HospitalInspections.org

Based on record review and interview, the facility (prior to COVID) failed to provide documentation for circuit breaker testing for the circuits of the emergency generator. This deficient practice increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility.

Findings are:
Record review conducted on 3-3-22 at 1:17 pm of the facility's generator inspection testing revealed:
1. Facility lacked evidence of inspection of the main and feeder circuit breakers were inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements.

During an interview on 3-3-22 at 1:17 pm, Administration Staff A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

NFPA Standard:
NFPA 110, 2010, 8.4.2.4
Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized.

Based on observation, interview and documentation review, the facility failed to maintain emergency lighting and failed to provide testing. The lack of emergency lighting would cause confusion and delay egress from the facility during an emergency

Findings are:
Observation on 3-3-22 at 12:50 pm revealed, the emergency lights at the main electrical room failed to operate when test button was depressed.

During an interview on 3-3-22 at 12:50 pm, Administration Staff A confirmed the emergency light failed to work.

Documentation review on 3-3-22 at 1:10 pm, revealed the facility failed to test emergency lighting on a monthly and annual basis.

During an interview on 3-3-22 at 1:10 pm, Administration Staff A confirmed the lack of testing of the emergency lighting

Based on observation and interview, the facility failed to assure that hazard areas were smoke tight. This deficient practice would allow smoke, fire, and gasses to spread out of the room and into the exit corridor.

Findings are:
Observations on 3-3-22 at 11:07 am revealed, the door to Laundry 506 equipped with a self-closing device failed to latch within the doorframe.

During an interview on 3-3-22 at 11:07 am, Administration Staff A confirmed the door failed to latch.

Based on observation and interview, the facility failed to assure fire extinguishers were not obstructed. This deficient practice would delay the extinguishment of a fire.

Findings are:
Observation on 3-3-22 at 11:38 am revealed, the fire extinguisher in the MRI area was obstructed by chairs.

During an interview on 3-3-22 at 11:38 am, Administration Staff A confirmed the chairs obstructing the fire extinguisher.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire, smoke and gasses within the exit corridors.

Findings are:
Observation on 3-3-22 at 11:44 am revealed, the east and west doors to the Chapel failed to latch.

During an interview on 3-3-22 at 11:44 am, Administration Staff A confirmed the doors failed to latch.

Based on observation and interview, the facility allowed storage to obstruct access to electrical panel box. This deficient practice could cause injury and delay when turning off the power during an electrical emergency.

Findings are:
Observations on 3-3-22 at 11:54 am revealed, child table and chairs, boxes and carts blocking the electrical panel box in the 500 electrical room.

During an interview on 3-3-22 at 11:54 am, Administration Staff A confirmed the items stored in front of the panel box

NFPA Standard:
2011 NFPA 70, 65.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

2011 NFPA 70,65.32
Sufficient space shall be provided and maintained about electrical equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed,
the minimum clear work space shall be not less than 2.0 m (6 1/2 ft) high (measured vertically from the floor or platform) or not less than 914 mm (3 ft) wide (measured parallel to the equipment). The depth shall be as required in 65.34(A). In all cases, the work space shall permit at least a 90 degree opening of doors or hinged panels.

Based on record review and interview, the facility (prior to COVID) failed to provide documentation for circuit breaker testing for the circuits of the emergency generator. This deficient practice increase the probability that the generator would fail to run during an emergency loss of power and the emergency systems in the facility.

Findings are:
Record review conducted on 3-3-22 at 1:17 pm of the facility's generator inspection testing revealed:
1. Facility lacked evidence of inspection of the main and feeder circuit breakers were inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements.

During an interview on 3-3-22 at 1:17 pm, Administration Staff A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

NFPA Standard:
NFPA 110, 2010, 8.4.2.4
Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized.

Based on observation and interview, the facility failed to prohibit the use of extension cords as a substitute for adequate wiring and allowed power strips. This deficient practice would create a fire hazard.

Findings are:
Observation on 3-3-22 at 11:18 am revealed:
1. Microwave and refrigerator plugged into a power strip in the EVS breakroom.
2. Refrigerator in the EVS breakroom connected to an extension cord.

During an interview on 3-3-22 at 11:18 am, Administration Staff A confirmed the use of extension cord and power strip.