HospitalInspections.org

A. Corrected 10/07/10

B. Corrected 10/07/10

C. The south stair door of the 1960 building on the 1st floor level was not positive latching to comply with 7.1.3.2.1 and 8.2.3.2.1.
UPDATE 10/07/10: Latching hardware was installed on the stair door, pending proper fire rated hardware.

D. Corrected 10/07/10

A. The fire alarm system did not comply with NFPA 72, 1999. Observed conditions include:

1. Corrected 10/07/10
2. Corrected 10/07/10

3. During testing of the fire alarm system where more than two strobes were observed within 55', they were not synchronized to comply with NFPA 72, 4-4.4.2.3. Locations observed include but are not necessarily limited to the following:

a. Corridor leading to the ORs.

b. Within the Radiology suite.

c. Within the ER suite.

4. The cross corridor doors between the elevators and the corridor leading to the OR suite are equipped with power openers that did not cease to operate under fire alarm activation to comply with 7.2.1.9.2.

UPDATE 10/07/10: Items 3 & 4 were not tested at this time due to time constraints on the surveyor. These items will be tested with the fire alarm at the next follow-up survey .

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

A. Documentation for the weekly/monthly testing of the generator system was not clear to judge compliance with applicable requirements. The following conditions were observed:

1. Corrected 10/07/10

2. The required minimum load to be transfered during monthly test under load was indicated to be the same for all three generators, but each generator is rated at different capacities; 200KW, 600KW, & 1200KW.

3. The forms indicate the load values to be expressed in "kiloamps" rather than "kilowatts" that may be read from the gauges on the generators. Load values are listed both as whole numbers and decimal values less than 1. It was not clear that the minimum cnnected load was being acheived.

UPDATE 10/07/10 : The facility was unclear as to the calculations requirements for items 2 & 3. The following calculation is an example as to how to figure the conversion:

200KW x 1000 = 200,000 watts.
If the generator is 480 volts and 3 phases then x 1.73 (3 phase multiplier) = 830
200,000 / 830 = 241, this would be the maximum for this generator.
241 @ 30% = 72 amps or .072 kiloamps which would be the MINIMUM monthly 30 minute load according to NFPA 110 (1999) 6-4.2.

4. Corrected 10/07/10
5. Corrected 10/07/10

A. Electrical systems did not appear to be in compliance with NFPA 70, 1999. The following conditions were observed:

1. The second floor Med/surg patient rooms were indicated to have all outlets on the emergency power system.

a. The arrangement did not appear to comply with NFPA 70, 517-18(a) which requires each bed location to be supplied by at least two branch circuits, one from the emergency system and one from the normal system. Alternatively, per Exception No. 3, it was not verified that the outlets were supplied from two separate transfer switches on the emergency system.

b. Corrected 10/07/10
c. Corrected 10/07/10

2. Corrected 10/07/10

3. Panel directories (observed at the second floor ICU but may be typical throughout) did not appear to accurately identify the locations served by the circuits. As an example: panel directories identified locations by room numbers which were not coordinated with signage installed.
UPDATE 10/07/10: The facility has started this process, but not complete at this time.