

4) On 7/15/2012, between approximately 5:15 and 7:00 pm the power from the electric utility failed, and the hospital had no emergency power because the AVR had completely failed.

5) On 7/16/2012 the AVR was replaced. The emergency power system was then tested and found to be in good working order.