HospitalInspections.org

Door Inspections:

Fire-rated door assemblies and certain other doors in the means of egress shall be tested annually or per an accepted performance-based evaluation schedule approved by the AHJ per NFPA 80, 2010, Ch. 5.2. A written record of the inspections and testing shall be signed and kept for inspection by the AHJ. NFPA101, 7.2.1.15.

Based on observation the facility failed to maintain properly all the doors along the means of egress.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that based on the inspection record of all the doors along the means of egress only 4% of the doors met the required standard of functionality as required by the code. Please, expedited repairs on the remaining 96% of the doors as soon as possible to bring them up to code.

Signage (System Identification and Labeling):

Containers, cylinders and tanks are designed, fabricated, tested, and marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations containing only oxygen or medical air have doors labeled with "Medical Gases, NO Smoking or Open Flame". Locations containing other gases have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Opening." 5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

Based on observation the facility failed to provide adequate signage at medical gas room.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that the signage at entrance to medical gas room was inadequate as it had no warning that the room may have insufficient oxygen.


Medical Gas Piping Labels:

"Pipe labels shall be located as follows: (1) at intervals of not more than 20 ft., (2) at least once in or above every room, (3) on both sides of walls or partitions penetrated by the piping, and (4) at least once in every story height traversed by risers." - NFPA 99, 2012, 5.1.11.1.2.

Based on observation the facility failed to provide adequate labeling of medical gas piping.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that the medical gas piping above in the mechanical room had no labels.


Mechanical Ventilation:

9.3.7.5.3.1? Mechanical exhaust to maintain a negative pressure in the space shall be provided continuously, unless an alternative design is approved by the authority having jurisdiction.
9.3.7.5.3.2? Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm).
9.3.7.5.3.3? Mechanical exhaust inlets shall be unobstructed and shall draw air from within 300 mm (1 ft) of the floor and adjacent to the cylinder or containers.
9.3.7.5.3.4? Mechanical exhaust air fans shall be supplied with electrical power from the essential electrical system.
9.3.7.5.3.5? Dedicated exhaust systems shall not be required, provided that the system does not connect to spaces that contain combustible or flammable materials.

Based on observation the facility failed to provide adequate mechanical ventilation.in the medical gas storage room.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that there was one mechanical exhaust in-let in the mid-section of the wall and it was out of service. The mechanical exhaust in-lets shall be located 1-ft off the floor.

FACP Marking:

"The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit." - NFPA 72, 2010, 10.5.5.2.1.

"For fire alarm systems the circuit disconnecting means shall have a red marking." - NFPA 72, 2010, 10.5.5.2.3.

Based on observation the facility failed to provide adequate marking on the breaker supplying power to the FACP.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that the breaker supplying power to the FACP was not colored red.


Critical Area Number Receptacles & Labeling:

There is also a state regulation for permanent labels on critical receptacles in critical areas.

"Critical care Areas, Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more form the emergency system and one or more circuits from the normal system. At least on Branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supply them." NFPA 70, 2011, 517.19(A)

"Patient Bed Location Receptacles. Minimum Number and Supply. Each patient bed location shall be provided with a minimum of six receptacles, at least one of which shall be connected to either of the following: (1) The normal system branch circuit required in 517.19(A), (2) An emergency system circuit supplied by a different transfer switch than the other receptacles at the same patient bed location." NFPA 70, 2011, 517.19(B)(1)

Based on observation the facility failed to provide adequate critical area receptacle and labeling

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that across all the patient care areas that it was difficult to differentiate critical receptacle from normal receptacles.



Essential Electrical System Segregation (Life Safety):

"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA
99, 2012, 6.4.2.2.1.1.
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 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 locations 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."


Based on observation the facility had incorrect circuits connected in the essential electrical system.


The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that there were:
1. There was no select receptacle in ATS location.



Essential Electrical System Segregation (Critical):

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 receptacles 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

Based on observation the facility had incorrect circuit connected to the essential electrical system.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that there were:

1. Nurse call system was not connected to the critical branch.

Panel directory:

"Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy." - NFPA 70, 2011, 408.4 (A) Note: Labeling includes all disconnecting means, see 110.22.

Based on observation the facility failed to provide adequate panel board directories.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that there were panels with unreadable directories, Update panels EO and other panels in the old generator location.

Based on observation the facility failed to provide all the required documentation for the essential electrical system maintenance.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that there were the following issues. They were:

1. The 36-month load bank test was not being done and there was no contract in place to ensure that future routine 36 months' load
bank test of the generator set is performed.
2. The monthly load tests were not being performed
3. The weekly inspections were not being properly performed as the record did not document all the required elements of the weekly
inspections being inspected and documented.
4. There was no record of the main and feeder circuit breakers being inspected annually.

Generator Remote Manual Stop:

"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" - NFPA 110, 2010, 5.6.5.6* Note: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified." A.5.6.5.6.

Based on observation the facility failed to provide remote emergency generator shut down button.

The inspector observed, while accompanied by the Chief Operating Officer (COO), Chief Executive Officer (CEO) and Maintenance Director during the hours of the inspection from 9:30 am to 4:00 pm on 04/02/2019 that there was no remote shutdown switch for generator. Provide easily accessible remote shutdown switch for the generator.