HospitalInspections.org

Based on observation and staff interview, the facility failed to maintain spray-applied fire proofing. This condition had the potential for a structural beam to weaken and collapse more quickly. The facility census was 9 patients.

Findings are:
Observation during the facility tour on 10/17/12, at 11:00 am revealed missing spray-applied fire proofing from a beam above ceiling near the 2nd Floor, East Stairwell.
In an interview conducted at the time of observation, (10/17/12, at 11:00 am), Engineering A confirmed the fire proofing failed to be re-applied.

Based on observation and interview, the facility failed to provide documentation to verify interior finishes for rooms and spaces not used for corridors or exit ways that have a flame spread rating of Class A or Class B. Facility census was 9 patients.

Findings are:
Observations on 10-12-11 at 2:43 pm revealed, a fabric accordion door room divider between Exam Rooms 7 and 8.
During an interview on 10-17-12 at 2:43 pm, Safety A confirmed the room divider and failed to provide documentation for a fire rating.

NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.2

Based on observation and interview, the facility failed to assure that medical equipment did not block exam room doors. This deficient practice would not contain the spread of fire and smoke into exit corridors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:48 pm revealed, a blood pressure machine obstructed the door to Exam Room 5 when the door was tested.
During an interview on 10-17-12 at 2:48 pm, Safety A confirmed the door was obstructed with equipment and failed to engage the door frame.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation, documentation review and staff interview, the facility failed to maintain or provide latching hardware in corridor doors or to ensure that corridor doors would resist the passage of smoke. This condition had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 between 10:12 am to 11:30 am revealed, that 8 of 8 OR rooms had double doors which failed to provide latching devices and with gaps greater than 1/8 inch between doors.
Documentation review on 10-17-12 revealed the floor plan indicated that the OR suite was 13,870 square feet.
During an interview on 10-17-12 between 10:12 am to 11:30 am, Safety A confirmed the findings.



27395

Observations during the facility tour on 10/17/12, from 9:52 am to 2:51 pm revealed:
1. A trash can prevented the In-Patient Physical Therapy room door from latching when the door released from the magnetic hold-open.
2. Food and bowls obstructed the Kitchen roll-down fire shutter from closing completely.
3. The Post-Op Doors failed to have latching hardware installed in the corridor doors.
In an interview conducted at the time of observation, (10/17/12, from 9:52 am to 2:51 pm), Engineering A acknowledged the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Any suite of rooms that complies with the requirements of 19.2.5 shall be permitted to be subdivided with non-fire-rated, noncombustible, or limited-combustible partitions. 2000, NFPA 101, 19.2.5.4

Intervening rooms shall not be hazardous areas as defined by 19.3.2. 2000, NFPA 101, 19.2.5.5

Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2.
2000, NFPA 101, 19.2.5.7

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 9.

Findings are:
Observations during the facility tour on 10/17/12, from 9:48 am to 10:15 am on the 2nd Floor revealed:
1. An exit sign failed to be installed above the west double doors near the X-Ray.
2. An exit sign failed to be installed above the east double doors on the east side of the doors.
In an interview conducted at the time of observations (10/17/12, from 9:48 am to 10:15 am), Engineering A confirmed that exit signs were not visible in two directions when the double doors closed.

Based on observation and interview, the facility failed to ensure that smoke separation doors are capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread smoke compartments. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 11:27 am and 11:55 am revealed:
1. The space between the smoke doors in the East OR corridor was greater than 1/8 inch.
2. The space between the smoke doors in the West OR corridor was greater than 1/8 inch.

During an interview on 10-17-12 at 11:27 am and 11:55 am, Safety A confirmed the space between the doors were greater than 1/8 inch.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview the facility failed to maintain the doors to hazardous areas so that they would close and latch within the door frame or provide self-closing devices on those doors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:15 pm and 2:26 pm revealed:
1. The door to the dirty side of the Decontamination Room failed to latch within the door frame.
2. The ED Break room door failed to provide a self-closing device, appeared to have been removed.
During an interview on 10-17-12 at both times of observations, Safety A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for smoke and fire to spread into the egress corridors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 between 10:07 am and 11:15 am revealed:
1. The doors to the " Future OR " which was used as a storage room failed to close and latch within the door frames.
2. The door to the " Viewing Room " which was used as a storage room failed to close and latch within the door frame.
3. OR Clean Storage room double doors failed to close and latch, doors failed to close in sequence. The inactive leaf failed to provide latching device and was not locked into the frame.
4. The double doors to Clean OR storage room failed to provide latching device.
5. Hopper room in the Decon area was over 50 square feet and failed to provide a self-closing device on the door.
6. Radiology Processing room over 50 square feet and failed to provide a self-closing device on the door.
7. Unsealed penetration around electrical conduit above the ceiling tile outside the " Viewing room " above the door.
8. The double doors to Decon Room failed to provide latching device.

During an interview on 10-17-12 between 10:07 am and 11:15 am, Safety A confirmed all the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and interview the facility failed to allow egress from the access-controlled egress doors at the ED front exit as required by the NFPA (National Fire Protection Association) by allowing the exit doors to be manually locked. This deficient practice would prevent egress and delay evacuation in a fire emergency. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:59 pm revealed, 2 of 2 of the access-controlled doors at the ED front lobby exit were equipped with a thumb turn lock.
During an interview on 10-17-12 at 2:59 pm, Safety A confirmed all the findings.

NFPA Standard:
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

NFPA Standard:
Doors located in the means of egress that are permitted to be locked shall have adequate provisions for the rapid removal of occupants such as remote control, the keying of all locks to keys carried by staff at all times, or knowledge of the code. Only one such locking device shall be permitted on each door. 2000 NFPA 101, 19.2.2.2.5

Based on observation and interview, the facility failed to provide exit access from an egress without the use of a special tool or knowledge from the egress side. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 11:33 am, revealed a magnetic lock on the exit door in the Clean Room leading to the Break Down room. The facility failed to indicate how the function works for the " push to exit button " and the automatic eye failed to operate.
During an interview on 10-17-12 at 11:33 am, Safety A confirmed the lack of signage on the " push to exit button " and stated the automatic eye failed to operate.



20404

Observations on October 17, 2012 at 10:10am and 10:31am revealed that the only marked exits from the enclosed parking garage were to the stair towers on the west and east sides of the garage and when the latch on the doors were operated the doors did not open. It was observed that there were magnetic locking devices installed on the doors that prevented them from opening unless someone first presented a proper card to the card reader adjacent to the door, otherwise the doors would not open. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and staff interview, the facility failed to maintain the doors found in a two-hour fire barrier. This condition had the potential to allow smoke and fire to migrate into separate buildings. The facility census was 9 patients.

Findings are:
Observation during the facility tour on 10/17/12, at 9:38 am revealed both sets of doors in the Hospital and Oakview Medical Office Building (OMB) Link failed to have latching hardware installed in the side of the doors near the bottom. Both sets of doors exceeded 1/8 " gap at the meeting edge of the doors as well.
In an interview conducted at the time of observation, (10/17/12, at 9:38 am), Engineering A acknowledged the findings.

Actual NFPA Standard:
NFPA 80, 3-4.3.2 Components.
Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
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. (3.18 mm ? 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Based on observation and interview the facility failed to have the required amount of emergency lighting installed in the enclosed parking garage to provide an average of at least 1 foot-candle throughout the means of egress of the entire parking garage. This deficient practice would affect all persons in the garage in the event of a power failure to the normal lighting to the area. The facility census is 9.
Findings are:
Observation on October 17, 2012 at 10:45am revealed that there was not the required average of 1 foot-candle of emergency lighting installed in the enclosed parking garage when all the normal lighting was turned off to the area. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation, record review and staff interview, the facility failed to maintain battery backup emergency lighting throughout the facility. This condition had the potential to leave occupants in darkness during a loss of power. The facility census was 9 patients.

Findings are:
Observations during the facility tour on 10/17/12, from 1:00 pm to 3:26 pm revealed:
1. The Aquatic Physical Therapy Area revealed battery backup emergency lights/exit signs failed to function when tested at the Pool ' s Main Exit.
2. The facility failed to provide verification that ceiling light fixtures were battery backup in the Aquatic Physical Therapy Area.
3. The MRI Services Area revealed battery backup emergency lights/exit signs failed to function when tested in the Cave Conference Room.
Record review revealed the facility failed to test battery backup emergency lights/exit signs monthly and annually based on the documentation reviewed. Documentation of testing failed to be provided for the whole facility.
In an interview conducted at the time of record review (10/17/12, from 1:00 pm to 3:26 pm), Engineering B confirmed the findings.

Actual NFPA Standard:
NFPA 101, 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 ? hours. Equipment shall be fully operation 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.

Based on observation, record review and staff interview, the facility failed to have the fire alarm installed and maintained in accordance with the National Fire Protection Association (NFPA), 72. This condition had the potential of not effectively alerting occupants of a fire emergency. The facility census was 9 patients.

Findings are:
During the fire alarm test on 10-17-12 between 1:00 pm to 2:00 pm revealed, the audible visual device in Sterile Processing storage room near the Break down exit door was blocked by restocking totes located on rolling carts.
During an interview on 10-17-12 at 1:45 pm, Safety A confirmed the audible visual device was blocked.



20404

Observations on October 16, 2012 from 3:00pm to 4:00pm revealed that none of the remote fire alarm control panels had the electrical branch circuit that supplies them marked at the control panel. These observations were confirmed in an interview with Engineering B at the above date and times.
Record review of fire alarm testing on 10/16/12, at 4:08 pm revealed that the Hospital failed to have the fire alarm inspected on a semi-annual frequency. Annual inspection reports were only available for review.
In an interview conducted at the time of observation and record review, (10/16/12, from 4:08 pm to 10/17/12, at 2:00 pm), Engineering A acknowledged the findings.



27395

Observations during the fire alarm test on 10/17/12, from 1:00 pm to 2:00 pm, revealed:
1. Strobes failed to be synced inside of the Link between the Hospital and the Oakview Medical Office Building (OMB) and the minimum decibel level failed to be met in the Link.
2. The fire alarm in the Oakview Medical Office Building (OMB) extended into the Link that connected the Hospital and the OMB. The fire alarm zones failed to be coincident to the outer walls, and not extend into separate occupancies.
3. Minimum decibel levels failed to be met throughout the Hospital.
4. The Aquarium Kitchen failed to have a fire alarm notification device installed in the room.

Actual NFPA Standard:
NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

NFPA 72, 7-3 Inspection and Testing Frequency.
7-3.1* Visual Inspection.
Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

NFPA 72, 6.8.6.2.2 The boundaries of notification zones shall be coincident with building outer walls, building fire or smoke compartment boundaries, floor separations, or other fire safety subdivisions.

Nebraska State Fire Marshal Official Interpretaton 03-04


NFPA 72, 1999ed. 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation, record review and staff interview, the facility failed to have the fire alarm installed and maintained in accordance with the National Fire Protection Association (NFPA), 72. This condition had the potential of not effectively alerting occupants of a fire emergency. The facility census was 9 patients.

Findings are:
Observations on October 16, 2012 from 1:00pm to 3:00pm revealed that none of the remote fire alarm control panels had the electrical branch circuit that supplies them marked at the control panel. These observations were confirmed in an interview with Engineering B at the above date and times.



27395

Observation on 10/17/12, between 1:00 pm and 2:00 pm revealed:
1. The Nebraska Orthopedic Conference Room 201 failed to have fire alarm notification installed in the room.
2. The MRI Equipment Room fire alarm strobe was blocked by an electrical panel/equipment and failed to be visible.
3. The Infusion Center failed to have an audible fire alarm notification device installed for the area.
4. The Human Resources Area 203 failed to have an audible fire alarm notification device installed for the area.
Record review of fire alarm testing on 10/16/12, at 3:52 pm revealed that the Oakview Medical Office Building failed to have the fire alarm inspected on a semi-annual frequency. Annual inspection reports were only available for review.
In an interview conducted at the time of observation and record review, (10/16/12, from 3:52 pm to 10/17/12, at 2:00 pm), Engineering A acknowledged the findings.

Actual NFPA Standard:
NFPA 72, 1999ed. 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Nebraska Fire Marshal Official Interpretation 95-03


NFPA 72, 7-3 Inspection and Testing Frequency.
7-3.1* Visual Inspection.
Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Based on observation and interview the facility failed to have a complete automatic sprinkler system installed in accordance with NFPA 13 by not having sprinkler protection under obstructions over 4 feet in width, by having sprinkler patterns that were obstructed, by not having and maintaining the required quantity and types of spare sprinkler heads, and by not having a pressure gauge installed on the supply side of the backflow preventer to determine if water was available to the building. These deficient practices have the potential to affect all residents, visitors and staff of the facility. The facility census is 9.
Findings are:
Observation on October 17, 2012 at 10:14am revealed that there was a sprinkler pattern obstruction on the south end of the sub-basement by Air Handling Unit #2 and its ductwork. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 10:17am revealed that there was no pressure gauge installed on the supply side of the sprinkler system backflow preventer to indicate if the there was water to the building or not. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 10:19am revealed that there was not a spare sprinkler head for all types and ratings of heads that are installed in the building so that they can be readily replaced if one is damaged. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 10:34am revealed that there was not sprinkler protection under obstructions over four feet in width in the marketing cage area garage ductwork. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that the X-ray machine in the ceiling tracks would not obstruct the sprinkler heads. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:36 am revealed an x-ray machine with a ceiling track in the ED area which has the potential to obstruct the sprinkler heads in the path of the track.
During an interview on 10-17-12 at 2:36 pm, Safety A confirmed the x-ray track in the ceiling which would obstruct the sprinkler heads.

NFPA Standard:
Unacceptable obstructions to spray patterns shall be corrected. 1998, NFPA 25, 2-2.1.2

Based on observation record review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the National Fire Protection Association (NFPA), 25. This condition increased the likelihood that the fire alarm would fail to activate when the sprinkler system activated. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:36 am revealed an x-ray machine with a ceiling track in the ED area which has the potential to obstruct the sprinkler heads in the path of the track.
During an interview on 10-17-12 at 2:36 pm, Safety A confirmed the x-ray track in the ceiling which would obstruct the sprinkler heads.



27395

Record review during the facility tour on 10/16/12, at 4:08 pm revealed that quarterly sprinkler inspections failed to be conducted for the Oakview Medical Office Building.
In an interview conducted at the time of record review, (10/16/12, at 4:08 pm), Engineering A confirmed that the sprinkler system was only tested annually.

NFPA Standard:
Unacceptable obstructions to spray patterns shall be corrected. 1998, NFPA 25, 2-2.1.2

NFPA 25, 2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7* Hydraulic Nameplate.
The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

Based on observation and interview the facility failed to have portable fire extinguishers installed throughout the enclosed parking garage such that the travel distance from any point in the garage to an extinguisher did not exceed 75 feet and that the extinguisher locations were readily identifiable. This deficient practice would affect all persons in the enclosed parking garage in the event of a fire. Facility census is 9.

Findings are:
Observation on October 17, 2012 at 10:40am revealed that the travel distance from some areas of the enclosed parking garage to a portable fire extinguisher exceeded 75 feet and that some locations of portable fire extinguishers were not readily identifiable from all areas of the parking garage. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation and interview the facility failed to have and maintain the kitchen hood suppression system in accordance with NFPA 96 by not having the Class K portable fire extinguisher properly mounted, by not having the manual activation device installed at the correct height, by not having a positive placement device installed on appliances with wheels such that they are returned to the proper design location, and by not having proper coverage for the protected appliances. This deficient practice has the potential to affect all residents, visitors, and staff of the facility. The facility census is 9.

Findings are:
Observation on October 17, 2012 at 9:49am revealed that the Class K portable fire extinguisher in the kitchen was installed such that the top of the extinguisher was more than five feet above the finished floor of the kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:52am revealed that the manual activation device for the kitchen hood suppression system was not installed such that the activation portion of the handle was located between 42 and 48 inches above the finished floor of the kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:54am revealed that the fryer was on wheels and that there was no positive placement device installed to ensure that when the appliance was moved for cleaning that it is returned to the proper design location for the suppression system. This observation was confirmed in an interview with Engineering B at the above date and time.
An interview with Engineering B on October 17, 2012 at 9:54am revealed that the fryer was a newly installed fryer and that the old one was in the parking garage and that the suppression system had not been re-evaluated for the proper protection of the new fryer.
Observation on October 17, 2012 at 9:55am revealed that nozzle for the fryer was not properly aimed at the center of the fryer. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation and interview, the facility failed to maintain the egress corridor at the Ambulance ramp free of obstructions. This deficient practice would delay exiting through this corridor during an emergency. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:29 pm revealed, that the exit through the Ambulance ramp was used as a storage area for a decontamination shower, buckets, chairs and totes.
During an interview at 10-17-12 at 2:29 pm, Safety A confirmed the obstructions in the Ambulance ramp exit.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview, the facility failed to maintain exit corridors free of obstructions at all. This condition had the potential to slow evacuation during a fire. Facility census was 9.

Findings are:
Observations on 10-17-12 at 2:29 pm revealed, that the exit through the Ambulance ramp was used as a storage area for a decontamination shower, buckets, chairs and totes.
During an interview at 10-17-12 at 2:29 pm, Safety A confirmed the obstructions in the Ambulance ramp exit.




27395

Observation during the facility tour on 10/17/12, at 3:33 pm revealed combustible storage of cardboard recycling containers in the exit corridor from the MRI Kitchen.
In an interview conducted at the time of observation, (10/17/12, at 3:33 pm), Engineering B acknowledged the storage left unattended in the exit corridor.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on Observation and interview the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 2002 edition by not providing proper emergency lighting in the area of the emergency generator. This deficient practice has the potential to affect all occupants of the facility. The facility census is 9.

Findings are:
Observation on October 16, 2012 at 3:02pm revealed that the emergency lighting in the area of the emergency generator in the generator enclosure was not connected to the normal lighting for the area and that the emergency light was plugged into a receptacle circuit in the enclosure with a cord that was longer than 3 feet. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
NFPA 70, 1999ed. 700-12(e) Unit Equipment. ...Unit equipment shall be permanently fixed in place and shall have all wiring to each unit installed in accordance with requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 feet in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches ....

Based on observation and interview the facility failed to maintain compressed gas cylinders such that they were restrained to prevent them from falling or being knocked over to prevent them from becoming a flying projectile. This deficient practice has the potential to harm all residents, visitors, and staff of the facility. The facility census is 9.

Findings are:
Observation on October 17, 2012 at 10:06am revealed that there were four unrestrained carbon dioxide compressed gas cylinders in the garage area kitchen storage. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. The facility census was 9 patients.

Findings are:
Record review during the facility tour of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of the Hospital generator.
In an interview conducted at the time of record review (10/17/12 at 7:42 am), Engineering A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

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.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. The facility census was 9 patients.

Findings are:
Record review during the facility tour of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of the generator for the Oakview Medical Office Building.
In an interview conducted at the time of record review (10/17/12 at 7:42 am), Engineering A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Refer to A-6-3.1 for an example of a complete maintenance checklist.

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.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 9.

Findings are:
Observation on October 16, 2012 at 3:13pm revealed that there were the following non-Life Safety loads connected to the Life Safety branch panel LLLA; (14) Water Softeners, (16) Mechanical room receptacles, (18) AHU #2 Controls, and (22) AHU #1 Controls . This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 16, 2012 at 3:23pm revealed that the Life Safety load for the fire alarm communicator was connected only to normal power panel LQTA. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 16, 2012 at 3:33pm revealed that there were the following Life Safety loads connected to the Equipment system branch panel LQEL; (1) Elevator Cab Lights, (3) Elevator Cab Lights, and (4) elevator Shaft dampers. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 8:47am revealed that there were the following Life Safety loads connected to the critical branch panel 1CLB; (40) Recovery Med Gas alarm panel and (42) Fire Alarm Booster. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 8:53am revealed that there were the following Life Safety loads connected to the critical branch panel T1CLC; (8) Fire Alarm Booster Panel, (16) Med Gas, and (28) Fire Suppression Panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 8:56am revealed that there were the following Life Safety loads connected to the equipment system panel 1QLA; (10) Center Corridor Doors, (12) Front west entry doors, (14) front west entry doors, (15) Fire alarm Relay power, (17) Nitrous Oxide Gas panel, and (19) Nitrogen Control Panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:02am revealed that there was the following Critical Branch loads connected to the equipment system panel 1QTA; (1) Nurse Call. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:04am revealed that there were the following Life Safety loads connected to the critical branch panel 1CLA; (5) Med Gas Alarm Panel and (18) Area gas alarm panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:16am revealed that there was the following Life Safety load connected to the critical branch panel 2BLC; (5) Med Gas alarm panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:16am revealed that there was the following non-critical load connected to the critical branch panel 2CLB; (26) temperature control panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:18am revealed that there was the following Critical load connected to the equipment system panel 2QTA; (7) Nurse call control cabinet. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:22am revealed that there were the following Life Safety loads connected to the critical branch panel 2CLA; (1) Med gas alarms and (28) Ansul micro switch kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:22am revealed that there were the following non-critical loads connected to the critical branch panel 2CLA; (26) temperature control panel, (30) Closet receptacles, (31,33,35) Turbo in Kitchen, and (32,34,36) Flat top in Kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:44am revealed that the kitchen hood exhaust fan was not connected to the equipment as required and is only connected to the normal power panel 2NLK. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA 70, 1999ed.
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 maintenance (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 ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This condition created the potential of an electrical fire. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:05 pm and 2:41 pm revealed:
1. IT cabinet with equipment which runs patients medical equipment was plugged into a non-hospital grade power-strip in the Staff Hall in the OR area.
2. Medical equipment in Exam Room 5 plugged into a non-hospital grade power-strip.
During an interview on 10-17-12 at 2:05 pm and 2:41 pm, Safety A confirmed the use of non-hospital grade power-strips for medical equipment.



27395

Observations during the facility tour on 10/17/12, from 10:02 am to 2:20 pm revealed:
1. A microwave failed to be plugged directly into a wall outlet in the 2nd Floor Break Room. The microwave was plugged into a power strip.
2. Power strips failed to be plugged directly into a wall outlet in the 2nd Floor Housekeeping Room. Power strips were plugged into each other.
3. Nurse call equipment was plugged into an extension cord in the 2nd Floor East Storage Room near the Stairwell. Extension cords are not to be used in lieu of permanent wiring.
4. Power strips failed to be plugged directly into a wall outlet and were plugged into each other in the 1st Floor Front Corridor IT Office under the desk by the window.
In an interview conducted at the time of observations, (10/17/12, from 10:02 am to 2:20 pm), Engineering A acknowledged the findings.

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8



20404

Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose, by using cords and relocatable power taps as a substitute for permanent wiring, by not having approved covers installed on all electrical boxes, by not having proper exit hardware on doors from large equipment rooms and by not providing signage at the main electrical service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 9.
Findings are:
Observation on October 18, 2012 at 8:52am revealed that the feeder for the Critical branch panel T1CLC was not properly identified. It was only labeled as 1CLC. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 18, 2012 at 9:06am revealed that the electrical panel adjacent to critical panel 1CLA in the OR staff lounge electrical room was not identified at all. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:19am revealed that not all circuits in the equipment system panel 2QTA were identified as to their use. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on October 16, 2012 at 3:07pm revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.
Observation on October 16, 2012 at 3:08pm revealed that the main electrical room contained large equipment rated at 1200 amperes or more and over six feet in width. The egress door from the room was not equipped with panic hardware. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 2002ed. 110-26(2) Large Equipment. For equipment rated 1200 amperes or more and over 1.8 m (6 ft) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance to the required working space not less than 610 mm (24 in.) wide and 2.0 m (6? ft) high at each end of the working space. Where the entrance has a personnel door(s), the door(s) shall open in the direction of egress and be equipped with panic bars, pressure plates, or other devices that are normally latched but open under simple pressure.

Observation on October 17, 2012 at 9:08am revealed that there was an extension cord plugged into a relocatable power tap that was run through the wall to a television in permanent use in the OR staff lounge electrical room to the OR scheduling television monitor. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:20am revealed that there was a relocatable power tap installed as a substitute for permanent wiring in the second floor housekeeping electrical room. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA 70, 1999ed. 110-3(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included with the listing and labeling.
NFPA 70, 1999ed. 400-8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure, (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors, (3) Where run through doorways, windows, or similar openings, (4) Where attached to building surfaces, (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings, or (6) Where installed in raceways, except as otherwise permitted in this Code.

Observation on October 17, 2012 at 10:24am revealed that there were two open electrical boxes with wires exposed to the two overhead door operators for the enclosed parking garage. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 370.25 Covers and Canopies. In completed installations, each box, shall have a cover, faceplate, or fixture canopy.

Based on observation and interview, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This practice affected all patients, visitors and staff that are in the area of the open electrical boxes and power strips. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:05 pm and 2:41 pm revealed:
1. IT cabinet with equipment which runs patients medical equipment was plugged into a non-hospital grade power-strip in the Staff Hall in the OR area.
2. Medical equipment in Exam Room 5 plugged into a non-hospital grade power-strip.
During an interview on 10-17-12 at 2:05 pm and 2:41 pm, Safety A confirmed the use of non-hospital grade power-strips for medical equipment.

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8



20404

Based on observation and interview the facility failed to identify the multiple main disconnects and to identify the type, size and location of the emergency power supply system at the main service disconnect for the building to alert responding personnel that there is an alternate source of power in the building and that shutting off the main service disconnect will not turn off all power in the building in the case of an emergency. The facility also failed to correctly identify all feeders and branch circuits and failed to have approved covers installed on all devices. This deficient practice has the potential to affect all occupants of the facility. The facility census is 9.

Findings are
Observation on October 17, 2012 at 8:39am revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.
Observation on October 17, 2012 at 8:38am revealed that the facility had three main disconnects for the facility and that they were not identified as being three mains are required by code. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 230-72(a) Grouping of Disconnects-General. The two to six disconnects as permitted in 230-71 shall be grouped. Each disconnect shall be marked to indicate the load served.
Observation on October 16, 2012 at 2:18pm revealed that the panel EP1E2-1 was actually labeled as being panel EP1E2-2. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 110.22 Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on October 16, 2012 at 2:30pm revealed that the receptacle in room 1087 did not have an approved cover installed. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 16, 2012 at 2:33pm revealed that the receptacle in the second floor electrical room did not have an approved cover installed. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA 70, 1999ed. 410-56(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 inches from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Based on observation and interview the facility failed to have Alcohol Based Hand Rub (ABHR) dispensers installed so that they are not installed immediately above an ignition source, which increased the potential for electrical ignition for a fire. The facility census was 9 patients.

Findings are:
Observations on 10-17-11 at 2:27 pm revealed an ABHR installed above electrical outlet in the OMB sterile room.
During an interview on 10-17-12 at 2:27 pm, Safety A confirmed the alcohol based hand sanitizer installed immediately above an electrical source.

Regulation:
Nebraska State Fire Marshal Official Interpretation 05-04.

Based on observation and staff interview, the facility failed to maintain spray-applied fire proofing. This condition had the potential for a structural beam to weaken and collapse more quickly. The facility census was 9 patients.

Findings are:
Observation during the facility tour on 10/17/12, at 11:00 am revealed missing spray-applied fire proofing from a beam above ceiling near the 2nd Floor, East Stairwell.
In an interview conducted at the time of observation, (10/17/12, at 11:00 am), Engineering A confirmed the fire proofing failed to be re-applied.

Based on observation and interview, the facility failed to provide documentation to verify interior finishes for rooms and spaces not used for corridors or exit ways that have a flame spread rating of Class A or Class B. Facility census was 9 patients.

Findings are:
Observations on 10-12-11 at 2:43 pm revealed, a fabric accordion door room divider between Exam Rooms 7 and 8.
During an interview on 10-17-12 at 2:43 pm, Safety A confirmed the room divider and failed to provide documentation for a fire rating.

NFPA Standard:
Ceiling and wall materials shall be limited as specified in 2000 NFPA 101, 10.2.3 Existing materials may be Class A or Class B except that rooms protected by an approved, supervised automatic sprinkler system use of existing Class C finish shall be permitted within rooms separated from the exit access corridors in accordance with 19.3.6. New materials must be Class A except that new walls/ceilings shall be permitted to have Class A or Class B finish in individual rooms having a capacity of four persons. Newly installed corridor wall finish not exceeding 4 feet in height on the lower half of the wall shall be permitted to be Class A or Class B. 2000 NFPA 101, 19.3.3.2

Based on observation and interview, the facility failed to assure that medical equipment did not block exam room doors. This deficient practice would not contain the spread of fire and smoke into exit corridors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:48 pm revealed, a blood pressure machine obstructed the door to Exam Room 5 when the door was tested.
During an interview on 10-17-12 at 2:48 pm, Safety A confirmed the door was obstructed with equipment and failed to engage the door frame.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation, documentation review and staff interview, the facility failed to maintain or provide latching hardware in corridor doors or to ensure that corridor doors would resist the passage of smoke. This condition had the potential to allow smoke or fire to migrate into exit corridors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 between 10:12 am to 11:30 am revealed, that 8 of 8 OR rooms had double doors which failed to provide latching devices and with gaps greater than 1/8 inch between doors.
Documentation review on 10-17-12 revealed the floor plan indicated that the OR suite was 13,870 square feet.
During an interview on 10-17-12 between 10:12 am to 11:30 am, Safety A confirmed the findings.



27395

Observations during the facility tour on 10/17/12, from 9:52 am to 2:51 pm revealed:
1. A trash can prevented the In-Patient Physical Therapy room door from latching when the door released from the magnetic hold-open.
2. Food and bowls obstructed the Kitchen roll-down fire shutter from closing completely.
3. The Post-Op Doors failed to have latching hardware installed in the corridor doors.
In an interview conducted at the time of observation, (10/17/12, from 9:52 am to 2:51 pm), Engineering A acknowledged the findings.

NFPA Standard:
Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Any suite of rooms that complies with the requirements of 19.2.5 shall be permitted to be subdivided with non-fire-rated, noncombustible, or limited-combustible partitions. 2000, NFPA 101, 19.2.5.4

Intervening rooms shall not be hazardous areas as defined by 19.3.2. 2000, NFPA 101, 19.2.5.5

Suites of rooms, other than patient sleeping rooms, shall not exceed 10,000 ft2.
2000, NFPA 101, 19.2.5.7

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 9.

Findings are:
Observations during the facility tour on 10/17/12, from 9:48 am to 10:15 am on the 2nd Floor revealed:
1. An exit sign failed to be installed above the west double doors near the X-Ray.
2. An exit sign failed to be installed above the east double doors on the east side of the doors.
In an interview conducted at the time of observations (10/17/12, from 9:48 am to 10:15 am), Engineering A confirmed that exit signs were not visible in two directions when the double doors closed.

Based on observation and interview, the facility failed to ensure that smoke separation doors are capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread smoke compartments. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 11:27 am and 11:55 am revealed:
1. The space between the smoke doors in the East OR corridor was greater than 1/8 inch.
2. The space between the smoke doors in the West OR corridor was greater than 1/8 inch.

During an interview on 10-17-12 at 11:27 am and 11:55 am, Safety A confirmed the space between the doors were greater than 1/8 inch.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 19.3.7.6*.

Based on observation and interview the facility failed to maintain the doors to hazardous areas so that they would close and latch within the door frame or provide self-closing devices on those doors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:15 pm and 2:26 pm revealed:
1. The door to the dirty side of the Decontamination Room failed to latch within the door frame.
2. The ED Break room door failed to provide a self-closing device, appeared to have been removed.
During an interview on 10-17-12 at both times of observations, Safety A confirmed the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential for smoke and fire to spread into the egress corridors. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 between 10:07 am and 11:15 am revealed:
1. The doors to the " Future OR " which was used as a storage room failed to close and latch within the door frames.
2. The door to the " Viewing Room " which was used as a storage room failed to close and latch within the door frame.
3. OR Clean Storage room double doors failed to close and latch, doors failed to close in sequence. The inactive leaf failed to provide latching device and was not locked into the frame.
4. The double doors to Clean OR storage room failed to provide latching device.
5. Hopper room in the Decon area was over 50 square feet and failed to provide a self-closing device on the door.
6. Radiology Processing room over 50 square feet and failed to provide a self-closing device on the door.
7. Unsealed penetration around electrical conduit above the ceiling tile outside the " Viewing room " above the door.
8. The double doors to Decon Room failed to provide latching device.

During an interview on 10-17-12 between 10:07 am and 11:15 am, Safety A confirmed all the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and interview the facility failed to allow egress from the access-controlled egress doors at the ED front exit as required by the NFPA (National Fire Protection Association) by allowing the exit doors to be manually locked. This deficient practice would prevent egress and delay evacuation in a fire emergency. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:59 pm revealed, 2 of 2 of the access-controlled doors at the ED front lobby exit were equipped with a thumb turn lock.
During an interview on 10-17-12 at 2:59 pm, Safety A confirmed all the findings.

NFPA Standard:
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, provided that the following criteria are met: doors shall unlock upon actuation of an approved, supervised automatic sprinkler system or any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system; the doors shall unlock upon loss of power; an irreversible process shall release the lock within 15 seconds upon application of a force not to exceed 15 pounds nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only; on the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch wide on a contrasting background that reads as follows: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS. 2000 NFPA 101, 7.2.1.6.1

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

NFPA Standard:
Doors located in the means of egress that are permitted to be locked shall have adequate provisions for the rapid removal of occupants such as remote control, the keying of all locks to keys carried by staff at all times, or knowledge of the code. Only one such locking device shall be permitted on each door. 2000 NFPA 101, 19.2.2.2.5

Based on observation and interview, the facility failed to provide exit access from an egress without the use of a special tool or knowledge from the egress side. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 11:33 am, revealed a magnetic lock on the exit door in the Clean Room leading to the Break Down room. The facility failed to indicate how the function works for the " push to exit button " and the automatic eye failed to operate.
During an interview on 10-17-12 at 11:33 am, Safety A confirmed the lack of signage on the " push to exit button " and stated the automatic eye failed to operate.



20404

Observations on October 17, 2012 at 10:10am and 10:31am revealed that the only marked exits from the enclosed parking garage were to the stair towers on the west and east sides of the garage and when the latch on the doors were operated the doors did not open. It was observed that there were magnetic locking devices installed on the doors that prevented them from opening unless someone first presented a proper card to the card reader adjacent to the door, otherwise the doors would not open. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA Standard:
A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor. Doors shall be operable with not more than one releasing operation. 2000 NFPA 101, 7.2.1.5.4

Based on observation and staff interview, the facility failed to maintain the doors found in a two-hour fire barrier. This condition had the potential to allow smoke and fire to migrate into separate buildings. The facility census was 9 patients.

Findings are:
Observation during the facility tour on 10/17/12, at 9:38 am revealed both sets of doors in the Hospital and Oakview Medical Office Building (OMB) Link failed to have latching hardware installed in the side of the doors near the bottom. Both sets of doors exceeded 1/8 " gap at the meeting edge of the doors as well.
In an interview conducted at the time of observation, (10/17/12, at 9:38 am), Engineering A acknowledged the findings.

Actual NFPA Standard:
NFPA 80, 3-4.3.2 Components.
Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
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. (3.18 mm ? 1.59 mm) for steel doors and shall not exceed 1/8 in. (3.18 mm) for wood doors.

Based on observation and interview the facility failed to have the required amount of emergency lighting installed in the enclosed parking garage to provide an average of at least 1 foot-candle throughout the means of egress of the entire parking garage. This deficient practice would affect all persons in the garage in the event of a power failure to the normal lighting to the area. The facility census is 9.
Findings are:
Observation on October 17, 2012 at 10:45am revealed that there was not the required average of 1 foot-candle of emergency lighting installed in the enclosed parking garage when all the normal lighting was turned off to the area. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation, record review and staff interview, the facility failed to maintain battery backup emergency lighting throughout the facility. This condition had the potential to leave occupants in darkness during a loss of power. The facility census was 9 patients.

Findings are:
Observations during the facility tour on 10/17/12, from 1:00 pm to 3:26 pm revealed:
1. The Aquatic Physical Therapy Area revealed battery backup emergency lights/exit signs failed to function when tested at the Pool ' s Main Exit.
2. The facility failed to provide verification that ceiling light fixtures were battery backup in the Aquatic Physical Therapy Area.
3. The MRI Services Area revealed battery backup emergency lights/exit signs failed to function when tested in the Cave Conference Room.
Record review revealed the facility failed to test battery backup emergency lights/exit signs monthly and annually based on the documentation reviewed. Documentation of testing failed to be provided for the whole facility.
In an interview conducted at the time of record review (10/17/12, from 1:00 pm to 3:26 pm), Engineering B confirmed the findings.

Actual NFPA Standard:
NFPA 101, 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 ? hours. Equipment shall be fully operation 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.

Based on observation, record review and staff interview, the facility failed to have the fire alarm installed and maintained in accordance with the National Fire Protection Association (NFPA), 72. This condition had the potential of not effectively alerting occupants of a fire emergency. The facility census was 9 patients.

Findings are:
During the fire alarm test on 10-17-12 between 1:00 pm to 2:00 pm revealed, the audible visual device in Sterile Processing storage room near the Break down exit door was blocked by restocking totes located on rolling carts.
During an interview on 10-17-12 at 1:45 pm, Safety A confirmed the audible visual device was blocked.



20404

Observations on October 16, 2012 from 3:00pm to 4:00pm revealed that none of the remote fire alarm control panels had the electrical branch circuit that supplies them marked at the control panel. These observations were confirmed in an interview with Engineering B at the above date and times.
Record review of fire alarm testing on 10/16/12, at 4:08 pm revealed that the Hospital failed to have the fire alarm inspected on a semi-annual frequency. Annual inspection reports were only available for review.
In an interview conducted at the time of observation and record review, (10/16/12, from 4:08 pm to 10/17/12, at 2:00 pm), Engineering A acknowledged the findings.



27395

Observations during the fire alarm test on 10/17/12, from 1:00 pm to 2:00 pm, revealed:
1. Strobes failed to be synced inside of the Link between the Hospital and the Oakview Medical Office Building (OMB) and the minimum decibel level failed to be met in the Link.
2. The fire alarm in the Oakview Medical Office Building (OMB) extended into the Link that connected the Hospital and the OMB. The fire alarm zones failed to be coincident to the outer walls, and not extend into separate occupancies.
3. Minimum decibel levels failed to be met throughout the Hospital.
4. The Aquarium Kitchen failed to have a fire alarm notification device installed in the room.

Actual NFPA Standard:
NFPA Standard:
A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, and NFPA 72. 2000 NFPA 101, 9.6.1.4

NFPA 72, 7-3 Inspection and Testing Frequency.
7-3.1* Visual Inspection.
Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

NFPA 72, 6.8.6.2.2 The boundaries of notification zones shall be coincident with building outer walls, building fire or smoke compartment boundaries, floor separations, or other fire safety subdivisions.

Nebraska State Fire Marshal Official Interpretaton 03-04


NFPA 72, 1999ed. 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Based on observation, record review and staff interview, the facility failed to have the fire alarm installed and maintained in accordance with the National Fire Protection Association (NFPA), 72. This condition had the potential of not effectively alerting occupants of a fire emergency. The facility census was 9 patients.

Findings are:
Observations on October 16, 2012 from 1:00pm to 3:00pm revealed that none of the remote fire alarm control panels had the electrical branch circuit that supplies them marked at the control panel. These observations were confirmed in an interview with Engineering B at the above date and times.



27395

Observation on 10/17/12, between 1:00 pm and 2:00 pm revealed:
1. The Nebraska Orthopedic Conference Room 201 failed to have fire alarm notification installed in the room.
2. The MRI Equipment Room fire alarm strobe was blocked by an electrical panel/equipment and failed to be visible.
3. The Infusion Center failed to have an audible fire alarm notification device installed for the area.
4. The Human Resources Area 203 failed to have an audible fire alarm notification device installed for the area.
Record review of fire alarm testing on 10/16/12, at 3:52 pm revealed that the Oakview Medical Office Building failed to have the fire alarm inspected on a semi-annual frequency. Annual inspection reports were only available for review.
In an interview conducted at the time of observation and record review, (10/16/12, from 3:52 pm to 10/17/12, at 2:00 pm), Engineering A acknowledged the findings.

Actual NFPA Standard:
NFPA 72, 1999ed. 1-5.2.5.2 Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.

Nebraska Fire Marshal Official Interpretation 95-03


NFPA 72, 7-3 Inspection and Testing Frequency.
7-3.1* Visual Inspection.
Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Based on observation and interview the facility failed to have a complete automatic sprinkler system installed in accordance with NFPA 13 by not having sprinkler protection under obstructions over 4 feet in width, by having sprinkler patterns that were obstructed, by not having and maintaining the required quantity and types of spare sprinkler heads, and by not having a pressure gauge installed on the supply side of the backflow preventer to determine if water was available to the building. These deficient practices have the potential to affect all residents, visitors and staff of the facility. The facility census is 9.
Findings are:
Observation on October 17, 2012 at 10:14am revealed that there was a sprinkler pattern obstruction on the south end of the sub-basement by Air Handling Unit #2 and its ductwork. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 10:17am revealed that there was no pressure gauge installed on the supply side of the sprinkler system backflow preventer to indicate if the there was water to the building or not. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 10:19am revealed that there was not a spare sprinkler head for all types and ratings of heads that are installed in the building so that they can be readily replaced if one is damaged. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 10:34am revealed that there was not sprinkler protection under obstructions over four feet in width in the marketing cage area garage ductwork. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that the X-ray machine in the ceiling tracks would not obstruct the sprinkler heads. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:36 am revealed an x-ray machine with a ceiling track in the ED area which has the potential to obstruct the sprinkler heads in the path of the track.
During an interview on 10-17-12 at 2:36 pm, Safety A confirmed the x-ray track in the ceiling which would obstruct the sprinkler heads.

NFPA Standard:
Unacceptable obstructions to spray patterns shall be corrected. 1998, NFPA 25, 2-2.1.2

Based on observation record review and staff interview, the facility failed to maintain the fire sprinkler system in accordance with the National Fire Protection Association (NFPA), 25. This condition increased the likelihood that the fire alarm would fail to activate when the sprinkler system activated. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:36 am revealed an x-ray machine with a ceiling track in the ED area which has the potential to obstruct the sprinkler heads in the path of the track.
During an interview on 10-17-12 at 2:36 pm, Safety A confirmed the x-ray track in the ceiling which would obstruct the sprinkler heads.



27395

Record review during the facility tour on 10/16/12, at 4:08 pm revealed that quarterly sprinkler inspections failed to be conducted for the Oakview Medical Office Building.
In an interview conducted at the time of record review, (10/16/12, at 4:08 pm), Engineering A confirmed that the sprinkler system was only tested annually.

NFPA Standard:
Unacceptable obstructions to spray patterns shall be corrected. 1998, NFPA 25, 2-2.1.2

NFPA 25, 2-2.6 Alarm Devices.
Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7* Hydraulic Nameplate.
The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

Based on observation and interview the facility failed to have portable fire extinguishers installed throughout the enclosed parking garage such that the travel distance from any point in the garage to an extinguisher did not exceed 75 feet and that the extinguisher locations were readily identifiable. This deficient practice would affect all persons in the enclosed parking garage in the event of a fire. Facility census is 9.

Findings are:
Observation on October 17, 2012 at 10:40am revealed that the travel distance from some areas of the enclosed parking garage to a portable fire extinguisher exceeded 75 feet and that some locations of portable fire extinguishers were not readily identifiable from all areas of the parking garage. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation and interview the facility failed to have and maintain the kitchen hood suppression system in accordance with NFPA 96 by not having the Class K portable fire extinguisher properly mounted, by not having the manual activation device installed at the correct height, by not having a positive placement device installed on appliances with wheels such that they are returned to the proper design location, and by not having proper coverage for the protected appliances. This deficient practice has the potential to affect all residents, visitors, and staff of the facility. The facility census is 9.

Findings are:
Observation on October 17, 2012 at 9:49am revealed that the Class K portable fire extinguisher in the kitchen was installed such that the top of the extinguisher was more than five feet above the finished floor of the kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:52am revealed that the manual activation device for the kitchen hood suppression system was not installed such that the activation portion of the handle was located between 42 and 48 inches above the finished floor of the kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:54am revealed that the fryer was on wheels and that there was no positive placement device installed to ensure that when the appliance was moved for cleaning that it is returned to the proper design location for the suppression system. This observation was confirmed in an interview with Engineering B at the above date and time.
An interview with Engineering B on October 17, 2012 at 9:54am revealed that the fryer was a newly installed fryer and that the old one was in the parking garage and that the suppression system had not been re-evaluated for the proper protection of the new fryer.
Observation on October 17, 2012 at 9:55am revealed that nozzle for the fryer was not properly aimed at the center of the fryer. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on observation and interview, the facility failed to maintain the egress corridor at the Ambulance ramp free of obstructions. This deficient practice would delay exiting through this corridor during an emergency. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:29 pm revealed, that the exit through the Ambulance ramp was used as a storage area for a decontamination shower, buckets, chairs and totes.
During an interview at 10-17-12 at 2:29 pm, Safety A confirmed the obstructions in the Ambulance ramp exit.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on observation and staff interview, the facility failed to maintain exit corridors free of obstructions at all. This condition had the potential to slow evacuation during a fire. Facility census was 9.

Findings are:
Observations on 10-17-12 at 2:29 pm revealed, that the exit through the Ambulance ramp was used as a storage area for a decontamination shower, buckets, chairs and totes.
During an interview at 10-17-12 at 2:29 pm, Safety A confirmed the obstructions in the Ambulance ramp exit.




27395

Observation during the facility tour on 10/17/12, at 3:33 pm revealed combustible storage of cardboard recycling containers in the exit corridor from the MRI Kitchen.
In an interview conducted at the time of observation, (10/17/12, at 3:33 pm), Engineering B acknowledged the storage left unattended in the exit corridor.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

Based on Observation and interview the facility failed to have the Level 1 emergency generator installed in accordance with NFPA 110, 2002 edition by not providing proper emergency lighting in the area of the emergency generator. This deficient practice has the potential to affect all occupants of the facility. The facility census is 9.

Findings are:
Observation on October 16, 2012 at 3:02pm revealed that the emergency lighting in the area of the emergency generator in the generator enclosure was not connected to the normal lighting for the area and that the emergency light was plugged into a receptacle circuit in the enclosure with a cord that was longer than 3 feet. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 110, 2002ed. 7.3 The Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This requirement shall not apply to units located outdoors in enclosures that do not include walk-in access. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
NFPA 70, 1999ed. 700-12(e) Unit Equipment. ...Unit equipment shall be permanently fixed in place and shall have all wiring to each unit installed in accordance with requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 feet in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the normal lighting in the area and connected ahead of any local switches ....

Based on observation and interview the facility failed to maintain compressed gas cylinders such that they were restrained to prevent them from falling or being knocked over to prevent them from becoming a flying projectile. This deficient practice has the potential to harm all residents, visitors, and staff of the facility. The facility census is 9.

Findings are:
Observation on October 17, 2012 at 10:06am revealed that there were four unrestrained carbon dioxide compressed gas cylinders in the garage area kitchen storage. This observation was confirmed in an interview with Engineering B at the above date and time.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. The facility census was 9 patients.

Findings are:
Record review during the facility tour of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of the Hospital generator.
In an interview conducted at the time of record review (10/17/12 at 7:42 am), Engineering A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Please refer to A-6-3.1 for an example of a complete maintenance checklist.

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.

Based on record review and staff interview, the facility failed to provide documentation that the generator had been tested in accordance with the National Fire Protection Association 110. This condition increased the potential that the generator would not function during an emergency. The facility census was 9 patients.

Findings are:
Record review during the facility tour of emergency generator maintenance and testing revealed that the facility failed to document weekly testing of the generator for the Oakview Medical Office Building.
In an interview conducted at the time of record review (10/17/12 at 7:42 am), Engineering A confirmed that the information was not recorded.

Actual NFPA Standard:
NFPA 110, 6-3.1*
The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

Note: Refer to A-6-3.1 for an example of a complete maintenance checklist.

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.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 9.

Findings are:
Observation on October 16, 2012 at 3:13pm revealed that there were the following non-Life Safety loads connected to the Life Safety branch panel LLLA; (14) Water Softeners, (16) Mechanical room receptacles, (18) AHU #2 Controls, and (22) AHU #1 Controls . This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 16, 2012 at 3:23pm revealed that the Life Safety load for the fire alarm communicator was connected only to normal power panel LQTA. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 16, 2012 at 3:33pm revealed that there were the following Life Safety loads connected to the Equipment system branch panel LQEL; (1) Elevator Cab Lights, (3) Elevator Cab Lights, and (4) elevator Shaft dampers. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 8:47am revealed that there were the following Life Safety loads connected to the critical branch panel 1CLB; (40) Recovery Med Gas alarm panel and (42) Fire Alarm Booster. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 8:53am revealed that there were the following Life Safety loads connected to the critical branch panel T1CLC; (8) Fire Alarm Booster Panel, (16) Med Gas, and (28) Fire Suppression Panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 8:56am revealed that there were the following Life Safety loads connected to the equipment system panel 1QLA; (10) Center Corridor Doors, (12) Front west entry doors, (14) front west entry doors, (15) Fire alarm Relay power, (17) Nitrous Oxide Gas panel, and (19) Nitrogen Control Panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:02am revealed that there was the following Critical Branch loads connected to the equipment system panel 1QTA; (1) Nurse Call. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:04am revealed that there were the following Life Safety loads connected to the critical branch panel 1CLA; (5) Med Gas Alarm Panel and (18) Area gas alarm panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:16am revealed that there was the following Life Safety load connected to the critical branch panel 2BLC; (5) Med Gas alarm panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:16am revealed that there was the following non-critical load connected to the critical branch panel 2CLB; (26) temperature control panel. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:18am revealed that there was the following Critical load connected to the equipment system panel 2QTA; (7) Nurse call control cabinet. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:22am revealed that there were the following Life Safety loads connected to the critical branch panel 2CLA; (1) Med gas alarms and (28) Ansul micro switch kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:22am revealed that there were the following non-critical loads connected to the critical branch panel 2CLA; (26) temperature control panel, (30) Closet receptacles, (31,33,35) Turbo in Kitchen, and (32,34,36) Flat top in Kitchen. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:44am revealed that the kitchen hood exhaust fan was not connected to the equipment as required and is only connected to the normal power panel 2NLK. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA 70, 1999ed.
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 maintenance (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 ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This condition created the potential of an electrical fire. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:05 pm and 2:41 pm revealed:
1. IT cabinet with equipment which runs patients medical equipment was plugged into a non-hospital grade power-strip in the Staff Hall in the OR area.
2. Medical equipment in Exam Room 5 plugged into a non-hospital grade power-strip.
During an interview on 10-17-12 at 2:05 pm and 2:41 pm, Safety A confirmed the use of non-hospital grade power-strips for medical equipment.



27395

Observations during the facility tour on 10/17/12, from 10:02 am to 2:20 pm revealed:
1. A microwave failed to be plugged directly into a wall outlet in the 2nd Floor Break Room. The microwave was plugged into a power strip.
2. Power strips failed to be plugged directly into a wall outlet in the 2nd Floor Housekeeping Room. Power strips were plugged into each other.
3. Nurse call equipment was plugged into an extension cord in the 2nd Floor East Storage Room near the Stairwell. Extension cords are not to be used in lieu of permanent wiring.
4. Power strips failed to be plugged directly into a wall outlet and were plugged into each other in the 1st Floor Front Corridor IT Office under the desk by the window.
In an interview conducted at the time of observations, (10/17/12, from 10:02 am to 2:20 pm), Engineering A acknowledged the findings.

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8



20404

Based on Observation and interview the facility failed to maintain the electrical system in accordance with the National Electrical Code by not having feeders and branch circuits clearly identified as to use and purpose, by using cords and relocatable power taps as a substitute for permanent wiring, by not having approved covers installed on all electrical boxes, by not having proper exit hardware on doors from large equipment rooms and by not providing signage at the main electrical service disconnect to indicate the presence of an emergency power supply system. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility census is 9.
Findings are:
Observation on October 18, 2012 at 8:52am revealed that the feeder for the Critical branch panel T1CLC was not properly identified. It was only labeled as 1CLC. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 18, 2012 at 9:06am revealed that the electrical panel adjacent to critical panel 1CLA in the OR staff lounge electrical room was not identified at all. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:19am revealed that not all circuits in the equipment system panel 2QTA were identified as to their use. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on October 16, 2012 at 3:07pm revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.
Observation on October 16, 2012 at 3:08pm revealed that the main electrical room contained large equipment rated at 1200 amperes or more and over six feet in width. The egress door from the room was not equipped with panic hardware. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 2002ed. 110-26(2) Large Equipment. For equipment rated 1200 amperes or more and over 1.8 m (6 ft) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance to the required working space not less than 610 mm (24 in.) wide and 2.0 m (6? ft) high at each end of the working space. Where the entrance has a personnel door(s), the door(s) shall open in the direction of egress and be equipped with panic bars, pressure plates, or other devices that are normally latched but open under simple pressure.

Observation on October 17, 2012 at 9:08am revealed that there was an extension cord plugged into a relocatable power tap that was run through the wall to a television in permanent use in the OR staff lounge electrical room to the OR scheduling television monitor. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 17, 2012 at 9:20am revealed that there was a relocatable power tap installed as a substitute for permanent wiring in the second floor housekeeping electrical room. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA 70, 1999ed. 110-3(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included with the listing and labeling.
NFPA 70, 1999ed. 400-8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure, (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors, (3) Where run through doorways, windows, or similar openings, (4) Where attached to building surfaces, (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings, or (6) Where installed in raceways, except as otherwise permitted in this Code.

Observation on October 17, 2012 at 10:24am revealed that there were two open electrical boxes with wires exposed to the two overhead door operators for the enclosed parking garage. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 370.25 Covers and Canopies. In completed installations, each box, shall have a cover, faceplate, or fixture canopy.

Based on observation and interview, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This practice affected all patients, visitors and staff that are in the area of the open electrical boxes and power strips. The facility census was 9 patients.

Findings are:
Observations on 10-17-12 at 2:05 pm and 2:41 pm revealed:
1. IT cabinet with equipment which runs patients medical equipment was plugged into a non-hospital grade power-strip in the Staff Hall in the OR area.
2. Medical equipment in Exam Room 5 plugged into a non-hospital grade power-strip.
During an interview on 10-17-12 at 2:05 pm and 2:41 pm, Safety A confirmed the use of non-hospital grade power-strips for medical equipment.

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8



20404

Based on observation and interview the facility failed to identify the multiple main disconnects and to identify the type, size and location of the emergency power supply system at the main service disconnect for the building to alert responding personnel that there is an alternate source of power in the building and that shutting off the main service disconnect will not turn off all power in the building in the case of an emergency. The facility also failed to correctly identify all feeders and branch circuits and failed to have approved covers installed on all devices. This deficient practice has the potential to affect all occupants of the facility. The facility census is 9.

Findings are
Observation on October 17, 2012 at 8:39am revealed that there was no signage at the main service disconnect for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.
Observation on October 17, 2012 at 8:38am revealed that the facility had three main disconnects for the facility and that they were not identified as being three mains are required by code. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 230-72(a) Grouping of Disconnects-General. The two to six disconnects as permitted in 230-71 shall be grouped. Each disconnect shall be marked to indicate the load served.
Observation on October 16, 2012 at 2:18pm revealed that the panel EP1E2-1 was actually labeled as being panel EP1E2-2. This observation was confirmed in an interview with Engineering B at the above date and time.
NFPA 70, 1999ed. 110.22 Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
Observation on October 16, 2012 at 2:30pm revealed that the receptacle in room 1087 did not have an approved cover installed. This observation was confirmed in an interview with Engineering B at the above date and time.
Observation on October 16, 2012 at 2:33pm revealed that the receptacle in the second floor electrical room did not have an approved cover installed. This observation was confirmed in an interview with Engineering B at the above date and time.

NFPA 70, 1999ed. 410-56(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 inches from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.