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Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations and support steel covered with rated fire proofing. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 2:42 PM, observation revealed on the 1st floor in room 118, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included a conduit that went up through the ceiling/floor assembly. The penetration was covered on the bottom with Styrofoam. The floor/ceiling fire rated assembly could not be confirmed in this location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

2. On July 14, 2015 at 2:30 PM, observation revealed on the 2nd floor in the passage between exam rooms 5 and 6 in the emergency department, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces. In addition, there was patient treatment in spaces that were open to the corridor. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all PT/OT patients, staff and visitors within the PT/OT suite.

FINDINGS INCLUDE:

On July 13, 2015 at 1:36 PM, observation revealed on the 1st floor in the OT/PT Reception Desk that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space had a drop down shutter that was installed in the corridor wall. Staff B did not know when to close the shutter when asked what she would do if a fire alarm sounded. The hole in the corridor wall would not resist the passage of smoke. The space was considered a space open to the corridor, but was not equipped with a smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A and Staff B.

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage when the egress path was not readily apparent. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On July 14, 2015 at 9:00 AM, observation revealed on the 3rd floor in the across corridor doors from the dining area to the clinic area,that the path of egress in the corridor was not readily apparent and an exit sign was not provided above the across corridor doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not enclose hazardous rooms by having sealed wall penetrations. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 12:50 PM, observation revealed on the 1st floor, in the storage room of the maintenance room, that penetrations were not sealed according to an approved method. The deficiency included 3 pipes that were not caulked This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2. On July 13, 2015 at 2:51 PM, observation revealed on the 1st floor in the Recycle room, that penetrations were not sealed according to an approved method. The deficiency included many holes around various pipes, fire rated walls that were not taped, screws that were not mudded and ceilings that were not fire caulked to the wall joint. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide enclosures around exit stairs by not having openings to unoccupied rooms. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 4:05 PM, observation revealed on the 1st floor in the boiler room that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

2. On July 14, 2015 at 4:00 PM, observation revealed on the 3rd floor in the penthouse that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide egress paths at all times with multiple delayed-egress locks in the same egress path. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On July 14, 2015 at 8:48 am, observation revealed on the 3rd floor, in the across corridor doors from the dining area to the clinic area, that the path of egress required travel through two delayed egress locks (DEL) to exit the building. DEL's were located at across corridor doors from the dining area to the clinic area This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.2.4 (exception 2).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not maintain a written evacuation plan that included staff being trained on life safety procedures. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On July 13, 2015 at 3:00 pm, observation and interview revealed on the lower level floor in the kitchen, that staff were not familiar with their responsibilities in the event of a fire, including usage of the K fire extinguisher. Staff C did not know what type of fire extinguisher was for grease fires. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities) and staff C (cook).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and compliant fire dampers. This deficiency occurred in 3 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 2:05 PM, observation revealed on the 1st floor in the Accounting Office room 105, that airflow between the corridor and this room was not neutral. There was a return duct, but no supply duct. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

2. On July 13, 2015 at 2:17 PM, observation revealed on the 1st floor in the room 113, that airflow between the corridor and this room was not neutral. There was a supply duct, but no return duct. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

3. On July 14, 2015 at 3:52 PM, observation revealed on the 2nd floor in the penthouse that a fire damper was not installed in an air duct that penetrated the rated floor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.),
3-3.2.

4. On July 14, 2015 at 5:00 PM, observation revealed on the 1st floor in the isolation exam rooms of the emergency department, that airflow between the corridor and these rooms was not neutral. There was a transfer duct to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.),
2-3.11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes by having properly sized storage containers for soiled/trash. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 1:50 PM, observation revealed on the 1st floor in the Administration copy room that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. The mobile collection receptacle is a 70 gallon confidential waste container This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

2. On July 14, 2015 at 1:50 PM, observation revealed on the 2nd floor in the passage outside of exam rooms 2 and 3 in the emergency department, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. The were 2 five gallon trash containers, 32 gallon dirty linen container and a 32 gallon waste paper container next to each other outside of the exam rooms. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping, maintaining combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, 25 feet away from a 1000 gallon tank or less of liquid oxygen, and having properly labeled med gas pipes. These deficiencies could affect 6 of the 6 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On July 13, 2015 at 12:45 PM, observation revealed on the 1st floor in the maintenance room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included that the riser shut off valve was missing for the oxygen pipes on the west side of the hospital. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

2. On July 13, 2015 at 3:30 PM, observation revealed on the 1st floor in the vacuum pump room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the vacuum piping not being labeled in the vacuum pump room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

3. On July 13, 2015 at 12:50 PM, surveyor observed that the bulk oxygen tank in the parking lot area had combustibles, such as the trash container, located within 50 feet of the Oxygen Tank, greater than 1000 gallons. In addition, the surveyor observed that a vehicle parking stall was within 10'-0" of the Oxygen Tanks. The surveyor observed that the oxygen tank's pressure regulator, safety devises, vaporizer, manifolds and interconnecting piping was less than 10 feet from the building windows. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.4 and NFPA 99 section 4-3.1.1.2(a)
10 b.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not maintain the emergency electrical generator room in accordance with the codes by having storage in the room. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors in the hospital.

FINDINGS INCLUDE:

On July 13, 2015 at 2:30 PM, surveyor observed, during an inspection of the generator room on the 1st floor, that items were being stored in the room which included recycle bins and plastic garbage containers. Per NFPA 110, 5-2.1, 1999 edition the generator room should not be used for storage. This observed situation was not compliant with NFPA 110 (1999 ed.), 6-4.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, working clearances at electrical panels, and proper use of extension cords. This deficiency occurred in 3 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 2:32 PM, observation revealed on the 1st floor in the generator room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the generator engine block heater. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

2. On July 13, 2015 at 2:55 PM, observation revealed on the 1st floor in the recycle room, that access to the electrical panel was less than 3'-0" clearance. There was a cart in front of 4 electrical panels. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

3. On July 14, 2015 at 10:10 AM, observation revealed on the 2nd floor in the Operating room B that a strip plug extension cord (temporary power tap) was used in a patient care area as a substitute for fixed wiring. The strip plug was used to provide power to medical equipment in the operating room. The power strip was located on the floor. UL User Guide UL 1363 for relocatable power (T) taps dictate that they are not intended for use with medical or healthcare facilities equipment. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8 and 517-18.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain the required building construction type with sealed floor penetrations and support steel covered with rated fire proofing. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 2:42 PM, observation revealed on the 1st floor in room 118, that there were penetrations through the floor that were not fire stopped according to an approved method. The deficiency included a conduit that went up through the ceiling/floor assembly. The penetration was covered on the bottom with Styrofoam. The floor/ceiling fire rated assembly could not be confirmed in this location. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6 and 8.2.3.2.4.2.

2. On July 14, 2015 at 2:30 PM, observation revealed on the 2nd floor in the passage between exam rooms 5 and 6 in the emergency department, that fire proofing was missing from the structural steel beam. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.1.6.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain wall construction to protect the corridor from non-corridor spaces. In addition, there was patient treatment in spaces that were open to the corridor. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all PT/OT patients, staff and visitors within the PT/OT suite.

FINDINGS INCLUDE:

On July 13, 2015 at 1:36 PM, observation revealed on the 1st floor in the OT/PT Reception Desk that the area was not separated from the exit egress corridor by wall construction and was used for the treatment of patients. The space had a drop down shutter that was installed in the corridor wall. Staff B did not know when to close the shutter when asked what she would do if a fire alarm sounded. The hole in the corridor wall would not resist the passage of smoke. The space was considered a space open to the corridor, but was not equipped with a smoke detector. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.6.1 (exception 6).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A and Staff B.

Based on observation and interview, the facility did not ensure the path of egress was clearly identified by appropriate exit signage when the egress path was not readily apparent. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On July 14, 2015 at 9:00 AM, observation revealed on the 3rd floor in the across corridor doors from the dining area to the clinic area,that the path of egress in the corridor was not readily apparent and an exit sign was not provided above the across corridor doors. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.10.1.4.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not enclose hazardous rooms by having sealed wall penetrations. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 12:50 PM, observation revealed on the 1st floor, in the storage room of the maintenance room, that penetrations were not sealed according to an approved method. The deficiency included 3 pipes that were not caulked This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

2. On July 13, 2015 at 2:51 PM, observation revealed on the 1st floor in the Recycle room, that penetrations were not sealed according to an approved method. The deficiency included many holes around various pipes, fire rated walls that were not taped, screws that were not mudded and ceilings that were not fire caulked to the wall joint. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide enclosures around exit stairs by not having openings to unoccupied rooms. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 4:05 PM, observation revealed on the 1st floor in the boiler room that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

2. On July 14, 2015 at 4:00 PM, observation revealed on the 3rd floor in the penthouse that an opening in an exit enclosure was from an unoccupied space. This observed situation was not compliant with NFPA 101 (2000 ed.), 7.1.3.2.1(d).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide egress paths at all times with multiple delayed-egress locks in the same egress path. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On July 14, 2015 at 8:48 am, observation revealed on the 3rd floor, in the across corridor doors from the dining area to the clinic area, that the path of egress required travel through two delayed egress locks (DEL) to exit the building. DEL's were located at across corridor doors from the dining area to the clinic area This observed situation was not compliant with NFPA 101 (2000 ed.), 19.2.2.2.2.4 (exception 2).

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not maintain a written evacuation plan that included staff being trained on life safety procedures. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

On July 13, 2015 at 3:00 pm, observation and interview revealed on the lower level floor in the kitchen, that staff were not familiar with their responsibilities in the event of a fire, including usage of the K fire extinguisher. Staff C did not know what type of fire extinguisher was for grease fires. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.1.3.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities) and staff C (cook).

Based on observation and interview, the facility did not provide a ventilation system in accordance with manufacturer specifications and NFPA 90A with neutral airflow between the corridor and rooms, and compliant fire dampers. This deficiency occurred in 3 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 2:05 PM, observation revealed on the 1st floor in the Accounting Office room 105, that airflow between the corridor and this room was not neutral. There was a return duct, but no supply duct. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

2. On July 13, 2015 at 2:17 PM, observation revealed on the 1st floor in the room 113, that airflow between the corridor and this room was not neutral. There was a supply duct, but no return duct. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.), 2-3.11.1.

3. On July 14, 2015 at 3:52 PM, observation revealed on the 2nd floor in the penthouse that a fire damper was not installed in an air duct that penetrated the rated floor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1 and NFPA 90A (1999 ed.),
3-3.2.

4. On July 14, 2015 at 5:00 PM, observation revealed on the 1st floor in the isolation exam rooms of the emergency department, that airflow between the corridor and these rooms was not neutral. There was a transfer duct to the corridor. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.5.2.1, section 9.2, and NFPA 90A (1999 ed.),
2-3.11.1.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain linen/trash collection receptacles in compliance with the codes by having properly sized storage containers for soiled/trash. This deficiency occurred in 2 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 1:50 PM, observation revealed on the 1st floor in the Administration copy room that mobile collection receptacles exceeded the 32 gallon maximum size when located outside of a hazardous area. The mobile collection receptacle is a 70 gallon confidential waste container This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

2. On July 14, 2015 at 1:50 PM, observation revealed on the 2nd floor in the passage outside of exam rooms 2 and 3 in the emergency department, that mobile collection receptacles exceeded the 32 gallon per 64 square foot maximum density when located outside of a hazardous area. The were 2 five gallon trash containers, 32 gallon dirty linen container and a 32 gallon waste paper container next to each other outside of the exam rooms. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.7.5.5.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide medical gas piping as required by NFPA 99 with compliant medical gas piping, maintaining combustibles at least 50 feet away from a 1000 gallon or greater liquid oxygen tank, 25 feet away from a 1000 gallon tank or less of liquid oxygen, and having properly labeled med gas pipes. These deficiencies could affect 6 of the 6 smoke compartments in the building, as well as an undetermined number of staff and visitors.

FINDINGS INCLUDE:

1. On July 13, 2015 at 12:45 PM, observation revealed on the 1st floor in the maintenance room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included that the riser shut off valve was missing for the oxygen pipes on the west side of the hospital. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

2. On July 13, 2015 at 3:30 PM, observation revealed on the 1st floor in the vacuum pump room, that medical gas piping was not installed according to the requirements of the code. The inappropriate piping installation included the vacuum piping not being labeled in the vacuum pump room. This observed situation was not compliant with NFPA 101 (2000 ed.), 19.3.2.4 and NFPA 99 (1999 ed.), Chap 4.

3. On July 13, 2015 at 12:50 PM, surveyor observed that the bulk oxygen tank in the parking lot area had combustibles, such as the trash container, located within 50 feet of the Oxygen Tank, greater than 1000 gallons. In addition, the surveyor observed that a vehicle parking stall was within 10'-0" of the Oxygen Tanks. The surveyor observed that the oxygen tank's pressure regulator, safety devises, vaporizer, manifolds and interconnecting piping was less than 10 feet from the building windows. This observed situation was not compliant with NFPA 50 (1998 edition) section 2.2.4 and NFPA 99 section 4-3.1.1.2(a)
10 b.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not maintain the emergency electrical generator room in accordance with the codes by having storage in the room. This deficiency occurred in 1 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors in the hospital.

FINDINGS INCLUDE:

On July 13, 2015 at 2:30 PM, surveyor observed, during an inspection of the generator room on the 1st floor, that items were being stored in the room which included recycle bins and plastic garbage containers. Per NFPA 110, 5-2.1, 1999 edition the generator room should not be used for storage. This observed situation was not compliant with NFPA 110 (1999 ed.), 6-4.2.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).

Based on observation and interview, the facility did not provide and maintain an electrical installation compliant with NFPA 70, National Electrical Code with fixed wiring rather than extension cords, working clearances at electrical panels, and proper use of extension cords. This deficiency occurred in 3 of the 6 smoke compartments and had the potential to affect all inpatients, outpatients, staff and visitors within these smoke compartments.

FINDINGS INCLUDE:

1. On July 13, 2015 at 2:32 PM, observation revealed on the 1st floor in the generator room, that a strip plug extension cord (temporary power tap) was used as a substitute for fixed wiring. The strip plug was used to provide power to the generator engine block heater. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8(1) and 517-18.

2. On July 13, 2015 at 2:55 PM, observation revealed on the 1st floor in the recycle room, that access to the electrical panel was less than 3'-0" clearance. There was a cart in front of 4 electrical panels. This observed situation was not compliant with NFPA 70 (1999 ed.), 110-26.

3. On July 14, 2015 at 10:10 AM, observation revealed on the 2nd floor in the Operating room B that a strip plug extension cord (temporary power tap) was used in a patient care area as a substitute for fixed wiring. The strip plug was used to provide power to medical equipment in the operating room. The power strip was located on the floor. UL User Guide UL 1363 for relocatable power (T) taps dictate that they are not intended for use with medical or healthcare facilities equipment. This observed situation was not compliant with NFPA 70 (1999 ed.), 400-8 and 517-18.

This condition was confirmed at the time of discovery by a concurrent observation and interview with staff A (Director Facilities).