HospitalInspections.org

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 9/10/2014, at 9:40 a.m., there were multiple penetrations within the 2hr. barrier wall between the I-2 Occupancy (Hospital) and the B-Occupancy (Administration). Penetrations were noted above the double doors in the corridor and within the Administration area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 9/10/2014, at 9:45 a.m., there were multiple penetrations within the stairwell adjacent to the main entrance that ranged in approximate size from 1 1/2" to 3" diameter.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain minimum smoke barrier fire resistance ratings in smoke compartments throughout the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.75, 8.3). Findings include, but are not limited to:
1. On 9/10/2014, at 9:52 a.m., there were multiple penetrations in the smoke barrier wall noted within the PACU above Bed A.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:
1. On 9/10/2014, at 10:55 a.m., the door to the Dirty Utility Room within the ED Vestibule was not closing or latching completely.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 19.2.2.2.4. This resulted in the potential for panic and injury to patients and staff. Findings include, but are not limited to:
1. On 9/10/2014, at 11:10 a.m., there was a medical supplies storage cart blocking the north exit within the OR Corridor.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually. This resulted in the potential for confusion and panic by patients & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facility. Last annual 90 minute test was conducted on 12/01/2012 and was past due since 12/01/2013.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:
1. On 9/9/2014, during record review between 10:45 a.m. and 5:30 p.m., the Facility Disaster Manuals Hazard Vulnerability Assessment (HVA) was not complete. The HVA only included natural hazards and was missing human hazards, technological hazards and hazardous materials hazards. The Disaster Manual was also missing policies such as Hurricane Policy, Wildfire Policy, Landside Policy and Snow Fall Policy which were identified within the HVA Natural Hazards section.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as type of fire and simulated evacuation time of occupants.
2. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., the facility had no documentation on conducting the 4th quarter night shift fire drill for 2013. A fire drill was conducted by the surveyor at 2:59 p.m. and observed no staff activating the fire alarm pull station, clearing the corridors, the alarm immediately silenced and the overhead announcement was completed once and not repeated three times.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems. This resulted in the potential for system and device failure and delay and panic during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 9/10/2014, at 9:27 a.m., the location for the breaker for the main Fire Alarm Control Panel (FACP) was not identified on the door of the main FACP. The electrical panel housing the breaker for the FACP was not labeled in red and did not have a mechanical set screw lock on the breaker.
2. On 9/10/2014, at 9:29 a.m. there were not signs on the doors leading to the main Fire Alarm Control Panel (FACP).

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:
1. On 9/9/2014, during record review between 10:45 a.m. and 5:30 p.m., monthly maintenance/testing was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted NFPA 72 standards.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 9/10/2014, at 9:10 a.m., there was missing signage (6" "FDC" letters; white on red or red on white) on the facilities Fire Department Connection.
2. On 9/10/2014, at 9:29 a.m., there was missing signage, "Fire Sprinkler Riser Room" on the door leading to the fire sprinkler riser.

Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 9/9/2014, during record review between 10:45 a.m. and 5:30 p.m., weekly and monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire sprinklers to the adopted edition of NFPA 25 standards.
2. On 9/10/2014, at 9:58 a.m., there were approximately 6 corroded sprinkler heads located in the exterior awning at the main entrance.
3. On 9/10/2014, at 10:00 a.m., there was not a spare dry sidewall sprinkler head within the spare sprinkler cabinet.
4. On 9/10/2014, at 10:02 a.m., there were approximately 9 corroded sprinkler heads located in the exterior awning at the ED entrance.
5. On 9/10/2014, at 10:12 a.m., there was a corroded sprinkler head within the Radiology Managers Office.
6. On 9/10/2014, at 10:30 a.m., there was not a spare dry pendant sprinkler head within the spare sprinkler cabinet.
7. On 9/10/2014, at 10:32 a.m., there was a corroded sprinkler head within OPT/Rehab above the door leading to the fax machine.
8. On 9/10/2014, at 11:20 a.m., there was a cabinet that stored gloves and labels that was blocking/obstructing the pull station for the hood system within the Facility Kitchen.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor for corridors of the building. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 9/10/2014, at 10:25 a.m., there were charting stations within the patient care corridor that were not self closing when opened.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that no furnishings or decorations of highly flammable character are used, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Findings include, but are not limited to:
1. On 11/8/2012, at 11:30 a.m., there were multiple hand-made afghan's hanging on the walls within the reception/waiting area of the hospital that were not treated with flame retardant materials.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide safe storage for compressed gas for the facility. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
1. On 9/10/2014, at 10:05 a.m., there were 3 compressed gas cylinders that were not properly secured by evidence of only a single chain near the top of the cylinders that would allow the bottom of the cylinders to kick out and strike other cylinders or walls within the Med Gas farm during a seismic event.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., documentation provided to the surveyor only showed an annual test of the main part of the system and not the testing of valves and outlets as required by NFPA 99.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 9/9/2014, at 10:45 a.m. and 5:30 p.m., the humidity policy dated 08/08 that was presented to the surveyor did not have recommendations or procedures on what needed to be accomplished when the humidity was not within the adopted/specified range.

Based on record review and interviews it was determined through on-going dialog with the Director of Engineering that the facility failed to properly maintain the generator affecting the entire facility. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator to the adopted NFPA 110 standards.
2. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., the Director of Engineering informed the surveyor that the batteries for the generator were maintenance free batteries.
3. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., there was no documentation showing weekly water (electrolyte) checks and monthly specific gravity checks since March 2014 because of the installation of maintenance free batteries.
4. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., the 3yr. 4hr. load bank test presented to the surveyor was only a 2hr. load bank test.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and patients in a power outage. Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., there was no documentation showing the required monthly 30 second and annual 90 minute testing of the battery powered emergency lights at the generator and generator transfer switch.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 9/10/2014, at 9:25 a.m., there was an open electrical junction box adjacent to the HAM Radio desk within the 2nd floor mechanical room.
2. On 9/10/2014, at 9:25 a.m., there were 3 permanently mounted relocatable power taps at the telecommunications rack/server area within the 2nd floor mechanical room.
3. On 9/10/2014, at 10:15 a.m., there was a relocatable power tap in use on the floor within the Radiology Reception Area.
4. On 9/10/2014, at 10:51 a.m., there was a relocatable power tap in use on the floor within the Pharmacy Warehouse.
5. On 9/10/2014, at 11:09 a.m., there was a non-patient relocatable power tap on the floor in use within OR #1 for the Anesthetizing Cart.
6. On 9/10/2014, at 3:15 p.m., there was a relocatable power tap in use on the floor within the Respiratory Therapy Office.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to separate sections of health care facilities from non-healthcare facilities. This resulted in the potential for the spread of fire & smoke into other sections of the health care facility (LSC 19.1.2.3, 19.1.1.4, 19.1.2.3). Findings include, but are not limited to:
1. On 9/10/2014, at 9:40 a.m., there were multiple penetrations within the 2hr. barrier wall between the I-2 Occupancy (Hospital) and the B-Occupancy (Administration). Penetrations were noted above the double doors in the corridor and within the Administration area.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain the integrity of smoke separations. This resulted in the potential for uncontrolled smoke migration into the egress corridor in the event of a fire, causing the exposure of patients & staff to hazardous products of fire (LSC 19.3.6.1, .2, .5). Findings include, but are not limited to:
1. On 9/10/2014, at 9:45 a.m., there were multiple penetrations within the stairwell adjacent to the main entrance that ranged in approximate size from 1 1/2" to 3" diameter.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain minimum smoke barrier fire resistance ratings in smoke compartments throughout the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 19.3.75, 8.3). Findings include, but are not limited to:
1. On 9/10/2014, at 9:52 a.m., there were multiple penetrations in the smoke barrier wall noted within the PACU above Bed A.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide a one hour separation between hazardous areas and the corridor for the building. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:
1. On 9/10/2014, at 10:55 a.m., the door to the Dirty Utility Room within the ED Vestibule was not closing or latching completely.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain accessible exits for the building as required by 2000 NFPA 101, 19.2.2.2.4. This resulted in the potential for panic and injury to patients and staff. Findings include, but are not limited to:
1. On 9/10/2014, at 11:10 a.m., there was a medical supplies storage cart blocking the north exit within the OR Corridor.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain exit illumination on emergency power for a minimum of 90 minutes annually. This resulted in the potential for confusion and panic by patients & staff during emergency evacuation conditions (LSC 19.2.8). Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., there was no documentation showing the required annual 90 minute test on emergency lights within the facility. Last annual 90 minute test was conducted on 12/01/2012 and was past due since 12/01/2013.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.1.1). Findings include, but are not limited to:
1. On 9/9/2014, during record review between 10:45 a.m. and 5:30 p.m., the Facility Disaster Manuals Hazard Vulnerability Assessment (HVA) was not complete. The HVA only included natural hazards and was missing human hazards, technological hazards and hazardous materials hazards. The Disaster Manual was also missing policies such as Hurricane Policy, Wildfire Policy, Landside Policy and Snow Fall Policy which were identified within the HVA Natural Hazards section.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as type of fire and simulated evacuation time of occupants.
2. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., the facility had no documentation on conducting the 4th quarter night shift fire drill for 2013. A fire drill was conducted by the surveyor at 2:59 p.m. and observed no staff activating the fire alarm pull station, clearing the corridors, the alarm immediately silenced and the overhead announcement was completed once and not repeated three times.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to install fire alarm system in accordance with NFPA 72 "private mode" systems. This resulted in the potential for system and device failure and delay and panic during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:
1. On 9/10/2014, at 9:27 a.m., the location for the breaker for the main Fire Alarm Control Panel (FACP) was not identified on the door of the main FACP. The electrical panel housing the breaker for the FACP was not labeled in red and did not have a mechanical set screw lock on the breaker.
2. On 9/10/2014, at 9:29 a.m. there were not signs on the doors leading to the main Fire Alarm Control Panel (FACP).

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.4, NFPA 70, NFPA 72). Findings include, but are not limited to:
1. On 9/9/2014, during record review between 10:45 a.m. and 5:30 p.m., monthly maintenance/testing was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted NFPA 72 standards.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:
1. On 9/10/2014, at 9:10 a.m., there was missing signage (6" "FDC" letters; white on red or red on white) on the facilities Fire Department Connection.
2. On 9/10/2014, at 9:29 a.m., there was missing signage, "Fire Sprinkler Riser Room" on the door leading to the fire sprinkler riser.

Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition for the entire building. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:
1. On 9/9/2014, during record review between 10:45 a.m. and 5:30 p.m., weekly and monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire sprinklers to the adopted edition of NFPA 25 standards.
2. On 9/10/2014, at 9:58 a.m., there were approximately 6 corroded sprinkler heads located in the exterior awning at the main entrance.
3. On 9/10/2014, at 10:00 a.m., there was not a spare dry sidewall sprinkler head within the spare sprinkler cabinet.
4. On 9/10/2014, at 10:02 a.m., there were approximately 9 corroded sprinkler heads located in the exterior awning at the ED entrance.
5. On 9/10/2014, at 10:12 a.m., there was a corroded sprinkler head within the Radiology Managers Office.
6. On 9/10/2014, at 10:30 a.m., there was not a spare dry pendant sprinkler head within the spare sprinkler cabinet.
7. On 9/10/2014, at 10:32 a.m., there was a corroded sprinkler head within OPT/Rehab above the door leading to the fax machine.
8. On 9/10/2014, at 11:20 a.m., there was a cabinet that stored gloves and labels that was blocking/obstructing the pull station for the hood system within the Facility Kitchen.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor for corridors of the building. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:
1. On 9/10/2014, at 10:25 a.m., there were charting stations within the patient care corridor that were not self closing when opened.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that no furnishings or decorations of highly flammable character are used, unless in limited quantities or flame retardant. This resulted in the potential for excessive fire spread (LSC 19.7.5.4). Findings include, but are not limited to:
1. On 11/8/2012, at 11:30 a.m., there were multiple hand-made afghan's hanging on the walls within the reception/waiting area of the hospital that were not treated with flame retardant materials.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide safe storage for compressed gas for the facility. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 4.3.1.1.2). Findings include, but are not limited to:
1. On 9/10/2014, at 10:05 a.m., there were 3 compressed gas cylinders that were not properly secured by evidence of only a single chain near the top of the cylinders that would allow the bottom of the cylinders to kick out and strike other cylinders or walls within the Med Gas farm during a seismic event.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that piped in medical gas systems comply with NFPA 99. This resulted in the potential for injury to patients during medical procedures. Findings include but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., documentation provided to the surveyor only showed an annual test of the main part of the system and not the testing of valves and outlets as required by NFPA 99.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that piped-in medical gas complied with NFPA 99, 5-4.1.1. This resulted in the potential for injury to patients during medical procedures. Findings include, but are not limited to:
1. On 9/9/2014, at 10:45 a.m. and 5:30 p.m., the humidity policy dated 08/08 that was presented to the surveyor did not have recommendations or procedures on what needed to be accomplished when the humidity was not within the adopted/specified range.

Based on record review and interviews it was determined through on-going dialog with the Director of Engineering that the facility failed to properly maintain the generator affecting the entire facility. This resulted in the potential for the lack of emergency electrical power (LSC 4.6.12.1, NFPA 110, NFPA 99, 3.4.4.1, 6.4.2). Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator to the adopted NFPA 110 standards.
2. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., the Director of Engineering informed the surveyor that the batteries for the generator were maintenance free batteries.
3. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., there was no documentation showing weekly water (electrolyte) checks and monthly specific gravity checks since March 2014 because of the installation of maintenance free batteries.
4. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., the 3yr. 4hr. load bank test presented to the surveyor was only a 2hr. load bank test.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to provide an alternate source of power in accordance with NFPA 99 3.6, which would provide a minimum of 90 minutes of power in an outage. This resulted in the potential for panic and confusion for staff and patients in a power outage. Findings include, but are not limited to:
1. On 9/10/2014, during record review between 10:45 a.m. and 5:30 p.m., there was no documentation showing the required monthly 30 second and annual 90 minute testing of the battery powered emergency lights at the generator and generator transfer switch.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70 for the building. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:
1. On 9/10/2014, at 9:25 a.m., there was an open electrical junction box adjacent to the HAM Radio desk within the 2nd floor mechanical room.
2. On 9/10/2014, at 9:25 a.m., there were 3 permanently mounted relocatable power taps at the telecommunications rack/server area within the 2nd floor mechanical room.
3. On 9/10/2014, at 10:15 a.m., there was a relocatable power tap in use on the floor within the Radiology Reception Area.
4. On 9/10/2014, at 10:51 a.m., there was a relocatable power tap in use on the floor within the Pharmacy Warehouse.
5. On 9/10/2014, at 11:09 a.m., there was a non-patient relocatable power tap on the floor in use within OR #1 for the Anesthetizing Cart.
6. On 9/10/2014, at 3:15 p.m., there was a relocatable power tap in use on the floor within the Respiratory Therapy Office.