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. NFPA;101, 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 Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that the facility had not performed the required inspection of all the doors along the means of egress to ascertain their level of functionality as required by the code.

Signs

All fire walls, fire barriers, fire partitions, smoke barriers, and smoke partitions shall be effectively and permanently identified with signs or stenciling per IBC 2012 section 703.7.

Based on observation the facility failed to provide adequate signs on the separation walls.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that there were no 2-hour wall stenciled on the separation wall between the hospital and the Nursing home.

Final filters and Frames:

Final filters and filter frames should be visually inspected for pressure drop and for bypass monthly. Filters should be replaced based on pressure drop or maintenance schedule with filters that provide the efficiencies specified. (ASHRAE 170, Informative Appendix A, Operations and Maintenance Procedures.) A log of filter replacements should be maintained for each air handler.

Based on observation the facility failed to provide adequate monthly pressure drop records.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that there was no record of the monthly pressure drops across the filters in the air handling units.

Based on observation the facility failed to provide risk assessment per NFPA 99,2012.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that risk analyses for the essential electrical system and the medical gas system that complies with NFPA 99, 2012 had not been performed.

Cross referencing FACP:

"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.

Based on observation the facility failed to provide adequate cross referencing of the FACP to the panel and breaker supplying power to the FACP.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that the location of the dedicated branch circuit for disconnecting the FACP was not identified at the control unit.

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 failed to provide proper circuits on the essential electrical system.


The inspector observed, while accompanied by the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that there were:
1. There were unknown circuit breakers in the critical panel. Breaker #7 was labelled Map 1, Map 2. Breaker #9 was labelled
AAP 1and AAP 2. Verify what these circuits are and move to the correct branch if need be.
2. Nurse call system was not connected to the critical branch.
3. FACP circuit was connected to the critical panel. Move the FACP to Life Safety panel.
4. No patient care area receptacles were shown or connected to critical panel. Verify and make corrections.

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 Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that the critical and life safety panel were not populated correctly.

Based on observation the facility failed to provide:

1. Evidence of adequate receptacles test in all the patient care areas.
2. Record of electrical maintenance and required tests performed.

The inspector observed, while accompanied by the Chief Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that there were the following issues:

1. there were no records of testing data and test interval of the patient care area receptacles as defined by Documented
Performance Data.
2. no records of where, type of repair performed and date of electrical maintenance and required tests performed in all the patient care
areas.

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 Executive Officer (CEO), Chief Nursing Officer (CNO) and Director of Plant Operations during the hours of the inspection from 9:15 am to 12:15 pm on 4/04/2019 that there were:

1. The 36 months' load testing had not been done and there was no contract in place to ensure future routine 36 months' load testing
of the generator set is scheduled to be performed.
2. The monthly load test was not being done correctly. The generator switch over time was on a 10 second timer instead of on
automatic.
3. There was no record of the main and feeder circuit breakers being inspected annually.