HospitalInspections.org

Based on random observation during the survey walk-through on May 7, 2012, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and/or 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors in the event of a fire condition.

Findings include:

A. Piping was observed to be cut and unsealed at the west wall of the Boiler room. This piping was not determined to be sealed at the opposite end of the piping which extended into the crawl space.

B. Doors to hazardous areas were observed not to be self-closing to a latched condition.

1. The basement Medical Records room door from the Kitchen did not completely close to a latched condition.

2. Two food storage rooms accessed from the basement corridor were equipped with foot peg hold-open devices in non-compliance with NFPA 101, 7.2.1.8.2.

3. The food storage room accessed from the Kitchen was equipped with a foot peg hold-open device in non-compliance with NFPA 101, 7.2.1.8.2.

4. The fire door into the 1920 building basement maintenance and housekeeping area did not latch upon closing. The weighted closer and multiple latch point door "bounced" in the frame so as not to engage the latching bars.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, , exit access to two remote exits in the 1920 building basement were not readily accessible at all times in accordance with 7.5 and 39.2.4. This deficiency could affect all occupants within this area of the facility by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. The basement of the 1920 building was observed to have only a single exit available through the the fire door into the adjacent hospital building. The resulting common path of travel appeared to exceed the 75' permitted by 39.2.5.3 when considered a business occupancy area and the 50' permitted by 42.2.5.4 when considered a storage occupancy area. The exterior doors from the basement were observed to either be padlocked or equipped with a crossbar to secure the door.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, exit stairs are not constructed in accordance with 7.1 and 19.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, which must utilize this exit from the building during an event requiring such exiting.

Findings include:

A. The north exit stair was observed to contain oxygen piping running through the stair enclosure at both the upper and lower landings in non-compliance with 7.1.3.2.1. Fire rated separation of this piping from the stair was not otherwise provided.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, exit access was not readily accessible at all times in accordance with 7.1 and 19.2.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. A wall mounted fan in the basement corridor near the dishwashing room was mounted below 6'-8" in non-comformance with NFPA 101-2000, 7.1.5.

B. Locks are utilized to secure exit acces doors which can prevent use of the exit door in the direction of egress. Conditions observed include but may not be limited to the following:

1. Hasps and padlocks were observed to be used on the walk-in cooler and freezer located in the kitchen.

2. Self-latching deadbolt locks were observed to be installed on numerous room doors in the former nursing home/outpatient building in addition to a privacy latchset. The two devices constitute more than one releasing operation to allow the door to be opened which does not comply with 7.2.1.5.4.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. Exit signage was not provided in the former nursing home/outpatient building to identify two separate paths to an exit from all locations in the corridors. Additional signage near the former nurse station appeared to be required.

B. Signage was not provided on each side of the smoke barrier doors in the former nursing home/outpatient building. Surveyor notes that signage is visible when the half-glass doors are held open, but visibility of signage is obscured when they would close during fire alarm activation.

C. Signage in the basement level hallway outside the dining room located above the east stair door was not visible from the west end of the corridor due to overhead obstructions.
.

Based on staff interview and document review during the survey on the morning of May 7, 2012, the written fire plan was not complete and updated to reflect the current conditions at the facility to comply with 19.7. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by being confused by the written plan that differs from the actual conditions.

Finding include:

A. The Fire Safety Manual (last revised 6/26/02) was indicated by staff to require updating due to the closure of the nursing home facility. The area is currently being utilized as outpatient services space.

1. The Fire Safety Manual contains numerous references to the Long Term Care personnel and there duties and responsibilities but they no longer exist.

2. The Fire Safety Manual contains references to the OB Dept., Delivery and Nursery but these areas and services no longer exist.
.

Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being held at unexpected times under varying conditions, at least quarterly on each shift.

Findings include:

A. During a record review it was determined that quarterly fire drills do not meet the requirement of varying conditions (times) in all shifts throughout the annual cycle. NFPA 101 Section 19.7.1.2 requires varying times per shift to be documented. Fire drill documentation recorded times for the 11pm-7am 3rd shift indicated that drills were consistantly conducted near the end of the shift between 5:45am and 6:17am. Therefore, not considered to meet the requirement for varying times.

B. The fire drill response forms indentified the "area of activation" but did not define the area evaluated for which the particular response was signed by the drill participants.
.

Based on staff interview and random observation during the survey walk-through on the afternoon of May 7, 2012, the building fire alarm system did not comply with applicable portions of NFPA 101-2000, 19.3.4 and NFPA 72-1999. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by failing to adequately warn occupants of a fire event.

Findings include:

A. Fire alarm manual pull stations were observed to be installed in non-compliance with NFPA 72-1999 2-8.1 which requires them to be located between 3.5' and 4.5' above the floor.

1. The pull station at the exterior door of the north stair was mounted at approximately 6' above the landing.

2. The pull station at the 2-hour separation between the hospital and the former nursing home appeared to be above 4.5'.

3. Other similar installations may exist throughout the building areas.

B. Staff indicated that a replacement of the fire alarm system was currently underway. The work includes an upgrade of the system from a zoned system to a fully addressable system requiring replacement of main panels and devices with possible reuse of wiring systems. However, the installation of additional devices (including but not limited to visual notification devices) which are required under the Code did not appear to be planned for. Work has included shut-downs of the system for greater than 4 hour periods where a fire watch was implemented and documented. The scope of this project requires compliance with NFPA 72-1999 and submission of plans to IDPH for review.


26665


Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include;

C. During the survey of the new out patient portion of the facility, numerous smoke detectors were observed to be mounted within 3' of supply or return diffusers and not in accordance with 2-3.5.1.
Areas observed include;

1. The nurse station.

2. The waiting area.

3. The north corridor.

Air flow can delay activation of the detector allowing the fire more time to develop injuring patients or staff.

D. The electrical room where the fire alarm control panel is located was observed to be a normally unoccupied space with out a smoke detector installed at the panel location in accordance with 1-5.6.

This deficiency could allow the control panel to fail causing injury to patients or staff in the event of a fire.
.

Based on random observation during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's sprinkler system are installed in accordance with NFPA 13-1999.

Findings include:

A. Sprinkler heads located along the north side of the Central Stores room located at the north side of the basement were obstructed by large electrical conduit installed NFPA 13-1999, 5-6.5.1.2.
.

Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's fire sprinkler system are installed and tested in accordance with NFPA 25 1998.

Findings include;

A. During the record review, documents for the quarterly flow switch test showed the last flow conducted on March 2011 and not quarterly in accordance with 2-3.3.

Failure to test sprinkler components can cause failure endangering patients and staff.
.

Based on random observation and document review during the survey walk-through on the afternoon of May 7, 2012, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include;

A. During the survey tour of the lower level the two medical vacuum systems were observed without a valve at the receiver labeled as the medical vacuum source valve for the areas served by the system in accordance with 4-3.1.2.3 (a).

B. The medical vacuum system for the 1978 addition was observed to have a common discharge exhaust line to the outside without check, manual valve or other means for isolating the running pump from the other pump for maintenance purposes in accordance with 4-3.2.1.9.

C. During the survey tour of the lower level boiler room, the medical vacuum pumps were observed to have each pump's exhaust piped to a 5 gallon bucket and not piped to the outside in accordance with 4-3.2.1.9.

D. During an interview held in the boiler room area with the Director of Maintenance, it was discovered that neither vacuum pump set was connected to the building master medical gas alarm panels in accordance with 4-3.2.2.8.

E. During the survey tour of the lower level corridor and north stair, oxygen valves were observed with a red security cover and no label to identify the areas served by the valve in accordance with 4-3.1.2.14 (b).

These deficiencies could cause injury to patients requiring medical gases.
.

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 random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's emergency electrical system are tested in accordance with NFPA 110 1999.

Findings include;

A. During the record review for monthly exercising the generator under load, April 2012 was documented as "emergency" with no operating parameters documented to show a load on the generator in accordance with 6-4.2.

B. During the document review for monthly generator testing did not document the voltage on each leg of the 3 phase generator in accordance with 6-4.2.

Failure to test and document operating parameters for comparison to previous readings can cause an impending failure of the system to go un-noticed.
.

Based on random observation and document review during the survey walk-through on the afternoon of May 7, 2012, not all portions of the facility's emergency electrical system are installed in accordance with NFPA 99 and 70 1999.

Findings include;

A. During the survey tour of the 1964 general patient care addition on the first floor, patient room 22 was observed to only have receptacles powered from the normal electric service with none from the emergency power circuit in accordance with NFPA 70 517-18. During an interview held at the location it was confirmed emergency power transfer switches were replaced in 1996 and emergency circuits for this area had not been brought up to current standards for this room and this was typical for all patient bed locations.

B. During the survey tour of the operating room suite an isolated power panel for the endoscopy room was observed. During staff interview at the location it was discovered no monthly testing of the lamps and alarms had been documented in accordance with 99 3-3.3.4.2 (b).

C. During the survey tour electrical panels were observed to be identified as "C Panel #1 and #2" or Fire Panel Breakers and not as Life Safety, Critical or Equipment for separation of normal and emergency electrical circuits in accordance with NFPA 99, 3-4.2.2.2 and 3-4.2.2.3. Based on staff interview and observation it appeared that the emergency electrical system was not divided into the three required branches.

D. During the survey tour of the small electric room, the medical vacuum pumps were observed to be powered from Panel - 1, breaker 23 and not from an equipment branch of the emergency power system in accordance with NFPA 99, 3-4.2.2.3 (d) 1.

E. During the survey of the small electric room breaker panel labeled as "Fire Panel" provided the power to the Fire Alarm Control Panel and not a Life Safety Branch of the emergency power system in accordance with NFPA 99, 3-4.2.2.2 (b) 3 (a).

These deficiencies could allow the connection of the normal and emergency power systems leading to a possible failure of both electric systems.
.

Based on random observation during the survey walk-thru on the morning of May 7, 2012, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. An electrical conduit with duplex receptacle supplying power to a permanent piece of equipment was observed in the Boiler room hanging loose from the ceiling and not properly supported to comply with NFPA 70-1999, 300-11.

B. Electrical panels were observed to be missing complete enclosure to comply with NFPA 70-1999, 384-18.

1. A panel in the electrical room accessed through central stores was observed to be missing a panel closure at the circuit breaker.

2. "Panel 3" in the Kitchen at the south hood was observed to be missing a panel closure at the circuit breaker.

C. Extension cords were observed to be installed from receptacles and traversed above ceilings to plug-in equipment which was used on a permanent basis in non-compliance with NFPA 70-1999, 240-4 and 305-3b.

1. A wall mounted fan was installed in this manner in the Kitchen.

2. A dehumidifier was installed in this manner in the Central Stores room.

D. The disconnect switch for the elevator equipment located adjacent the Kitchen was not installed in conformance with NFPA 70-1999, 110-26 because it was mounted to require reaching over and above the elevator equipment to operate. Multiple other disconnects were also mounted similarly but were indicated to be abandoned or unused.


26665


Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's electrical system are installed in accordance with NFPA 70 1999.

Findings include;

E. During the survey tour all electrical panels require review and update to correctly identify circuits on panel directories in accordance with 384-13.

This deficiency could cause staff or patient injury due to wrong breaker being shut off.
.

Based on random observation during the survey walk-through on May 7, 2012, not all hazardous areas are separated from the remainder of the building in accordance with 19.3.2.1 and/or 8.4.1. These deficiencies could affect all patients within the smoke compartment of the location, as well as any staff and visitors present, by allowing smoke and fire to escape from hazardous rooms into the building's exit access corridors in the event of a fire condition.

Findings include:

A. Piping was observed to be cut and unsealed at the west wall of the Boiler room. This piping was not determined to be sealed at the opposite end of the piping which extended into the crawl space.

B. Doors to hazardous areas were observed not to be self-closing to a latched condition.

1. The basement Medical Records room door from the Kitchen did not completely close to a latched condition.

2. Two food storage rooms accessed from the basement corridor were equipped with foot peg hold-open devices in non-compliance with NFPA 101, 7.2.1.8.2.

3. The food storage room accessed from the Kitchen was equipped with a foot peg hold-open device in non-compliance with NFPA 101, 7.2.1.8.2.

4. The fire door into the 1920 building basement maintenance and housekeeping area did not latch upon closing. The weighted closer and multiple latch point door "bounced" in the frame so as not to engage the latching bars.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, , exit access to two remote exits in the 1920 building basement were not readily accessible at all times in accordance with 7.5 and 39.2.4. This deficiency could affect all occupants within this area of the facility by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. The basement of the 1920 building was observed to have only a single exit available through the the fire door into the adjacent hospital building. The resulting common path of travel appeared to exceed the 75' permitted by 39.2.5.3 when considered a business occupancy area and the 50' permitted by 42.2.5.4 when considered a storage occupancy area. The exterior doors from the basement were observed to either be padlocked or equipped with a crossbar to secure the door.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, exit stairs are not constructed in accordance with 7.1 and 19.2. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, which must utilize this exit from the building during an event requiring such exiting.

Findings include:

A. The north exit stair was observed to contain oxygen piping running through the stair enclosure at both the upper and lower landings in non-compliance with 7.1.3.2.1. Fire rated separation of this piping from the stair was not otherwise provided.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, exit access was not readily accessible at all times in accordance with 7.1 and 19.2.1. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. A wall mounted fan in the basement corridor near the dishwashing room was mounted below 6'-8" in non-comformance with NFPA 101-2000, 7.1.5.

B. Locks are utilized to secure exit acces doors which can prevent use of the exit door in the direction of egress. Conditions observed include but may not be limited to the following:

1. Hasps and padlocks were observed to be used on the walk-in cooler and freezer located in the kitchen.

2. Self-latching deadbolt locks were observed to be installed on numerous room doors in the former nursing home/outpatient building in addition to a privacy latchset. The two devices constitute more than one releasing operation to allow the door to be opened which does not comply with 7.2.1.5.4.
.

Based on random observation during the survey walk-through on the afternoon of May 7, 2012, exit signs were not fully visible to designate the path of egress in all cases in accordance with 18.2.10.1. and 7.10. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by preventing those occupants from readily utilizing an available exit from the building during an event requiring such exiting.

Findings include:

A. Exit signage was not provided in the former nursing home/outpatient building to identify two separate paths to an exit from all locations in the corridors. Additional signage near the former nurse station appeared to be required.

B. Signage was not provided on each side of the smoke barrier doors in the former nursing home/outpatient building. Surveyor notes that signage is visible when the half-glass doors are held open, but visibility of signage is obscured when they would close during fire alarm activation.

C. Signage in the basement level hallway outside the dining room located above the east stair door was not visible from the west end of the corridor due to overhead obstructions.
.

Based on staff interview and document review during the survey on the morning of May 7, 2012, the written fire plan was not complete and updated to reflect the current conditions at the facility to comply with 19.7. These deficiencies could affect all patients within the areas of the facility, as well as any staff and visitors present, by being confused by the written plan that differs from the actual conditions.

Finding include:

A. The Fire Safety Manual (last revised 6/26/02) was indicated by staff to require updating due to the closure of the nursing home facility. The area is currently being utilized as outpatient services space.

1. The Fire Safety Manual contains numerous references to the Long Term Care personnel and there duties and responsibilities but they no longer exist.

2. The Fire Safety Manual contains references to the OB Dept., Delivery and Nursery but these areas and services no longer exist.
.

Based on record review it was determined that the facility failed to document that fire drills are being conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintainance engineers, and adminsitrative staff) with the signals and emergency action as required. Fire drills are not being held at unexpected times under varying conditions, at least quarterly on each shift.

Findings include:

A. During a record review it was determined that quarterly fire drills do not meet the requirement of varying conditions (times) in all shifts throughout the annual cycle. NFPA 101 Section 19.7.1.2 requires varying times per shift to be documented. Fire drill documentation recorded times for the 11pm-7am 3rd shift indicated that drills were consistantly conducted near the end of the shift between 5:45am and 6:17am. Therefore, not considered to meet the requirement for varying times.

B. The fire drill response forms indentified the "area of activation" but did not define the area evaluated for which the particular response was signed by the drill participants.
.

Based on staff interview and random observation during the survey walk-through on the afternoon of May 7, 2012, the building fire alarm system did not comply with applicable portions of NFPA 101-2000, 19.3.4 and NFPA 72-1999. These deficiencies could affect all patients of the facility, as well as any staff and visitors present, by failing to adequately warn occupants of a fire event.

Findings include:

A. Fire alarm manual pull stations were observed to be installed in non-compliance with NFPA 72-1999 2-8.1 which requires them to be located between 3.5' and 4.5' above the floor.

1. The pull station at the exterior door of the north stair was mounted at approximately 6' above the landing.

2. The pull station at the 2-hour separation between the hospital and the former nursing home appeared to be above 4.5'.

3. Other similar installations may exist throughout the building areas.

B. Staff indicated that a replacement of the fire alarm system was currently underway. The work includes an upgrade of the system from a zoned system to a fully addressable system requiring replacement of main panels and devices with possible reuse of wiring systems. However, the installation of additional devices (including but not limited to visual notification devices) which are required under the Code did not appear to be planned for. Work has included shut-downs of the system for greater than 4 hour periods where a fire watch was implemented and documented. The scope of this project requires compliance with NFPA 72-1999 and submission of plans to IDPH for review.


26665


Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's fire alarm system are installed in accordance with NFPA 72 1999.

Findings include;

C. During the survey of the new out patient portion of the facility, numerous smoke detectors were observed to be mounted within 3' of supply or return diffusers and not in accordance with 2-3.5.1.
Areas observed include;

1. The nurse station.

2. The waiting area.

3. The north corridor.

Air flow can delay activation of the detector allowing the fire more time to develop injuring patients or staff.

D. The electrical room where the fire alarm control panel is located was observed to be a normally unoccupied space with out a smoke detector installed at the panel location in accordance with 1-5.6.

This deficiency could allow the control panel to fail causing injury to patients or staff in the event of a fire.
.

Based on random observation during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's sprinkler system are installed in accordance with NFPA 13-1999.

Findings include:

A. Sprinkler heads located along the north side of the Central Stores room located at the north side of the basement were obstructed by large electrical conduit installed NFPA 13-1999, 5-6.5.1.2.
.

Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's fire sprinkler system are installed and tested in accordance with NFPA 25 1998.

Findings include;

A. During the record review, documents for the quarterly flow switch test showed the last flow conducted on March 2011 and not quarterly in accordance with 2-3.3.

Failure to test sprinkler components can cause failure endangering patients and staff.
.

Based on random observation and document review during the survey walk-through on the afternoon of May 7, 2012, not all portions of the facility's piped medical gas system are installed in accordance with NFPA 99 1999.

Findings include;

A. During the survey tour of the lower level the two medical vacuum systems were observed without a valve at the receiver labeled as the medical vacuum source valve for the areas served by the system in accordance with 4-3.1.2.3 (a).

B. The medical vacuum system for the 1978 addition was observed to have a common discharge exhaust line to the outside without check, manual valve or other means for isolating the running pump from the other pump for maintenance purposes in accordance with 4-3.2.1.9.

C. During the survey tour of the lower level boiler room, the medical vacuum pumps were observed to have each pump's exhaust piped to a 5 gallon bucket and not piped to the outside in accordance with 4-3.2.1.9.

D. During an interview held in the boiler room area with the Director of Maintenance, it was discovered that neither vacuum pump set was connected to the building master medical gas alarm panels in accordance with 4-3.2.2.8.

E. During the survey tour of the lower level corridor and north stair, oxygen valves were observed with a red security cover and no label to identify the areas served by the valve in accordance with 4-3.1.2.14 (b).

These deficiencies could cause injury to patients requiring medical gases.
.

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 random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's emergency electrical system are tested in accordance with NFPA 110 1999.

Findings include;

A. During the record review for monthly exercising the generator under load, April 2012 was documented as "emergency" with no operating parameters documented to show a load on the generator in accordance with 6-4.2.

B. During the document review for monthly generator testing did not document the voltage on each leg of the 3 phase generator in accordance with 6-4.2.

Failure to test and document operating parameters for comparison to previous readings can cause an impending failure of the system to go un-noticed.
.

Based on random observation and document review during the survey walk-through on the afternoon of May 7, 2012, not all portions of the facility's emergency electrical system are installed in accordance with NFPA 99 and 70 1999.

Findings include;

A. During the survey tour of the 1964 general patient care addition on the first floor, patient room 22 was observed to only have receptacles powered from the normal electric service with none from the emergency power circuit in accordance with NFPA 70 517-18. During an interview held at the location it was confirmed emergency power transfer switches were replaced in 1996 and emergency circuits for this area had not been brought up to current standards for this room and this was typical for all patient bed locations.

B. During the survey tour of the operating room suite an isolated power panel for the endoscopy room was observed. During staff interview at the location it was discovered no monthly testing of the lamps and alarms had been documented in accordance with 99 3-3.3.4.2 (b).

C. During the survey tour electrical panels were observed to be identified as "C Panel #1 and #2" or Fire Panel Breakers and not as Life Safety, Critical or Equipment for separation of normal and emergency electrical circuits in accordance with NFPA 99, 3-4.2.2.2 and 3-4.2.2.3. Based on staff interview and observation it appeared that the emergency electrical system was not divided into the three required branches.

D. During the survey tour of the small electric room, the medical vacuum pumps were observed to be powered from Panel - 1, breaker 23 and not from an equipment branch of the emergency power system in accordance with NFPA 99, 3-4.2.2.3 (d) 1.

E. During the survey of the small electric room breaker panel labeled as "Fire Panel" provided the power to the Fire Alarm Control Panel and not a Life Safety Branch of the emergency power system in accordance with NFPA 99, 3-4.2.2.2 (b) 3 (a).

These deficiencies could allow the connection of the normal and emergency power systems leading to a possible failure of both electric systems.
.

Based on random observation during the survey walk-thru on the morning of May 7, 2012, electrical wiring and equipment was not installed and maintained in accordance with NFPA 70 National Electric Code and NFPA 101, 9.1.2. These deficiencies could result in exposure of occupants to electrical shock.

Findings include:

A. An electrical conduit with duplex receptacle supplying power to a permanent piece of equipment was observed in the Boiler room hanging loose from the ceiling and not properly supported to comply with NFPA 70-1999, 300-11.

B. Electrical panels were observed to be missing complete enclosure to comply with NFPA 70-1999, 384-18.

1. A panel in the electrical room accessed through central stores was observed to be missing a panel closure at the circuit breaker.

2. "Panel 3" in the Kitchen at the south hood was observed to be missing a panel closure at the circuit breaker.

C. Extension cords were observed to be installed from receptacles and traversed above ceilings to plug-in equipment which was used on a permanent basis in non-compliance with NFPA 70-1999, 240-4 and 305-3b.

1. A wall mounted fan was installed in this manner in the Kitchen.

2. A dehumidifier was installed in this manner in the Central Stores room.

D. The disconnect switch for the elevator equipment located adjacent the Kitchen was not installed in conformance with NFPA 70-1999, 110-26 because it was mounted to require reaching over and above the elevator equipment to operate. Multiple other disconnects were also mounted similarly but were indicated to be abandoned or unused.


26665


Based on random observation and document review during the survey walk-through on the morning of May 7, 2012, not all portions of the facility's electrical system are installed in accordance with NFPA 70 1999.

Findings include;

E. During the survey tour all electrical panels require review and update to correctly identify circuits on panel directories in accordance with 384-13.

This deficiency could cause staff or patient injury due to wrong breaker being shut off.
.