HospitalInspections.org

Based on observation the facility failed to provide adequate smoke barriers.

The inspector observed, while accompanied by the Acting Director of Plant Operations and the Director of Risk Management during the hours of the inspection from 8:00 am to 12:00 pm on 5/22/2013 that there were penetrations in the smoke barriers at the following locations: 1) patient luggage corridor, 2) between military and adult, 3) the adolescent boys and employee corridor, 4) PICU corridor, 5) PICU main entry

Based on observation the facility failed to keep stored items out of the 18 inch plane below the fire sprinkler heads and provide a complete fire sprinkler system.

The inspector observed, while accompanied by the Acting Director of Plant Operations and the Director of Risk Management during the hours of the inspection from 8:00 am to 12:00 pm on 5/22/2013 that there were the following problems.

A. There were items in multiple storage rooms that were violating the 18 inch rule. This was observed in the following locations: 1) the patient luggage room, 2) the military supply room, and 3) the marketing supply room on the employee corridor.
B. The maintenance storage by the employee entry did not have a sprinkler head.

" A minimum clearance of 18 inches shall be maintained between the top of storage and sprinkler deflectors " - NFPA 13, 2002: 8.5.6.1.

Based on observation the facility failed to provide a label on all fire extinguishers indicating the last inspection date.

The inspector observed, while accompanied by the Acting Director of Plant Operations and the Director of Risk Management during the hours of the inspection from 8:00 am to 12:00 pm on 5/22/2013 that there was a fire extinguisher in the maintenance storage room by the employee entry that did not have a label.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a history of records for receptacle testing per NFPA 99: 3-3.3.3. in patient care areas.

The inspector observed, while accompanied by the Acting Director of Plant Operations and the Director of Risk Management during the hours of the inspection from 8:00 am to 12:00 pm on 5/22/2013 that there were no records of receptacle testing according to NFPA.


Fuel and Water Preferred Customer Status

" Continuity of Essential Building Systems. When designated by the emergency preparedness management plan to provide continuous service in a disaster or emergency, health care facilities shall establish contingency plans for the continuity of essential building systems, as applicable: (a) Electricity, (b) Water, (c) Ventilation, (d) Fire protection systems, (e) Fuel sources, (f) Medical gas and vacuum systems (if applicable), (g) Communications systems. " - NFPA 99, 1999, 11-5.3.2

Based on observation the facility failed to provide letters from vendors for emergency water indicating that they have a preferred customer status in the event of an emergency.

The inspector observed, while accompanied by the Acting Director of Plant Operations and the Director of Risk Management during the hours of the inspection from 8:00 am to 12:00 pm on 5/22/2013 that there was not a letter from a vendor indicating that they have preferred customer status for water in the event of an emergency.

Based on observation the facility failed to provide a complete electrical system.

The inspector observed, while accompanied by the Acting Director of Plant Operations and the Director of Risk Management during the hours of the inspection from 8:00 am to 12:00 pm on 5/22/2013 that there were the following issues.

A. There was an open j-box above the ceiling at the smoke barrier between the military and adult wings.

B. The Life Safety Panel in the Gero Electrical Room did not have the FACP. It appeared to be in an adjacent Critical Panel. The Life Safety panels throughout the facility had loads that are not allowed on the Life Safety branch. This must be removed.

C. There were ATS cabinets and electrical panels that were part of the EES that did not have a labeled on the cabinet indicating the branch served.

NEC 517-32. Life Safety Branch
No function other than those listed in (a) through (f) 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.
FPN: See Life Safety Code, NFPA 101-1997, Sections 5-8 and 5-9.
(b) Exit Signs. Exit signs and exit directional signs.
FPN: See Life Safety Code, NFPA 101-1997, Section 5-10.
(c) Alarm and Alerting Systems. Alarm and alerting systems including the following:
1. Fire alarms
FPN: See Life Safety Code, NFPA 101-1997, Sections 7-6 and 12-3.4.
2. Alarms required for systems used for the piping of nonflammable medical gases
FPN: See Standard for Health Care Facilities, NFPA 99-1996, 12-3.4.1.
(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.

" All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system. " - NFPA 70, 2002: 700-9(a). They shall be labeled "LIFE SAFETY", "CRITICAL", or "EQUIPMENT" as applicable.