HospitalInspections.org

Based on observation the facility failed to provide an adequate stair enclosure.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues: 1) stair " E " on the fifth floor of Bethania had a door that stuck, and 2) on the 3rd and 4th floor of Bethania, stair " A " had a gap between the double doors to the stair.

Based on observation the facility failed to maintain the integrity of the smoke barriers.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. There were penetrations in the Bridwell Building at the following: 1) 11SF4021, 2) 11SF1048, 3) 11SF1025.

Based on observation the facility failed to maintain the integrity of the smoke barriers.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. They were penetrations in the following locations in Bethania: 1) by stair E, 11F9001, 2) 11F8008, 3) 11F7020, 4) 11F7009, 5) 7 west 2, near room 736, 6) 11F5019, 7) 11C5001, 8) 11C4082, 9) 11C2022, 10) 11F1045, 11) 11F1063, 12) 11F1047, 13) 11FB001, 14) 11FB030, 15) door by vending machine in basement, 16) door by Hardamin room in basement.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. They were: 1) storage room on 7th floor of Bethania requires closer to be adjusted, 2) storage room 11C3033, the door did not latch, 3) storage room on 1st floor Bethania did not have a closer, 4) clean supply of Bethania did not have a closer, 5) Bethania 11C3012, and 6) storage rooms in central supply did not have closers. This last point for the storage rooms in a central supply suite would not be required if the entire central supply is fire sprinkled and the doors going in and out of the suite have closers.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. They were: 1) the shell space on the 5th floor of the Bridwell building had a penetration in the 1 hour fire wall, 2) equipment storage on 3rd floor Bridwell did not have a closer, 3) there was a storage room that was a satellite pharmacy that did not have a labeled door on the 3rd floor of Bridwell, 4) the soiled utility in the nursery of 4th floor Bridwell did not latch properly, 5) door 1SF1045 was a clean linen and requires the closer to be adjusted.

Based on observation the facility failed to maintain all sprinkler heads.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there was a sprinkler head on the 9th floor of Bethania in stair " D " that was covered with tape.

Based on observation the facility failed to provide adequate signage on the medical gas piping.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that the medical gas piping on the 3rd floor of Bethania was not labeled well.

Labeling Med Gas Piping: " The gas content of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft and at least once in each room and each story traversed by the piping system. " - NFPA 99, 1999: 4-3.1.2.13.

In the basement of Bethania there was a Nitrous Oxide Room that did not have adequate ventilation. " Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with. NFPA 99, 1999, 4-3.1.1.2(c). "

Based on observation the facility failed to secure all medical gas bottoles.

There was an unsecured cylinder of oxygen in the well baby nursery on the 4th floor of Bridwell. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Exit Signs:

" Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. " - NFPA 101, 2000, 7.10.1.2.

" Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. " - NFPA 101, 2000, 7.10.1.4.

Based on observation the facility failed to maintain exit signage.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there was the following issue. There was not an exit sign to the exterior in the UPS room of the first floor of the Bridwell building.


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 must 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 grounding test of electrical receptacles per NFPA 99: 3-3.3.3. for patient care areas.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 the facility was not conducting receptacle testing at all. The facility sited the 2012 edition of NFPA 99, 6.3.4.1.3 as justification for not doing the testing. This reference addresses non hospital grade receptacles and does not apply to this situation.


Nurse Call Duty Stations:

CMS requires a complete nurse call systems in all hospitals. Duty stations are required in the following locations: clean work room, soiled work room, medication room, charting room, clean linen storage, nourishment room, equipment storage, exam and treatment rooms. H.L.R. 2007, Table 7, Notes 1, 2, and 3.

Based on observation the facility failed to provide adequate duty stations.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were missing duty stations in the following locations: 1) Bridwell 4th floor, clean storage, 2) Bridwell, 1st floor, clean storage at nurse station, 3) Bridwell, 1st floor, clean equipment, and 4) Bridwell, 1st floor, clean utility.

Fire Pump Enclosure:

NFPA 13, 2003, 13.4.2.1.1 Indoor fire pump units shall be separated from all other areas of the building by 2-hour fire rated construction.
Exception No. 1: The pumps outlined in 13.4.2.1.2.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinker System, the separation requirement shall be reduced to 1-hour fire rated construction. [20:2.7.1.1]

Based on observation the facility failed to provide an acceptable enclosure for the fire pump.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there was the following issue. There were penetrations in the walls of the fire pump room in the basement of Bethania.


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 must 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 grounding test of electrical receptacles per NFPA 99: 3-3.3.3. for patient care areas.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 the facility was not conducting receptacle testing at all. The facility sited the 2012 edition of NFPA 99, 6.3.4.1.3 as justification for not doing the testing. This reference addresses non hospital grade receptacles and does not apply to this situation.


Nurse Call Duty Stations:

CMS requires a complete nurse call systems in all hospitals. Duty stations are required in the following locations: clean work room, soiled work room, medication room, charting room, clean linen storage, nourishment room, equipment storage, exam and treatment rooms. H.L.R. 2007, Table 7, Notes 1, 2, and 3.

Based on observation the facility failed to provide adequate duty stations.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were missing duty stations in the following locations: 1) Bethania, E.R. department soiled utility, 2) Bethania, E.R. clean utility, 3) Bethania, E.R. second soiled utility, 4) Bethania 6th floor, clean utility, 5) Bethania 6th floor, second clean utility, 6) Bethania 6th floor, soiled utility, and 7) Bethania 3rd floor, soiled utility.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues.

There was an open J-Box at 11C5001 and 11C4082.

In the basement electrical room of Bethania there were no labels on the essential electrical system panels stating which branch of the system they served. The label must spell out the branch, that is " LIFE SAFETY " , " CRITICAL " , OR " EQUIPMENT " must be on panels and ATS panels.

Based on observation the facility failed to provide an adequate electrical system.

The labels on the critical outlets in all critical spaces must be permanent. Permanent means that it can not be readily removed with your fingernail. The following locations did not have permanent labels: 1) surgery and center core in the Bridwell building, 2) E.D., 3) 4th floor Bridwell L & D recovery, and 4) cardiac recovery on the 8th floor of Bethania.

Based on observation the facility failed to provide an adequate stair enclosure.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues: 1) stair " E " on the fifth floor of Bethania had a door that stuck, and 2) on the 3rd and 4th floor of Bethania, stair " A " had a gap between the double doors to the stair.

Based on observation the facility failed to maintain the integrity of the smoke barriers.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. There were penetrations in the Bridwell Building at the following: 1) 11SF4021, 2) 11SF1048, 3) 11SF1025.

Based on observation the facility failed to maintain the integrity of the smoke barriers.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. They were penetrations in the following locations in Bethania: 1) by stair E, 11F9001, 2) 11F8008, 3) 11F7020, 4) 11F7009, 5) 7 west 2, near room 736, 6) 11F5019, 7) 11C5001, 8) 11C4082, 9) 11C2022, 10) 11F1045, 11) 11F1063, 12) 11F1047, 13) 11FB001, 14) 11FB030, 15) door by vending machine in basement, 16) door by Hardamin room in basement.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. They were: 1) storage room on 7th floor of Bethania requires closer to be adjusted, 2) storage room 11C3033, the door did not latch, 3) storage room on 1st floor Bethania did not have a closer, 4) clean supply of Bethania did not have a closer, 5) Bethania 11C3012, and 6) storage rooms in central supply did not have closers. This last point for the storage rooms in a central supply suite would not be required if the entire central supply is fire sprinkled and the doors going in and out of the suite have closers.

Based on observation the facility failed to provide adequate hazardous area separation.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues. They were: 1) the shell space on the 5th floor of the Bridwell building had a penetration in the 1 hour fire wall, 2) equipment storage on 3rd floor Bridwell did not have a closer, 3) there was a storage room that was a satellite pharmacy that did not have a labeled door on the 3rd floor of Bridwell, 4) the soiled utility in the nursery of 4th floor Bridwell did not latch properly, 5) door 1SF1045 was a clean linen and requires the closer to be adjusted.

Based on observation the facility failed to maintain all sprinkler heads.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there was a sprinkler head on the 9th floor of Bethania in stair " D " that was covered with tape.

Based on observation the facility failed to provide adequate signage on the medical gas piping.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that the medical gas piping on the 3rd floor of Bethania was not labeled well.

Labeling Med Gas Piping: " The gas content of medical gas piping systems shall be readily identifiable by appropriate labeling with the name and pressure of the gas contained. Such labeling shall be by means of metal tags, stenciling, stamping, or adhesive markers, in a manner that is not readily removable. Labeling shall appear on the piping at intervals of not more than 20 ft and at least once in each room and each story traversed by the piping system. " - NFPA 99, 1999: 4-3.1.2.13.

In the basement of Bethania there was a Nitrous Oxide Room that did not have adequate ventilation. " Storage Requirements for Nonflammable Gases Less Than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied with. NFPA 99, 1999, 4-3.1.1.2(c). "

Based on observation the facility failed to secure all medical gas bottoles.

There was an unsecured cylinder of oxygen in the well baby nursery on the 4th floor of Bridwell. " Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over. " - NFPA 99, 1999: 4-3.1.1.1.

Exit Signs:

" Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access. " - NFPA 101, 2000, 7.10.1.2.

" Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. " - NFPA 101, 2000, 7.10.1.4.

Based on observation the facility failed to maintain exit signage.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there was the following issue. There was not an exit sign to the exterior in the UPS room of the first floor of the Bridwell building.


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 must 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 grounding test of electrical receptacles per NFPA 99: 3-3.3.3. for patient care areas.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 the facility was not conducting receptacle testing at all. The facility sited the 2012 edition of NFPA 99, 6.3.4.1.3 as justification for not doing the testing. This reference addresses non hospital grade receptacles and does not apply to this situation.


Nurse Call Duty Stations:

CMS requires a complete nurse call systems in all hospitals. Duty stations are required in the following locations: clean work room, soiled work room, medication room, charting room, clean linen storage, nourishment room, equipment storage, exam and treatment rooms. H.L.R. 2007, Table 7, Notes 1, 2, and 3.

Based on observation the facility failed to provide adequate duty stations.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were missing duty stations in the following locations: 1) Bridwell 4th floor, clean storage, 2) Bridwell, 1st floor, clean storage at nurse station, 3) Bridwell, 1st floor, clean equipment, and 4) Bridwell, 1st floor, clean utility.

Fire Pump Enclosure:

NFPA 13, 2003, 13.4.2.1.1 Indoor fire pump units shall be separated from all other areas of the building by 2-hour fire rated construction.
Exception No. 1: The pumps outlined in 13.4.2.1.2.
Exception No. 2: In buildings protected with an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinker System, the separation requirement shall be reduced to 1-hour fire rated construction. [20:2.7.1.1]

Based on observation the facility failed to provide an acceptable enclosure for the fire pump.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there was the following issue. There were penetrations in the walls of the fire pump room in the basement of Bethania.


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 must 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 grounding test of electrical receptacles per NFPA 99: 3-3.3.3. for patient care areas.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 the facility was not conducting receptacle testing at all. The facility sited the 2012 edition of NFPA 99, 6.3.4.1.3 as justification for not doing the testing. This reference addresses non hospital grade receptacles and does not apply to this situation.


Nurse Call Duty Stations:

CMS requires a complete nurse call systems in all hospitals. Duty stations are required in the following locations: clean work room, soiled work room, medication room, charting room, clean linen storage, nourishment room, equipment storage, exam and treatment rooms. H.L.R. 2007, Table 7, Notes 1, 2, and 3.

Based on observation the facility failed to provide adequate duty stations.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were missing duty stations in the following locations: 1) Bethania, E.R. department soiled utility, 2) Bethania, E.R. clean utility, 3) Bethania, E.R. second soiled utility, 4) Bethania 6th floor, clean utility, 5) Bethania 6th floor, second clean utility, 6) Bethania 6th floor, soiled utility, and 7) Bethania 3rd floor, soiled utility.

Based on observation the facility failed to provide an adequate electrical system.

The inspector observed, while accompanied by the Construction Manager, Facilities Manager, Facility Management Director, GS/Security Director, S.O./Trama, Life Safety Specialist, Quality Management, and V.P. Facilities during the hours of the inspection from 4:30 pm to 6:00 pm on 8/21/2012 and 8:00 am to 4:00 pm on 8/22/2012 that there were the following issues.

There was an open J-Box at 11C5001 and 11C4082.

In the basement electrical room of Bethania there were no labels on the essential electrical system panels stating which branch of the system they served. The label must spell out the branch, that is " LIFE SAFETY " , " CRITICAL " , OR " EQUIPMENT " must be on panels and ATS panels.

Based on observation the facility failed to provide an adequate electrical system.

The labels on the critical outlets in all critical spaces must be permanent. Permanent means that it can not be readily removed with your fingernail. The following locations did not have permanent labels: 1) surgery and center core in the Bridwell building, 2) E.D., 3) 4th floor Bridwell L & D recovery, and 4) cardiac recovery on the 8th floor of Bethania.