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NFPA 101, 7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the
direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation, the facility failed to ensure that all exit signs were properly located and correctly indicated the true direction of egress.

Findings include:

On 10/5/13 at 12:20 PM, it was observed that one door in Building F had exit signage installed on both sides of this same door, presenting opposing directions of egress. On one side of the door was an enclosed courtyard, on the other side of the door was a corridor between Buildings G and E. Directly across from the aforementioned door was another door with an exit sign directing occupants to a public way.

Note: On 10/6/13 during the afternoon, one of the two exit signs over the door between the courtyard and the corridor had been removed, and the remaining sign directed building occupants to a true exit.

NFPA 101, 7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the
direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation, the facility failed to ensure that all exit signs were provided with directional indicators.

Findings include:

On 10/5/13 at 3:05 PM, an exit sign was observed to be tacked to a wall near room number B 171. This sign was not provided with a directional arrow. The true path of egress was to the left of the sign ( No arrow suggested that egress was directly ahead).

NFPA 13 (1996 ed.) 4-5.5 Obstructions to Sprinkler Discharge. 4-5.5.2 Obstructions to Sprinkler Discharge Pattern Development. 4-5.5.2.1 Continuous or noncontinuous obstructions less than 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with this section.

Based on observation the facility failed to insure that there were no obstructions 18 in. or less below the sprinkler deflector.

Findings include:

Observed on 10/5/13 at 3:00 PM, were suspended light fixtures hung below sprinkler heads with a clearance of ten inches or less. The rooms in which sprinkler patterns could have been affected were: B173, B178, B179, B169, B168, B167, B168b, B187, B164, B163.

Based on observation, the facility failed to ensure that smokers utilized only ashtrays of safe design.

Findings include:

On 11/5/13 at 3:40 PM, it was observed that in the designated staff smoking area, between Buildings D and B, there was a picnic table with an open, ten-inch diameter, metal bowl with a rock in the center of it to hold it down. The bowl was being used as an ashtray. Remnants of cigarettes were not protected from being blown out of the bowl by the wind.

On 11/7/13 at 7:00 AM, it was observed that in the visitor smoking area, north of the main entrance, there was a similar metal bowl located on top of a picnic table. This area was covered by a small canopy which provided little protection from the wind.

Based on staff interview the facility failed to ensure that it had developed written policies and procedures for emergencies specific to the laboratory.

Findings include:

On 10/5/13 at 9:30 AM, the Director of Laboratory and Infection Control staff member indicated that there was no written policies and procedures for handling laboratory emergencies.

NFPA 110, 8.4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating...

8.4.2.3* Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Based on record review, the facility failed to ensure that the required, annual load bank test met the requirements of the Code.

Findings include:

On 10/6/13, during a review of maintenance documents, it was revealed that the emergency generator was not being properly tested. The Rawson Neal building receives emergency power from an on-site, 1800 kilowatt (kW), diesel generator. A private vendor performed a load bank test on 5/29/13, for one hour and forty-five minutes at 16.9-20.1% of the nameplate rating. On 6/3/13, the same vendor tested the equipment for one hour and forty-five minutes at 30.5% of the nameplate rating.

NFPA 70, ARTICLE 408 Switchboards and Panelboards, 408.38 Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.

NFPA 70, 408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

Based on observation, the facility failed to ensure that open spaces in an electrical panel box were properly covered.

Findings include:

On 11/6/13 at 9:30 AM, it was observed that one electrical panel box (Panel L1) had open space from slot #32 through slot #40.

Based on staff interview the facility failed to ensure that it had developed written policies and procedures for emergencies specific to the laboratory.

Findings include:

On 10/5/13 at 9:30 AM, the Director of Laboratory and Infection Control staff member indicated that there was no written policies and procedures for handling laboratory emergencies.