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Based on observation and interview the fire pump connected to the complete automatic fire sprinkler system is not installed/mounted in accordance with NFPA 20, Section 3-4. This deficient practice could effect all building occupants in the event of a fire.

Findings include:

During the facility tour on 4-7-14 at 1:00PM, it was observed that the fire pump located in the fire pump room, main level, is not installed in accordance with NFPA 20 section 3-4. The standard would require the pump to be mounted solidly in concrete. Currently the pump is supported (in the air) by "ready rod". As installed the pump is prone to failure caused by vibration from the normal rotation of the pump when it is running. This installation occurred in the 2013 construction project. The original installer should be responsible for correcting this installation.

This deficient practice was confirmed by the Director of Plant Operations (JB) and the Administrator (CC) at the time of exit.

Based on observation and interview unapproved electrical appliances are being used in the ER employee break area. These devices do not meet the requirements of MSFC(07) for use in a Health Care facility. This deficient practice could effect all occupants if they were to cause a fire.

Findings include:

During the facility tour on 4-7-14, at 1:30PM it was observed that unapproved electrical appliances, ie., coffee pot, microwave oven, pizza oven, toaster, etc. were in use in the ER employee break area. Based on interview with the Director of Plant Operations, "these appliances were not provided by the hospital".

This deficient practice was confirmed by the Director of Plant Operation (JB) and he Administrator (CC) at the time of exit.

Based on observation and interview the back up emergency electrical generator is not being monitored as required by NFPA (99) Sections 3-1.1.14 & 3-4.1.1.15. This deficient practice could effect all building occupants in the event of loss of normal electrical power from the utility company.

Findings include:

At the conclusion of the tour on 4-8-14, at approximately 10:30AM, it was observed and confirmed by interview with the Plant Operations Supervisor (JB) that the run functions of the generator is not being monitored at a 24/7 occupied location , i.e. the nurses station. The standard outlines both visual and audible functions required to be monitored.

This deficient practice was not confirmed by the Director of Plant Operation (JB) and the Administrator (CC) at the time of exit. Based on code research, after the inspection, this finding was confirmed and the facility was advised

Based on observation and interview, at the time of inspection, it could not be verified if the electrical outlets in the 3 operating rooms (OR's) are served by ground fault interruption (GFI) or line isolation monitors, OR's are considered to be "wet locations". This deficient practice could effect all occupants of the OR's.

Finding include:

At the conclusion of the facility tour on 4-8-14, at approximately 10:30AM, based on interview with the Director of Plant Operations (JB), it could not be verified if all of the electrical outlets are served by GFI's and or line isolation equipment. The requirements for this standard are outline in NFPA99 (99) section 3-3-2-1-2 and NFPA 70.

This deficient practice was confirmed by the Director of Plant Operations (JB) and the Administrator (CC) at the time of exit.

Based on observation and interview the fire pump connected to the complete automatic fire sprinkler system is not installed/mounted in accordance with NFPA 20, Section 3-4. This deficient practice could effect all building occupants in the event of a fire.

Findings include:

During the facility tour on 4-7-14 at 1:00PM, it was observed that the fire pump located in the fire pump room, main level, is not installed in accordance with NFPA 20 section 3-4. The standard would require the pump to be mounted solidly in concrete. Currently the pump is supported (in the air) by "ready rod". As installed the pump is prone to failure caused by vibration from the normal rotation of the pump when it is running. This installation occurred in the 2013 construction project. The original installer should be responsible for correcting this installation.

This deficient practice was confirmed by the Director of Plant Operations (JB) and the Administrator (CC) at the time of exit.

Based on observation and interview unapproved electrical appliances are being used in the ER employee break area. These devices do not meet the requirements of MSFC(07) for use in a Health Care facility. This deficient practice could effect all occupants if they were to cause a fire.

Findings include:

During the facility tour on 4-7-14, at 1:30PM it was observed that unapproved electrical appliances, ie., coffee pot, microwave oven, pizza oven, toaster, etc. were in use in the ER employee break area. Based on interview with the Director of Plant Operations, "these appliances were not provided by the hospital".

This deficient practice was confirmed by the Director of Plant Operation (JB) and he Administrator (CC) at the time of exit.

Based on observation and interview the back up emergency electrical generator is not being monitored as required by NFPA (99) Sections 3-1.1.14 & 3-4.1.1.15. This deficient practice could effect all building occupants in the event of loss of normal electrical power from the utility company.

Findings include:

At the conclusion of the tour on 4-8-14, at approximately 10:30AM, it was observed and confirmed by interview with the Plant Operations Supervisor (JB) that the run functions of the generator is not being monitored at a 24/7 occupied location , i.e. the nurses station. The standard outlines both visual and audible functions required to be monitored.

This deficient practice was not confirmed by the Director of Plant Operation (JB) and the Administrator (CC) at the time of exit. Based on code research, after the inspection, this finding was confirmed and the facility was advised

Based on observation and interview, at the time of inspection, it could not be verified if the electrical outlets in the 3 operating rooms (OR's) are served by ground fault interruption (GFI) or line isolation monitors, OR's are considered to be "wet locations". This deficient practice could effect all occupants of the OR's.

Finding include:

At the conclusion of the facility tour on 4-8-14, at approximately 10:30AM, based on interview with the Director of Plant Operations (JB), it could not be verified if all of the electrical outlets are served by GFI's and or line isolation equipment. The requirements for this standard are outline in NFPA99 (99) section 3-3-2-1-2 and NFPA 70.

This deficient practice was confirmed by the Director of Plant Operations (JB) and the Administrator (CC) at the time of exit.