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1) Based on observation and interview with staff, the facility failed to protect corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas with substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

a) Door to Janitors closet across from Dietary is not provided with Latching Hardware.

b) Dietary Door is not provided with Latching Hardware.

c) Surgery Door is not provided with Latching Hardware.

Based on observation and interview with staff, the facility failed to provide Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Findings include:

a) Voids and penetrations were found not sealed over both doors that separated the three smoke zones. The compartment walls shall be sealed with material capable of maintaining the fire resistance of the fire barrier from outside of wall to outside of wall and from floor to deck.

Based on observation and interview with staff, the facility failed to protect hazardous areas in accordance with 8.4.1 and/or 19.3.5.4. When the approved automatic fire extinguishing system option is used, the areas are required to be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:

NFPA 101 chapter 5.8.14, Performance-Based Design Option, requires that the change in design for any part of the hospital requires that the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions made. The room that once was a telephone room and maintenance area is now the IT Room. The IT equipment requires a room that does not overheat because of the heat producing equipment. The room does not have sufficient air available, a 2 foot by 2 foot grill was cut into the General Store Room (Purchasing) separating the two rooms, allowing air to flow from room to room. Also the door to IT and to Purchasing does not have a closure on the doors, both doors are scotched or are just left open.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm system that is required for life safety and is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system did not have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a)The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital, the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, the fire alarm system that was renovated with a new panel installed, required submission of plans and a approval for construction. There is no documentation that the renovation install meet new requirements of NFPA 72.

b) The fire alarm system was renovated in March of 2013, The facility failed to get and provide close out documents with a re-acceptance test for the system. NFPA 72 7-1.6.2, 7-1.6.2.1, 7-1.2

c) The facility had an annual inspection in March of 2013, however the current annual inspection is 2 months past due. Fire Alarm Systems shall be tested in accordance with 7-3.2

d) All devices connected to the fire alarm system were not documented. Combination fire and smoke dampers were not on the March 2013 Fire Alarm Report. The facility could not provide a Directory of Devices for the system . All devices installed are to be checked with an annual report conducted to validate that all devices were checked.

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning equipment that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions. Endo-scope and procedures were not invented when the hospital was designed and built. The facility created an area to wash scope and store them. This area was not designed for the use of alcohol and other agents to clean the scopes and creat a flow from dirty to clean area. The exhaust system was not designed for scope washing, also exhaust installed did not work (motor was burnt out or was not turned on).The storage of scopes shall be in a positive air flow room, the scopes were hung in a room that was not documented as positive or negative and the room was re-purposed.

b)The wall mounted HVAC Units located in the Operating and Endoscope rooms were not submitted, they do not provide smoke evacuation, humidification, proper filtration, and have Anesthesia use. Anesthesia locations do not allow for units that re-circulate the air.

c) The manometers on the HVAC Air Handler were broken and not functioning.

d) HEPA Filter was not installed in the filter bank on Thursday May 8th.

e) 2 of the 4 Exhaust fans motors were burnt out, the other 2 were not turned on, one makes a lot of noise. Staff Member CC stated that the exhaust over the Central Sterilizer has not worked for years. Exhaust for the Soiled Utility room on the north wing does not work. Exhaust for OR and the OR Smoke Removal is or was tied together. Staff CC could not provide information on how systems worked.

f) Staff Member CC did not know that there was a filter that had been homemade and installed in the grill above the Central Sterile Room Door. The air coming out was very minimal. There was no test and balance documentation for the room. The HVAC Unit in the boiler room that supplies air to the Central Sterile Supply does not have final filters that provided 90%.efficiency.

1)Based on observation and interview with staff, the facility failed to have piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is repurposed shall be submitted for approval. The room being used for recovery was a lounge in accordance with blue prints provided for review from Director of Engineering. The room did not have piped in Oxygen and Vacuum outlets with Zone Valves and Alarms. The Operating room used to conduct endo-scope procedures requires piped in Medical Vacuum.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99 1999 edition, Standard for Health Care Facilities. Findings include:

a) Based on interview with Director of Engineering, there is no Humidifier hooked up to the HVAC system. NFPA 99 1999 edition chapter 5-6.1.1 requires that ventilating and humidifying equipment for anesthetizing locations be kept in operable condition and shall be continually operating during surgical procedures. The requirements/equipment was not
operational.
b) The HVAC system that is installed does not have a smoke control system that will automatically vent smoke and products of combustion out of the suite. NFPA 101 chapter 5.8.14, Performance-Based Design Option, requires that the change in design for any part of the hospital requires that the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, the Operating Room Suite was installed with an HVAC System that had HEPA filtration, smoke evacuation, low returns, etc. On the evening of May 8th at 5 pm, the facility was using wall mounted units that did not have HEPA filtration, these units were installed in 2009, no documentation or any submittal for approval was submitted for approval. There was a switch on the exterior of the Operating Room Suite that was used when the Operating Room procedures were being conducted, Staff Member H demonstrated that she would flipped the switch, the switch would activate a exhaust fan that created an negative pressure, unfiltered air would be inducted to the room under the door, wall mounted fans would cool the air to the room. Rooms for surgery require positive air movement in-relationship to adjacent rooms, 3 outdoor air exchanges, 15 total air exchanges, room shall not re-circulate air by room units , 30-60% humidity levels, and 68-73 temperature is required. Humidity Levels below 30% were logged many times, on the evening of the 8th, the room was in negative air flow and room units were being used.

c) The facility failed to adopt and post NFPA 99 12-4.1.1.4 Rules and Regulations that requires authorities and professional staff to jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption of rules and regulations, these rules shall be prominently posted in the operating room suite. There were no rules posted for Fire Loss Prevention . These positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement. The governing body of the hospital failed to correlate regulations and standard operating procedures to ensure that both the physical qualities and the operating maintenance methods pertaining to anesthetizing locations meet the standards set in chapter 12. The controls adopted shall cover the conduct of professional personnel in anesthetizing locations, periodic inspection to ensure the proper grounding of dead metal (see 3-3.3.2), and inspection of all electrical equipment, including testing of line isolation monitors. Line Isolation Monitories were not on an Preventive Maintenance program and staff was not cognizant of the complete operation of equipment. Staff Member H knew that the Line Isolation Monitor Panel had breakers in it, however she did not know function of equipment. The facility did not have a Bio-Medical Equipment Program. Some Equipment was checked and had current stickers; other equipment was not checked and stickered, Whirlpool Dehumidifier and a Rolling Light; and other equipment was not checked in accordance with testing intervals established in accordance with NFPA 99 7-6.2.1.2, Vacuum Pumps and Sequential Compression Device, these devices were checked, however there next scheduled PM was year from its last test , all equipment in critical care areas are required to be checked every 6 months instead of yearly checks, unless documented data is submitted and approved by the governing body. This facility had no documented data to place equipment on a yearly check.

1) Based on observation and interview with staff, the facility failed to provide and test battery operated lighting in accordance NFPA 101 7.10 Findings Include:

a) Battery Backup lighting in CT Scan room did not function. The facility failed to test and document Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals

2) Based on observation and interview with staff, the facility failed to provide a program that includes periodic review of manufactures' safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5. As an example a onetime use battery cautery devices (box of twelve in the ER) was found in the ER. No documentation was available for review that shows staff was in-serviced or cognizant of the potential for fire in the Emergency Room Department with its use.

1) Based on observation and interview with staff, the facility failed to inspect the Emergency Generator weekly and exercise under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a)The emergency generator logs failed to show that the system was run under load.

b) The facility has not calculated how much load is on the Emergency Generator, the log sheet does not reflect what percent equals 30% . The generator is to run 30 minutes with at least 30% load.

c) The Emergency Generator Logs only had two of the 5 months of this year. Logs were not reported to the governing Body.

1) Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.Findings include:

a) The generator and automatic transfer switch does not have separation of the life safety and critical branch panels. Drawings were commissioned, however the scope of work documented on the drawing was not completed.

b) There was no remote annunciator at a 24 hour manned station.

c) There is not a 90 minute back lighting over the automatic transfer switch.

1) Based on observation and interview with staff, the facility did not have Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is re-purposed will be submitted for approval. The room being used for recovery was a lounge in accordance with blue prints provided for review from Staff Member CC. The room did not have Emergency Electrical Receptacles and Circuits tied in from the Critical Care Branch of the Emergency Power System.

b) The facility was cited in the last survey for not having a single line drawing with Life Safety, Critical Care, and Emergency Equipment Branches separated. The facility hired a firm to create construction documents, but failed to implement construction. On May 9th, Staff Member CC could not identify circuits or the Critical or Life Safety Branches. The panels located throughout the hospital were not labeled and panel schedules were not accurate. Staff member CC had to abort the means and method that was going to be used to provide emergency power to the recovery room. Panel that was being used was not marked and located in the IT Room. It is unclear at this time what branch is supplying power to the IT Department. Provide documentation for what branch is supplying emergency power to the brown Electrical Panel in the IT Room.

c) There is no battery backup lighting in the Operating Room Suite or above the transfer switch room located in the Boiler Room.

1) Based on observation and interview with staff, the facility failed to protect corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas with substantial doors, such as those constructed of 1¾ inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Findings include:

a) Door to Janitors closet across from Dietary is not provided with Latching Hardware.

b) Dietary Door is not provided with Latching Hardware.

c) Surgery Door is not provided with Latching Hardware.

Based on observation and interview with staff, the facility failed to provide Smoke barriers that are constructed to provide at least a one half hour fire resistance rating in accordance with 8.3. Findings include:

a) Voids and penetrations were found not sealed over both doors that separated the three smoke zones. The compartment walls shall be sealed with material capable of maintaining the fire resistance of the fire barrier from outside of wall to outside of wall and from floor to deck.

Based on observation and interview with staff, the facility failed to protect hazardous areas in accordance with 8.4.1 and/or 19.3.5.4. When the approved automatic fire extinguishing system option is used, the areas are required to be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Findings include:

NFPA 101 chapter 5.8.14, Performance-Based Design Option, requires that the change in design for any part of the hospital requires that the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions made. The room that once was a telephone room and maintenance area is now the IT Room. The IT equipment requires a room that does not overheat because of the heat producing equipment. The room does not have sufficient air available, a 2 foot by 2 foot grill was cut into the General Store Room (Purchasing) separating the two rooms, allowing air to flow from room to room. Also the door to IT and to Purchasing does not have a closure on the doors, both doors are scotched or are just left open.

1) Based on observation and interview with staff, the facility failed to provide a fire alarm system that is required for life safety and is installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system did not have an approved maintenance and testing program complying with applicable requirements of NFPA 70 and 72. 9.6.1.4 Findings include:

a)The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital, the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, the fire alarm system that was renovated with a new panel installed, required submission of plans and a approval for construction. There is no documentation that the renovation install meet new requirements of NFPA 72.

b) The fire alarm system was renovated in March of 2013, The facility failed to get and provide close out documents with a re-acceptance test for the system. NFPA 72 7-1.6.2, 7-1.6.2.1, 7-1.2

c) The facility had an annual inspection in March of 2013, however the current annual inspection is 2 months past due. Fire Alarm Systems shall be tested in accordance with 7-3.2

d) All devices connected to the fire alarm system were not documented. Combination fire and smoke dampers were not on the March 2013 Fire Alarm Report. The facility could not provide a Directory of Devices for the system . All devices installed are to be checked with an annual report conducted to validate that all devices were checked.

1) Based on observation and interview with staff, the facility failed to provide heating, ventilating, and air conditioning equipment that complies with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2 Findings include:

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions. Endo-scope and procedures were not invented when the hospital was designed and built. The facility created an area to wash scope and store them. This area was not designed for the use of alcohol and other agents to clean the scopes and creat a flow from dirty to clean area. The exhaust system was not designed for scope washing, also exhaust installed did not work (motor was burnt out or was not turned on).The storage of scopes shall be in a positive air flow room, the scopes were hung in a room that was not documented as positive or negative and the room was re-purposed.

b)The wall mounted HVAC Units located in the Operating and Endoscope rooms were not submitted, they do not provide smoke evacuation, humidification, proper filtration, and have Anesthesia use. Anesthesia locations do not allow for units that re-circulate the air.

c) The manometers on the HVAC Air Handler were broken and not functioning.

d) HEPA Filter was not installed in the filter bank on Thursday May 8th.

e) 2 of the 4 Exhaust fans motors were burnt out, the other 2 were not turned on, one makes a lot of noise. Staff Member CC stated that the exhaust over the Central Sterilizer has not worked for years. Exhaust for the Soiled Utility room on the north wing does not work. Exhaust for OR and the OR Smoke Removal is or was tied together. Staff CC could not provide information on how systems worked.

f) Staff Member CC did not know that there was a filter that had been homemade and installed in the grill above the Central Sterile Room Door. The air coming out was very minimal. There was no test and balance documentation for the room. The HVAC Unit in the boiler room that supplies air to the Central Sterile Supply does not have final filters that provided 90%.efficiency.

1)Based on observation and interview with staff, the facility failed to have piped in medical gas systems that comply with NFPA 99, Chapter 4. Findings include:

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is repurposed shall be submitted for approval. The room being used for recovery was a lounge in accordance with blue prints provided for review from Director of Engineering. The room did not have piped in Oxygen and Vacuum outlets with Zone Valves and Alarms. The Operating room used to conduct endo-scope procedures requires piped in Medical Vacuum.

1) Based on observation and interview with staff, the facility failed to protect Anesthetizing locations in accordance with NFPA 99 1999 edition, Standard for Health Care Facilities. Findings include:

a) Based on interview with Director of Engineering, there is no Humidifier hooked up to the HVAC system. NFPA 99 1999 edition chapter 5-6.1.1 requires that ventilating and humidifying equipment for anesthetizing locations be kept in operable condition and shall be continually operating during surgical procedures. The requirements/equipment was not
operational.
b) The HVAC system that is installed does not have a smoke control system that will automatically vent smoke and products of combustion out of the suite. NFPA 101 chapter 5.8.14, Performance-Based Design Option, requires that the change in design for any part of the hospital requires that the ownership or management of the building, will have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, the Operating Room Suite was installed with an HVAC System that had HEPA filtration, smoke evacuation, low returns, etc. On the evening of May 8th at 5 pm, the facility was using wall mounted units that did not have HEPA filtration, these units were installed in 2009, no documentation or any submittal for approval was submitted for approval. There was a switch on the exterior of the Operating Room Suite that was used when the Operating Room procedures were being conducted, Staff Member H demonstrated that she would flipped the switch, the switch would activate a exhaust fan that created an negative pressure, unfiltered air would be inducted to the room under the door, wall mounted fans would cool the air to the room. Rooms for surgery require positive air movement in-relationship to adjacent rooms, 3 outdoor air exchanges, 15 total air exchanges, room shall not re-circulate air by room units , 30-60% humidity levels, and 68-73 temperature is required. Humidity Levels below 30% were logged many times, on the evening of the 8th, the room was in negative air flow and room units were being used.

c) The facility failed to adopt and post NFPA 99 12-4.1.1.4 Rules and Regulations that requires authorities and professional staff to jointly consider and agree upon necessary rules and regulations for the control of personnel concerned with anesthetizing locations. Upon adoption of rules and regulations, these rules shall be prominently posted in the operating room suite. There were no rules posted for Fire Loss Prevention . These positive measures are necessary to acquaint all personnel with the rules and regulations established and to ensure enforcement. The governing body of the hospital failed to correlate regulations and standard operating procedures to ensure that both the physical qualities and the operating maintenance methods pertaining to anesthetizing locations meet the standards set in chapter 12. The controls adopted shall cover the conduct of professional personnel in anesthetizing locations, periodic inspection to ensure the proper grounding of dead metal (see 3-3.3.2), and inspection of all electrical equipment, including testing of line isolation monitors. Line Isolation Monitories were not on an Preventive Maintenance program and staff was not cognizant of the complete operation of equipment. Staff Member H knew that the Line Isolation Monitor Panel had breakers in it, however she did not know function of equipment. The facility did not have a Bio-Medical Equipment Program. Some Equipment was checked and had current stickers; other equipment was not checked and stickered, Whirlpool Dehumidifier and a Rolling Light; and other equipment was not checked in accordance with testing intervals established in accordance with NFPA 99 7-6.2.1.2, Vacuum Pumps and Sequential Compression Device, these devices were checked, however there next scheduled PM was year from its last test , all equipment in critical care areas are required to be checked every 6 months instead of yearly checks, unless documented data is submitted and approved by the governing body. This facility had no documented data to place equipment on a yearly check.

1) Based on observation and interview with staff, the facility failed to provide and test battery operated lighting in accordance NFPA 101 7.10 Findings Include:

a) Battery Backup lighting in CT Scan room did not function. The facility failed to test and document Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals

2) Based on observation and interview with staff, the facility failed to provide a program that includes periodic review of manufactures' safety guidelines and usage requirements for electrosurgical units and similar appliances with all personnel concerned with the application and maintenance of electric appliances, including physicians, nurses, nurse aids, engineers, technicians, and orderlies, shall be cognizant of the risks associated with their use. To achieve this end the hospital shall provide appropriate programs of continuing education for its personnel in accordance with Qualification and Training of Personnel NFPA 99 chapter 7-6.5. As an example a onetime use battery cautery devices (box of twelve in the ER) was found in the ER. No documentation was available for review that shows staff was in-serviced or cognizant of the potential for fire in the Emergency Room Department with its use.

1) Based on observation and interview with staff, the facility failed to inspect the Emergency Generator weekly and exercise under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1. Findings include:

a)The emergency generator logs failed to show that the system was run under load.

b) The facility has not calculated how much load is on the Emergency Generator, the log sheet does not reflect what percent equals 30% . The generator is to run 30 minutes with at least 30% load.

c) The Emergency Generator Logs only had two of the 5 months of this year. Logs were not reported to the governing Body.

1) Based on observation and interview with staff, the facility failed to provide a Type I EES that is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.Findings include:

a) The generator and automatic transfer switch does not have separation of the life safety and critical branch panels. Drawings were commissioned, however the scope of work documented on the drawing was not completed.

b) There was no remote annunciator at a 24 hour manned station.

c) There is not a 90 minute back lighting over the automatic transfer switch.

1) Based on observation and interview with staff, the facility did not have Electrical wiring and equipment that is in accordance with NFPA 70, National Electrical Code. 9.1.2

a) The hospital was designed with Performance-Based Design that requires that any change in design for any part of the hospital ,the ownership or management of the building shall have a re-evaluation and re-approval for any remodeling, modification, renovation, or change in use. The building was approved with performance-based design and certain specified design criteria and assumptions, any room that is re-purposed will be submitted for approval. The room being used for recovery was a lounge in accordance with blue prints provided for review from Staff Member CC. The room did not have Emergency Electrical Receptacles and Circuits tied in from the Critical Care Branch of the Emergency Power System.

b) The facility was cited in the last survey for not having a single line drawing with Life Safety, Critical Care, and Emergency Equipment Branches separated. The facility hired a firm to create construction documents, but failed to implement construction. On May 9th, Staff Member CC could not identify circuits or the Critical or Life Safety Branches. The panels located throughout the hospital were not labeled and panel schedules were not accurate. Staff member CC had to abort the means and method that was going to be used to provide emergency power to the recovery room. Panel that was being used was not marked and located in the IT Room. It is unclear at this time what branch is supplying power to the IT Department. Provide documentation for what branch is supplying emergency power to the brown Electrical Panel in the IT Room.

c) There is no battery backup lighting in the Operating Room Suite or above the transfer switch room located in the Boiler Room.