HospitalInspections.org

Based on observation and staff interview, the facility failed to separate use areas from corridors by smoke resisting partitions. This condition had the potential to allow smoke to migrate into the exit corridor. Facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13, from 2:38 pm to 5/7/13, at 8:41 am revealed:

1. The sliding glass reception window in the Surgery Scheduling Room corridor wall failed to resist the passage of smoke when shut.

2. A hole around an orange cable failed to be sealed above ceiling at Door 2039.

In an interview conducted at the time of observation, (5/6/13, from 2:38 pm to 5/7/13, at 8:41 am), Safety A acknowledged the findings.

Based on observation and staff interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13, from 2:30 pm to 4:35 pm, on the 4th floor revealed:

1. Patient room door 4212 failed to be a positive latching door when the door was closed. At 2:42 pm the small leaf door failed to be latched in the closed position.

2. Patient room door 4208 failed to be a positive latching door when the door was closed. At 2:49 pm the small leaf door failed to be latched in the closed position.

3. Patient room door 4207 failed to be a positive latching door when the door was closed at 2:52 pm.

4. Patient room door 4203 failed to be a positive latching door when the door was closed at 2:53 pm.

5. Patient room door 4228 failed to be a positive latching door when the door was closed at 2:55 pm.

6. Patient room door 4222 failed to be a positive latching door when the door was closed at 3:00 pm.

7. Rehab/Training room double doors 4015 failed to be positive latching doors when the doors were closed at 4:12 pm. The door closure had been removed.
In an interview conducted at the time of observations (5/6/13, from 2:30 pm to 4:35 pm), with Facilities E personal confirmed the corridor doors not positive latching when the doors were closed.

A.
Based on observation and interview the facility failed to provide separation from the kitchen cooking and serving area from the atrium by automatic closing doors. This condition will not allow the automatic roll down doors to shut to provide separation from the atrium and all floors open to the atrium. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 3:30 p.m. it was revealed that the fusible link device for the roll down doors to the kitchen and serving area was concealed above the suspended ceiling.

Facilities B and Maintenance A also confirmed this finding at the times of the observations.




27395

B.
Based on observation and staff interview, the facility failed to provide separation of the Atrium from the Hospital in accordance with the National Fire Protection Association, 101. This condition had the potential for smoke to fill the Atrium, and extend to other areas of the facility. Facility census was 74.
Findings are:

Observation during the facility tour on 5/8/13, from 12:58 pm to 1:46 pm revealed:

1. An engineering analysis document that demonstrated that the building was designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater, failed to be provided for review.

2. Smoke detection failed to be installed every 30 feet throughout the Atrium and the Conference Center for smoke evacuation and door magnetic hold open control. The facility failed to provide the engineering analysis document to verify that the current smoke detection met the smoke evacuation requirements for an Atrium.

3. Projected beam smoke detectors failed to be installed within three feet of the peak of the Atrium.

4. Glass walls and inoperable windows on each floor of the Atrium where a walkway was present failed to have sprinklers spaced on both sides of the glass so that the entire surface of the glass was wet upon operation of the sprinklers.

5. The Public Elevator Shaft failed to be separated by a fire resistance rating of at least 20 minutes where the elevator shaft opened onto the Atrium. Documentation failed to be provided to verify the fire resistance rating of the elevator door.

In an interview conducted at the time of observation, (5/8/13, from 12:58 pm to 1:46 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
8.2.5.6*
Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)
Exception No. 1: Any number of levels of the building shall be permitted to open directly to the atrium without enclosure based on the results of the engineering analysis required in 8.2.5.6(5).
Exception No. 2*: Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.
(2) Access to exits is permitted to be within the atrium, and exit discharge in accordance with 7.7.2 is permitted to be within the atrium.
(3) The occupancy within the space meets the specifications for classification as low or ordinary hazard contents. (See 6.2.2.)
(4) The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
(5) * For other than existing, previously approved atria, an engineering analysis is performed that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
(6) * In other than existing, previously approved atria, where an engineered smoke control system is installed to meet the requirements of 8.2.5.6(5), the system is independently activated by each of the following:
a. The required automatic sprinkler system
b. Manual controls that are readily accessible to the fire department

NFPA 72, 2-3.4.4 Projected Beam-Type Smoke Detectors.
Projected beam-type smoke detectors shall be located with their projected beams parallel to the ceiling and in accordance with the manufacturer ' s documented instructions. The effects of stratification shall be evaluated when locating the detectors.
2-3.4.7* Peaked.
Detectors shall first be spaced and located within 3 ft (0.9 m) of the peak, measured horizontally. The number and spacing of additional detectors, if any, shall be based on the horizontal projection of the ceiling.

A.
Based on observation and interview, the facility failed to provide exits that are marked by approved, readily visible exit signs. This condition will cause occupants of the conference center to not be able to locate an exit in an emergency. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 2:06 p.m., it was revealed that the exits in the movable partitions, in the conference center, were not marked by exit signs.

2. On 5/6/2013 at approximately 2:45 p.m. it was revealed that no exit signs were provided in the outdoor garden area to indicate the egress route to the parking lot.

Facilities B and Maintenance A also confirmed this finding at the times of the observations.
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27395

B.
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 74.
Findings are:

Observations during the facility tour on 5/6/13, from 1:20 pm to 5/8/13, at 1:33 pm revealed:

1. Both exits out of the East Penthouse failed to be marked with exit signage.

2. The double doors leading into the Medical Office Building (MOB) from the Hospital failed to be marked with exit signage on the Hospital side.

In an interview conducted at the time of observations (5/6/13, from 1:20 pm to 5/8/13, at 1:33 pm), Safety A acknowledged that exit signs were not visible in these areas.





19980

Findings are:
Observations during the facility tour on 5/7/13, from 11:35 am to 11:52 am, on the 1st floor revealed:

3. An exit sign failed to be installed above the Medical records exit door 1139.

4. An exit sign failed to be installed above the Quality management exit door 1142.

5. Exit signs failed to be installed in the Medical records/Quality management Suite to direct occupants to the exits.

6. An exit sign failed to be installed at the stair tower exit door 1043.

In an interview conducted at the time of observations (5/7/13, from 11:35 am to 11:52 am), with Facilities E personal confirmed that the exits were not visible in two directions out of the Medical records and Quality management suite. Facilities E personal also confirmed the exit sign location being located above the non-exit double doors into the Diagnostic Center and not at the stair tower exit door.

Based on observation and staff interview, the facility failed to provide exits out of all smoke zones that don ' t lead into the same smoke zone. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13 at 3:28 pm revealed both required exits leading out of smoke zone 4-2 lead directly into smoke zone 4-1 and are not separated from one another.

In an interview conducted at the time of observations, (5/6/13 at 3:28 pm), With Facilities E personal confirmed that both exits lead directly into smoke zone 4-1 without separation.

Based on observation and interview, the facility failed to provide smoke partitions, with at least a one half hour rating. This condition will allow smoke to travel into the adjacent smoke compartments. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 9:00 a.m. it was revealed that there was an unsealed penetration around a conduit, above the ceiling, in #3204.

2. On 5/7/2013 at approximately 9:10 a.m. it was revealed that there was an unsealed conduit, above the ceiling, above the door to #3224.

3. On 5/7/2013 at approximately 10:22 a.m. it was revealed that there was an unsealed penetration around a conduit in the smoke wall, above the ceiling, above the tube station on POD G.

4. On 5/8/2013 at approximately 9:15 a.m. it was revealed that there was an open conduit, above the ceiling, across from #1048.

5. On 5/8/2013 at approximately 9:35 a.m. it was revealed that there was an unsealed penetration around cables penetrating the smoke wall, above the ceiling, above #1059.

6. On 5/8/2013 at approximately 10:00 a.m. it was revealed that there was an unsealed penetration around cables penetrating the smoke wall, above the ceiling, above #1083.

Facilities B and Maintenance A both confirmed all of the findings at the times of the observations.
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A.
Based on observation and staff interview, the facility failed to install self-closing devices on all doors in smoke barrier walls. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 74.
Findings are:

Observations during the facility tour on 5/8/13 at 9:39 am revealed room CT 1038 exit door failed to have a door closure installed on this door.

In an interview conducted at the time of observations (5/8/13, at 9:39 am), with Safety E confirmed that no door closure is installed on this door.



27394


B.
Based on observation and interview, the facility failed to have corridor fire doors close and positive latch upon activation of the building fire alarm system. This would allow smoke and fire to spread to other areas of the building, past the fire barrier. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 2:15 p.m. it was revealed that the North elevator Lobby doors, on the 3rd Floor did not close and positive latch upon activation of the fire alarm system.

2. On 5/7/2013 at approximately 2:25 p.m. it was revealed that the corridor fire doors by Exit 3003 did not close and positive latch upon activation of the fire alarm system.

3. On 5/7/2013 at approximately 2:33 p.m. it was revealed that the corridor fire doors on the third floor were not provided with astragals, rabbits or bevels to prevent smoke and fire spread through the gap in the doors to the other side of the fire barrier.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.
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Based on observation and interview, the facility failed to provide separation from hazardous areas from the remainder of the building. This would allow a fire in these rooms to spread smoke and fire throughout the smoke compartment. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 1:30 p.m. it was revealed that the door to the storage room #137, in the Sleep Clinic, did not self close and latch.

2. On 5/6/2013 at approximately 1:33 p.m. it was revealed that the doors to storage room #142, in the Sleep Clinic, did not self- close and latch and were louvered doors only.

Facilities B and Maintenance A both confirmed the findings on 5/6/2013 at 1:30 p.m. and 1:33 p.m.

Based on observation and interview, the facility failed to provide separation from hazardous areas from the remainder of the building. This would allow a fire in these rooms to spread smoke and fire throughout the smoke compartment. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 1:48 p.m. it was revealed that the doors to storage rooms #152 and #153, in Physical Therapy, did not self-close and latch.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.

Based on observation and interview, the facility failed to provide separation from hazardous areas from the remainder of the building. This would allow a fire in these rooms to spread smoke and fire throughout the smoke compartment. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 2:17 p.m. it was revealed that the door to #L-104, in the Midwest Cancer Center, did not self- close and latch.

2. On 5/6/2013 at approximately 2:30 p.m. it was revealed that the garage, in the Midwest Cancer Center, had numerous penetrations around pipes and conduits that were not sealed.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.

Based on observation and staff interview, the facility failed to provide smoke resisting partitions for hazardous areas, and 1 hour fire-rated partitions where hazardous areas exceeded 100 square feet. This condition had the potential for smoke and fire to spread into the egress corridors. Facility census was 74.
Findings are:

Observations during the facility tour 5/6/13, from 2:09 pm to 5/8/13, at 9:17 am revealed:

1. Oxygen Storage Room 2037 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

2. The Soiled Linen Room 2042 Door failed to latch when the door was automatically closed.

3. Clean Supply Room 2006 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

4. Clean Supply Room 2008 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

5. The Pharmacy 2091 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating. The doors failed to positively latch, as the doors were held shut by a magnetic lock only.

6. Resource Staff Door 2058 failed to latch when the door was closed. An automatic closure failed to be installed on the storage room door.

7. Operating Room 6 was used for storage. Both doors failed to have automatic closures installed on the doors.

8. Mamo File Room 1097 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

In an interview conducted at the time of observations (5/6/13, from 2:09 pm to 5/8/13, at 9:17 am), Safety A acknowledged the findings.



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Findings are:

9. On 5/6/2013 at approximately 2:40 p.m. it was revealed that the electrical room of the Siemens Theatre had unsealed penetrations around pipes and cables.

10. On 5/6/2013 at approximately 2:43 p.m. it was revealed that the door to storage room #0053 did not self- close and latch.

11. On 5/6/2013 at approximately 2:52 p.m. it was revealed that Biohazard Room #0011 had missing ceiling tiles that would allow smoke to spread out of this room.

12. On 5/6/2013 at approximately 3:05 p.m. it was revealed that the kitchen pantry and storage area was not provided with a door that would resist the passage of smoke in the event of a fire in this room.

13. On 5/7/2013 at approximately 9:03 a.m. it was revealed that the empty patient rooms, on the third floor, by ICU, were being used as storage rooms and were not provided with doors that were self closing and latching.

14. On 5/7/2013 at approximately 9:08 a.m. it was revealed that room #3000A was being used as a storage room and was not provided with a door that self closes and latches.

15. On 5/7/2013 at approximately 11:00 a.m. it was revealed that the storage room #1087 did not have a self-closing and latching door.

16. On 5/7/2013 at approximately 11:17 a.m. it was revealed that storage room #1067 did not have self closing and latching door.

17. On 5/8/2013 at approximately 10:10 a.m. it was revealed that the storage room #1014B did not have a self-closing and latching door.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.




19980


Findings are:
Observations during the facility tour on 5/6/13, from 3:00 pm to 4:30 pm revealed:
18. Soiled utility room 4055 door not closing and latching with the door closure when the door is opened.

19. Storage room 4000A door not closing and latching with the door closure when the door is opened.

Observations during the facility tour on 5/7/13, from 9:00 am to 11:30 am revealed:

20. A combustible storage room larger than 100 sq. feet failed to have a rated fire door, door closure, and latching hardware installed on this storage room.

21. Door to the parking garage on the first floor failed to have a 2 hour fire rating on the door.
In an interview conducted at the time of observations (5/6/13 from 3:00 pm to 4:30 pm and 5/7/13 from 9:00 am to 11:30 am), with facilities E confirmed the doors not closing and latching and the lack of fire separation between occupied spaces and hazardous areas.

Based on observation and staff interview, the facility failed to penetrate a stair enclosure with the items only allowed by NFPA 101, 7.1.3.2.1(e). This condition had the potential to allow smoke to enter the exit stairwells. Facility census was 74.
Findings are:

Observations during the facility tour on 5/7/13, at 4:01 pm revealed conduit for smoke damper actuators on the 4th floor of Stair 2 that did not serve Stair 2. The conduit failed to be separated from the Stair Tower by two hour fire-rated construction.

In an interview conducted at the time of observation, (5/7/13, at 4:01 pm), Safety acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

Based on observation and staff interview, the facility failed to arrange so that exits were readily accessible at all times. This condition had the potential to prevent the evacuation of occupants. Facility census was 74.
Findings are:

Observations during the facility tour on 5/7/13, from 4:09 pm to 5/8/13, at 9:17 am revealed:

1. The ER Exit adjacent to the Ambulance Bay emptied into a vestibule. The vestibule failed to be separated from the Ambulance Bay by one hour fire rated construction.

2. Stair Tower doors throughout the facility failed to have fire exit hardware installed so that the door could be opened by a panic device.

In an interview conducted at the time of observations (5/7/13, from 4:09 pm to 5/8/13, at 9:17 am), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.5.1.7
Exit access from rooms or spaces shall be permitted to be through adjoining or intervening rooms or areas, provided that such adjoining rooms are accessory to the area served. Foyers, lobbies, and reception rooms constructed as required for corridors shall not be construed as intervening rooms. Exit access shall be arranged so that it is not necessary to pass through any area identified under Protection from Hazards in Chapters 11 through 42.

NFPA 80, 2-4.4.1
Only labeled locks and latches or labeled fire exit hardware (panic devices) meeting both life safety requirements and fire protection requirements shall be used. [See A-1-1(c) and (d).]
2-4.4.2
Fire exit hardware shall be installed only on fire doors bearing the marking, " Fire Door To Be Equipped with Fire Exit Hardware. " Fire exit hardware shall be labeled for both fire and panic. Fire exit hardware shall have a permanently attached label that bears the serial number and shows the manufacturer ' s name and type of approval. The label shall differentiate between panic hardware, which is not acceptable for use on fire doors and fire exit hardware.



19980


Findings are:
Observations during the facility tour on 5/6/13 at 2:46 pm on the fourth floor and on 5/8/13 at 9:04 am revealed:

3. Stair tower three, exit door, on the fourth floor, failed to open with the required maximum force to open a door in a means of egress.

4. A motion sensor, a push to exit button, the mag lock tied into the fire alarm system, and the mag lock fail safe as to when the power drops the doors unlocks failed to be installed on doors 1150A and 1150B.

In an interview conducted at the time of observations (5/6/13 at 2:46m and 5/8/13 at 9:04 am), Facilities personal E confirmed the stair tower door not meeting the required manually means to open the door and Safety E personal confirmed the mag locks not having installed on them a sensor, a push to exit button and not tied into the fire alarm system.
-NFPA Standard: The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to set release the latch, 30 lbf to set the door in motion and 15 lbf to open the door to the minimum required width. 2000 NFPA 101, 7.2.1.4.5
-NFPA Standard: Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset. 2000 ed NFPA 101, 7.2.1.6.2

Based on observation and staff interview, the facility failed to provide a horizontal exit in accordance with the National Fire Protection Association 101, 7.2.4. This condition had the potential to prevent the evacuation of occupants. Facility census was 74.
Findings are:

Observation during the facility tour on 5/8/13, at 1:42 pm revealed the double doors between the Hospital and the MOB failed to swing in opposite directions to allow egress from the Hospital through the horizontal exit to the MOB.

In an interview conducted at the time of observations (5/8/13, at 1:42 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.2.4.3.6 Swinging fire doors shall be permitted in horizontal exits, provided that the criteria of both 7.2.4.3.6(1) and (2), or the criteria of 7.2.4.3.6(1) and (3), are met as follows:
(1) The doors shall swing in the direction of egress travel.
(2) Where a horizontal exit serves areas on both sides of a fire barrier, there shall be adjacent openings with swinging doors that open in opposite directions, with signs on each side of the fire barrier identifying the door that swings with the travel from that side.
Exception: Sleeping room areas in detention and correctional occupancies shall be exempt from the sign requirement.
(3) The doors shall be of any other approved arrangement, provided that the doors always swing with any possible egress travel.
Exception No. 1: The requirements of 7.2.4.3.6 shall not apply to horizontal exit door swing as provided in Chapters 19 and 23.
Exception No. 2: The requirements of 7.2.4.3.6 shall not apply to horizontal exit doors in corridors no greater than 6 ft (1.8 m) wide in existing buildings.

Based on observation and staff interview, the facility failed to provide illumination of the egress path and lighting at exit discharges so that the failure of one bulb would not leave the area in darkness. This condition had the potential to leave exits in darkness. Facility census was 74.
Findings are:

Observation during the facility tour on 5/7/13, from 11:48 am to 5/8/13, at 1:36 pm revealed:

1. Two-bulb lighting failed to be installed at the exit discharge of Stair Tower 3. Stair Towers throughout the Hospital failed to have two-bulb lighting at the exit discharges.

2. The egress path from the East Penthouse to the Stair Tower Door failed to be illuminated.

In an interview conducted at the time of observations (5/7/13, from 11:48 am to 5/8/13, at 1:36 pm), Safety A acknowledged the findings.



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Findings are:
3. Observations during the facility tour on 5/7/13 at 11:45 am revealed the exit door to the outside next to door 1135 failed to have installed more than one light fixture on the outside of the building at this exit.

4. Observations during the facility tour on 5/8/13 at 8:57 am revealed the exit door out of the doctors lounge on the first floor to the outside failed to have installed more than one light fixture on the outside of the building at this exit.

In an interview conducted at the time of observations (5/7/13 at 11:45 am), with Facilities E and with Safety E on (5/8/13 at 8:57 am) confirmed the area on the outside of the building not having installed more than a single exit light fixture.

Based on observation, record review and staff interview, the facility failed to have a written plan to shut off the piped in oxygen in the event of an emergency in the patient rooms. This condition would not allow staff or occupants to efficiently evacuate the occupant ' s in the patient rooms if fire occurred in that room. Facility census was 74.
Findings are:
Observations during the facility tour on 5/6/13, from 2:35 pm to 4:00 pm on the 4th floor revealed:

1. Interview with nursing staff in East 4 failed to know how to shut off the piped in oxygen to the patient rooms in the event of a fire emergency in the room.

2. Interview with nursing staff in West 4 failed to know how to shut off the piped in oxygen to the patient rooms in the event of a fire emergency in the room.

3. Interview with nursing staff in both East and West 4 failed to provide documentation of policy or procedures as how to shut off the piped in oxygen.

In an interview conducted at the time of observations (5/6/13, from 2:35 pm to 4:00pm), with Facilities E personal confirmed that staff did know how shut off the oxygen in the event of a fire emergency in the patient rooms.

Based on record review and staff interview, the facility failed to conduct fire drills at least quarterly on each shift. In addition the drills failed to be conducted under varied conditions at different times of the day for three of five quarters reviewed. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:
1. Documentation review on 5/6/13 revealed that no fire drills had been conducted for the Night shift in the fourth quarter of 2012.

2. Documentation review on 5/6/13 revealed that no fire drills for the Day shift had been conducted on the Day shift the first quarter of 2013.

3. Documentation review on 5/6/13 revealed that three of four fire drills conducted on the night shift had been conducted at 5:00 am. In addition three of four night shift drills were conducted in the Engineering office area.

Interview with Facilities Staff D, Safety Staff B and Security Staff A throughout the documentation reviews on 5/6/13 and 5/17/13 confirmed the lack of fire drills being conducted and that the Safety Officer position had been empty and not overseen.

Based on record review and staff interview, the facility failed to conduct fire exit drills at the Lakeside Hospital Central IV Sterile MFG Pharmacy. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:
Documentation review on 5/9/13 revealed no documentation for any fire exit drills for the Lakeside Hospital Central IV Sterile MFG Pharmacy had been provided for review.
Interview with Safety Staff B on 5/7/13 during documentation review between 8:00 am and 17:30 pm confirmed that all drill documentation had been provided for the off-sites. I

NFPA Standard: In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable. 2000 NFPA 101, 38.7.1, 39.7.1

Based on record review and staff interview, the facility failed to conduct unannounced fire drills at the Cancer Centers. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills and practice of the procedures can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:
1. Documentation review on 5/6/13 of the fire drill form for the Cancer Center stated " Coordinate best time for least disruption with key personnel in all areas. "
2. " Go through all areas and remind the key individuals of the drill and ask them to review with their personnel the location of the drill fire and appropriate actions to be taken. "
3. " Have reception person make announcement in Suite 200. "
Interview with Safety Staff B on 5/7/13 during documentation review between 8:00 am and 17:30 pm confirmed that all drill documentation had been provided for the off-sites. In addition Safety Staff B confirmed that the drills should not be planned for convenience, and that the key personnel should not be advised as to when and where the drill is being conducted.

NFPA Standard: In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable. 2000 NFPA 101, 38.7.1, 39.7.1

Based on observation and interview the facility failed to provide a fire alarm system with approved components, devices or equipment that is installed according to NFPA 72, National Fire Alarm Code, to provide effective detection and warning of a fire emergency in the building. This would allow a fire to be undetected and unnoticed in certain portions of the building. The facility census was 74.
Findings are:


1. On 5/6/2013 at approximately 2:19 p.m. it was revealed that the smoke detector in the kitchen dry storage room was not 3 feet from the air vent diffusor. NFPA 72 section 72.5.7.4.1 requires smoke detectors to be 3 feet from all air vent diffusor.

2. On 5/7/2013 at approximately 2:30 p.m. it was revealed that the fire alarm system on the third floor has two different fire alarm signal tones and the tones are not synchronized.

3. On 5/7/2013 at approximately 3:00 p.m. it was revealed that the fire alarm system on the first floor, near stair 1043, had two different fire alarm signal tones and the tones were not synchronized.

4. On 5/8/2013 at approximately 10:00 a.m. it was revealed that the conference room #1046D was not provided with a fire alarm notification device.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.





27395


Findings are:

Observations during the facility tour on 5/6/13, from 2:44 pm to 5/7/13, at 3:34 pm revealed:

5. Fire alarm notification failed to be installed in the Link between the Hospital and the MOB on the 3rd Floor.

6. Fire alarm notification failed to be installed in Break Room 2057.

7. The magnetic locks on the Emergency Department Doors by Restroom 1012 failed to unlock with the activation of the fire alarm. The doors were marked as an exit.

8. Voice evacuation fire alarm notification failed to be installed in the Conference Center and throughout the Atrium.

9. Audible notification signals failed to be synced on the 2nd, 3rd and 4th floors of the Hospital.

10. Fire alarm notification decibel levels failed to meet the minimum requirements of NFPA 72.

11. The fire alarm notification failed to meet the required ambient noise level while the HUGS Infant Protection Security System Alarm was active. The decibel level of the HUGS Infant Protection Security System Alarm exceeded the fire alarm notification.

In an interview conducted at the times of observation, (5/6/13, from 2:44 pm to 5/7/13, at 3:34 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
Nebraska State Fire Marshal Official Interpretations 95-03, 00-04, 03-04 and 07-02.

NFPA 101, 12.3.4.1 General.
Assembly occupancies with occupant loads of more than 300 and all theaters with more than one audience-viewing room shall be provided with an approved fire alarm system in accordance with 9.6.1 and 12.3.4.

NFPA 72, 4-3.2.2*
To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.



19980


Findings are:

12. Observations during the facility tour on 5/6/13 at 3:21 pm revealed on the fourth floor service elevators 5 and 6 west side failed to have the smoke detector installed at least three feet away from the air register.

13. Observation during the facility tour on 5/7/13 at 9:29 am revealed corridor next to room door 4021 failed to have fire alarm horn strobe devices installed within 15 foot of the end of a corridor and within 15 foot of corridor doors that close.
In an interview conducted at the time of observations (5/6/13 at 3:21 pm and 5/7/13 at 9:29 am), with Facilities E confirmed the fire alarm components not being installed in the corridor.

Based on observation and interview, the facility failed to provide a fire alarm system that was installed and maintained per the requirements of NFPA 72 National Fire Alarm Code. The practice would allow a fire to go undetected in the sleeping rooms of the sleep clinic. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 1:30 p.m. it was revealed that the patient sleeping rooms, in the Sleep Clinic, were not provided with smoke detection.

Facilities B and Maintenance A both confirmed the finding at 1:30 p.m. on 5/6/13.

Based on record review and interview, the facility failed to provide a properly tested and maintained fire alarm system as per Table 7-7.2. All of the facility was directly affected by the deficient practice. The facility had at the time of the survey the census was 74.
Findings are:

Documentation review on 5/6/13 revealed the fire alarm system of the last two completed inspection forms of the fire alarm system for the year 2011 and 2012 revealed tests on 12/12/11 and 12/6/12. This indicated an annual inspection and not semi-annual as required.

Interview with Facilities Staff D on 5/6/13 during documentation review from approximately 10:00 am through 5:00 pm confirmed the fire alarm had only been inspected and tested annually. On 5/7/13 at approximately 9:00 am Facilities Staff D stated the facility had planned on having an in-house licensed maintenance staff inspect and test the fire alarm but, that had not happened.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2
NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on observation and staff interview, the facility failed to install the sprinkler system in accordance with the National Fire Protection Association 13. This condition had the potential that the system would fail to operate as designed. Facility census was 74.
Findings are:

Observation during the facility tour on 5/6/13, from 1:42 pm to 3:19 pm revealed:

1. The PIV for the Hospital failed to be protected from physical damage in the parking lot.

2. Ceiling tiles failed to be replaced and a gap around wires failed to be sealed in the suspended ceiling of Electrical Closet 2015A.

In an interview conducted at the times of observation, (5/6/13, at 1:42 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 24, 3-3.4
Post indicator valves shall be properly protected against mechanical damage where needed.



19980


Findings are:
3. Observations during the facility tour on 5/8/13 at 9:15 am revealed sprinkler heads across from room 1150 that failed to be installed in accordance with NFPA 13 by being installed closer than 6 feet apart.

In an interview conducted at the time of observations (5/8/13 at 9:15 am), With Safety E confirmed that the sprinkler heads being less than 6 foot apart.

Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing in the Lakeside Cancer Center building housing Image Recovery, Oncology Service, Cancer Imaging, Radiation/Oncology, and Midwest Cancer Center. All smoke compartments and all occupants could be affected by the deficient practice. The facility census was 74.
Findings are:
Documentation review on 5/13/13 revealed the sprinkler system water flow had been tested on 1/16/13 and 1/26/12 indicating an annual inspection and not quarterly as required.
Interview with Safety Staff B on 5/7/13 between 8:00 am and 5:15 pm confirmed the only documentation available had been provided for review.


NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing in the Lakeside MOB building housing the Outpatient Cardiac Rehab and Sleep Disorders Clinic. All smoke compartments and all occupants could be affected by the deficient practice. The facility census was 74.
Findings are:

1. Documentation review on 5/7/13 of the sprinkler inspection reports revealed the sprinkler system for the Lakeside MOB building had been inspected on 9/7/12.

Interview with Safety Staff B on 5/7/13 between 8:00 am and 5:15 pm confirmed the only documentation available had been provided for review.


NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation and interview, the facility failed to have the sprinkler system continuously maintained in a reliable operating condition. This would allow a fire to spread because the sprinkler system in the area of fire origin would not properly operate. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 3:30 p.m. it was revealed that the sprinkler head in the garden level library, off of the cafeteria, was obstructed by the hanging light fixture.

2. On 5/8/2013 at approximately 9:20 a.m. it was revealed that the sprinkler head in room #1091D was missing the protective escutcheon plate.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.
.




19980


Findings are:

3. Observations during the facility tour on 5/7/13 at 11:35 am revealed the sprinkler head located in the corridor next to Quality Management room door 1142 failed to have a sprinkler cover plate installed on the sprinkler head.

In an interview conducted at the time of observations (5/7/13 at 11:35 am) Facilities E confirmed the cover plate not being installed on the sprinkler head.

Based on observation and interview, the facility failed to provide heating equipment that was installed and maintained to current NFPA 211 standards. This practice would allow carbon monoxide gas to spread throughout the facility by means of the open atrium. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 9:15 a.m. it was revealed that the third floor was not provided with carbon monoxide detection in the general area of the gas fire place per NFPA 211 requirements.

2. On 5/6/2013 at approximately 2:30 p.m. it was revealed that the garden level was not provided with carbon monoxide detection in the general area of the gas fire place per NFPA 211 requirements.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.




19980


Findings are:

3. Observations during the facility tour on 5/6/13 at 4:10 pm revealed a fire place in room 4000 that failed to be installed in accordance with manufacturer ' s specifications by not having a CO detector installed next to the fire place.

In an interview conducted at the time of observations (5/6/13 at 4:10pm) with Facilities E confirmed the CO detector not being installed.

Based on observation and interview, the facility failed to provide kitchen cooking equipment that was properly protected by automatic extinguishing systems in accordance with NFPA 96. This would allow a fire in the kitchen, under the hood with a cooking appliance, to not be properly extinguished. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 4:00 p.m. it was revealed that the appliances under the hood systems, in the kitchen, were not provided with devices that allow the appliance to be returned to its original, approved location after being moved for cleaning or maintenance.

Facilities B and Maintenance A both confirmed the finding at the times of the observations.
.

Based on observation and interview the facility failed to have means of egress corridors continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This would allow corridors to become blocked and in turn slow or hinder egress and escape during an emergency in that smoke compartment. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 8:53 a.m. it was revealed that the third floor ICU hallways were being blocked by isolation and housekeeping carts.

Facilities B and Maintenance A both confirmed the finding at the times of the observations.





19980


Findings are:

Observations during the facility tour on 5/6/13, from 2:30 pm to 4:35 pm on the 4th floor revealed:

2. Observations on 5/6/13 from 2:30 pm to 3:15 pm revealed storage in the corridor on the 4th floor next to room 4214 for more than 30 minutes. This storage consisted of chairs being stored in the corridor reducing the width of the corridor down to 5 foot 6 inches.

3. Observations on 5/6/13 from 2:45 pm to 3:30 pm revealed storage in the corridor on the 4th floor next to room 4209 for more than 30 minutes. This storage consisted of 3 chairs being stored in the corridor reducing the width of the corridor down to less than 8 foot.

4. Observations on 5/6/13 from 3:50 pm to 4:30 pm revealed storage in the corridor on the 4th floor next to room 4223 for more than 30 minutes. This storage consisted of 3 chairs being stored in the corridor reducing the width of the corridor down to less than 8 foot.

5. Observations on 5/6/13 from 3:55 pm to 4:35 pm revealed storage in the corridor on the 4th floor next to room 4228 for more than 30 minutes. This storage consisted of 2 chairs and 1 plant being stored in the corridor reducing the width of the corridor down to less than 8 foot.
In an interview conducted at the time of observations (5/6/13, from 2:35 pm to 4:35pm), with Facilities E personal confirmed the storage in the corridor and the width of the corridor being less than 8 foot because of the storage.

Based on observation and staff interview, the facility failed to regulate the total capacity of soiled linen receptacles so that they would not exceed 32 gallons in a 64 square foot area. This condition had the potential to add combustible fuel loads in the exit corridors in the event of a fire. Facility census was 74.
Findings are:

Observation during the facility tour on 5/6/13, from 1:58 pm to 2:26 revealed:

1. Two soiled linen carts were stored in Restroom 2159. The carts together exceeded 32 gallons of soiled linen in a 64 square foot area. The Restroom failed to be rated as a hazardous area.

2. Two soiled linen carts were stored in the Recovery area by Room 2035. The carts together exceeded 32 gallons of soiled linen in a 64 square foot area. The carts failed to be stored in a room separated as a hazardous area.

In an interview conducted at the time of observation, (5/6/13, from 1:58 pm to 2:26), Safety A confirmed the containers exceeded 32 gallons in a 64 square foot area.

A.
Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter outlets in the Operating Rooms in accordance with NFPA 99. This condition had the potential to allow a patient to receive electrical shock during a surgery. The facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13, from 3:16 pm to 4:45 pm revealed GFCI outlets, GFCI breakers or line isolation monitors failed to be installed in all Operating Room and the C-Section Room.

Record review revealed no written specifics of which type of procedures would normally take place in the operating rooms to determine if any special protection against electric shock had to be provided if wet procedures are likely to be performed or not.

In an interview conducted at the time of observation, (5/6/13, from 3:16 pm to 4:45 pm), Safety A verified that GFCI outlets, GFCI Breakers or line isolation monitoring failed to be installed and that a policy of normally conducted procedures with what, if any, special protection needed did not exist.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.



20404

B.
Based on observation and interview the facility failed to have the emergency generator installed in accordance with NFPA 110 by not having a remote shutdown for the emergency generator other than on the generator itself and by having a large amount of storage of combustibles inside the generator building without any separation. This deficient practice has the potential to effect all residents, staff and visitors of the facility in the event of an emergency condition.
Findings are:
1. Observation on May 7, 2013 at 8:54am revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

2. Observation on May 7, 2013 at 8:57am revealed that there was a large amount of combustible storage of decontamination supplies in the emergency generator building with no separation. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

NFPA 110, 2002ed. 7.2.1.2 No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.

Based on record review and staff interview, the facility failed to conduct Laboratory fire exit drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:

1. Documentation review on 5/7/13 revealed the Laboratory provided documentation of one fire drill for 2012.

Interview with Lab Operations Director A on 5/7/13 during documentation review between 8:00 am and 17:30 pm confirmed that only one drill had been conducted during 2012 in the Laboratory. In addition they were unaware of the quarterly exit drill requirement.

NFPA Standard: Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually. 1999 NFPA 99 10-2.1.4.3

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.
Findings are:
1. Observation on May 7, 2013 at 8:49am revealed that panel CLGEN in the generator building contained life safety loads for the emergency generator building and system and at 9:13am it was revealed that this panel was connected to the critical branch panel CDPLBA. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and times.

2. Observation on May 7, 2013 at 9:31am revealed that Critical Branch panel GCL2 contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

3. Observation on May 7, 2013 at 9:43am revealed that the Critical Branch panel 1CL1 contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

4. Observation on May 7, 2013 at 9:52am revealed that the Critical Branch panel 4CL1 contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

5. Observation on May 7, 2013 at 10:21am revealed that the Critical Branch panel CLBK contained both non-critical loads and Life Safety Loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

6. Observation on May 7, 2013 at 10:41am revealed that the Critical Branch panel CLBH contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

7. Observation on May 7, 2013 at 10:51am revealed that the Critical Branch panel CH1B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

8. Observation on May 7, 2013 at 11:06am revealed that the Critical Branch panel CL1B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

9. Observation on May 7, 2013 at 11:11am revealed that the Critical Branch panel CL1C contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

10. Observation on May 7, 2013 at 11:13am revealed that the Critical Branch panel CL1D contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

11. Observation on May 7, 2013 at 11:20am revealed that the Critical Branch panel CL1A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

12. Observation on May 7, 2013 at 11:28am revealed that the Life Safety Branch panel LH2B contained non-life safety loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

13. Observation on May 7, 2013 at 11:30am revealed that the Critical Branch panel CL2B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

14. Observation on May 7, 2013 at 11:37am revealed that the Critical Branch panel CL2A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

15. Observation on May 8, 2013 at 8:48am revealed that the Critical Branch panel labeled 5NL1 is actually 5CL1 and that it contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

16. Observation on May 8, 2013 at 8:56am revealed that the Critical Branch panel CL3B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

17. Observation on May 8, 2013 at 9:00am revealed that the Life Safety Branch panel LL3A contained non-life safety loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

18. Observation on May 8, 2013 at 9:05am revealed that the Critical Branch panel CL3A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

19. Observation on May 8, 2013 at 9:05am revealed that the Critical Branch panel CL3A contained Life Safety loads for Med Gas Alarms. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

20. Observation on May 8, 2013 at 9:12am revealed that the Critical Branch panel CL4A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

21. Observation on May 8, 2013 at 9:34am revealed that there was not the required amount of emergency lighting outside the building to extend from the exit discharge to the public way. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

22. Observation on May 8, 2013 at 9:40am revealed that the emergency shunt trip power for the kitchen appliances was connected to normal power panel LBK-2. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

23. Observation on May 8, 2013 at 9:42am revealed that the circuit for the kitchen fire protection system was connected to the normal power panel LBKA. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

24. Observation on May 8, 2013 at 10:52am revealed that the kitchen hood exhaust fans were connected only to normal power at MCCP. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed 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)]

A.
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 provide proper working clearances for electrical equipment and maintaining the integrity of the electrical equipment. This deficient practice has the potential to affect all occupants of the facility.
Findings are

1. Observation on May 8, 2013 at 9:29am revealed that there was no signage at the main service disconnects for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed 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.

2. Observation on May 8, 2013 at 9:25am 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 Facilities C and Contractor A at the above listed 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.

3. Observation on May 7, 2013 at 11:02am revealed that the circuit directory for the Critical Branch panel CL1B did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

4. Observation on May 7, 2013 at 11:08am revealed that the feeder for panel CL1C was not identified as coming from panel CL1B. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

5. Observation on May 7, 2013 at 11:11am revealed that the circuit directory for the Critical Branch panel CL1C did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

6. Observation on May 7, 2013 at 11:20am revealed that the circuit directory for the Critical Branch panel CL1A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

7. Observation on May 7, 2013 at 11:38am revealed that the circuit directory for the Critical Branch panel CL2A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

8. Observation on May 8, 2013 at 8:44am revealed that the feeder labeled 5CL1 in Critical Branch Panel 3CL1 actually goes to the penthouse and feeds the panel labeled 5NL1. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

9. Observation on May 8, 2013 at 8:55am revealed that the circuit directory for the Critical Branch panel CL3B did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

10. Observation on May 8, 2013 at 9:04am revealed that the circuit directory for the Critical Branch panel CL3A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

11. Observation on May 8, 2013 at 9:43am revealed that the circuit directory for the Normal Branch panel LBKA did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

12. Observation on May 8, 2013 at 9:55am revealed that the circuit directory for the Normal Branch panel L1C did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

13. Observation on May 8, 2013 at 10:14am revealed that the circuit directory for the Normal Branch panel L3B did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

14. Observation on May 8, 2013 at 10:17am revealed that the circuit directory for the Normal Branch panel L3A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

15. Observation on May 8, 2013 at 10:59am revealed that the normal power motor control center in the penthouse was not labeled. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed 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 May 7, 2013 at 8:45am revealed that there was not the required working clearance in front of the Critical Branch Panel CLGEN in the Emergency Generator Building. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.
Observation on May 7, 2013 at 9:00am revealed that the Emergency switchgear room contained large electrical equipment and did not have double the required working clearances and the exit doors from the room were not provided with Panic type hardware. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.
Observation on May 8, 2013 at 9:30am revealed that the Main electrical room in the original building contained large electrical equipment and did not have double the required working clearances and the exit doors from the room were not provided with panic type hardware. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.
NFPA 70, 1999ed.
110.26 Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
Table 110.26(A)(1) Working Spaces

Nominal Voltage to Ground Minimum Clear Distance
Condition 1 Condition 2 Condition 3
0-150 900 mm (3 ft) 900 mm (3 ft) 900 mm (3 ft)
151-600 900 mm (3 ft) 1 m (3? ft) 1.2 m (4 ft)

Note: Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switchboards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on nonelectrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all uninsulated parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volts dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 750 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(E). Within the height requirements of this section, other equipment that is associated with the electrical installation and is located above or below the electrical equipment shall be permitted to extend not more than 150 mm (6 in.) beyond the front of the electrical equipment.
(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(C) Entrance to Working Space.
(1) Minimum Required. At least one entrance of sufficient area shall be provided to give access to working space about electrical equipment.
(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.
A single entrance to the required working space shall be permitted where either of the conditions in 110.26(C)(2)(a) or (b) is met.
(a) Unobstructed Exit. Where the location permits a continuous and unobstructed way of exit travel, a single entrance to the working space shall be permitted.
(b) Extra Working Space. Where the depth of the working space is twice that required by 110.26(A)(1), a single entrance shall be permitted. It shall be located so that the distance from the equipment to the nearest edge of the entrance is not less than the minimum clear distance specified in Table 110.26(A)(1) for equipment operating at that voltage and in that condition.
(D) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting outlets shall not be required where the work space is illuminated by an adjacent light source or as permitted by 210.70(A)(1), Exception No. 1, for switched receptacles. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.
(E) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 2.0 m (6? ft). Where the electrical equipment exceeds 2.0 m (6? ft) in height, the minimum headroom shall not be less than the height of the equipment.
Exception: In existing dwelling units, service equipment or panelboards that do not exceed 200 amperes shall be permitted in spaces where the headroom is less than 2.0 m (6? ft).
(F) Dedicated Equipment Space. All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage.
Exception: Control equipment that by its very nature or because of other rules of the Code must be adjacent to or within sight of its operating machinery shall be permitted in those locations.
(1) Indoor. Indoor installations shall comply with 110.26(F)(1)(a) through (d).
(a) Dedicated Electrical Space. The space equal to the width and depth of the equipment and extending from the floor to a height of 1.8 m (6 ft) above the equipment or to the structural ceiling, whichever is lower, shall be dedicated to the electrical installation. No piping, ducts, leak protection apparatus, or other equipment foreign to the electrical installation shall be located in this zone.
Exception: Suspended ceilings with removable panels shall be permitted within the 1.8-m (6-ft) zone.
(b) Foreign Systems. The area above the dedicated space required by 110.26(F)(1)(a) shall be permitted to contain foreign systems, provided protection is installed to avoid damage to the electrical equipment from condensation, leaks, or breaks in such foreign systems.
(c) Sprinkler Protection. Sprinkler protection shall be permitted for the dedicated space where the piping complies with this section.
(d) Suspended Ceilings. A dropped, suspended, or similar ceiling that does not add strength to the building structure shall not be considered a structural ceiling.
(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in 110.26(A). No architectural appurtenance or other equipment shall be located in this zone.

16. Observation on May 8, 2013 at 8:57am revealed that there was an unused opening in the top of the Critical Branch panel CL3B that was not effectively closed to maintain the integrity of the panel enclosure. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.



27394


B.
Based on observation and interview the facility failed to have all electrical wiring and equipment in accordance with NFPA 70 National Electrical Code. This would allow an exposure to possible shock hazard and also increase the fire hazard due to damage of the electrical wiring. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 4:30 p.m. it was revealed that an electrical junction box, above the ceiling, above the kitchen serving area doors, was missing the protective cover leaving the wires exposes.

Facilities B and Maintenance A both confirmed the finding at the times of the observations.




19980


Findings are:

2. Observations during the facility tour on 5/6/13 at 4:05 pm revealed in the physical therapy room 4011 by monitor GM 32 and Monitor BW 3, non-hospital grade power taps being used as a power source.

In an interview conducted at the time of observations (5/6/13 at 4:05 pm), with Facilities E confirmed the use of non-hospital grade power taps being used in patient care areas.

Based on observation and staff interview, the facility failed to separate use areas from corridors by smoke resisting partitions. This condition had the potential to allow smoke to migrate into the exit corridor. Facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13, from 2:38 pm to 5/7/13, at 8:41 am revealed:

1. The sliding glass reception window in the Surgery Scheduling Room corridor wall failed to resist the passage of smoke when shut.

2. A hole around an orange cable failed to be sealed above ceiling at Door 2039.

In an interview conducted at the time of observation, (5/6/13, from 2:38 pm to 5/7/13, at 8:41 am), Safety A acknowledged the findings.

Based on observation and staff interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13, from 2:30 pm to 4:35 pm, on the 4th floor revealed:

1. Patient room door 4212 failed to be a positive latching door when the door was closed. At 2:42 pm the small leaf door failed to be latched in the closed position.

2. Patient room door 4208 failed to be a positive latching door when the door was closed. At 2:49 pm the small leaf door failed to be latched in the closed position.

3. Patient room door 4207 failed to be a positive latching door when the door was closed at 2:52 pm.

4. Patient room door 4203 failed to be a positive latching door when the door was closed at 2:53 pm.

5. Patient room door 4228 failed to be a positive latching door when the door was closed at 2:55 pm.

6. Patient room door 4222 failed to be a positive latching door when the door was closed at 3:00 pm.

7. Rehab/Training room double doors 4015 failed to be positive latching doors when the doors were closed at 4:12 pm. The door closure had been removed.
In an interview conducted at the time of observations (5/6/13, from 2:30 pm to 4:35 pm), with Facilities E personal confirmed the corridor doors not positive latching when the doors were closed.

A.
Based on observation and interview the facility failed to provide separation from the kitchen cooking and serving area from the atrium by automatic closing doors. This condition will not allow the automatic roll down doors to shut to provide separation from the atrium and all floors open to the atrium. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 3:30 p.m. it was revealed that the fusible link device for the roll down doors to the kitchen and serving area was concealed above the suspended ceiling.

Facilities B and Maintenance A also confirmed this finding at the times of the observations.




27395

B.
Based on observation and staff interview, the facility failed to provide separation of the Atrium from the Hospital in accordance with the National Fire Protection Association, 101. This condition had the potential for smoke to fill the Atrium, and extend to other areas of the facility. Facility census was 74.
Findings are:

Observation during the facility tour on 5/8/13, from 12:58 pm to 1:46 pm revealed:

1. An engineering analysis document that demonstrated that the building was designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater, failed to be provided for review.

2. Smoke detection failed to be installed every 30 feet throughout the Atrium and the Conference Center for smoke evacuation and door magnetic hold open control. The facility failed to provide the engineering analysis document to verify that the current smoke detection met the smoke evacuation requirements for an Atrium.

3. Projected beam smoke detectors failed to be installed within three feet of the peak of the Atrium.

4. Glass walls and inoperable windows on each floor of the Atrium where a walkway was present failed to have sprinklers spaced on both sides of the glass so that the entire surface of the glass was wet upon operation of the sprinklers.

5. The Public Elevator Shaft failed to be separated by a fire resistance rating of at least 20 minutes where the elevator shaft opened onto the Atrium. Documentation failed to be provided to verify the fire resistance rating of the elevator door.

In an interview conducted at the time of observation, (5/8/13, from 12:58 pm to 1:46 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
8.2.5.6*
Unless prohibited by Chapters 12 through 42, an atrium shall be permitted, provided that the following conditions are met:
(1) In other than existing, previously approved atria, atriums are separated from the adjacent spaces by fire barriers with not less than a 1-hour fire resistance rating with opening protectives for corridor walls. (See 8.2.3.2.3.1(2), Exception No. 1.)
Exception No. 1: Any number of levels of the building shall be permitted to open directly to the atrium without enclosure based on the results of the engineering analysis required in 8.2.5.6(5).
Exception No. 2*: Glass walls and inoperable windows shall be permitted in lieu of the fire barriers where automatic sprinklers are spaced along both sides of the glass wall and the inoperable window at intervals not to exceed 6 ft (1.8 m). The automatic sprinklers shall be located at a distance from the glass not to exceed 1 ft (0.3 m) and shall be arranged so that the entire surface of the glass is wet upon operation of the sprinklers. The glass shall be tempered, wired, or laminated glass held in place by a gasket system that allows the glass framing system to deflect without breaking (loading) the glass before the sprinklers operate. Automatic sprinklers shall not be required on the atrium side of the glass wall and the inoperable windows where there is no walkway or other floor area on the atrium side above the main floor level. Doors in such walls shall be glass or other material that resists the passage of smoke. Doors shall be self-closing or automatic-closing upon detection of smoke.
(2) Access to exits is permitted to be within the atrium, and exit discharge in accordance with 7.7.2 is permitted to be within the atrium.
(3) The occupancy within the space meets the specifications for classification as low or ordinary hazard contents. (See 6.2.2.)
(4) The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
(5) * For other than existing, previously approved atria, an engineering analysis is performed that demonstrates that the building is designed to keep the smoke layer interface above the highest unprotected opening to adjoining spaces, or 6 ft (1.85 m) above the highest floor level of exit access open to the atrium for a period equal to 1.5 times the calculated egress time or 20 minutes, whichever is greater.
(6) * In other than existing, previously approved atria, where an engineered smoke control system is installed to meet the requirements of 8.2.5.6(5), the system is independently activated by each of the following:
a. The required automatic sprinkler system
b. Manual controls that are readily accessible to the fire department

NFPA 72, 2-3.4.4 Projected Beam-Type Smoke Detectors.
Projected beam-type smoke detectors shall be located with their projected beams parallel to the ceiling and in accordance with the manufacturer ' s documented instructions. The effects of stratification shall be evaluated when locating the detectors.
2-3.4.7* Peaked.
Detectors shall first be spaced and located within 3 ft (0.9 m) of the peak, measured horizontally. The number and spacing of additional detectors, if any, shall be based on the horizontal projection of the ceiling.

A.
Based on observation and interview, the facility failed to provide exits that are marked by approved, readily visible exit signs. This condition will cause occupants of the conference center to not be able to locate an exit in an emergency. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 2:06 p.m., it was revealed that the exits in the movable partitions, in the conference center, were not marked by exit signs.

2. On 5/6/2013 at approximately 2:45 p.m. it was revealed that no exit signs were provided in the outdoor garden area to indicate the egress route to the parking lot.

Facilities B and Maintenance A also confirmed this finding at the times of the observations.
.




27395

B.
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 74.
Findings are:

Observations during the facility tour on 5/6/13, from 1:20 pm to 5/8/13, at 1:33 pm revealed:

1. Both exits out of the East Penthouse failed to be marked with exit signage.

2. The double doors leading into the Medical Office Building (MOB) from the Hospital failed to be marked with exit signage on the Hospital side.

In an interview conducted at the time of observations (5/6/13, from 1:20 pm to 5/8/13, at 1:33 pm), Safety A acknowledged that exit signs were not visible in these areas.





19980

Findings are:
Observations during the facility tour on 5/7/13, from 11:35 am to 11:52 am, on the 1st floor revealed:

3. An exit sign failed to be installed above the Medical records exit door 1139.

4. An exit sign failed to be installed above the Quality management exit door 1142.

5. Exit signs failed to be installed in the Medical records/Quality management Suite to direct occupants to the exits.

6. An exit sign failed to be installed at the stair tower exit door 1043.

In an interview conducted at the time of observations (5/7/13, from 11:35 am to 11:52 am), with Facilities E personal confirmed that the exits were not visible in two directions out of the Medical records and Quality management suite. Facilities E personal also confirmed the exit sign location being located above the non-exit double doors into the Diagnostic Center and not at the stair tower exit door.

Based on observation and staff interview, the facility failed to provide exits out of all smoke zones that don ' t lead into the same smoke zone. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13 at 3:28 pm revealed both required exits leading out of smoke zone 4-2 lead directly into smoke zone 4-1 and are not separated from one another.

In an interview conducted at the time of observations, (5/6/13 at 3:28 pm), With Facilities E personal confirmed that both exits lead directly into smoke zone 4-1 without separation.

Based on observation and interview, the facility failed to provide smoke partitions, with at least a one half hour rating. This condition will allow smoke to travel into the adjacent smoke compartments. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 9:00 a.m. it was revealed that there was an unsealed penetration around a conduit, above the ceiling, in #3204.

2. On 5/7/2013 at approximately 9:10 a.m. it was revealed that there was an unsealed conduit, above the ceiling, above the door to #3224.

3. On 5/7/2013 at approximately 10:22 a.m. it was revealed that there was an unsealed penetration around a conduit in the smoke wall, above the ceiling, above the tube station on POD G.

4. On 5/8/2013 at approximately 9:15 a.m. it was revealed that there was an open conduit, above the ceiling, across from #1048.

5. On 5/8/2013 at approximately 9:35 a.m. it was revealed that there was an unsealed penetration around cables penetrating the smoke wall, above the ceiling, above #1059.

6. On 5/8/2013 at approximately 10:00 a.m. it was revealed that there was an unsealed penetration around cables penetrating the smoke wall, above the ceiling, above #1083.

Facilities B and Maintenance A both confirmed all of the findings at the times of the observations.
.

A.
Based on observation and staff interview, the facility failed to install self-closing devices on all doors in smoke barrier walls. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 74.
Findings are:

Observations during the facility tour on 5/8/13 at 9:39 am revealed room CT 1038 exit door failed to have a door closure installed on this door.

In an interview conducted at the time of observations (5/8/13, at 9:39 am), with Safety E confirmed that no door closure is installed on this door.



27394


B.
Based on observation and interview, the facility failed to have corridor fire doors close and positive latch upon activation of the building fire alarm system. This would allow smoke and fire to spread to other areas of the building, past the fire barrier. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 2:15 p.m. it was revealed that the North elevator Lobby doors, on the 3rd Floor did not close and positive latch upon activation of the fire alarm system.

2. On 5/7/2013 at approximately 2:25 p.m. it was revealed that the corridor fire doors by Exit 3003 did not close and positive latch upon activation of the fire alarm system.

3. On 5/7/2013 at approximately 2:33 p.m. it was revealed that the corridor fire doors on the third floor were not provided with astragals, rabbits or bevels to prevent smoke and fire spread through the gap in the doors to the other side of the fire barrier.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.
.

Based on observation and interview, the facility failed to provide separation from hazardous areas from the remainder of the building. This would allow a fire in these rooms to spread smoke and fire throughout the smoke compartment. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 1:30 p.m. it was revealed that the door to the storage room #137, in the Sleep Clinic, did not self close and latch.

2. On 5/6/2013 at approximately 1:33 p.m. it was revealed that the doors to storage room #142, in the Sleep Clinic, did not self- close and latch and were louvered doors only.

Facilities B and Maintenance A both confirmed the findings on 5/6/2013 at 1:30 p.m. and 1:33 p.m.

Based on observation and interview, the facility failed to provide separation from hazardous areas from the remainder of the building. This would allow a fire in these rooms to spread smoke and fire throughout the smoke compartment. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 1:48 p.m. it was revealed that the doors to storage rooms #152 and #153, in Physical Therapy, did not self-close and latch.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.

Based on observation and interview, the facility failed to provide separation from hazardous areas from the remainder of the building. This would allow a fire in these rooms to spread smoke and fire throughout the smoke compartment. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 2:17 p.m. it was revealed that the door to #L-104, in the Midwest Cancer Center, did not self- close and latch.

2. On 5/6/2013 at approximately 2:30 p.m. it was revealed that the garage, in the Midwest Cancer Center, had numerous penetrations around pipes and conduits that were not sealed.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.

Based on observation and staff interview, the facility failed to provide smoke resisting partitions for hazardous areas, and 1 hour fire-rated partitions where hazardous areas exceeded 100 square feet. This condition had the potential for smoke and fire to spread into the egress corridors. Facility census was 74.
Findings are:

Observations during the facility tour 5/6/13, from 2:09 pm to 5/8/13, at 9:17 am revealed:

1. Oxygen Storage Room 2037 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

2. The Soiled Linen Room 2042 Door failed to latch when the door was automatically closed.

3. Clean Supply Room 2006 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

4. Clean Supply Room 2008 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

5. The Pharmacy 2091 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating. The doors failed to positively latch, as the doors were held shut by a magnetic lock only.

6. Resource Staff Door 2058 failed to latch when the door was closed. An automatic closure failed to be installed on the storage room door.

7. Operating Room 6 was used for storage. Both doors failed to have automatic closures installed on the doors.

8. Mamo File Room 1097 exceeded 100 square feet, and failed to have a door with a 45 minute fire-resistance rating.

In an interview conducted at the time of observations (5/6/13, from 2:09 pm to 5/8/13, at 9:17 am), Safety A acknowledged the findings.



27394


Findings are:

9. On 5/6/2013 at approximately 2:40 p.m. it was revealed that the electrical room of the Siemens Theatre had unsealed penetrations around pipes and cables.

10. On 5/6/2013 at approximately 2:43 p.m. it was revealed that the door to storage room #0053 did not self- close and latch.

11. On 5/6/2013 at approximately 2:52 p.m. it was revealed that Biohazard Room #0011 had missing ceiling tiles that would allow smoke to spread out of this room.

12. On 5/6/2013 at approximately 3:05 p.m. it was revealed that the kitchen pantry and storage area was not provided with a door that would resist the passage of smoke in the event of a fire in this room.

13. On 5/7/2013 at approximately 9:03 a.m. it was revealed that the empty patient rooms, on the third floor, by ICU, were being used as storage rooms and were not provided with doors that were self closing and latching.

14. On 5/7/2013 at approximately 9:08 a.m. it was revealed that room #3000A was being used as a storage room and was not provided with a door that self closes and latches.

15. On 5/7/2013 at approximately 11:00 a.m. it was revealed that the storage room #1087 did not have a self-closing and latching door.

16. On 5/7/2013 at approximately 11:17 a.m. it was revealed that storage room #1067 did not have self closing and latching door.

17. On 5/8/2013 at approximately 10:10 a.m. it was revealed that the storage room #1014B did not have a self-closing and latching door.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.




19980


Findings are:
Observations during the facility tour on 5/6/13, from 3:00 pm to 4:30 pm revealed:
18. Soiled utility room 4055 door not closing and latching with the door closure when the door is opened.

19. Storage room 4000A door not closing and latching with the door closure when the door is opened.

Observations during the facility tour on 5/7/13, from 9:00 am to 11:30 am revealed:

20. A combustible storage room larger than 100 sq. feet failed to have a rated fire door, door closure, and latching hardware installed on this storage room.

21. Door to the parking garage on the first floor failed to have a 2 hour fire rating on the door.
In an interview conducted at the time of observations (5/6/13 from 3:00 pm to 4:30 pm and 5/7/13 from 9:00 am to 11:30 am), with facilities E confirmed the doors not closing and latching and the lack of fire separation between occupied spaces and hazardous areas.

Based on observation and staff interview, the facility failed to penetrate a stair enclosure with the items only allowed by NFPA 101, 7.1.3.2.1(e). This condition had the potential to allow smoke to enter the exit stairwells. Facility census was 74.
Findings are:

Observations during the facility tour on 5/7/13, at 4:01 pm revealed conduit for smoke damper actuators on the 4th floor of Stair 2 that did not serve Stair 2. The conduit failed to be separated from the Stair Tower by two hour fire-rated construction.

In an interview conducted at the time of observation, (5/7/13, at 4:01 pm), Safety acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

Based on observation and staff interview, the facility failed to arrange so that exits were readily accessible at all times. This condition had the potential to prevent the evacuation of occupants. Facility census was 74.
Findings are:

Observations during the facility tour on 5/7/13, from 4:09 pm to 5/8/13, at 9:17 am revealed:

1. The ER Exit adjacent to the Ambulance Bay emptied into a vestibule. The vestibule failed to be separated from the Ambulance Bay by one hour fire rated construction.

2. Stair Tower doors throughout the facility failed to have fire exit hardware installed so that the door could be opened by a panic device.

In an interview conducted at the time of observations (5/7/13, from 4:09 pm to 5/8/13, at 9:17 am), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.5.1.7
Exit access from rooms or spaces shall be permitted to be through adjoining or intervening rooms or areas, provided that such adjoining rooms are accessory to the area served. Foyers, lobbies, and reception rooms constructed as required for corridors shall not be construed as intervening rooms. Exit access shall be arranged so that it is not necessary to pass through any area identified under Protection from Hazards in Chapters 11 through 42.

NFPA 80, 2-4.4.1
Only labeled locks and latches or labeled fire exit hardware (panic devices) meeting both life safety requirements and fire protection requirements shall be used. [See A-1-1(c) and (d).]
2-4.4.2
Fire exit hardware shall be installed only on fire doors bearing the marking, " Fire Door To Be Equipped with Fire Exit Hardware. " Fire exit hardware shall be labeled for both fire and panic. Fire exit hardware shall have a permanently attached label that bears the serial number and shows the manufacturer ' s name and type of approval. The label shall differentiate between panic hardware, which is not acceptable for use on fire doors and fire exit hardware.



19980


Findings are:
Observations during the facility tour on 5/6/13 at 2:46 pm on the fourth floor and on 5/8/13 at 9:04 am revealed:

3. Stair tower three, exit door, on the fourth floor, failed to open with the required maximum force to open a door in a means of egress.

4. A motion sensor, a push to exit button, the mag lock tied into the fire alarm system, and the mag lock fail safe as to when the power drops the doors unlocks failed to be installed on doors 1150A and 1150B.

In an interview conducted at the time of observations (5/6/13 at 2:46m and 5/8/13 at 9:04 am), Facilities personal E confirmed the stair tower door not meeting the required manually means to open the door and Safety E personal confirmed the mag locks not having installed on them a sensor, a push to exit button and not tied into the fire alarm system.
-NFPA Standard: The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf to set release the latch, 30 lbf to set the door in motion and 15 lbf to open the door to the minimum required width. 2000 NFPA 101, 7.2.1.4.5
-NFPA Standard: Where permitted in Chapters 11 through 42, doors in the means of egress shall be permitted to be equipped with an approved entrance and egress access control system, provided that the following criteria are met.
(a) A sensor shall be provided on the egress side and arranged to detect an occupant approaching the doors, and the doors shall be arranged to unlock in the direction of egress upon detection of an approaching occupant or loss of power to the sensor.
(b) Loss of power to the part of the access control system that locks the doors shall automatically unlock the doors in the direction of egress.
(c) The doors shall be arranged to unlock in the direction of egress from a manual release device located 40 in. to 48 in. (102 cm to 122 cm) vertically above the floor and within 5 ft (1.5 m) of the secured doors. The manual release device shall be readily accessible and clearly identified by a sign that reads as follows:
PUSH TO EXIT
When operated, the manual release device shall result in direct interruption of power to the lock - independent of the access control system electronics - and the doors shall remain unlocked for not less than 30 seconds.
(d) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the doors in the direction of egress, and the doors shall remain unlocked until the fire-protective signaling system has been manually reset.
(e) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the doors in the direction of egress and the doors shall remain unlocked until the fire-protective signaling system has been manually reset. 2000 ed NFPA 101, 7.2.1.6.2

Based on observation and staff interview, the facility failed to provide a horizontal exit in accordance with the National Fire Protection Association 101, 7.2.4. This condition had the potential to prevent the evacuation of occupants. Facility census was 74.
Findings are:

Observation during the facility tour on 5/8/13, at 1:42 pm revealed the double doors between the Hospital and the MOB failed to swing in opposite directions to allow egress from the Hospital through the horizontal exit to the MOB.

In an interview conducted at the time of observations (5/8/13, at 1:42 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.2.4.3.6 Swinging fire doors shall be permitted in horizontal exits, provided that the criteria of both 7.2.4.3.6(1) and (2), or the criteria of 7.2.4.3.6(1) and (3), are met as follows:
(1) The doors shall swing in the direction of egress travel.
(2) Where a horizontal exit serves areas on both sides of a fire barrier, there shall be adjacent openings with swinging doors that open in opposite directions, with signs on each side of the fire barrier identifying the door that swings with the travel from that side.
Exception: Sleeping room areas in detention and correctional occupancies shall be exempt from the sign requirement.
(3) The doors shall be of any other approved arrangement, provided that the doors always swing with any possible egress travel.
Exception No. 1: The requirements of 7.2.4.3.6 shall not apply to horizontal exit door swing as provided in Chapters 19 and 23.
Exception No. 2: The requirements of 7.2.4.3.6 shall not apply to horizontal exit doors in corridors no greater than 6 ft (1.8 m) wide in existing buildings.

Based on observation and staff interview, the facility failed to provide illumination of the egress path and lighting at exit discharges so that the failure of one bulb would not leave the area in darkness. This condition had the potential to leave exits in darkness. Facility census was 74.
Findings are:

Observation during the facility tour on 5/7/13, from 11:48 am to 5/8/13, at 1:36 pm revealed:

1. Two-bulb lighting failed to be installed at the exit discharge of Stair Tower 3. Stair Towers throughout the Hospital failed to have two-bulb lighting at the exit discharges.

2. The egress path from the East Penthouse to the Stair Tower Door failed to be illuminated.

In an interview conducted at the time of observations (5/7/13, from 11:48 am to 5/8/13, at 1:36 pm), Safety A acknowledged the findings.



19980


Findings are:
3. Observations during the facility tour on 5/7/13 at 11:45 am revealed the exit door to the outside next to door 1135 failed to have installed more than one light fixture on the outside of the building at this exit.

4. Observations during the facility tour on 5/8/13 at 8:57 am revealed the exit door out of the doctors lounge on the first floor to the outside failed to have installed more than one light fixture on the outside of the building at this exit.

In an interview conducted at the time of observations (5/7/13 at 11:45 am), with Facilities E and with Safety E on (5/8/13 at 8:57 am) confirmed the area on the outside of the building not having installed more than a single exit light fixture.

Based on observation, record review and staff interview, the facility failed to have a written plan to shut off the piped in oxygen in the event of an emergency in the patient rooms. This condition would not allow staff or occupants to efficiently evacuate the occupant ' s in the patient rooms if fire occurred in that room. Facility census was 74.
Findings are:
Observations during the facility tour on 5/6/13, from 2:35 pm to 4:00 pm on the 4th floor revealed:

1. Interview with nursing staff in East 4 failed to know how to shut off the piped in oxygen to the patient rooms in the event of a fire emergency in the room.

2. Interview with nursing staff in West 4 failed to know how to shut off the piped in oxygen to the patient rooms in the event of a fire emergency in the room.

3. Interview with nursing staff in both East and West 4 failed to provide documentation of policy or procedures as how to shut off the piped in oxygen.

In an interview conducted at the time of observations (5/6/13, from 2:35 pm to 4:00pm), with Facilities E personal confirmed that staff did know how shut off the oxygen in the event of a fire emergency in the patient rooms.

Based on record review and staff interview, the facility failed to conduct fire drills at least quarterly on each shift. In addition the drills failed to be conducted under varied conditions at different times of the day for three of five quarters reviewed. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:
1. Documentation review on 5/6/13 revealed that no fire drills had been conducted for the Night shift in the fourth quarter of 2012.

2. Documentation review on 5/6/13 revealed that no fire drills for the Day shift had been conducted on the Day shift the first quarter of 2013.

3. Documentation review on 5/6/13 revealed that three of four fire drills conducted on the night shift had been conducted at 5:00 am. In addition three of four night shift drills were conducted in the Engineering office area.

Interview with Facilities Staff D, Safety Staff B and Security Staff A throughout the documentation reviews on 5/6/13 and 5/17/13 confirmed the lack of fire drills being conducted and that the Safety Officer position had been empty and not overseen.

Based on record review and staff interview, the facility failed to conduct fire exit drills at the Lakeside Hospital Central IV Sterile MFG Pharmacy. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:
Documentation review on 5/9/13 revealed no documentation for any fire exit drills for the Lakeside Hospital Central IV Sterile MFG Pharmacy had been provided for review.
Interview with Safety Staff B on 5/7/13 during documentation review between 8:00 am and 17:30 pm confirmed that all drill documentation had been provided for the off-sites. I

NFPA Standard: In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable. 2000 NFPA 101, 38.7.1, 39.7.1

Based on record review and staff interview, the facility failed to conduct unannounced fire drills at the Cancer Centers. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills and practice of the procedures can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:
1. Documentation review on 5/6/13 of the fire drill form for the Cancer Center stated " Coordinate best time for least disruption with key personnel in all areas. "
2. " Go through all areas and remind the key individuals of the drill and ask them to review with their personnel the location of the drill fire and appropriate actions to be taken. "
3. " Have reception person make announcement in Suite 200. "
Interview with Safety Staff B on 5/7/13 during documentation review between 8:00 am and 17:30 pm confirmed that all drill documentation had been provided for the off-sites. In addition Safety Staff B confirmed that the drills should not be planned for convenience, and that the key personnel should not be advised as to when and where the drill is being conducted.

NFPA Standard: In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable. 2000 NFPA 101, 38.7.1, 39.7.1

Based on observation and interview the facility failed to provide a fire alarm system with approved components, devices or equipment that is installed according to NFPA 72, National Fire Alarm Code, to provide effective detection and warning of a fire emergency in the building. This would allow a fire to be undetected and unnoticed in certain portions of the building. The facility census was 74.
Findings are:


1. On 5/6/2013 at approximately 2:19 p.m. it was revealed that the smoke detector in the kitchen dry storage room was not 3 feet from the air vent diffusor. NFPA 72 section 72.5.7.4.1 requires smoke detectors to be 3 feet from all air vent diffusor.

2. On 5/7/2013 at approximately 2:30 p.m. it was revealed that the fire alarm system on the third floor has two different fire alarm signal tones and the tones are not synchronized.

3. On 5/7/2013 at approximately 3:00 p.m. it was revealed that the fire alarm system on the first floor, near stair 1043, had two different fire alarm signal tones and the tones were not synchronized.

4. On 5/8/2013 at approximately 10:00 a.m. it was revealed that the conference room #1046D was not provided with a fire alarm notification device.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.





27395


Findings are:

Observations during the facility tour on 5/6/13, from 2:44 pm to 5/7/13, at 3:34 pm revealed:

5. Fire alarm notification failed to be installed in the Link between the Hospital and the MOB on the 3rd Floor.

6. Fire alarm notification failed to be installed in Break Room 2057.

7. The magnetic locks on the Emergency Department Doors by Restroom 1012 failed to unlock with the activation of the fire alarm. The doors were marked as an exit.

8. Voice evacuation fire alarm notification failed to be installed in the Conference Center and throughout the Atrium.

9. Audible notification signals failed to be synced on the 2nd, 3rd and 4th floors of the Hospital.

10. Fire alarm notification decibel levels failed to meet the minimum requirements of NFPA 72.

11. The fire alarm notification failed to meet the required ambient noise level while the HUGS Infant Protection Security System Alarm was active. The decibel level of the HUGS Infant Protection Security System Alarm exceeded the fire alarm notification.

In an interview conducted at the times of observation, (5/6/13, from 2:44 pm to 5/7/13, at 3:34 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
Nebraska State Fire Marshal Official Interpretations 95-03, 00-04, 03-04 and 07-02.

NFPA 101, 12.3.4.1 General.
Assembly occupancies with occupant loads of more than 300 and all theaters with more than one audience-viewing room shall be provided with an approved fire alarm system in accordance with 9.6.1 and 12.3.4.

NFPA 72, 4-3.2.2*
To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.



19980


Findings are:

12. Observations during the facility tour on 5/6/13 at 3:21 pm revealed on the fourth floor service elevators 5 and 6 west side failed to have the smoke detector installed at least three feet away from the air register.

13. Observation during the facility tour on 5/7/13 at 9:29 am revealed corridor next to room door 4021 failed to have fire alarm horn strobe devices installed within 15 foot of the end of a corridor and within 15 foot of corridor doors that close.
In an interview conducted at the time of observations (5/6/13 at 3:21 pm and 5/7/13 at 9:29 am), with Facilities E confirmed the fire alarm components not being installed in the corridor.

Based on observation and interview, the facility failed to provide a fire alarm system that was installed and maintained per the requirements of NFPA 72 National Fire Alarm Code. The practice would allow a fire to go undetected in the sleeping rooms of the sleep clinic. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 1:30 p.m. it was revealed that the patient sleeping rooms, in the Sleep Clinic, were not provided with smoke detection.

Facilities B and Maintenance A both confirmed the finding at 1:30 p.m. on 5/6/13.

Based on record review and interview, the facility failed to provide a properly tested and maintained fire alarm system as per Table 7-7.2. All of the facility was directly affected by the deficient practice. The facility had at the time of the survey the census was 74.
Findings are:

Documentation review on 5/6/13 revealed the fire alarm system of the last two completed inspection forms of the fire alarm system for the year 2011 and 2012 revealed tests on 12/12/11 and 12/6/12. This indicated an annual inspection and not semi-annual as required.

Interview with Facilities Staff D on 5/6/13 during documentation review from approximately 10:00 am through 5:00 pm confirmed the fire alarm had only been inspected and tested annually. On 5/7/13 at approximately 9:00 am Facilities Staff D stated the facility had planned on having an in-house licensed maintenance staff inspect and test the fire alarm but, that had not happened.

NFPA Standard: Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2. 1999 NFPA 72, 7-2.2
NFPA Standard: A permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per 1999 NFPA 72, 7-5.2.2 and figure 7-5.2.2; A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70. 2000 NFPA 101, 9.6.1.4

Based on observation and staff interview, the facility failed to install the sprinkler system in accordance with the National Fire Protection Association 13. This condition had the potential that the system would fail to operate as designed. Facility census was 74.
Findings are:

Observation during the facility tour on 5/6/13, from 1:42 pm to 3:19 pm revealed:

1. The PIV for the Hospital failed to be protected from physical damage in the parking lot.

2. Ceiling tiles failed to be replaced and a gap around wires failed to be sealed in the suspended ceiling of Electrical Closet 2015A.

In an interview conducted at the times of observation, (5/6/13, at 1:42 pm), Safety A acknowledged the findings.

Actual NFPA Standard:
NFPA 24, 3-3.4
Post indicator valves shall be properly protected against mechanical damage where needed.



19980


Findings are:
3. Observations during the facility tour on 5/8/13 at 9:15 am revealed sprinkler heads across from room 1150 that failed to be installed in accordance with NFPA 13 by being installed closer than 6 feet apart.

In an interview conducted at the time of observations (5/8/13 at 9:15 am), With Safety E confirmed that the sprinkler heads being less than 6 foot apart.

Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing in the Lakeside Cancer Center building housing Image Recovery, Oncology Service, Cancer Imaging, Radiation/Oncology, and Midwest Cancer Center. All smoke compartments and all occupants could be affected by the deficient practice. The facility census was 74.
Findings are:
Documentation review on 5/13/13 revealed the sprinkler system water flow had been tested on 1/16/13 and 1/26/12 indicating an annual inspection and not quarterly as required.
Interview with Safety Staff B on 5/7/13 between 8:00 am and 5:15 pm confirmed the only documentation available had been provided for review.


NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing in the Lakeside MOB building housing the Outpatient Cardiac Rehab and Sleep Disorders Clinic. All smoke compartments and all occupants could be affected by the deficient practice. The facility census was 74.
Findings are:

1. Documentation review on 5/7/13 of the sprinkler inspection reports revealed the sprinkler system for the Lakeside MOB building had been inspected on 9/7/12.

Interview with Safety Staff B on 5/7/13 between 8:00 am and 5:15 pm confirmed the only documentation available had been provided for review.


NFPA Standard: Automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25 per NFPA 101, 9.7.5. Obstructions shall not prevent sprinkler discharge from reaching the protected area. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 inches below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with this section. The requirements of this section shall also apply to obstructions 18 in. or less below the sprinkler for light and ordinary hazard occupancies per NFPA 13, 5-6.5.3. Water flow alarm devices including, but not limited to, mechanical water motor gongs, vane-type water flow devices, and pressure switches that provide audible or visual signals shall be tested quarterly per 1998 NFPA 25, 2-3.3
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1
NFPA Standard: A sprinkler system installed in accordance with this standard shall be properly inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 1999 NFPA 13, 12.1

Based on observation and interview, the facility failed to have the sprinkler system continuously maintained in a reliable operating condition. This would allow a fire to spread because the sprinkler system in the area of fire origin would not properly operate. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 3:30 p.m. it was revealed that the sprinkler head in the garden level library, off of the cafeteria, was obstructed by the hanging light fixture.

2. On 5/8/2013 at approximately 9:20 a.m. it was revealed that the sprinkler head in room #1091D was missing the protective escutcheon plate.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.
.




19980


Findings are:

3. Observations during the facility tour on 5/7/13 at 11:35 am revealed the sprinkler head located in the corridor next to Quality Management room door 1142 failed to have a sprinkler cover plate installed on the sprinkler head.

In an interview conducted at the time of observations (5/7/13 at 11:35 am) Facilities E confirmed the cover plate not being installed on the sprinkler head.

Based on observation and interview, the facility failed to provide heating equipment that was installed and maintained to current NFPA 211 standards. This practice would allow carbon monoxide gas to spread throughout the facility by means of the open atrium. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 9:15 a.m. it was revealed that the third floor was not provided with carbon monoxide detection in the general area of the gas fire place per NFPA 211 requirements.

2. On 5/6/2013 at approximately 2:30 p.m. it was revealed that the garden level was not provided with carbon monoxide detection in the general area of the gas fire place per NFPA 211 requirements.

Facilities B and Maintenance A both confirmed the findings at the times of the observations.




19980


Findings are:

3. Observations during the facility tour on 5/6/13 at 4:10 pm revealed a fire place in room 4000 that failed to be installed in accordance with manufacturer ' s specifications by not having a CO detector installed next to the fire place.

In an interview conducted at the time of observations (5/6/13 at 4:10pm) with Facilities E confirmed the CO detector not being installed.

Based on observation and interview, the facility failed to provide kitchen cooking equipment that was properly protected by automatic extinguishing systems in accordance with NFPA 96. This would allow a fire in the kitchen, under the hood with a cooking appliance, to not be properly extinguished. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 4:00 p.m. it was revealed that the appliances under the hood systems, in the kitchen, were not provided with devices that allow the appliance to be returned to its original, approved location after being moved for cleaning or maintenance.

Facilities B and Maintenance A both confirmed the finding at the times of the observations.
.

Based on observation and interview the facility failed to have means of egress corridors continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This would allow corridors to become blocked and in turn slow or hinder egress and escape during an emergency in that smoke compartment. The facility census was 74.
Findings are:

1. On 5/7/2013 at approximately 8:53 a.m. it was revealed that the third floor ICU hallways were being blocked by isolation and housekeeping carts.

Facilities B and Maintenance A both confirmed the finding at the times of the observations.





19980


Findings are:

Observations during the facility tour on 5/6/13, from 2:30 pm to 4:35 pm on the 4th floor revealed:

2. Observations on 5/6/13 from 2:30 pm to 3:15 pm revealed storage in the corridor on the 4th floor next to room 4214 for more than 30 minutes. This storage consisted of chairs being stored in the corridor reducing the width of the corridor down to 5 foot 6 inches.

3. Observations on 5/6/13 from 2:45 pm to 3:30 pm revealed storage in the corridor on the 4th floor next to room 4209 for more than 30 minutes. This storage consisted of 3 chairs being stored in the corridor reducing the width of the corridor down to less than 8 foot.

4. Observations on 5/6/13 from 3:50 pm to 4:30 pm revealed storage in the corridor on the 4th floor next to room 4223 for more than 30 minutes. This storage consisted of 3 chairs being stored in the corridor reducing the width of the corridor down to less than 8 foot.

5. Observations on 5/6/13 from 3:55 pm to 4:35 pm revealed storage in the corridor on the 4th floor next to room 4228 for more than 30 minutes. This storage consisted of 2 chairs and 1 plant being stored in the corridor reducing the width of the corridor down to less than 8 foot.
In an interview conducted at the time of observations (5/6/13, from 2:35 pm to 4:35pm), with Facilities E personal confirmed the storage in the corridor and the width of the corridor being less than 8 foot because of the storage.

Based on observation and staff interview, the facility failed to regulate the total capacity of soiled linen receptacles so that they would not exceed 32 gallons in a 64 square foot area. This condition had the potential to add combustible fuel loads in the exit corridors in the event of a fire. Facility census was 74.
Findings are:

Observation during the facility tour on 5/6/13, from 1:58 pm to 2:26 revealed:

1. Two soiled linen carts were stored in Restroom 2159. The carts together exceeded 32 gallons of soiled linen in a 64 square foot area. The Restroom failed to be rated as a hazardous area.

2. Two soiled linen carts were stored in the Recovery area by Room 2035. The carts together exceeded 32 gallons of soiled linen in a 64 square foot area. The carts failed to be stored in a room separated as a hazardous area.

In an interview conducted at the time of observation, (5/6/13, from 1:58 pm to 2:26), Safety A confirmed the containers exceeded 32 gallons in a 64 square foot area.

A.
Based on observation, record review and staff interview, the facility failed to install a line isolation monitor or ground-fault circuit interrupter outlets in the Operating Rooms in accordance with NFPA 99. This condition had the potential to allow a patient to receive electrical shock during a surgery. The facility census was 74.
Findings are:

Observations during the facility tour on 5/6/13, from 3:16 pm to 4:45 pm revealed GFCI outlets, GFCI breakers or line isolation monitors failed to be installed in all Operating Room and the C-Section Room.

Record review revealed no written specifics of which type of procedures would normally take place in the operating rooms to determine if any special protection against electric shock had to be provided if wet procedures are likely to be performed or not.

In an interview conducted at the time of observation, (5/6/13, from 3:16 pm to 4:45 pm), Safety A verified that GFCI outlets, GFCI Breakers or line isolation monitoring failed to be installed and that a policy of normally conducted procedures with what, if any, special protection needed did not exist.

Actual NFPA Standard:
NFPA 99, 3-3.2.1.2 All Patient Care Areas.
(f) Wet Locations.
1. * Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
2. The use of an isolated power system (IPS) shall be permitted as a protective means capable of limiting ground fault current without power interruption. When installed, such a power system shall conform to the requirements of 3-3.2.2.
3. Where power interruption under first fault condition (line-to-ground fault) is tolerable, the use of a ground-fault circuit interrupter (GFCI) shall be permitted as the protective means that monitors the actual ground fault current and interrupts the power when that current exceeds 6 mA.



20404

B.
Based on observation and interview the facility failed to have the emergency generator installed in accordance with NFPA 110 by not having a remote shutdown for the emergency generator other than on the generator itself and by having a large amount of storage of combustibles inside the generator building without any separation. This deficient practice has the potential to effect all residents, staff and visitors of the facility in the event of an emergency condition.
Findings are:
1. Observation on May 7, 2013 at 8:54am revealed that the emergency shutdown switch for the emergency generator was located in the same room as the generator and would not allow for safe shutdown of the emergency generator in the case of fire or other emergency involving the generator itself. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

NFPA 110, 2002ed. 5.6.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

2. Observation on May 7, 2013 at 8:57am revealed that there was a large amount of combustible storage of decontamination supplies in the emergency generator building with no separation. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

NFPA 110, 2002ed. 7.2.1.2 No other equipment, including architectural appurtenances, except those that serve this space, shall be permitted in this room.

Based on record review and staff interview, the facility failed to conduct Laboratory fire exit drills at least quarterly on each shift. This deficient practice effects all occupants including staff, visitors and patients, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. This facility has a capacity of 157 and a census of 74 residents.
Findings are:

1. Documentation review on 5/7/13 revealed the Laboratory provided documentation of one fire drill for 2012.

Interview with Lab Operations Director A on 5/7/13 during documentation review between 8:00 am and 17:30 pm confirmed that only one drill had been conducted during 2012 in the Laboratory. In addition they were unaware of the quarterly exit drill requirement.

NFPA Standard: Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually. 1999 NFPA 99 10-2.1.4.3

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.
Findings are:
1. Observation on May 7, 2013 at 8:49am revealed that panel CLGEN in the generator building contained life safety loads for the emergency generator building and system and at 9:13am it was revealed that this panel was connected to the critical branch panel CDPLBA. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and times.

2. Observation on May 7, 2013 at 9:31am revealed that Critical Branch panel GCL2 contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

3. Observation on May 7, 2013 at 9:43am revealed that the Critical Branch panel 1CL1 contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

4. Observation on May 7, 2013 at 9:52am revealed that the Critical Branch panel 4CL1 contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

5. Observation on May 7, 2013 at 10:21am revealed that the Critical Branch panel CLBK contained both non-critical loads and Life Safety Loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

6. Observation on May 7, 2013 at 10:41am revealed that the Critical Branch panel CLBH contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

7. Observation on May 7, 2013 at 10:51am revealed that the Critical Branch panel CH1B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

8. Observation on May 7, 2013 at 11:06am revealed that the Critical Branch panel CL1B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

9. Observation on May 7, 2013 at 11:11am revealed that the Critical Branch panel CL1C contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

10. Observation on May 7, 2013 at 11:13am revealed that the Critical Branch panel CL1D contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

11. Observation on May 7, 2013 at 11:20am revealed that the Critical Branch panel CL1A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

12. Observation on May 7, 2013 at 11:28am revealed that the Life Safety Branch panel LH2B contained non-life safety loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

13. Observation on May 7, 2013 at 11:30am revealed that the Critical Branch panel CL2B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

14. Observation on May 7, 2013 at 11:37am revealed that the Critical Branch panel CL2A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

15. Observation on May 8, 2013 at 8:48am revealed that the Critical Branch panel labeled 5NL1 is actually 5CL1 and that it contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

16. Observation on May 8, 2013 at 8:56am revealed that the Critical Branch panel CL3B contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

17. Observation on May 8, 2013 at 9:00am revealed that the Life Safety Branch panel LL3A contained non-life safety loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

18. Observation on May 8, 2013 at 9:05am revealed that the Critical Branch panel CL3A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

19. Observation on May 8, 2013 at 9:05am revealed that the Critical Branch panel CL3A contained Life Safety loads for Med Gas Alarms. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

20. Observation on May 8, 2013 at 9:12am revealed that the Critical Branch panel CL4A contained non-critical loads. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

21. Observation on May 8, 2013 at 9:34am revealed that there was not the required amount of emergency lighting outside the building to extend from the exit discharge to the public way. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

22. Observation on May 8, 2013 at 9:40am revealed that the emergency shunt trip power for the kitchen appliances was connected to normal power panel LBK-2. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

23. Observation on May 8, 2013 at 9:42am revealed that the circuit for the kitchen fire protection system was connected to the normal power panel LBKA. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

24. Observation on May 8, 2013 at 10:52am revealed that the kitchen hood exhaust fans were connected only to normal power at MCCP. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed 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)]

A.
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 provide proper working clearances for electrical equipment and maintaining the integrity of the electrical equipment. This deficient practice has the potential to affect all occupants of the facility.
Findings are

1. Observation on May 8, 2013 at 9:29am revealed that there was no signage at the main service disconnects for the building to indicate the presence of the emergency power supply system for the building. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed 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.

2. Observation on May 8, 2013 at 9:25am 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 Facilities C and Contractor A at the above listed 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.

3. Observation on May 7, 2013 at 11:02am revealed that the circuit directory for the Critical Branch panel CL1B did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

4. Observation on May 7, 2013 at 11:08am revealed that the feeder for panel CL1C was not identified as coming from panel CL1B. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

5. Observation on May 7, 2013 at 11:11am revealed that the circuit directory for the Critical Branch panel CL1C did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

6. Observation on May 7, 2013 at 11:20am revealed that the circuit directory for the Critical Branch panel CL1A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

7. Observation on May 7, 2013 at 11:38am revealed that the circuit directory for the Critical Branch panel CL2A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

8. Observation on May 8, 2013 at 8:44am revealed that the feeder labeled 5CL1 in Critical Branch Panel 3CL1 actually goes to the penthouse and feeds the panel labeled 5NL1. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

9. Observation on May 8, 2013 at 8:55am revealed that the circuit directory for the Critical Branch panel CL3B did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

10. Observation on May 8, 2013 at 9:04am revealed that the circuit directory for the Critical Branch panel CL3A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

11. Observation on May 8, 2013 at 9:43am revealed that the circuit directory for the Normal Branch panel LBKA did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

12. Observation on May 8, 2013 at 9:55am revealed that the circuit directory for the Normal Branch panel L1C did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

13. Observation on May 8, 2013 at 10:14am revealed that the circuit directory for the Normal Branch panel L3B did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

14. Observation on May 8, 2013 at 10:17am revealed that the circuit directory for the Normal Branch panel L3A did not clearly indicate the purposes for the loads served. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.

15. Observation on May 8, 2013 at 10:59am revealed that the normal power motor control center in the penthouse was not labeled. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed 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 May 7, 2013 at 8:45am revealed that there was not the required working clearance in front of the Critical Branch Panel CLGEN in the Emergency Generator Building. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.
Observation on May 7, 2013 at 9:00am revealed that the Emergency switchgear room contained large electrical equipment and did not have double the required working clearances and the exit doors from the room were not provided with Panic type hardware. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.
Observation on May 8, 2013 at 9:30am revealed that the Main electrical room in the original building contained large electrical equipment and did not have double the required working clearances and the exit doors from the room were not provided with panic type hardware. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.
NFPA 70, 1999ed.
110.26 Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
Table 110.26(A)(1) Working Spaces

Nominal Voltage to Ground Minimum Clear Distance
Condition 1 Condition 2 Condition 3
0-150 900 mm (3 ft) 900 mm (3 ft) 900 mm (3 ft)
151-600 900 mm (3 ft) 1 m (3? ft) 1.2 m (4 ft)

Note: Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switchboards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on nonelectrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all uninsulated parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volts dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 750 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(E). Within the height requirements of this section, other equipment that is associated with the electrical installation and is located above or below the electrical equipment shall be permitted to extend not more than 150 mm (6 in.) beyond the front of the electrical equipment.
(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(C) Entrance to Working Space.
(1) Minimum Required. At least one entrance of sufficient area shall be provided to give access to working space about electrical equipment.
(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.
A single entrance to the required working space shall be permitted where either of the conditions in 110.26(C)(2)(a) or (b) is met.
(a) Unobstructed Exit. Where the location permits a continuous and unobstructed way of exit travel, a single entrance to the working space shall be permitted.
(b) Extra Working Space. Where the depth of the working space is twice that required by 110.26(A)(1), a single entrance shall be permitted. It shall be located so that the distance from the equipment to the nearest edge of the entrance is not less than the minimum clear distance specified in Table 110.26(A)(1) for equipment operating at that voltage and in that condition.
(D) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting outlets shall not be required where the work space is illuminated by an adjacent light source or as permitted by 210.70(A)(1), Exception No. 1, for switched receptacles. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.
(E) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 2.0 m (6? ft). Where the electrical equipment exceeds 2.0 m (6? ft) in height, the minimum headroom shall not be less than the height of the equipment.
Exception: In existing dwelling units, service equipment or panelboards that do not exceed 200 amperes shall be permitted in spaces where the headroom is less than 2.0 m (6? ft).
(F) Dedicated Equipment Space. All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage.
Exception: Control equipment that by its very nature or because of other rules of the Code must be adjacent to or within sight of its operating machinery shall be permitted in those locations.
(1) Indoor. Indoor installations shall comply with 110.26(F)(1)(a) through (d).
(a) Dedicated Electrical Space. The space equal to the width and depth of the equipment and extending from the floor to a height of 1.8 m (6 ft) above the equipment or to the structural ceiling, whichever is lower, shall be dedicated to the electrical installation. No piping, ducts, leak protection apparatus, or other equipment foreign to the electrical installation shall be located in this zone.
Exception: Suspended ceilings with removable panels shall be permitted within the 1.8-m (6-ft) zone.
(b) Foreign Systems. The area above the dedicated space required by 110.26(F)(1)(a) shall be permitted to contain foreign systems, provided protection is installed to avoid damage to the electrical equipment from condensation, leaks, or breaks in such foreign systems.
(c) Sprinkler Protection. Sprinkler protection shall be permitted for the dedicated space where the piping complies with this section.
(d) Suspended Ceilings. A dropped, suspended, or similar ceiling that does not add strength to the building structure shall not be considered a structural ceiling.
(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in 110.26(A). No architectural appurtenance or other equipment shall be located in this zone.

16. Observation on May 8, 2013 at 8:57am revealed that there was an unused opening in the top of the Critical Branch panel CL3B that was not effectively closed to maintain the integrity of the panel enclosure. This observation was confirmed in an interview with Facilities C and Contractor A at the above listed date and time.



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B.
Based on observation and interview the facility failed to have all electrical wiring and equipment in accordance with NFPA 70 National Electrical Code. This would allow an exposure to possible shock hazard and also increase the fire hazard due to damage of the electrical wiring. The facility census was 74.
Findings are:

1. On 5/6/2013 at approximately 4:30 p.m. it was revealed that an electrical junction box, above the ceiling, above the kitchen serving area doors, was missing the protective cover leaving the wires exposes.

Facilities B and Maintenance A both confirmed the finding at the times of the observations.




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Findings are:

2. Observations during the facility tour on 5/6/13 at 4:05 pm revealed in the physical therapy room 4011 by monitor GM 32 and Monitor BW 3, non-hospital grade power taps being used as a power source.

In an interview conducted at the time of observations (5/6/13 at 4:05 pm), with Facilities E confirmed the use of non-hospital grade power taps being used in patient care areas.