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Based on observation and staff interview, the facility failed to seal smoke barrier penetrations. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 8/4/14, from 11:15 am to 1:36 pm revealed:
1. A hole around a conduit failed to be sealed above the ER Doors by the Nurse Station.
2. Holes around wires and a conduit above the North ER Fire Doors failed to be sealed.
In an interview conducted at the time of observation, (8/4/14, from 11:15 am to 1:36 pm), Maintenance A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to separate a hazardous area from a use area. This condition had the potential for smoke and fire to enter the use area.

Findings are:
Observations during the facility tour on 8/4/14, at 11:29 am revealed holes around conduits that penetrated the ceiling of the ER Housekeeping Closet failed to be sealed.
In an interview conducted at the time of observations, (8/4/14, at 11:29 am), Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to provide an exit that was accessible at all times. This condition would prevent the breakaway feature of the Main Entrance powered horizontal sliding doors from functioning.

Findings are:
Observation during the facility tour on 8/4/14, at 1:48 pm revealed the Main Entrance powered horizontal sliding doors had a lock operated by a thumb latch installed in the door. The doors failed to breakaway, and allow egress when the lock was engaged.
In an interview conducted at the time of observation, (8/4/14, at 1:48 pm), Maintenance A confirmed that the doors failed to breakaway when the lock was engaged.

Based on record review and staff interview, the facility failed to document battery backup emergency light testing. This condition had the potential to leave occupants in darkness during a loss of power.

Findings are:
Record review on 8/4/14, at 12:39 pm revealed the facility failed to provide documentation that battery backup emergency lights were tested annually in the OR and Procedure Room.
In an interview conducted at the time of record review (8/4/14, at 12:39 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.9.3, 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 1 ½ hours. Equipment shall be fully operation 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.

Based on record review and staff interview, the facility failed to maintain the Procedure Room and Operating Room (OR) line isolation panels. This condition would allow an electrical fault during an operation without notification to staff.

Findings are:
Record review on 8/4/14, at 1:01 pm revealed documentation of monthly line isolation panel testing for the OR and Procedure Room failed to be provided.
In an interview conducted at the time of record review, (8/4/14, at 1:01 pm), Maintenance A confirmed the testing was not conducted.

Actual NFPA Standard:
NFPA 99, 1999 Edition, 3-3.3.4.2 Line Isolation Monitor Tests.
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

Based on observation, record review and staff interview, the facility failed to adopt a policy for a chemical or flammable liquids spill in the Laboratory. This condition would allow hazardous liquids to spread before being contained.

Findings are:
Observation during the facility tour on 8/4/14, at 12:01 pm revealed flammable liquids were stored in the Laboratory.
Record review revealed the facility failed to adopt a policy for a chemical and flammable liquids spill in the Laboratory.
In an interview conducted at the time of observation, (8/4/14, at 12:01 pm) Laboratory Staff A failed to have any knowledge of a liquids spill policy.
Maintenance A confirmed that a policy failed to be available for review.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA) 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 8/4/14, at 10:16 am of the emergency generator maintenance documentation revealed a monthly load test for 5/2013 failed to be documented.
In an interview conducted at the time of record review, (8/4/14, at 10:16 am), Maintenance A confirmed that the generator testing documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 8/4/14, at 11:51 am revealed coolers and a warming appliance in the Kitchen were plugged into a 6-outlet power tap. The appliances failed to be plugged directly into a hardwired outlet.
In an interview conducted at the time of observation (8/4/14, at 11:51 am), Maintenance A acknowledged the findings.

Based on observation and staff interview, the facility failed to seal smoke barrier penetrations. This condition had the potential to allow smoke to migrate between smoke compartments.

Findings are:
Observation above ceiling during the facility tour on 8/4/14, from 11:15 am to 1:36 pm revealed:
1. A hole around a conduit failed to be sealed above the ER Doors by the Nurse Station.
2. Holes around wires and a conduit above the North ER Fire Doors failed to be sealed.
In an interview conducted at the time of observation, (8/4/14, from 11:15 am to 1:36 pm), Maintenance A confirmed the penetrations in the barrier walls.

Based on observation and staff interview, the facility failed to separate a hazardous area from a use area. This condition had the potential for smoke and fire to enter the use area.

Findings are:
Observations during the facility tour on 8/4/14, at 11:29 am revealed holes around conduits that penetrated the ceiling of the ER Housekeeping Closet failed to be sealed.
In an interview conducted at the time of observations, (8/4/14, at 11:29 am), Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to provide an exit that was accessible at all times. This condition would prevent the breakaway feature of the Main Entrance powered horizontal sliding doors from functioning.

Findings are:
Observation during the facility tour on 8/4/14, at 1:48 pm revealed the Main Entrance powered horizontal sliding doors had a lock operated by a thumb latch installed in the door. The doors failed to breakaway, and allow egress when the lock was engaged.
In an interview conducted at the time of observation, (8/4/14, at 1:48 pm), Maintenance A confirmed that the doors failed to breakaway when the lock was engaged.

Based on record review and staff interview, the facility failed to document battery backup emergency light testing. This condition had the potential to leave occupants in darkness during a loss of power.

Findings are:
Record review on 8/4/14, at 12:39 pm revealed the facility failed to provide documentation that battery backup emergency lights were tested annually in the OR and Procedure Room.
In an interview conducted at the time of record review (8/4/14, at 12:39 pm), Maintenance A acknowledged the findings.

Actual NFPA Standard:
NFPA 101, 7.9.3, 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 1 ½ hours. Equipment shall be fully operation 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.

Based on record review and staff interview, the facility failed to maintain the Procedure Room and Operating Room (OR) line isolation panels. This condition would allow an electrical fault during an operation without notification to staff.

Findings are:
Record review on 8/4/14, at 1:01 pm revealed documentation of monthly line isolation panel testing for the OR and Procedure Room failed to be provided.
In an interview conducted at the time of record review, (8/4/14, at 1:01 pm), Maintenance A confirmed the testing was not conducted.

Actual NFPA Standard:
NFPA 99, 1999 Edition, 3-3.3.4.2 Line Isolation Monitor Tests.
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 X V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months.

Based on record review and staff interview, the facility failed to maintain the emergency generator in accordance with the National Fire Protection Association (NFPA) 110. This condition increased the potential that the generator would fail to run during loss of power.

Findings are:
Record review on 8/4/14, at 10:16 am of the emergency generator maintenance documentation revealed a monthly load test for 5/2013 failed to be documented.
In an interview conducted at the time of record review, (8/4/14, at 10:16 am), Maintenance A confirmed that the generator testing documentation failed to be completed.

Actual NFPA Standard:
NFPA 110, 1999, 6-4.1*
Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on observation and staff interview, the facility failed to use electrical wiring in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical fire.

Findings are:
Observation during the facility tour on 8/4/14, at 11:51 am revealed coolers and a warming appliance in the Kitchen were plugged into a 6-outlet power tap. The appliances failed to be plugged directly into a hardwired outlet.
In an interview conducted at the time of observation (8/4/14, at 11:51 am), Maintenance A acknowledged the findings.