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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by the failure to repair and seal penetrations in the walls. This could result in the spread of smoke or fire from one smoke compartment to the next smoke compartment, and increase the risk of injury to patients, visitors, and staff due to smoke and fire. This affected 4 of 12 smoke compartments.

Findings:

During the facility tour with the facility staff from 4/9/2013 through 4/11/2013, the facility walls were observed.

4/10/2013:

1. At 1:34 p.m., there was an approximately 3 inch by 4 inch unsealed penetration in the bottom left of the back wall inside the Telephone room located in the Med Surge Lounge.

2. At 2:30 p.m., there were two approximately 1/2 inch unsealed penetrations running through the top left wall in Materials Management to the new kitchen under construction. The Director of Human Resources confirmed the penetrations in the separation wall.



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3. At 1:35 p.m., there were three penetrations approximately 1/4 inch each in the bathroom corridor wall in Medical Records.

4. At 1:39 p.m., there were two penetrations approximately 1/2 inch each in the utility room in the Women's Center.

Based on observation, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to positive latch, by corridor doors that were obstructed from closing, and by penetrations in corridor doors. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 3 of 12 smoke compartments.

Findings:

During the facility tour with the facility staff from 4/9/2013 through 4/11/2013, the corridor doors were observed.

4/10/2013:

1. At 10:45 a.m., in the Emergency Department waiting room one of two doors was obstructed from closing by a chair. The door was equipped with a magnetic door hold open device.

2. At 10:57 a.m., in the Emergency Department, office door #7 failed to shut and latch.

3. 11:17 a.m., the door to the ultra sound room in Radiology had 2 penetrations in the door. There was one penetration below the door knob, and one penetration above the door knob, that were approximately 1/4 inch each.

4. 11:18 a.m., the door to the Employee Lounge in Radiology failed to shut and latch.

5. 11:25 a.m., the door to the Physical Therapy office was obstructed from closing by a chair.


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6. At 2:05 p.m., the corridor door failed to latch shut to Patient Room 111. The latch plate was stuffed with paper that prevented the door from latching. The Director of Human Resources confirmed that the latch plate was stuffed with paper that prevented the door from latching.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls as evidenced by penetrations in smoke barrier walls. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 4 of 12 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour and interview with facility staff from 4/9/2013 through 4/11/2013, the smoke barrier walls were observed, and staff was interviewed.

4/10/2013:

1. At 10:38 a.m., there was an approximately 1/2 inch by 1 1/4 inch unsealed penetration in the smoke barrier wall surrounding a pipe over the right door leaf of smoke barrier door #61, by Physical Therapy. The Director of Human Resources confirmed the penetrations in the smoke barrier wall.
2. At 10:55 a.m., there was an approximately 3/4 inch unsealed penetration in the smoke barrier wall above the smoke barrier door at the entrance to Obstetrics. The Director of Human Resources confirmed the penetration in the smoke barrier wall, and stated that the penetrations would be repaired immediately.

Based on observation and interview, the facility failed to maintain the smoke barrier doors as evidenced by gaps between two sets of cross-corridor smoke barrier doors. This could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 4 of 12 smoke compartments.

Findings:

During the facility tour and interview with the facility staff from 4/9/2013 through 4/11/2013, the smoke barrier doors were observed, and staff was interviewed.

4/10/2013:

1. At 2:40 p.m., , there was an approximately 1/2 inch gap between a set of cross-corridor smoke barrier doors located next to Physical Therapy.

2. At 3:09 p.m., there was an approximately 1/2 inch gap between a set of cross-corridor smoke barrier doors located next to Room 123 in Med Surg. The Director of Plant Operations confirmed the gaps in the cross-corridor smoke barrier doors, and stated that the doors would be repaired.

Based on observation, and interview, the facility failed to maintain the exit signs. This was evidenced by exit signs with no date of expiration or installation. This could result in the failure of an exit sign in the event of an emergency, and in a delay in exiting from the area in the event of an emergency. This affected 12 of 12 smoke compartments.


Findings:

During the facility tour and interview with facility staff on 4/9/13 through 4/10/13, the exit signs were observed. The exit signs did not have any date of installation or expiration on the signs.

1. At 10:45 a.m., the exit sign in the Emergency Department waiting room had no date of expiration or date of installation. During an interview with the Plant Operations Director, staff did not know when the signs were installed, or how long were designed to last. Plant operations staff 2 stated they did not know when they were installed. No documentation was available for when the signs were installed.

2. At 10:54 a.m., the exit sign above the Emergency Department door had no date of installation or date of expiration. The Director of Plant Operations stated they did not have documentation of when the signs were installed.

3. At 11:37 a.m., the exit sign from the kitchen to the dining room had no installation date or expiration date.

4. At 3:01 p.m., the exit sign above the exit doors by room 113, had no date of installation or expiration date.

Based on observation and interview, the facility failed to
maintain the fire alarm system. This was evidenced by
no audible or visible fire alarm devices provided inside the Cafeteria, and by two fire alarm devices that failed to activate an audible alarm. This could result in the delay of notification in the event of a fire. This affected 2 of 12 smoke compartments.

NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999 Edition National Fire Alarm Code
4-3 Audible Requirements
4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

Findings:

On 4/10/13, during testing of the fire alarm system with facility staff, the audible and visual devices were observed.

1. At 2:51 p.m., the smoke detector in the cafeteria was activated using canned smoke. There was no audible or visual fire alarm notification device installed in the cafeteria. There was a fire alarm device in the corridor, but the device was not fully audible inside the cafeteria. The cafeteria was closed at the time of testing, and the Director of Human Resources agreed that the device was not fully audible, and if the cafeteria was open and the fire alarm was activated, visitors, staff and patients would not be able to hear the alarm.


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2. At 2:53 p.m., the fire alarm bell in the Kitchen made a clicking noise, and did not sound an audible alarm when tested.

3. At 3:12 p.m., the fire alarm chime made a clicking noise, and did not sound an audible alarm in the office corridor across from Conference Room B.

Based on document review, the facility failed to provide complete documentation for maintaining the automatic sprinkler system. This was evidenced by documentation for the 5 year certification for the automatic sprinkler system that failed to include the organization that performed the certification, and by failing to provide documentation for one of four quarterly testing. This could result in the failure of the automatic sprinkler system in the event of a fire, and affected 12 of 12 smoke compartments.


NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1999 Edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results and date.

Findings:

During document review with facility staff on 4/09/13, the documentation for the automatic sprinkler system was reviewed.

1. At 2:02 p.m., the 5 year certification report dated 9/11/08 was reviewed, and did not indicate the organization that performed the work.

2. At 3:00 p.m., there was no documentation for the third quarterly sprinkler testing.

Based on observation, the facility failed to provide the required types of receptacles in a designated smoking area. This was evidenced by failing to provide a metal container with a self closing cover device to dispose of cigarettes in a designated smoking area. This could result in an increased risk of fire, and affected 1 of 12 smoke compartments.

Findings:

On 4/10/13, on a tour of the facility with the plant operations staff, the designated smoking areas were observed.

At 11:43 a.m., the smoking area across from the cafeteria had no metal container with a self closing cover device to dispose of cigarettes. The area was provided with one ashtray, and a trash can.

Based on document review, the facility failed to repair dampers that failed during testing. This could result in the failure of the damper to function in the event of fire, and allow the passage of smoke and flames into other smoke compartments. This affected 3 of 12 smoke compartments.

Findings:

During document review with facility staff on 4/09/13, the documentation for the dampers was reviewed.

At 12:02 p.m., during document review, the damper testing records dated 2/20/12, were reviewed. The report indicated that there were 52 dampers in the facility, and 10 failed during testing.

Documentation provided indicated that 4 of the 10 dampers have not been repaired, as follows:
1. Damper 8054 OR 2 bad motor.
2. Damper 8053 O/S Registration Admitting, bad motor.
3. Damper 9104 Women's Center lobby bad motor.
4. Damper 8106 Women's Center lobby bad motor.

Based on document review, the facility failed to provide evidence of weekly visual inspections for Generators 1 and 2. This could result in the failure of the emergency generators in the event of an emergency. This affected 12 of 12 smoke compartments.

During document review with facility staff on 4/09/13, the testing and maintenance documentation for the generators was reviewed.


At 2:35 p.m., during document review of the Generator Run Log for 2 of 2 emergency generators, there was no documentation for weekly visual inspections for Generator 1 and 2 for the weeks of 2/10/13, through 2/16/2013, and 2/24/13, through 3/2/13.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by electrical appliances plugged into surge protectors and not directly into electrical outlets, by surge protectors plugged into each other, by the use of extension cords, and by a broken electrical coverplate. This could result in an electrical fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 6 of 12 smoke compartments.

NFPA 70, National Electrical Code?, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

400-8 Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with facility staff on 4/9/2013 through 4/11/2013, the the electrical wiring and connections were observed.

4/10/2013:

1. At 10:31 a.m., in the Tele Room there was a refrigerator plugged into a surge protector.

2. At 10:34 a.m., in the Laboratory break room there was an extension cord with a coffee maker, a microwave oven, and a rice cooker plugged into it.

3. At 11:05 a.m., in the Emergency Department break room there was a broken outlet cover plate.

4. At 11:14 a.m., in the Radiology reception area, there was an extension cord plugged into a universal power strip (UPS) that was run against the wall to the other side of the room, and plugged into a surge protector.

5. At 11:16 a.m., in the radiology directors office there was a surge protector plugged into a UPS.

6. At 1:29 p.m., in the Respiratory Therapy office there was an extension cord in use.

7. At 1:33 p.m., in the Cardiac Rehabilitation office there was an extension cord plugged into a surge protector, and a surge protector plugged into a surge protector.

8. At 1:42 p.m., in Information Technology, there was a surge protector plugged into a surge protector.



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9. At 1:36 p.m., there was an orange extension cord in use in the House Supervisor Office.

Based on observation, the facility failed to ensure that all alcohol based hand rub (ABHR) dispensers were installed away from ignition sources. This was evidenced by ABHR dispensers that were installed above or adjacent to electrical devices. This could result in a fire and increase the risk of injury to patients, visitors and staff. This affected 5 of 12 smoke compartments.


Findings:

During the facility tour with facility staff on 4/9/2013 through 4/11/2013, the Alcohol Based Hand Rub (ABHR) dispensers were observed.

On 4/10/2013:

1. At 10:38 a.m., the ABHR was installed adjacent to the light switch at the entrance to Intensive Care Unit (ICU).

2. At 10:41 a.m., the ABHR was installed adjacent to the light switch in the ICU, near the water machine.

3. From 11:00 a.m., to 11:05 a.m., during a tour of the Emergency Room there were ABHR dispensers installed adjacent to electrical outlets and light switches in Bed 1 through Bed 6, the GYN room, and in the Rapid Care room.

4. At 1:49 p.m., the room behind the nurses station in Labor and Delivery was installed above a light switch.

5. At 1:55 p.m., in Labor and Delivery Room 3, the ABHR was installed adjacent to the light switch.

6. At 2:48 p.m., the ABHR in the Cafeteria was installed above a light switch.



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7. At 1:30 p.m., the Alcohol Based Hand Rub dispenser was mounted over a light switch at the entrance to the Pharmacy.

8. At 1:32 p.m., the Alcohol Based Hand Rub dispenser was mounted over a light switch in Medical Records.

9. At 1:45 p.m., the Alcohol Based Hand Rub dispenser was mounted over an electrical outlet in Patient Room 118.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by the failure to repair and seal penetrations in the walls. This could result in the spread of smoke or fire from one smoke compartment to the next smoke compartment, and increase the risk of injury to patients, visitors, and staff due to smoke and fire. This affected 4 of 12 smoke compartments.

Findings:

During the facility tour with the facility staff from 4/9/2013 through 4/11/2013, the facility walls were observed.

4/10/2013:

1. At 1:34 p.m., there was an approximately 3 inch by 4 inch unsealed penetration in the bottom left of the back wall inside the Telephone room located in the Med Surge Lounge.

2. At 2:30 p.m., there were two approximately 1/2 inch unsealed penetrations running through the top left wall in Materials Management to the new kitchen under construction. The Director of Human Resources confirmed the penetrations in the separation wall.



18996

3. At 1:35 p.m., there were three penetrations approximately 1/4 inch each in the bathroom corridor wall in Medical Records.

4. At 1:39 p.m., there were two penetrations approximately 1/2 inch each in the utility room in the Women's Center.

Based on observation, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to positive latch, by corridor doors that were obstructed from closing, and by penetrations in corridor doors. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 3 of 12 smoke compartments.

Findings:

During the facility tour with the facility staff from 4/9/2013 through 4/11/2013, the corridor doors were observed.

4/10/2013:

1. At 10:45 a.m., in the Emergency Department waiting room one of two doors was obstructed from closing by a chair. The door was equipped with a magnetic door hold open device.

2. At 10:57 a.m., in the Emergency Department, office door #7 failed to shut and latch.

3. 11:17 a.m., the door to the ultra sound room in Radiology had 2 penetrations in the door. There was one penetration below the door knob, and one penetration above the door knob, that were approximately 1/4 inch each.

4. 11:18 a.m., the door to the Employee Lounge in Radiology failed to shut and latch.

5. 11:25 a.m., the door to the Physical Therapy office was obstructed from closing by a chair.


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6. At 2:05 p.m., the corridor door failed to latch shut to Patient Room 111. The latch plate was stuffed with paper that prevented the door from latching. The Director of Human Resources confirmed that the latch plate was stuffed with paper that prevented the door from latching.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls as evidenced by penetrations in smoke barrier walls. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 4 of 12 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour and interview with facility staff from 4/9/2013 through 4/11/2013, the smoke barrier walls were observed, and staff was interviewed.

4/10/2013:

1. At 10:38 a.m., there was an approximately 1/2 inch by 1 1/4 inch unsealed penetration in the smoke barrier wall surrounding a pipe over the right door leaf of smoke barrier door #61, by Physical Therapy. The Director of Human Resources confirmed the penetrations in the smoke barrier wall.
2. At 10:55 a.m., there was an approximately 3/4 inch unsealed penetration in the smoke barrier wall above the smoke barrier door at the entrance to Obstetrics. The Director of Human Resources confirmed the penetration in the smoke barrier wall, and stated that the penetrations would be repaired immediately.

Based on observation and interview, the facility failed to maintain the smoke barrier doors as evidenced by gaps between two sets of cross-corridor smoke barrier doors. This could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 4 of 12 smoke compartments.

Findings:

During the facility tour and interview with the facility staff from 4/9/2013 through 4/11/2013, the smoke barrier doors were observed, and staff was interviewed.

4/10/2013:

1. At 2:40 p.m., , there was an approximately 1/2 inch gap between a set of cross-corridor smoke barrier doors located next to Physical Therapy.

2. At 3:09 p.m., there was an approximately 1/2 inch gap between a set of cross-corridor smoke barrier doors located next to Room 123 in Med Surg. The Director of Plant Operations confirmed the gaps in the cross-corridor smoke barrier doors, and stated that the doors would be repaired.

Based on observation, and interview, the facility failed to maintain the exit signs. This was evidenced by exit signs with no date of expiration or installation. This could result in the failure of an exit sign in the event of an emergency, and in a delay in exiting from the area in the event of an emergency. This affected 12 of 12 smoke compartments.


Findings:

During the facility tour and interview with facility staff on 4/9/13 through 4/10/13, the exit signs were observed. The exit signs did not have any date of installation or expiration on the signs.

1. At 10:45 a.m., the exit sign in the Emergency Department waiting room had no date of expiration or date of installation. During an interview with the Plant Operations Director, staff did not know when the signs were installed, or how long were designed to last. Plant operations staff 2 stated they did not know when they were installed. No documentation was available for when the signs were installed.

2. At 10:54 a.m., the exit sign above the Emergency Department door had no date of installation or date of expiration. The Director of Plant Operations stated they did not have documentation of when the signs were installed.

3. At 11:37 a.m., the exit sign from the kitchen to the dining room had no installation date or expiration date.

4. At 3:01 p.m., the exit sign above the exit doors by room 113, had no date of installation or expiration date.

Based on observation and interview, the facility failed to
maintain the fire alarm system. This was evidenced by
no audible or visible fire alarm devices provided inside the Cafeteria, and by two fire alarm devices that failed to activate an audible alarm. This could result in the delay of notification in the event of a fire. This affected 2 of 12 smoke compartments.

NFPA 101, 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, 1999 Edition National Fire Alarm Code
4-3 Audible Requirements
4-4.3.1 Visible notification appliances used in the public mode shall be located and shall be of a type, size, intensity, and number so that the operating effect of the appliance is seen by the intended viewers regardless of the viewer's orientation.

Findings:

On 4/10/13, during testing of the fire alarm system with facility staff, the audible and visual devices were observed.

1. At 2:51 p.m., the smoke detector in the cafeteria was activated using canned smoke. There was no audible or visual fire alarm notification device installed in the cafeteria. There was a fire alarm device in the corridor, but the device was not fully audible inside the cafeteria. The cafeteria was closed at the time of testing, and the Director of Human Resources agreed that the device was not fully audible, and if the cafeteria was open and the fire alarm was activated, visitors, staff and patients would not be able to hear the alarm.


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2. At 2:53 p.m., the fire alarm bell in the Kitchen made a clicking noise, and did not sound an audible alarm when tested.

3. At 3:12 p.m., the fire alarm chime made a clicking noise, and did not sound an audible alarm in the office corridor across from Conference Room B.

Based on document review, the facility failed to provide complete documentation for maintaining the automatic sprinkler system. This was evidenced by documentation for the 5 year certification for the automatic sprinkler system that failed to include the organization that performed the certification, and by failing to provide documentation for one of four quarterly testing. This could result in the failure of the automatic sprinkler system in the event of a fire, and affected 12 of 12 smoke compartments.


NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems, 1999 Edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results and date.

Findings:

During document review with facility staff on 4/09/13, the documentation for the automatic sprinkler system was reviewed.

1. At 2:02 p.m., the 5 year certification report dated 9/11/08 was reviewed, and did not indicate the organization that performed the work.

2. At 3:00 p.m., there was no documentation for the third quarterly sprinkler testing.

Based on observation, the facility failed to provide the required types of receptacles in a designated smoking area. This was evidenced by failing to provide a metal container with a self closing cover device to dispose of cigarettes in a designated smoking area. This could result in an increased risk of fire, and affected 1 of 12 smoke compartments.

Findings:

On 4/10/13, on a tour of the facility with the plant operations staff, the designated smoking areas were observed.

At 11:43 a.m., the smoking area across from the cafeteria had no metal container with a self closing cover device to dispose of cigarettes. The area was provided with one ashtray, and a trash can.

Based on document review, the facility failed to repair dampers that failed during testing. This could result in the failure of the damper to function in the event of fire, and allow the passage of smoke and flames into other smoke compartments. This affected 3 of 12 smoke compartments.

Findings:

During document review with facility staff on 4/09/13, the documentation for the dampers was reviewed.

At 12:02 p.m., during document review, the damper testing records dated 2/20/12, were reviewed. The report indicated that there were 52 dampers in the facility, and 10 failed during testing.

Documentation provided indicated that 4 of the 10 dampers have not been repaired, as follows:
1. Damper 8054 OR 2 bad motor.
2. Damper 8053 O/S Registration Admitting, bad motor.
3. Damper 9104 Women's Center lobby bad motor.
4. Damper 8106 Women's Center lobby bad motor.

Based on document review, the facility failed to provide evidence of weekly visual inspections for Generators 1 and 2. This could result in the failure of the emergency generators in the event of an emergency. This affected 12 of 12 smoke compartments.

During document review with facility staff on 4/09/13, the testing and maintenance documentation for the generators was reviewed.


At 2:35 p.m., during document review of the Generator Run Log for 2 of 2 emergency generators, there was no documentation for weekly visual inspections for Generator 1 and 2 for the weeks of 2/10/13, through 2/16/2013, and 2/24/13, through 3/2/13.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by electrical appliances plugged into surge protectors and not directly into electrical outlets, by surge protectors plugged into each other, by the use of extension cords, and by a broken electrical coverplate. This could result in an electrical fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 6 of 12 smoke compartments.

NFPA 70, National Electrical Code?, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

400-8 Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with facility staff on 4/9/2013 through 4/11/2013, the the electrical wiring and connections were observed.

4/10/2013:

1. At 10:31 a.m., in the Tele Room there was a refrigerator plugged into a surge protector.

2. At 10:34 a.m., in the Laboratory break room there was an extension cord with a coffee maker, a microwave oven, and a rice cooker plugged into it.

3. At 11:05 a.m., in the Emergency Department break room there was a broken outlet cover plate.

4. At 11:14 a.m., in the Radiology reception area, there was an extension cord plugged into a universal power strip (UPS) that was run against the wall to the other side of the room, and plugged into a surge protector.

5. At 11:16 a.m., in the radiology directors office there was a surge protector plugged into a UPS.

6. At 1:29 p.m., in the Respiratory Therapy office there was an extension cord in use.

7. At 1:33 p.m., in the Cardiac Rehabilitation office there was an extension cord plugged into a surge protector, and a surge protector plugged into a surge protector.

8. At 1:42 p.m., in Information Technology, there was a surge protector plugged into a surge protector.



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9. At 1:36 p.m., there was an orange extension cord in use in the House Supervisor Office.