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Based on random observation during the survey walk-through, and document review, the facility's written plan for the protection of patients is not complete as required by 19.7.1.1. These deficiencies could affect any patients, staff, or visitors in the building because the failure to identify key life safety components could result in the failure to protect them properly.

Findings include:

A. At 10:50 AM on April 9, 2013, a series of apparent errors were observed in the Life Safety Plans dated July 20, 2009; these plans are thus not sufficiently accurate to comply with 19.7.1.1. Apparent errors include:
1. The Center Exit Stair is shown as being provided with a fire rated Exit Passageway, and is not shown as discharging into a sprinklered, separated fire compartment.

Added 8/11/14: The reference plans posted throughout the building have not been updated to indicate the current understanding of building fire protection features as indicated on the Revised Life Safety Reference Plan. The Revised Life Safety Reference Plan indicates that the Center Exit Stair discharges into only a 1-hour separated sprinklered smoke compartment to comply with 7.7.2(2), therefore the designated fire rating for the Center Exit Stair can only be considered as a 1-hour rated stair enclosure rather than the 2-hour currently shown on the reference plans.

2. Corrected 8/11/14.

Based on document review and staff interview, fire drills are not held at varying times and varying conditions in accordance with 19.7.1.2. These deficiencies could affect any patients, staff, or visitors in the building because staff members may not be properly prepared for a fire emergency, and because the connection between the Hospital and the Monitoring Agency may not be intact.

Findings include:

A. Based on a review of Fire Drill Records, conducted at 9:27 AM on April 9, 2013, fire drills for the Second Shift are not conducted at varying times as required by 19.7.1.2. During the calendar years 2012 and 2013, fire drills for the following quarters were conducted at the similar times listed:

1. February 27, 2012: 11:30 PM.

2. May 27, 2012: 11:30 PM.

3. August 23, 2012: 11:00 PM.

4. November 19, 2012: 11:00 PM.

5. February 25, 2013: 11:25 PM.

6. Added 8/11/14: The records for the last two quarters indicated that drills were conducted at 11:00 PM on 5-24-14 and 11:00 PM on 3-31-14, thus not maintaining a drill schedule of varying times.

B. Corrected 8/11/14.

The fire alarm system is not maintained in accordance with 19.3.4, 9.6.1.4 and NFPA 72-1999. Failure to maintain the system could result in accidental interruption of the normal and emergency power supply for the fire alarm system.

Findings include:

A. On the afternoon of 8-11-14 at the First Floor Boiler Room, Electrical Panel XP6 was observed with a fire alarm circuit which was not provided with red markings and was not provided with a mechanical lock-on device to comply with NFPA 72-1999, 1-5.2.5.2.


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Based on random observation during the survey walk-through, not all portions of the building fire alarm system are installed in accordance with 19.3.4. This deficiency could affect any patients, staff, or visitors in the cited Corridor because they may not be made aware of a fire emergency.

Findings include:

A. Corrected 8-11-14.

Based on random observation during the survey walk-through, not all egress paths are maintained free of obstructions or impediments to full instant use in the case of fire or other emergency in accordance with 19.2.3.3. These deficiencies could affect any patients, staff, or visitors in the cited areas by preventing their egress from the building.

Findings include:

A. Carts, furnishings, and equipment were observed in exit access corridors that obstruct egress as prohibited by 19.2.3.3. and 7.1.10.2.1. Locations and items observed include:

1. 1:45 PM April 8, 2013: Linen cart in Second Floor Surgical Department East Corridor. (Added 8/11/14: Linen/scrub cart was observed at the entrance to the Surgical Dept. adjacent the horizontal sliding door/red line area.)

2. Corrected 8/11/14.

Based on random observation during the survey walk-through, document review, and staff interview, the facility is not in compliance with a series of Life Safety and other code requirements that are not documented under other K-Tags.

Findings include:

A. Due to the number, variety, and severity of the life safety deficiencies observed during the survey walk-through, the provider shall institute appropriate interim life safety measures until all cited deficiencies are corrected. The provider shall include, as an attachment to its Plan of Correction (PoC) and referenced therein, a detailed narrative and proposed schedule for all such measures. The narrative shall describe all measures to be implemented, as well as the frequency with which they are to be conducted, and shall indicate the manner in which the measures are to be documented. The narrative shall also include comments related to changes in the interim life safety measures to remain in place as work toward the completion of its PoC progresses.

Based on document review and staff interview, the emergency generator is not inspected and tested in accordance with NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the emergency generator may not function under power outage conditions.

Findings include:

A. During the document review process, it was determined that the emergency generator is not tested under load for 30 minutes each month, as required by NFPA 99 1999 3-4.4.1.1. and NFPA 110 1999 6-4.2. This determination was confirmed by the provider's Maintenance Supervisor during an interview held in his Office at 9:40 AM on April 9, 2013.

Added 8-11-14: The revised form used for the generator run documentation was not clear relative to generator run times. The form tabulates the "transfer" time as typically a time period of 30 minutes, but the actual "run time" for the generator is typically tabulated as 1.1 hours. Therefore, it could not be determined from the documentation the actual time the generator runs under load and how much of the run time can be attributed to "cool-down" or "no-load" run times.

B. During the document review process, it was determined that transfer switches are not operated monthly as required by NFPA 110 1999 6-4.5. This determination was confirmed by the provider's Maintenance Supervisor during an interview held in his Office at 9:41 AM on April 9, 2013.

Added 8-11-14: On the afternoon of 8/11/14 during record review, it was observed that the forms do not document the time period required for the transfer of power from the normal system to the emergency generator system. Therefore, it could not be determined whether the transfer of power was made within 10 seconds to comply with NFPA 99-1999, 3-4.4.1.1 and NFPA 110-1999, 2-2.2.

C. Added 8-11-14: On the afternoon of 8/11/14 during record review, it was observed that no information for the weekly inspection and testing of the starting batteries was available to indicate that electrolyte levels are inspected weekly and specific gravity testing is performed monthly to comply with NFPA 110-1999, 6-3.6 and NFPA 99-1999, 3-4.4.1.3. Although maintenance-free batteries are not permitted under NFPA 110-1999, 3-5.4.5, compliance with later editions of the Code have been accepted. While inspection and testing of the battery electrolyte levels and specific gravity are not required when utilizing a maintenance-free battery, alternative means of verifying the battery's state-of-health condition is still required in the form of conductance testing as permitted under NFPA 110-2005, 8.3.7.1.

Based on random observation during the survey walk-through and staff interview, the facility's Type 1 Emergency Electrical System (EES) is not divided into the Life Safety Branch, the Critical Branch, and the Equipment Branch as required by NFPA 99. These deficiencies could affect any patients, staff, or visitors in the building because the EES could become compromised.

Findings include:

A. The facility's Type 1 EES was observed to not be divided into a Life Safety, Critical, and Equipment Branch as required by NFPA 99 1999 3-4.2.2.2. and NFPA 70 1999 517-30. All Electrical Panels listed below were observed to serve electrical loads which are required to be served by different branches of the EES. Electrical Panels at which this condition was observed include, but are not limited to:
1. 11:57 AM April 8, 2013, Panel EX1, located in the Third Floor Center Equipment Room.

2. 1:56 PM April 8, 2013, Panel LPE-20, located in the Second Floor West Corridor.
3. 2:42 PM April 8, 2013, Panel X1, located in the First Floor Electrical Room.
4. 2:43 PM April 8, 2013, Panel X, also located in the First Floor Electrical Room.
5. 2:45 PM April 8, 2013, Panel HER, located in the First Floor Emergency Department Electrical Room.

6. 2:46 PM, Panel EER, also located in the First Floor Emergency Department Electrical Room.

7. 8:19 AM April 9, 2013, Panel XP5, located in the First Floor Boiler Room.

8. 8:20 AM, April 9, 2013, Panel XP6, also located in the First Floor Boiler Room.

B. The facility's Type 1 EES was observed to lack a separate transfer switch for each branch of the system (Life Safety, Critical, and Equipment) as required by NFPA 99 1999 3-4.2.2.1. and NFPA 70 1999 517-30(b)(4). During an interview held in his Office at 8:05 AM on April 9, 2013, the provider's Maintenance Supervisor confirmed that the facility has only 2 transfer switches, and that each of these serves a combination of Life Safety, Critical, and Equipment Branch loads.

Based on random observation during the survey walk-through and staff interview, not all portions of the building electrical system are installed in accordance with NFPA 70 1999. These deficiencies could affect any patients being treated in the cited areas because emergency power may not be available under certain conditions, or may affect any patients, staff, or visitors in the building because the fire alarm system could become compromised.

Findings include:

A. During an interview conducted in Second Floor Patient Sleeping Room 236 at 2:04 PM on April 8, 2013, the provider's Maintenance Supervisor confirmed that not all patient headwall locations in Patient Sleeping Rooms are provided with at least 1 circuit from the Critical Branch of the building's Type 1 Emergency Electrical System as required by NFPA 70 1999 517-18(a). Locations observed include all Second Floor Patient Sleeping Room headwall locations except the west beds in the 4-Bed Patient Sleeping Room immediately east of the Nurses' Station.

B. Corrected 8-11-14.