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Based on observation it was determined the facility failed to have smoke resistant Dutch doors and corridor doors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.6, "Dutch doors shall be permitted where they conform to 18.3.6.3 or 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.''

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.''

Findings Include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed corridor Dutch doors, and the following corridor doors that are not smoke tight:

1. Pharmacy, Dutch door not smoke tight.
2. Occupational Medical door, closing device disconnected.
3. Double doors by wound care, gap greater than 1/8 inch, no astragal.
4. Vending machine room, door tested three of three times, would not positively latch.
5. Double doors to vending machine room, one of two leaves will not positively latch after testing three of three times.
6. Clean utility room door will not close, impeded by an ice machine.
7. Room 105, door tested three of three times, will not positively latch.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed the following hazardous area doors:

1. Main mechanical room rated door missing one of three hinges.
2. Purchasing/storage door closing device disconnected.
3. Copier room door removed, room contains a shredder greater than thirty two gallons and storage of combustibles.
4. Central Supply door tested three of three times; will not positively latch.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation and staff interview it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3...Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width." Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed storage of a computer, plugged into an outlet; an EKG machine; a large blue cart; a gurney; two wheel chairs; two med carts; a tray; a scale; and a chair, within the exit corridor blocking two of two exit access. The storage was blocking the exit access located in the ER.

Staff members were interviewed as to the length of time the equipment has been stored. The answer equaled approximately six hours. Staff members were asked what they would do with the equipment when the Fire Alarm went off ? Staff stated "Nothing".

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on record review it was determined the facility failed to document the Monthly and Annual testing of battery back up emergency lighting units in the facility.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the facility's documentation of Monthly and Annual testing of the emergency lights. The facility did not have documentation of annual 1 1/2 hour testing for the year of 2014. The facility only had documentation of monthly testing for June 2014 and January, February, March and April of 2015.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to test and maintain emergency lighting units will cause harm to the patients.

Based on record review it was determined the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the facility's fire drill records. The surveyor noted there were no Fire Drill reports for the periods from first; second; and forth quarters first shift of 2014. There were no Fire Drill reports for first quarter, first shift of 2015.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation and document review it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

NFPA 13 Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the facility's fire sprinkle reports which indicated the November 2014 quarterly automatic sprinkler system was not inspected or tested. The facility has no documentation of the fire riser being inspected and the backflow preventer does not have an electronic tamper device. The kitchen freezer sprinkler head does not have 18" separation from supplies stored in the freezer.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on observation, it was determined the facility failed to provide the flame spread rating of the paper and other holiday directions covering the corridor door.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.7.5.4, "Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed the wound care/ activities office door completely wrapped in combustible paper, and other holiday directions. The facilities has no documentation of flame-retardant used on the decorations.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to maintain decorations in exit corridors could contribute to fire spread and cause harm to the patients.

Based on observation it was determined the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage room.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed the wall mounted electric light switch in the oxygen storage room. The switch was less than 60 inches above the floor. A tap measure was not available.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on record review and observation it was determined the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year...Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the generator test records. The facility has one legible monthly load transfer on January 2015 with a transfer time of eight seconds. No other documentation was available from July of 2013 monthly load transfers seconds (10 seconds or less) from normal power to emergency power.
The facility did not have any weekly maintenance documentation for the last fifty two weeks to include load bank test.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, and the facility failed to provide a guard on light bulbs.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities" 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms; Medical Unit Managers office, and the Clean Utility break room.
The mechanical room has two of two light bulbs with no cover.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard.

A fire could cause harm to the patients.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.

Based on observation it was determined the facility failed to have smoke resistant Dutch doors and corridor doors.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.6.3.6, "Dutch doors shall be permitted where they conform to 18.3.6.3 or 19.3.6.3. In addition, both the upper leaf and lower leaf shall be equipped with a latching device and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel. Dutch doors protecting openings in enclosures around hazardous areas shall comply with NFPA 80, Standard for Fire Doors and Fire Windows.''

NFPA 101 Life Safety Code 2000, Chapter 19, 19.3.6.3.1 " Doors protecting corridor openings in other than required enclosures of vertical openings, exit, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 in. thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke.''

Findings Include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed corridor Dutch doors, and the following corridor doors that are not smoke tight:

1. Pharmacy, Dutch door not smoke tight.
2. Occupational Medical door, closing device disconnected.
3. Double doors by wound care, gap greater than 1/8 inch, no astragal.
4. Vending machine room, door tested three of three times, would not positively latch.
5. Double doors to vending machine room, one of two leaves will not positively latch after testing three of three times.
6. Clean utility room door will not close, impeded by an ice machine.
7. Room 105, door tested three of three times, will not positively latch.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

The facility failed to protect patients from heat and smoke.

Based on observation it was determined the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.3.2.1 requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed the following hazardous area doors:

1. Main mechanical room rated door missing one of three hinges.
2. Purchasing/storage door closing device disconnected.
3. Copier room door removed, room contains a shredder greater than thirty two gallons and storage of combustibles.
4. Central Supply door tested three of three times; will not positively latch.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to prevent heat and smoke from spreading into the exit corridor will cause harm to patients.

Based on observation and staff interview it was determined the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 19 Section 19.2.1, and Section 19.2.3.3. Section 18.2.1 "Every aisle, passageway, corridor, exit discharge, exit location and access shall be in accordance with Chapter 7. Section 18.2.3.3...Aisles, corridors and ramps required for exit access in a hospital or nursing home shall be not less than 8 ft (Existing built to 8 feet must be maintained 8 feet clear) in clear and unobstructed width." Chapter 7 Section 7.5.1.1" Exits shall be so located and exit access shall be arranged so that exits are readily accessible at all times." Section 7.5.1.2 "Where exits are not immediately accessible from an open floor area, continuous passageways, aisles, or corridors leading directly to every exit and shall be maintained and shall be arranged to provide access for each occupant to not less than two exits by separate ways of travel."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed storage of a computer, plugged into an outlet; an EKG machine; a large blue cart; a gurney; two wheel chairs; two med carts; a tray; a scale; and a chair, within the exit corridor blocking two of two exit access. The storage was blocking the exit access located in the ER.

Staff members were interviewed as to the length of time the equipment has been stored. The answer equaled approximately six hours. Staff members were asked what they would do with the equipment when the Fire Alarm went off ? Staff stated "Nothing".

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to keep the exit corridors and exit access clear could hinder the evacuation during an emergency and will cause harm to patients.

Based on record review it was determined the facility failed to document the Monthly and Annual testing of battery back up emergency lighting units in the facility.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.2.9.1, "Emergency lighting shall be provided in accordance with Section 7.9". Section 7.9.3 " Periodic Testing of Emergency Lighting Equipment" " A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the facility's documentation of Monthly and Annual testing of the emergency lights. The facility did not have documentation of annual 1 1/2 hour testing for the year of 2014. The facility only had documentation of monthly testing for June 2014 and January, February, March and April of 2015.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to test and maintain emergency lighting units will cause harm to the patients.

Based on record review it was determined the facility failed to conduct the required fire drills.

NFPA 101, Life Safety Code, 2000, Chapter 19, Section 19.7.1.2 "Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the facility's fire drill records. The surveyor noted there were no Fire Drill reports for the periods from first; second; and forth quarters first shift of 2014. There were no Fire Drill reports for first quarter, first shift of 2015.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to train and drill the staff on fire procedures could result in harm to the patients.

Based on observation and document review it was determined the facility did not inspect, test and maintain the automatic sprinkler system in accordance with the requirements of the Life Safety Code.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.3.5.1. "Buildings containing health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7." Section 9.7.5 "All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing , and Maintenance of Water-Based Fire Protection Systems." NFPA 25, Water Based Extinguishment Systems, requires monthly, quarterly and annual testing of automatic sprinkler systems.

NFPA 13 Chapter 5, Section 5-8.5.1.1, "Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the facility's fire sprinkle reports which indicated the November 2014 quarterly automatic sprinkler system was not inspected or tested. The facility has no documentation of the fire riser being inspected and the backflow preventer does not have an electronic tamper device. The kitchen freezer sprinkler head does not have 18" separation from supplies stored in the freezer.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to inspect, test, and maintain the sprinkler system could result in harm to the patients through the spread of smoke and fire.

Installing obstructions next to the sprinkler head may prevent it from providing adequate coverage of the hazard. This may cause harm to the patients.

Based on observation, it was determined the facility failed to provide the flame spread rating of the paper and other holiday directions covering the corridor door.

NFPA 101 Life Safety Code 2000, Chapter 19, Section 19.7.5.4, "Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed the wound care/ activities office door completely wrapped in combustible paper, and other holiday directions. The facilities has no documentation of flame-retardant used on the decorations.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to maintain decorations in exit corridors could contribute to fire spread and cause harm to the patients.

Based on observation it was determined the facility failed to mount an electrical light switch five feet above the floor in the oxygen storage room.

NFPA 101 Life Safety Code, Chapter 19, Section 19.3.2.4 " Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 Chapter 8, Storage Requirements, Section 8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2 (a) 11d. Section 4-3.1.1.2 (a) 11(d) Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft. (1.5m) above the floor to avoid physical damage."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed the wall mounted electric light switch in the oxygen storage room. The switch was less than 60 inches above the floor. A tap measure was not available.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failing to mount a light switch five feet above the floor to prevent an accident/or possible fire could cause harm to the patients.

Based on record review and observation it was determined the facility failed to document the required testing of the emergency generator.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year...Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 6-4.1 "Level 1 and Level 2 EPSSs, including all appurtenant components shall be inspected weekly and shall be exercised under load at least monthly. NFPA 110, Chapter 6, Section 6-4.2 "Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes...Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, reviewed the generator test records. The facility has one legible monthly load transfer on January 2015 with a transfer time of eight seconds. No other documentation was available from July of 2013 monthly load transfers seconds (10 seconds or less) from normal power to emergency power.
The facility did not have any weekly maintenance documentation for the last fifty two weeks to include load bank test.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

Failure to test the emergency generator under load, inspect weekly, and document time from normal power to emergency power could result in harm to patients during lighting system failures.

Based on observation it was determined the facility allowed the use of a multiple outlet adapter, power strips and did not use the wall outlet receptacles for appliances, and the facility failed to provide a guard on light bulbs.

NFPA 101, Life Safety Code, 2000, Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities" 1999 Edition. NFPA 99, Chapter 3, Section 3-3.2.1.2, "All Patient Care Areas," Section 3-3.2.1.2 (d) Receptacles (2)" Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 101 Life Safety Code, 2000, Chapter 19, Section 19.5.1, "Utilities shall comply with the provisions of Section 9.1, Section 9.1.2, "Electrical wiring and equipment installed shall be in accordance with NFPA 70 National Electrical Code." NEC, 1999, Article 110, Section 110-27 (b) Prevent Physical Damage. " In locations where electric equipment is likely to be exposed to physical damage, enclosures or guards shall be so arranged and of such strength as to prevent such damage."

Findings include:

On May 18, 2015 the surveyor, accompanied by the Chief Executive Officer and the Director of Maintenance, observed refrigerators and microwaves plugged into multi-outlet power strips and not directly plugged in to the wall outlet receptacles in the following rooms; Medical Unit Managers office, and the Clean Utility break room.
The mechanical room has two of two light bulbs with no cover.

During the exit conference on May 18, 2015, the above findings were again acknowledged by the Chief Executive Officer and the Director of Maintenance.

The use of multiple outlet adapters could create an overload of the electrical system and could cause a fire or an electrical hazard.

A fire could cause harm to the patients.

Failure to keep light guards on the light bulbs could cause accidental damage or possibly a fire, which could cause harm to the patients.