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Based on observation the facility did not maintain the integrity, smoke resistance, of walls in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 Requires that hazardous areas be separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke.

Findings Include:

On October 17, 2012, the surveyor accompanied by the Manager of Safety and Security, Director of Facilities Services and staff observed cut out openings in the MRI Equipment Room. There are approximately four cut out areas above the door in one layer of sheet rock approximately six to ten inches in area each. The second area is the wall that separates the MRI unit from the equipment room. The cut out area is approximately four feet by five feet and penetrates through two layers of sheet rock.

During the exit conference on October 17, 2012, the above findings were again acknowledged by the CEO, CFO, CMO, and staff.

The penetrations or holes could allow heat and smoke to spread into walls, attics, or exit corridors which could cause harm to patients and staff.

Based on record review the facility failed to document the required testing of the emergency generators.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.9.7.6 " Maintenance and Testing (See 4.6.12) Section 4.6.12.2 " Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction." NFPA 99 "HEALTH CARE FACILITIES". Chapter 3, Section 3-5.4.1.1 (a) and Section 3-4.4.1.1 (b) "Generator sets shall be tested twelve (12) times a year... Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Chapter 6, Section 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. NFPA 110, Chapter 6, Section 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...
Chapter 3, Section 3-4.1.1.8. (Level/Type 1) "The generator sets shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
or Section 3-5.3.1 (Level/Type 2) "The emergency system shall be installed and connected to the alternate source of power specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system will be automatically restored to operation within 10 seconds after interruption of the normal source."

Findings Include:

On October 16, 2012, the surveyor, accompanied by the Manager of Safety and Security, Director of Facilities Services and staff reviewed the generator test records. From November 2011 thru September 2012 a monthly load test was conducted however there was not any documentation of emergency system transfer within ten seconds (10 seconds or less) from normal power to emergency power of each of the two Emergency Power Systems.

During the exit conference on October 17, 2012, the above findings were again acknowledged by the CEO, CFO, CMO, and staff.

Failure to test the emergency generator under load and document time from normal power to emergency power could result in harm to patients and staff during lighting system failures.