HospitalInspections.org

Based on observation, and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the ceiling. This affected two of six floors in the Main Building, and could result in the spread of smoke or fire to other locations in the event of a fire.

Findings:

During a tour of the facility and interview with FMS and HSETS, the ceiling were observed and staff was interviewed.

1. On 11/7/17 at 9:57 a.m., there was an approximately two inch penetration in the ceiling near the sprinkler escutcheon in the Women's Locker room. The penetration was near the shower stall. The Women's Locker room was located on the 5th Floor. This finding was confirmed by FMS and HSETS.

2. On 11/7/17 at 11:55 a.m., there was an approximately six inch by five inch unsealed penetration in the wall in Room 3509. Room 3509 was located on the 3rd Floor. When interviewed, FMS stated that a hopper sink was removed.

Based on observation, document review, and interview, the facility failed to maintain the emergency battery backup lighting system. This was evidenced by emergency battery backup lighting units that failed to illuminate when tested, and by the failure to provide documentation for the annual functional test of the emergency battery backup lighting system. This could result in a failure to provide backup lighting in the event of evacuation. This affected one of six floors in the Main Building.

NFPA 101, Life Safety Code, 2012 Edition
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility, document review, and interview with FMS, HSETS, and CQO, the emergency battery backup lighting system was observed, documents were requested, and staff were interviewed.


1. On 11/7/17 at 2:08 p.m., one of two emergency battery backup lighting units in the Generator room failed to illuminate when the test button was pressed by staff. This finding was confirmed by FMS and HSETS.

2. On 11/7/17 at 2:20 p.m., one of two emergency battery backup lighting units in the Switchgear Room, failed to illuminate when the test button was pressed by staff. This finding was confirmed by FMS and HSETS.

3. On 11/9/17 at 9:11 a.m., the facility failed to provide documentation for the annual testing of the emergency lighting system upon request. When interviewed, CQO stated that there was no documentation of the annual testing of the emergency lighting units.

Based on observation interview, the facility failed to maintain their exit signs. This was evidenced by a non-egress path that had an exit sign. This could result in delayed evacuation to the exits in case of an emergency. This affected one of six floors in the Main Building.

Findings:

During a tour of the facility, and interview with FMS and HSETS, the exit sign was observed and staff interviewed.

1. On 11/7/17 at 11:23 a.m., there was an exit sign above the double doors between 4C and 4 D units. The double doors were observed locked. There were gurney beds stored in front of the double doors in 4C and 4D unit. According to the evacuation map, it was not part of the exit path. When interviewed, FMS confirmed the finding.

Based on observation and interview, the facility failed to maintain its hazardous areas. This was evidenced by a door to a hazardous area enclosure that was impeded from latching. This affected one of six floors in the Main Building and could result in the spread of fire and/or smoke to other areas.

Findings:

During a tour of the facility and interview with FMS and HSETS, the hazardous area was observed and staff interviewed.

1. On 11/7/17 at 1:07 a.m., the door to the Trash/Linen Holding room was equipped with self-closing device. The door failed to latch. The strike plate was filled with pieces of paper. The paper inside the strike plate prevented the door from latching. When interviewed, FMS confirmed the finding.

Based on document review and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to provide the relative humidity logs. This affected six of six operating rooms in the Main Building, and could result in the ignition of a fire.

Findings:

During document review and interview with FM, the relative humidity logs were requested and staff interviewed.

1. On 11/9/17 at 12:45 p.m., the facility failed to provide relative humidity logs for the operating rooms upon request. Upon interview, FM confirmed the finding.

Based on observation, the facility failed to maintain the electrical equipment. This was evidenced by a circuit breaker for the fire alarm system that was not identified with a red marking. This affected one of two floors in the Laboratory Building and could result in staff inability to identify the circuit breaker in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.
9.6.1.3 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.5.5.2 Circuit Identification and Accessibility.
10.5.5.2.1 The location of the dedicated branch circuit disconnecting means shall be permanently identified at the control unit.
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.


Findings:

During a tour of the facility with FMS and HSETS, the electrical equipment was observed.


1. On 11/7/17 at 2:40 p.m., the electrical panel "ELC PNL ERX" that housed the fire alarm circuit breaker number 2 did not have a red marking on the circuit breaker, to identified as the fire alarm. The electrical panel was located on the 1st Floor in the Laboratory Building. This finding was confirmed FMS and HSETS.

Based on observation, document review, and interview, the facility failed maintain the fire alarm system and components. This was evidenced by devices that were not properly maintain and by incomplete testing records. This affected five of six floors in the Main Building, and coult result in a delay in notification in the event of a fire.


NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

9.6.1.3 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 and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

19.7.6 Maintenance and Testing. See 4.6.12.
4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)
Table 14.4.5 Testing Frequencies
15. Initiating Devices
18.3.5 Mounting.
18.3.5.1 Appliances shall be supported independently of their attachments to the circuit conductors.
18.3.5.2 Appliances shall be mounted in accordance with the manufacturer's published instructions.

Findings:

During a tour of the facility, document review, and interview with FMS, HSETS, ESS 1, and ESS 2, the fire alarm system and components were observed.

1. On 11/7/17 at 11:11 a.m., the smoke detector SDL5D80 in Room 4221 (Nourishment room) was not fully attached to the ceiling. There was an approximately 3/4 inch gap between the ceiling and the smoke detector. This finding was confirmed by FMS and HSETS.

2. On 11/7/17 At 11:12 a.m., the smoke detector SDL5D82 in Room 4122 was not fully attached to the ceiling. There was an approximately 1/2 inch gap between the ceiling and the smoke detector. This finding was confirmed by FMS and HSETS.

3. On 11/8/17 at 11:43 a.m., the document titled "Inspection and Testing Report" indicated some devices were not tested during the quarterly inspections and testing. The following are number of devices were not tested:

A) The inspection and testing report dated 4/3/17 had 2 Duct Smoke Detectors that did not shut down and 39 Photo Smoke Detectors that were not tested. When interviewed, ESS 1 stated that they were not tested because of the State Inspection.

B) The inspection and testing report dated 7/5/17 had 1 Photo Smoke Detector and 11 Duct Smoke Detectors that were not tested. When interviewed, ESS 1 stated that they were not tested because of safety reasons.

C) The inspection and testing report dated 12/1/17 had 1 Photo Smoke that was not tested.

These findings were confirmed by ESS 1 and ESS 2.

Based on document review, the facility failed to provide a complete fire watch policy. This was evidenced by the failure to indicate that the facility would notify the California Department of Public Health in the event that their fire alarm system went out of service for more than 4 hours in a 24-hour period. This affected the Main Building and the Laboratory Building, and could result in a delay in notification in the event of an emergency with the fire alarm system.

Findings:

During document review with FM, the fire watch procedure for the fire alarm system was reviewed.

1. On 11/9/17 at 12 p.m., the fire watch policy and procedure was reviewed. The fire watch procedure failed to indicate that the facility would contact the California Department of Public Health in the event that their fire alarm system went out of service for more than 4 hours in a 24 hour period. This finding was confirmed by FM.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to maintain sprinkler components, the failure to perform the required monthly inspections, and the failure to correct deficiencies noted during the annual sprinkler system inspection, testing, and maintenance report. This could affect the operation of the sprinkler system that could result in delay in extinguishing a fire, resulting in injury to residents. This affected six of six floors in the Main Building and one of three floors in Building 10.


NFPA 101, Life Safety Code, 2012 Edition

19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems


9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9.7.7 Documentation. All required documentation regarding the design of the fire protection system and the procedures for maintenance, inspection, and testing of the fire protection system shall be maintained at an approved, secured location for the life of the fire protection system.

9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition

5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

Findings:

During a tour of the facility, document review, and interview with FMS, ESS 1, and HSETS, the sprinkler system's testing and inspection records were reviewed, sprinkler observed, and staff interviewed.

1. On 11/7/17 at 9:50 a.m., the sprinkler in the Report Room in the Labor and Delivery unit had a foreign material hanging on the deflector. The Labor and Delivery unit was located on the 5th Floor. This finding was confirmed by FMS and HSETS.

2. On 11/7/17 at 10:07 a.m., the sprinkler in the Labor and Delivery Operating Rooms area was covered with debris. The sprinkler was across from the Janitor room. The Labor and Delivery unit was located on the 5th Floor. This finding was confirmed by FMS and HSETS.

3. On 11/7/17 at 11:08 a.m., the escutcheon in Room 4218 had shifted to the right, created an approximately one inch penetration in the ceiling. Room 4218 was located on the 4th Floor. This finding was confirmed by FMS and HSETS.

4. On 11/7/17 at 11:24 a.m., the Dental Front Office located on the South Side of the Second Floor was observed. The sprinkler head located above the Lead RDA desk was covered with debris. The frame, frangible bulb, and deflector were not visible.

5. On 11/7/17 at 11:33 a.m., the sprinkler in Room 3120 was covered with debris. Room 3120 was located on the 3rd Floor. This finding was confirmed by FMS and HSETS.

6. On 11/7/17 at 1:26 p.m., one of three escutcheons in the Laundry Chute room was not flush with ceiling. The escutcheon dropped approximately 1/2 inch from the ceiling. The Laundry Chute room was located on the 1st Floor. This finding was confirmed by FMS and HSETS.

7. On 11/8/17 at 1:28 p.m., the document titled "Annual Inspection, Testing, and Maintenance" dated 9/21/17 had the following deficiencies noted:

a) Missing headguard under stairs #2,
b) 2 Dusty sprinklers by back reception area (1S147 & 1S149) (1st Floor),
c) 3 Dusty sprinklers by reception area 1S116 (1st Floor),
d) 2 Dusty sprinklers at 1S111 & Main Corridor/Lobby (1st Floor),
e) Missing Viking white 2 pc escutcheon in 1N155 (1st Floor),
f) Adjust sprinkler outside 1N002A & 1N117 (1st Floor),
g) Dusty sprinkler at reception 1N117 (1st Floor),
h) Painted sprinkler near south hall by elevator lobby (2nd Floor),
i) 2 painted sprinklers in 2N266 & 2N280 (2nd Floor restrooms),
j) 6 Dusty sprinklers 2S216, 2S220, (outside of) 2N206 (restroom),
k) 5 Dusty sprinklers 2N277, 2N273,
l) 2 Loaded sprinkler outside of 2S239 & restroom 2S236 (2nd Floor),
m) Painted sprinkler in 2S215 (2nd Floor),
n) Missing Viking white 2 pc escutcheon in waiting area 2 North B (2nd Floor)

When interviewed, ESS 1 that the deficiencies have not been corrected.

8. On 11/8/17 at 2:01 p.m., the facility failed to provide records for the monthly inspections of the sprinkler gauges and valves during the survey. When interviewed, ESS 1 stated that they were unaware of the monthly inspections.

Based on document review, the facility failed to provide a complete fire watch policy. This was evidenced by the failure to indicate that the California Department of Public Health would be notified in the event that their automatic fire sprinkler system went out of service for more than 10 hours in a 24-hour period. This affected the Main Building and Laboratory Building, and could result in a delay in notification in the event of an emergency with the automatic fire sprinkler system.

Findings:

During document review with FM, the fire watch policy for the automatic fire sprinkler system was reviewed.

1. On 11/9/17 at 12 p.m., the fire watch procedure in the event of a disruption in automatic fire sprinkler system services was reviewed. The fire watch procedure did not indicate that the facility would contact the California Department of Public Health in the event that their automatic fire sprinkler system went out of service for more than 10 hours in a 24 hour period. This finding was confirmed by FM.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguishers that was obstructed from access and by another fire extinguisher that was unsecured. This affected one of six floors in the Main Building and Building 10. This could result in staff's inability to readily access the fire extinguishers in the event of a fire and could result in the fire extinguisher being knocked over and damaged.


NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
39.3.5 Extinguishment Requirements. Portable fire extinguishers
shall be provided in every business occupancy in accordance
with 9.7.4.1.

9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.


NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition

6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.


Findings:

During a tour of the facility and interview with FMS, HSETS, Staff 1, and Staff 3, the portable fire extinguishers were observed and staff interviewed.

1. On 11/7/17 at 10:20 a.m., access to the fire extinguisher near 5D corridor was observed obstructed by a vital machine. The vital machine was placed directly in front of the fire extinguisher. 5D corridor was located on the 5th Floor of the Main Building.

2. On 11/7/17 at 11:15 a.m., the fire alarm control panel (FACP) room IS002 in Building 10 was observed. There was an ABC type extinguisher sitting on the floor in the area below the FACP. Upon interview, Staff 1 and Staff 3 confirmed this finding.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by two roll down fire doors and a corridor door that were impeded from closing. This affected two of six floors in the Main Building and could result in the passage smoke and flames in the event of a fire.

Findings:

During a tour of the facility with FMS and HSETS, the corridor doors were observed.

1. On 11/7/17 at 9:41 a.m., the roll down fire door between the Nurse Station and Physician room had bundle of wires that crossed the bottom of the roll down fire door. The bundle of wires prevented the roll down fire door to fully closed. The Nurse Station was in the Labor and Delivery unit located on the 5th Floor. This finding was confirmed by FMS and HSETS.

2. On 11/7/17 at 11:57 a.m., the door to Room 3510B was equipped with a self-closing device. The door was held open by a rubber wedge. Room 3510B was located on the 3rd Floor. This finding was confirmed by FMS and HSETS.

3. On 11/7/17 at 12:08 p.m., the roll down fire door in the Reception area of the Diagnostic Imaging unit had a bell and a 8 inch by 11 inch signage that were placed directly below the roll down fire door. The items prevented the roll down fire door to fully closed. The Reception area was located on the 3rd Floor.

Based on observation, the facility failed to maintain the smoke integrity of the smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the spread of smoke and fire and increase the risk of injury to residents and staff in the event of a fire; and affected two of six floors in the Main Building.


NAPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Findings:

During a tour of the facility with FMS and HSETS, the smoke barrier walls were observed.

1. On 11/8/17 at 8:09 a.m., there were two unsealed penetrations in the fire wall above the elevator. The first penetration was approximately two inch and second penetration was approximately one inch. This was located on the 4th Floor. This finding was confirmed by FMS and HSETS.

2. On 11/8/17 at 8:15 a.m., there was an approximately four inch in diameter unsealed penetration. The penetration was above the smoke barrier wall in the south elevator lobby wall on the 4th Floor. This finding was confirmed by FMS and HSETS.

3. On 11/8/17 at 8:35 a.m., there was an approximately 1-1/2 inch penetration with two wires going through the fire wall above the elevator. This was located on the 2nd Floor. This finding was confirmed by FMS and HSETS.

Based on observation, the facility failed to maintain the electrical equipment. This was evidenced by electrical panels that were obstructed from access. This affected four of six floors in the Main Building. This could result in delay of access in the event of an emergency.


NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.


NFPA 70, National Electrical Code, 2011 Edition

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 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

Findings:

During a tour of the facility with FMS and HSETS, the electrical equipment were observed.

1. On 11/7/17 at 9:44 a.m., the door access to the electrical panel "5ELL" in the Labor and Delivery unit was obstructed by a five foot metal signage. The signage was placed directly in front of the panel. The Labor and Delivery unit was located on the 4th Floor.

2. On 11/7/17 at 10:39 a.m., the door access to the electrical panel "4ECL" located on the 4th Floor was obstructed by a six foot ladder. The ladder was placed directly in front of the door access.

3. On 11/7/17 at 11:02 a.m., the door access to electrical panel "4NLS and 4ECL1 in Room 4016 was obstructed by a carpenter's cart and ladder. The carpenter's cart and ladder were placed in front of the panel doors. Room 4016 was located on the 4th Floor.

4. On 11/7/17 at 12:57 p.m., the door access to the electrical panel "2ECL" in Room 2022A was obstructed by a four foot ladder. The ladder was placed directly in front of the door access. Room 2022A was located on the 2nd Floor.

Based on document review and interview, the facility failed to maintain the emergency power supply system. This was evidenced by the failure to perform the required monthly testing and recording of electrolyte specific gravity lead-acid battery. This could result in a malfunction of the generator due to a fire hazard. This affected the Main Building and Laboratory Building.


NFPA 101, Life Safety Code, 2012 Edition

19.5 Building Services.
19.5.1 Utilities.

19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.3.1 Emergency generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
8.3.3 A written schedule for routine maintenance and operational
testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising,
operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

Findings:

During document review and interview with AFMM, the document were requested and staff interviewed.

1. On 11/9/17 At 1:58 p.m., the facility failed to provide documentation for the required monthly testing of the electrolyte specific gravity lead-acid battery. The facility has diesel powered generators. When interviewed, AFMM stated that the batteries are tested during the annual maintenance service.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by power strips that were suspended off the floor. This affected two of six floors in the Main Building, and could result in an increased risk of an electrical fire.


NFPA 101, Life Safety Code, 2012 Edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.

Findings:

During a tour of the facility with FMS and HSETS, the electrical wiring were observed.

1. On 11/7/17 at 10:28 a.m., the power strip in Room 4004A (Data room) was suspended off the floor approximately two feet. There were four computer servers plugged into the suspended power strip. This finding was confirmed by FMS and HSETS.

2. On 11/7/17 at 12:03 p.m., the power strip in the MRI Computer room was suspended off the floor approximately 3-1/2 feet. There were MRI equipment plugged into the suspended power strip. The MRI Computer room was located outside 3rd Floor. This finding was confirmed by FMS and HSETS.