HospitalInspections.org

Based on observation and interview, the facility failed to maintain exterior exit lighting according to National Fire Protection Association (NFPA) standards. This deficient practice affected four (4) of eight (8) smoke compartments, staff, and other occupants of the building.

The findings include:

Observation during the Life Safety Code survey on 02/22/18, at 10:15 AM, with Maintenance staff revealed an exterior single-bulb light fixture was located at the 200 Hall exit and three (3) other exits. At least a double-bulb fixture is required at exits to help ensure the area outside is not left in total darkness in case one bulb burns out. This type of light is also required to be connected to the emergency generator.

An interview with Maintenance staff on 02/22/18 at 10:15 AM revealed he was not aware exterior lighting fixtures located at exits were required to have at least a double-bulb fixture.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 101 (2012 Edition).

7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

Based on observation and interview, the facility failed to maintain clearance around electrical panels according to National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect one (1) of eight (8) smoke compartments, staff, patients, and other occupants of the building.

The findings include:

Observation during the Life Safety Code tour on 02/22/18 at 10:05 AM, with Maintenance staff revealed an internet/TV cart located in an electrical room was blocking access to an electrical panel. These panels must be accessible to permit safe operation and maintenance at the panel when needed.

An interview on 02/22/18 at 10:05 AM with Maintenance staff revealed he was aware that electrical panels should be accessible; however, he was not aware this panel was being blocked.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 70 (2011 Edition).

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on interview and record review, the facility failed to maintain the emergency generator as required by National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect eight (8) of eight (8) smoke compartments, staff, patients, and other occupants of the building.

The findings include:

Review of the facility's Emergency Generator maintenance log on 02/20/18 at 11:30 AM, with Maintenance staff revealed no documented evidence the facility had a weekly maintenance schedule or had conducted weekly maintenance of the emergency generator. This type of maintenance schedule helps ensure the generator operates as intended in an emergency situation.

An interview with Maintenance staff on 02/20/18 at 11:30 AM revealed he was checking the generator on a weekly basis, but failed to document that maintenance was conducted.

The findings were revealed to the Administrator upon exit.

Reference: NFPA 110 (2010 Edition).

8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.

8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.