HospitalInspections.org

A. Based on observation and staff interview the facility failed to repair penentrations and openings in required 2 hour fire walls. This deficient practice would not prevent fire spreading through the fire walls. Facility census was N/A.

Findings are:

Observation on 6-27-17 between 3:46 PM and 4:20 PM revealed :

1. There was a ¼" gap around the fire sprinkler pipe passing through the West 2 hr fire wall in Room # 127
2. There was a 1"x1" hole next to conduit passing through the 2 hr fire wall above the ceiling in Room 121.
3. There was a 1"x3" hole with a conduit passing through the 2 hr fire wall above the ceiling in the hallway across from Room 266
4. There was a 3" x 3" opening with communication cables passing through the 2 hour fire wall above the 90 min Rated fire doors Between Rm 127 and Rm 302 in Corridor 103.
5. A 1" conduit in the 2 hr fire wall in Room 304 was not sealed.
6. A 1" conduit in the 2 hr fire wall in Room 305 was not sealed.
7. A 1" conduit in the 2 hr fire wall in Room 306 was not sealed.
8. A 1" conduit in the 2 hr fire wall in Room 307 was not sealed.
9. A1" conduit in the 2 hr fire wall in Room 308 was not sealed.
10. A 1" conduit in the 2 hr fire wall In Room 309 was not sealed.

During an interview on 6-27-17 between 3:46 PM and 4:20 PM , observations were acknowledged and verified by Maintenance A.

B. Based on observation, and staff interview, the facility failed ensure all battery backup emergency lighting was in operating condition. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal lighting. The facility census was N/A.

Findings are:

Observation on 6-27-17 at 11:51 AM and 11:54 AM revealed the Emergency Lighting across from Room P147 and in the Clean Agent Room had battery backup lights that did not function when the test button was depressed.

During an interview on 6-27-17 at 11:51 AM and 11:54 AM, observations were acknowledged and verified by Maintenance A.


NFPA 101, 2012, 7.9.3.1.2 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding
30 days.
(5) Functional testing shall be conducted annually for a minimum
of 11?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be fully operational for the duration
of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

C.
Based on observation and staff interview, the facility failed to provide a smoke barrier that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.. The facility census was n/a.

Findings are:

Observation on 6-27-17 at 3:01 PM and 3:03 PM revealed:

1. In the hallway across from Rm 212, a 2" x 2" hole in the 1 hr rated wall had a conduit going through it
2. Across from Rm 214 had a 1"x3" hole above the ceiling with a conduit going through a 1 hr wall by Electrical Junction box.

In an interview on 6-27-17 at 3:01 PM and 3:03 PM, Maintenance A acknowledged the opening in the smoke barrier.




D.


Based on record review and interview the facility failed to ensure that the fire alarm was inspected annually for the Clean Agent System. The deficient practice would delay detection of a fire and increased the potential that the fire alarm system would fail to operate in a fire emergency. Facility census was N/A.

Findings are:

Record review of the annual fire alarm system report for the Clean Agent System on 6-27-17 at 4:15 PM revealed that there was no documentation.

In an interview on 6-27-17 at 4:15 PM , Facilty Staff A acknowledged the lack of documentation.

A. Based on observation, and staff interview, the facility failed ensure all battery backup emergency lighting was in operating condition. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal lighting. The facility census was N/A.

Findings are:

Observation on 6-27-17 at 10:35 AM revealed the Emergency Lighting throughtout the facility had battery backup lights that did not function when the test button was depressed.

During an interview on 6-27-17 at 10:35 AM, observations were acknowledged and verified by Facilty Staff B.


NFPA 101, 2012, 7.9.3.1.2 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding
30 days.
(5) Functional testing shall be conducted annually for a minimum
of 11?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be fully operational for the duration
of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.


B. Based on observation, and staff interview, the facility failed ensure all battery backup exit signs were in operating condition. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal lighting. The facility census was N/A.

Findings are:

Observation on 6-27-17 at 10:25 AM revealed the Exit Signs throughtout the facility had battery backup lights that did not function when the test button was depressed.

During an interview on 6-27-17 at 10:25 AM, observations were acknowledged and verified by Facilty Staff B.

A. Based on observation, and staff interview, the facility failed ensure all battery backup emergency lighting was in operating condition. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal lighting. The facility census was N/A.

Findings are:

Observation on 6-27-17 at 11:46 AM revealed the emergency lighting across from Room 172 did not function when the test button was depressed.

During an interview on 6-27-17 at 11:51 AM and 11:54 AM, observations were acknowledged and verified by Maintenance A.


NFPA 101, 2012, 7.9.3.1.2 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding
30 days.
(5) Functional testing shall be conducted annually for a minimum
of 11?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be fully operational for the duration
of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

B. Based on observation and interview, the facility failed to separate hazardous areas by smoke resistive partitions. The deficient practice would allow smoke to migrate into the exit corridor and affect those that depended on the smoke compartments for exiting. The facility census was N/A.

Findings are:

Observation on 6-27-17 at 11:46 AM revealed an I-beam that penetrated the South 1-hour fire rated wall in Mechanical room Rm 102. The penetration for the I-beam was not sealed to resis the passage of smoke.

During an interview on 6-27-17 at 11:46 AM revealed in Rm 102, Maintenance A confirmed the findings.

Based on observation and staff interview the facility failed to maintain required 2 hour fire barriers. This deficient practice would allow fire to spread between compartments in the facility. Facility census was 21.

Findings are:

Observation on 6-26-17 between 1:39 PM and 4:25 PM revealed :
1. The West waiting room, #4A6-West had a 4 inch hole around the conduit that penetrated the 2 hr. Fire Barrier.
2. Room #4A11 had a 2 inch hole in the 2 hr. Fire Barrier.
3. The 2 hour fire barrier on West Elevator Lobby's southwest corner did not extend to the bottom of the floor deck above.
4. There was a 4" x 12" opening in the drywall in the 2 hr fire barrier above the double doors at Room 500 on the North Side .
5. There was 3 - 1" x 1" openings at the east end of the corridor above corridor door 2A30 where telephone lines ran through the 2 hr fire wall.
6. There was four openings (one 2" x 10", a 3" x 8" x 3" T shaped opening, a 1 1/2" x 5", and a 4" x 6") in the 2 hr fire wall in Rm 2A13.
7. There was an unsealed 1" opening around the conduit that penetrated the 2 hr fire wall above Rm 2A47.
had a

During an interview on 6-26-17 between 1:39 PM and 4:25 PM , observations were acknowledged and verified by Maintenance B and Maintenance C.

Based on observation and interview, the facility failed to provide or maintain the 2-hour fire rated separation of non-healthcare occupancies attached to the Health Care Occupancy. This practice would allow fire, gasses and smoke to spread between areas of the facility which would affect occupants that use the facility. The facility census was 21 patients.

Findings are:
Observations on 6-26-17 at 1:53 pm revealed, the fire rated door 1A-122A separating the existing health care facility from the facility failed to provide a self-closing device on a fire rated door into a mechanical space.

During an interview on 6-26-17 at 1:53 pm, Facility Staff A confirmed the fire rated door failed to provide a self-closing device, and stated the facility continued the need to access the room on the other side of the 2-hour wall for maintenance.

Based on observation and staff interview the facility allowed a non-UL listed equipment to be installed on a 90-minute UL listed fire door. This deficient practice could allow fire to spread between the two compartments and could void the fire resistance listing of the door. Facility census was 26.

Findings are:

Observation on 6-27-17 at 10: 50 AM revealed a non-UL Listed weather strip was installed on the fire door that separates the 100 Suite and the Hospital.

During an interview on 6-27-17 at 10: 50 AM , observations were acknowledged and verified by Maintenance A.

Based on observation and interview, the facility failed to provide means of egress on 3 of 6 floors by creating 4 new dead end corridors when the adjoining hospital closed. This deficient practice would cause confusion and delay egress from the fifth and third floors. The facility census was 21 patients.

Findings are:

A.

Observations on 6-26-17 between 9:35 AM and 2:35 PM revealed:
1. A 61 foot dead end corridor was created when the adjoining hospital closed and removed use of the horizontal exit on the Fifth Floor.
2. A 61 foot dead end corridor was created when the adjoining hospital closed and removed use of the horizontal Exit on the Third Floor.
3. A 75 foot dead end corridor was created when the adjoing hospital closed and removed use of the horizontal exti on the Second Floor, East Hall.
2. A 50 foot dead end corridor was created when the adjoining hospital closed and removed use of the horizontal exit on the Second Floor, North Hall.

During an interview on 6-26-17 between 9:35 AM and 2:35 PM, Facility Staff A confirmed the dead end corridors.

Based on observation, documentation review and interview, the facility failed to provide suite separation for the 5th and 4th floor Operating Room (OR) suite. This deficient practice would allow smoke, gasses and fire to spread into the exit corridor. The facility census was 21 patients.

Findings are:
Observations on 6-26-17 at 2:00 pm and 2:45 pm revealed:
1. Two of two sets of double doors leading into the fifth floor OR from the corridor failed to provide latching devices.
2. Two of two sets of double doors leading into the fourth floor OR from the corridor failed to provide latching devices.

Documentation review on 6-26-17 at 3:00 pm of the facilities floor plan indicated that the facility had designated the OR suite on the fourth and fifth floor as a non-sleeping suite.

During an interview on 6-26-17 at 3:05 pm, Facility Staff A confirmed the lack of latching devices on 2 of 2 sets of doors into the OR on fourth and fifth floor and the floor plan designating the spaces as a suite.

Based on observation and interview, the facility failed to verify egress illuminations so it did not leave the area in darkness for the area on the east side of the building. This deficient practice had the potential to delay or cause confusion during an emergency. The facility census was 21 patients.

Findings are:
Observations on 6-26-17 at 1:24 pm revealed, the facility was undergoing construction on the east side of the building at the Dock and failed to verify egress illumination was provided.

During an interview on 6-26-17 at 1:24 pm, Facility Staff A confirmed the lack of lighting on the east side of the building near the dock exit.

Based on observation, and staff interview, the facility failed ensure all battery backup emergency lighting was in operating condition. This deficient practice would slow or prevent evacuation of occupants during an emergency under loss of normal lighting. The facility census was 26.

Findings are:

Observation on 6-27-17 at 11:17 AM revealed the OR #6 and OR #7 Room battery backup light did not function when the test button was depressed.

During an interview on 6-27-17 at 11:17 AM, observations were acknowledged and verified by Maintenance A.


NFPA 101, 2012, 7.9.3.1.2 Testing of required emergency lighting systems
shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic
battery-operated emergency lighting equipment shall automatically
perform a test with a duration of a minimum of
30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding
30 days.
(5) Functional testing shall be conducted annually for a minimum
of 11?2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency
lighting equipment shall be fully operational for the duration
of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be
kept by the owner for inspection by the authority having
jurisdiction.

Based on observation and interview, the facility failed to provide all required exit signs. This deficient practice had the potential delay or cause confusion during an emergency as occupants. The facility census was 21 patients.

Findings are:
Observations on 6-26-17 at 10:57 am revealed, that while standing outside 3A34, no exit sign was visible to direct occupants to the exit.

During an interview on 6-26-17 at 10:57 am, Facility Staff A confirmed the lack of exit signage.

Based on observation and interview, the facility failed to separate a hazardous areas by smoke resistive partitions. The deficient practice would allow smoke to migrate into the exit corridor and affect those that depended on the smoke compartments for exiting. The facility census was 21 patients.

Findings are:

A. Observation on 6-26-17 between 9:17 am and 1:57 pm revealed:
1. Patient Room 5A5 was used as a storage room, and no self-closing device was provided for the door.
2. The 5th floor fire rated elevator lobby doors had a gap between the doors greater than 1/8 inch.
3. Broken ceiling tile was observed in Mail Room 3M44A.
4. The fire rated door to room 3A15C was blocked open with a dust pan and a trash can.
5. Broken ceiling tile was ovserved in the 1st floor Dark Room.
6. The undercut to the 1 ½ hour fire door to the Fire Pump Room was greater than ¾ inch.
7. Missing ceiling tile was observed in 1A123 Room.

During an interview on 6-26-17 between 9:17 am and 1:57 pm, Facility Staff A confirmed the findings.

B. Observation on 6-26-17 between 3:25 PM and 4:13 PM revealed:

1. Three ceiling tiles were out of position in the Housekeeping room 3M46.
2. The East wall of the fire pump room in the medical records room #1A124 had 2-inch gaps around pipe penetrations.
3. Mechanical room #2A86B had 2- 2" pipe penetrations that were not sealed.

During an interview on 6-26-17 between 3:25 PM and 4:13 PM , Maintenance C confirmed the findings.

C. Observation on 6-26-17 at 3:05 PM and 4:10 PM revealed:

1. The Biohazard Room , 2A214, had a 2" copper pipe that was not sealed.
2. The Dumb Waiter Room, 2A33 had a 1" opening in the ceiling tile.

During an interview on 6-26-17 at 3:05 PM and 4:10 PM ,Facility Staff A confirmed the findings.

Based on observation and interview, the facility failed to separate a hazardous areas by smoke resistive partitions. The deficient practice would allow smoke to migrate into the exit corridor and affect those that depended on the smoke compartments for exiting. The facility census was 21 patients. The facility census was 26 patients.

Findings are:

Observation on 6-27-17 at 9:45 AM and 11:00 AM revealed:

1. The Electrical Room in the basement had walls that did not extend to the bottom of the floor deck above.
2. Surgical Storage Room U99 had an 1/4" gap around the conduit above the ceiling.

During an interview on 6-27-17 at 9:45 AM and 11:00 AM, Facility Staff A confirmed the findings.

Based on observation and interview the facility failed to install an automatic sprinkler system to provide complete coverage for all portions of the building, or provide 2-hour fire separation between sprinkled and unsprinkled portions of the building, and failed ensure ceiling tiles were in place so the sprinkler heads would operate as designed. The deficient pratice did not ensure the sprinkler system would operate as designed to control or extinguish a fire. The facility census was 21 patients.

Findings are:
A. Observations on 6-26-17 between 10:23 am and 1:48 pm revealed:
1. The facility failed to provide a suppression system in the IT Room 3M40.
2. The facility failed to provide sprinkler protection under a duct in 3M Housekeeping 3M3 near AHU2.
3. The facility failed to provide sprinkler protection in Room 1A101.

During an interview on 6-26-17 between 10:23 am and 1:48 pm, Facility Staff A confirmed the lack of sprinkler protection.

B. Observations on 6-26-17 at 3:48 PM revealed the 2nd Floor North hall, West Side had a fire sprinkler head that had the ceiling grid removed around it due to construction.

During an interview on 6-26-17 at 3:48 PM , Facility Staff A confirmed the finding.

Based on observation and interview, the facility allowed accumulation of foreign matter on sprinkler heads and failed to prevent obstruction to the spray pattern of sprinkler heads. This deficient practice could impact the response and effectiveness of the sprinkler head and a larger fire could spread outside of the room into the exit corridor, and could cause damage to sprinkler piping leading to failure of the sprinkler system. The facility census was 21 patients.

Findings are:
Observations on 6-26-17 between 11:40 pm and 12:20 pm revealed:
1. There was foreign matter on the sprinkler head in Room 3A7C.
2. There was foreign matter on the sprinkler head in Room 3A6C.
3. There was foreign matter on the sprinkler head in Room 3A19C.
4. There wa an obstruction to the sprinkler head in 3A4C.

During an interview on 6-26-17 between 11:40 pm and 12:20 pm, Facility Staff A confirmed the findings.

Based on record review and interview, the facility failed to inspect all portable fire extinguishers throughout the facility every 30 days. This deficient practice would reduce the dependability of the fire extinguisher and would not ensure the fire extinguishers were in operating condition. Facility census was 26 residents.

Findings are:

Record review on 6-27-17 at 9:40 AM revealed that the fire extinguisher in the Boiler Room was not inspected in the month of October 2016.

During an interview on 6-27-17 at 9:40 AM, Maintenance A stated that October 2016 was missed.

NFPA 10, 2010 edition 7.2.1.2* Fire extinguishers shall be inspected either manually or by means of an electronic monitoring device/system at a minimum of 30-day intervals.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice doors would not prevent the spread of fire and smoke within the exit corridors. The facility census was 21 patients.

Findings are:
Observation on 6-26-17 at 9:28 am and 11:19 pm revealed:
1. The door to Room 5A16 was obstructed by thermometer caddy.
2. The door to Room 5A40 door was obstructed by large plastic bottle of bubbles.
3. The door Room 3A37 failed to latch within the door frame.

During an interview on 6-26-17 at 9:28 am and 11:19 am, Facility Staff A confirmed the doors to the corridor were obstructed.

NFPA Standard:
2012 NFPA 101, 19.3.6.3.10*
Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
2012 NFPA 101, A.19.3.6.3.10 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Based on observation and staff interview, the facility failed to provide smoke barriers that would resist the passage of smoke. This condition had the potential to allow smoke to migrate between smoke compartments.. The facility census was 21.

Findings are:

A. Observation on 6-26-17 between 1:45 PM and 3:51 PM revealed:

1. 2 electrical conduits above room #4A14 were not sealed.
2. The North wall in Room #4A13 had 2 electrical conduits that were not sealed.
3. The Nurse's station #4A28 above the ceiling grid had a 4" conduit that was not sealed.
4. The East elevator lobby #3A33-South side of lobby at the corridor Smoke Barrier had a 2-inch gap around sprinkler system pipe.
5. The West elevator lobby #3A1-Lobby side of corridor Smoke Barrier doors had 2, 2-inch gaps around sprinkler system pipe.
6. The Lab room #1A140-North Smoke Barrier had a 2-inch hole in the brick around conduit above the ceiling grid.
7. The Business service office #1A4-West Wall Smoke Barrier did not extend to floor above, and eight, 2-inch holes around wire and conduit penetrations

In an interview on 6-26-17 between 1:45 PM and 3:51 PM , Maintenance C acknowledged the openings in the smoke barrier.

B. Observation on 6-26-17 between 1:56 PM and 3:25 PM revealed:

1. There was a 1" Gap around a 12" x 12" Air ducted in Smoke wall above Room 5A22 on both sides of the corridor.
2. There was a 1" round hole in the smoke wall on the South Side Above Room 5A26.
3. There were two 1" x 1" holes with communications wires passing through the smoke wall above Room 5A41 below air duct.
4. There were 2 - 3" holes and 2 - 1 ½" holes with conduit going through the smoke wall above Door 3M44.
5. There was a 3/4" conduit going through a smoke wall on north wall of Room 3M21.
6. There was a 3' x 4' opening in the smoke wall in the southwest corner of Room 3M3.

In an interview on 6-26-17 between 1:56 PM and 3:25 PM , Maintenance B acknowledged the openings in the smoke barrier.

Based on observation and interview, the facility allowed storage to obstruct access to the electrical disconnects boxes and failed to provide circuit directories for electrical panels. These deficient practices could cause a delay and injury when turning off the power during an electrical issue emergency. The facility census was 21 patients.

Findings are:
Observations on 6-26-17 between 12:22 pm and 1:27 pm revealed:
1. Items were stored in front of the electrical panel box in IT Room 3M.
2. The electrical panel box H1AB in Room 1A005 was not provided with a directory of circuits.
3. The electrical panel box CRL1 in Room 1A003 fwas not provided with a directory of circuits.

During an interview on 6-26-17 between 12:22 pm and 1:27 pm, Facility Staff A confirmed the items stored in front of the electrical panel box and missing directories.

Based on documentation review and interview, the facility failed to hold fire drills under varied conditions for 3 of 4 quarters reviewed. The deficient practice did not provide simulated training for staff to respond to a fire emergency during various activities and staffing levels, which would affect staff preparation and experience in providing for the protection of all residents in the event of a fire. The deficient practice affected all residents. The facility census was 21 residents.

Findings are:

Record review of the fire drills on 6-26-17 at 1:46 PM revealed:
1. Three of the 3rd shift fire drills were conducted at 11:30 PM on 1-9-17, 11:16 PM on 4-10-17, and 11:17 PM on 12-2-16.


During an interview on 6-26-17 at 1:46 PM , record review were acknowledged and verified by Facility Staff A.

NFPA Standard:
NFPA 101, 2012 Edition
19.7.1.6 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.

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch and the Equipment System. This deficient practice had the potential to affect all patients of the facility by affecting the egress lighting and emergency systems of the facility. The facility census was 21 patients.

Findings are:
Observation on 6-26-17 at 10:24 am revealed:
1. Electrical panel EQMDP equipment branch, in 3M Center Mechanical Room contained circuits fo elevator equipment.(Life Safety)

During an interview on 6-26-17 at 10:44 am, Facility Staff A confirmed the findings.

NFPA Standard:
2011 NFPA 70, 517.30
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. 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, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure Facilities (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and interview, the facility failed to prohibit the use of power strips and extension cords. This deficient practice had the potential to increase the possibility for an electrical fire. The facility census was 21 patients.

Findings are:
Observation on 6-26-17 between 10:40 am and 2:17 pm revealed:
1. A refrigerator was plugged into a power strip in room 3A18D.
2. A microwave outside room 3A5D was plugged into a power strip.
3. A power strip was plugged into another power strip in Pharmacy 3A26.
4. A microwave was plugged into a power strip in the 3-M Maintenance Dressing area.
5. A C-arm X-ray machine in OR4 was plugged into an extension cord.

During an interview on 6-26-17 between 10:40 am and 2:17 pm, Facility Staff A acknowledged the high-current draw appliances were plugged into a power strip and the extension cord.

NFPA Standard:
2011 NFPA 70, 210.23 Permissible Loads.
In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size specified in 210.23(A) through (D) and as summarized in 210.24 and table 210.24.