HospitalInspections.org

Findings:

The inspector observed, while accompanied by the Administrator, Administrator's Assistant, Director of Maintenance, and Maintenance Staff 1 during the hours of the inspection from 11:00 AM to 2:00 PM on 4/12/19, that there were the following issues:
1) Based on staff interview, the facility has not yet implemented inspection of doors in means of egress as of this survey date (4/12/19). Please note the Centers for Medicare & Medicaid Services adopted the 2012 edition of NFPA 99 & 101 became effective as of July 5, 2016.

Findings:

The inspector observed, while accompanied by the Administrator, Administrator's Assistant, Director of Maintenance, and Maintenance Staff 1 during the hours of the inspection from 11:00 AM to 2:00 PM on 4/12/19, that there were the following issues:
1) Based on review of the records, facility failed to conduct fire drills at unexpected times under varying conditions for the current year (2019) and the previous year (2018).

Findings:

The inspector observed, while accompanied by the Administrator, Administrator's Assistant, Director of Maintenance, and Maintenance Staff 1 during the hours of the inspection from 11:00 AM to 2:00 PM on 4/12/19, that there were the following issues:
1) Based on review of the records, facility has not completed a risk assessment for the current year (2019) or the previous two years.

Findings:

The inspector observed, while accompanied by the Administrator, Administrator's Assistant, Director of Maintenance, and Maintenance Staff 1 during the hours of the inspection from 11:00 AM to 2:00 PM on 4/12/19, that there were the following issues:
1) Based on observation, the facility failed to have properly secured cover plates with all wiring secure inside junction box at the following locations: (a) mechanical room in Zone 1; (b) electrical room in Zone 1; and (c) above the cross corridor doors in Zone 6.

Findings:

The inspector observed, while accompanied by the Administrator, Administrator's Assistant, Director of Maintenance, and Maintenance Staff 1 during the hours of the inspection from 11:00 AM to 2:00 PM on 4/12/19, that there were the following issues:
1) Based on review of the records, facility failed to perform receptacle (both red and white receptacles) maintenance and testing for the current year (2019) and the previous two years. NFPA 99-2012, section 6.3.3.2 lists the minimum requirements for receptacle testing regardless of hospital-grade or not.

The Standard:

A record shall be maintained of the tests required by this chapter and associated repairs or modification. - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2012: 6.3.4.2.1.1
At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. - NFPA 99, Health Care Facilities Code. U.S.A.: NFPA; 2012: 6.3.4.2.1.2
Electrical receptacle tests were not being performed in patient care areas. 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.

Findings:

The inspector observed, while accompanied by the Administrator, Administrator's Assistant, Director of Maintenance, and Maintenance Staff 1 during the hours of the inspection from 11:00 AM to 2:00 PM on 4/12/19, that there were the following issues:
1) Based on observation, the facility failed to keep the electrical room free from accumulation of rubbish and materials that obstruct access to the electrical panels. There were many instances where rooms labeled as "Janitor" doubled as storage of combustible materials and housing for electrical panels. Because working space was used for storage, the width and depth of working space could not be adequately maintained.

The Standard:

"Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded." - NFPA 70, 2011, 110.26(B)
"Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 100.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed." - NFPA 70, 2011, 110.26(A)(1).
"Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels." - NFPA 70, 2011, 110.26(A)(2).