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A. Based on observation and interview, the hospital did not ensure that hazardous areas are protected as required.

Findings include:

During the tour of the facility on 05/25/10 at 2:30 PM, it was noted that the hospital created a new hazardous area as part of the construction for the new Emergency Department. This hazard area separates the currently occupied Emergency Department. It was noted that the fire shell (one hour protection) separation did not completely protect the construction area since it had holes/gaps by the deck end and penetrations made by cables that were open and not sealed by UL material.

In addition to creating a hazardous area, the facility has also failed to provide the above construction area with a complete one hour separation as required by NFPA.
NFPA 241 Standard for Construction Alteration and Demolition Operations 8.6.2

B. Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces, by smoke/fire resisting partitions and doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

The findings include:

1. During the tour of the facility from 05/24/10 to 05/26/10 between 10:30 AM to 4:00 PM, it was noted that multiple housekeeping/janitor's closets did not have a self-closing mechanism installed on the doors. Some examples are, including but not limited to:
a) On 05/26/10 at 10:45 AM, it was noted that the housekeeping closet in the maternity suite did not have any self-closing mechanism at the door.
b) On 05/24/10 at 01:45 PM, it was noted that the housekeeping closet opposite the nutrition office on the ground floor did not have any self-closing mechanism at the door.

Based on document review and staff interview, it was determined that the facility did not ensure that the fire drills were conducted under varying conditions and that planning/ evaluation of fire drills were done as per NFPA 101.

Findings include:

1- During fire drill record review on 05/27/10 at 11:45 AM, it was noted that the fire drill report is in the form of a checklist which is incomplete, highlighting only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no".

2.a.- Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

2.b.- Hospital fire drills also did not include staff utilization of different components of the fire alarm system, such as smoke detectors, sprinkler system, and others, to help ensure that staff are aware of the different bell/chime counts they elicit during drills, and they can determine if the fire alarm system is in optimal working order.

Staff #29 confirmed both these findings.

3- Although the facility's fire drill records included staff sign-in sheets, the facility failed to document in the records a critique of each staff's fire drill response and knowledge of evacuation procedure, to ensure staff is fully aware of fire drill/evacuation protocols .
Staff #29 stated that there were no other records to document the fire drill procedures and comments on them.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1- During survey of the ground floor on 05/21/10 at 01:45 PM, it was noted that a fire extinguisher by the elevators was installed on the wall with its topmost portion approximately 5 feet 8 inches above the floor. This is greater than the required 5 ft. (60 inches).

2- Similar finding was noted in the soiled utility room on Maternity Suite (2nd floor) where the fire extinguisher was also installed on the wall with its topmost portion at a height greater than 5 ft. (60 inches).

Findings were verified with Staff #4, Staff #29 and Staff #3.

Based on observations, the facility did not ensure that bulk oxygen storage tanks were stored in a safe manner protected from elements as per NFPA 2-2.12, and that the storage area was clear of debris as per NFPA 99 4-3.1.2.2

Findings include:

1. During survey of the oxygen bulk storage outside the building on 05/24/10 at 12:15 PM, it was noted that a car was parked near the metal fence that surrounds the oxygen bulk storage. As per Staff #4, this area is not a designated parking area; however no signage or barriers were around the fence cautioning people not to park there.

As per NFPA 99 Section 2-2.12, distance of the bulk storage from exposure should be '10 ft (3 m) from any public sidewalk or parked vehicles'. Also, Section 2-2.14 states that 'The distance in 2-2.12 shall not apply where protective structures having a minimum fire resistance of 2 hours interrupt the line-of-sight between uninsulated portions of the bulk oxygen storage installation and the exposure.

It is also noted that no ignition source should be near the oxygen storage area.

2. The oxygen bulk storage area was also dirty with accumulation of dry pine cones and dry leaves inside the fence (around the bulk oxygen tank). These are combustible materials which create a fire hazard.

Findings were shared with Staff #4 and Staff #3.

Based on observation and staff interview, it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

During the tour of the facility from 05/24/10 to 05/27/10 between 10:30 AM to 4:00 PM, it was noted that the oxygen pressure in various oxygen gauges in the medical gas alarm panels around the facility were reading between 47PSI - 49PSI. An example is that on 05/26/10 at 3:00 PM during tour of the Radiology department, the pressure reading on the oxygen gauge was 49PSI. As per NFPA 99, Table 4-3.1.2.4, the standard pressure for oxygen delivery to be maintained is 50 PSI (+5 and -0).

Findings were verified with Staff #4, who stated that he will ask the vendor to raise the pressure to the required level. However, he stated that some gauges may be old and might not be giving an accurate reading despite the presence of correct pressure. Facility needs to ensure that if the pressure is as per code, that the gauges/equipment are maintained in good operating condition to ensure that pressure readings are true.

Section 8.3.6.1 of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

1. During the tour of the facility between 05/24/10 to 05/26/10, the fire/smoke barriers above the drop ceiling of the double doors and other smoke barriers were inspected to assess the integrity of smoke barriers. It was noted that the smoke barriers were penetrated by ducts, pipes, conduits, cables, and wires for light fixtures. None of the penetrations were sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other. Examples include but are not limited to:
a) On 05/26/10 at 10:55 AM, a penetration made by conduit going through the wall to the corridor was noted in the janitorial closet of the Maternity suite (2nd floor).
b) On 05/26/10 at 11:45 AM, a penetration/gap made by a sprinkler pipe was noted above the drop ceiling of the double door between PCU and ICU.
c) On 05/26/10 at 2:15 PM, a HVAC duct was noted penetrating the fire wall near PCU and Chapel.
d) On 05/21/10 at 1:50 PM, during the survey of the ground floor, at the above the ceiling inspection of the fire barrier (above the double door near decontamination room), it was revealed that the penetration in the wall (made by a white conduit) was not sealed by a UL rated material. The penetration around the conduit was filled by a thin layer of joint compound.

This finding was verified with Staff #4, Staff #3 and Staff #29.

A. NFPA 101 2000, Section 19.7.2.1* states:
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

Based on document review, it was determined that the facility's fire plan 'Code F Procedure' was not written as per the above code.

Findings include:

During document review on 05/27/10 at 11:00 AM, it was noted that the fire alarm policy 'Code F' policy was not written as per NFPA 101 19.7.2.1.
The first bullet of the policy states that "The basic response required of staff shall include transmission of an appropriate fire alarm signal to warn other building occupants, confinement of the effect of the fire by closing doors to isolate the fire area, the removal of all occupants directly involved with the fire emergency and the execution of those evacuation duties as detailed in the Emergency Incident Plan."

Facility has summarized the response as ACRE (Alarm, Confine, Rescue, Evacuation). NFPA 19.7.2.1 requires the response to be RACE/ARACE (Alert & Rescue, Alarm, Confine, Evacuate), in which Rescue may be the first or second step in connection with transmission of alarm either in the case of rescuing the person directly involved with fire, or the person hearing the fire alarm trying to remove others from harm's way.

B. NFPA 101 Section 19.7.2.2 states
A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Based on document review, it was determined that the facility's fire plan 'Code F Procedure' was not written as per the above code.

Findings include:

During document review on 05/27/10 at 11:00 AM, it was noted that in the fire alarm policy 'Code F', bullet #11 states: 'Extinguish the fire if it is small using portable fire extinguisher'; however, no information or reference is provided in the policy regarding the steps for handling the extinguisher to extinguish the fire.

Based on document review, it was determined that the facility did not ensure that the 'Laboratory Fire Plan' was developed to ensure that plan outlined all specific details to control fire emergency.

Findings include:

Based on document review on 05/26/10 at 10:30 AM, review of 'Laboratory Fire Plan' indicated that Plan did not contain the following:
i) Coded phrase for fire to alert other co-workers
ii) Handling of extinguishers and type of extinguisher to be used in the laboratory.
ii) Any reference to the facility's main Fire Evacuation Plan.

Findings were verified with Staff #4.

Based on observation, it was determined that the facility did not ensure that 'No smoking' signs were installed around the fence where bulk oxygen was stored.

Findings include:

During the tour of the facility grounds on 05/24/10, it was noted that the area where bulk storage was located did not have any no smoking sign installed around the fence. It is to be noted that only one 'No Smoking' imprint was on the bulk storage tank which can be viewed from the front only. Facility has made a parking space by the oxygen bulk storage area and there is no sign of caution.
Findings were verified with Staff #4 and Staff #3.

As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Based on document review and staff interview, it was determined that the facility did not ensure that the life safety branch of Type I EES system supplying theWagner building, was maintained as per the above code.

Findings include:

1. During document review on 05/27/10 at 11:30 AM, it was noted that the ATS LS branch diagram of the emergency generator 600 Kw supplying 'Wagner', had its wiring/distribution going to the 'Lab'. Staff #4 had earlier stated that everything in the Lab was on this transfer switch. As per the code 3.4.2.2.2 (b), no other functions apart from life safety could be provided to any electrical outlet/receptacle or equipment.

2. As per the diagram of the 'Wagner' generator, the Elevators 1, 2 and 3 are on the ATS EQ, meaning equipment branch. As per the code 3.4.2.2.2 (b)(6), Elevator cab lighting, control, communication, and signal systems should be on life safety branch and not on the equipment branch. For the equipment branch of Type I EES, the code is:

Section 3.4.2.2.3(e) "Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be arranged for either delayed-automatic or manual connection to the alternate power source [also see A-3-4.2.2.3(d)]:
(2)'Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]'.

Based on document review, it could not be verified if all three elevator banks in the facility are equipped with fire fighter recall.

Findings include:

Staff #4 was requested to provide information regarding the fire fighter recall feature on all the elevators in the facility. During fire alarm documentation review on 05/27/10 at 11:30 AM, it was noted that the vendor 'Simplex' noted that the recall alarm for elevator was working; however it did not indicate how many elevators were connected and working with the recall feature. Finding was verified with Staff #4.

A. Based on observation and interview, the hospital did not ensure that hazardous areas are protected as required.

Findings include:

During the tour of the facility on 05/25/10 at 2:30 PM, it was noted that the hospital created a new hazardous area as part of the construction for the new Emergency Department. This hazard area separates the currently occupied Emergency Department. It was noted that the fire shell (one hour protection) separation did not completely protect the construction area since it had holes/gaps by the deck end and penetrations made by cables that were open and not sealed by UL material.

In addition to creating a hazardous area, the facility has also failed to provide the above construction area with a complete one hour separation as required by NFPA.
NFPA 241 Standard for Construction Alteration and Demolition Operations 8.6.2

B. Based on observation, the facility did not ensure that all hazardous areas are safeguarded from other spaces, by smoke/fire resisting partitions and doors which are self-closing or automatic-closing, and/or are provided with the positive latching devices to protect from fire/smoke, as detailed in 19.3.2.1.

The findings include:

1. During the tour of the facility from 05/24/10 to 05/26/10 between 10:30 AM to 4:00 PM, it was noted that multiple housekeeping/janitor's closets did not have a self-closing mechanism installed on the doors. Some examples are, including but not limited to:
a) On 05/26/10 at 10:45 AM, it was noted that the housekeeping closet in the maternity suite did not have any self-closing mechanism at the door.
b) On 05/24/10 at 01:45 PM, it was noted that the housekeeping closet opposite the nutrition office on the ground floor did not have any self-closing mechanism at the door.

Based on document review and staff interview, it was determined that the facility did not ensure that the fire drills were conducted under varying conditions and that planning/ evaluation of fire drills were done as per NFPA 101.

Findings include:

1- During fire drill record review on 05/27/10 at 11:45 AM, it was noted that the fire drill report is in the form of a checklist which is incomplete, highlighting only a few points of the drill on which the 'observer' of the drill checks off "yes" or "no".

2.a.- Review of fire drill records indicated that although the hospital's fire drills include transmission of a fire alarm signal, the hospital failed to conduct fire drills which include simulation of various types of emergency fire conditions to ensure that each staff has a full and clear understanding of facility's fire safety plan and how to execute it successfully under the varying conditions.

2.b.- Hospital fire drills also did not include staff utilization of different components of the fire alarm system, such as smoke detectors, sprinkler system, and others, to help ensure that staff are aware of the different bell/chime counts they elicit during drills, and they can determine if the fire alarm system is in optimal working order.

Staff #29 confirmed both these findings.

3- Although the facility's fire drill records included staff sign-in sheets, the facility failed to document in the records a critique of each staff's fire drill response and knowledge of evacuation procedure, to ensure staff is fully aware of fire drill/evacuation protocols .
Staff #29 stated that there were no other records to document the fire drill procedures and comments on them.

Based on observation, it was determined that the facility failed to ensure that all its portable fire extinguishers are installed such that the top of the fire extinguisher is not more than 5 feet (60 inches) above the floor (see reference NFPA 10, 1-6.10).

Findings include:

1- During survey of the ground floor on 05/21/10 at 01:45 PM, it was noted that a fire extinguisher by the elevators was installed on the wall with its topmost portion approximately 5 feet 8 inches above the floor. This is greater than the required 5 ft. (60 inches).

2- Similar finding was noted in the soiled utility room on Maternity Suite (2nd floor) where the fire extinguisher was also installed on the wall with its topmost portion at a height greater than 5 ft. (60 inches).

Findings were verified with Staff #4, Staff #29 and Staff #3.

Based on observations, the facility did not ensure that bulk oxygen storage tanks were stored in a safe manner protected from elements as per NFPA 2-2.12, and that the storage area was clear of debris as per NFPA 99 4-3.1.2.2

Findings include:

1. During survey of the oxygen bulk storage outside the building on 05/24/10 at 12:15 PM, it was noted that a car was parked near the metal fence that surrounds the oxygen bulk storage. As per Staff #4, this area is not a designated parking area; however no signage or barriers were around the fence cautioning people not to park there.

As per NFPA 99 Section 2-2.12, distance of the bulk storage from exposure should be '10 ft (3 m) from any public sidewalk or parked vehicles'. Also, Section 2-2.14 states that 'The distance in 2-2.12 shall not apply where protective structures having a minimum fire resistance of 2 hours interrupt the line-of-sight between uninsulated portions of the bulk oxygen storage installation and the exposure.

It is also noted that no ignition source should be near the oxygen storage area.

2. The oxygen bulk storage area was also dirty with accumulation of dry pine cones and dry leaves inside the fence (around the bulk oxygen tank). These are combustible materials which create a fire hazard.

Findings were shared with Staff #4 and Staff #3.

Based on observation and staff interview, it was determined that the facility did not maintain the piped in medical gas system as per NFPA 99.

Findings include:

During the tour of the facility from 05/24/10 to 05/27/10 between 10:30 AM to 4:00 PM, it was noted that the oxygen pressure in various oxygen gauges in the medical gas alarm panels around the facility were reading between 47PSI - 49PSI. An example is that on 05/26/10 at 3:00 PM during tour of the Radiology department, the pressure reading on the oxygen gauge was 49PSI. As per NFPA 99, Table 4-3.1.2.4, the standard pressure for oxygen delivery to be maintained is 50 PSI (+5 and -0).

Findings were verified with Staff #4, who stated that he will ask the vendor to raise the pressure to the required level. However, he stated that some gauges may be old and might not be giving an accurate reading despite the presence of correct pressure. Facility needs to ensure that if the pressure is as per code, that the gauges/equipment are maintained in good operating condition to ensure that pressure readings are true.

Section 8.3.6.1 of NFPA 101 states that:
Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:

(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:

a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Based on observation, it was determined that the facility did not ensure that penetrations of fire/smoke barrier walls were protected/sealed with a material capable of maintaining the smoke resistance of the barrier as per NFPA 101, 2000, 8.3.6

Findings include:

1. During the tour of the facility between 05/24/10 to 05/26/10, the fire/smoke barriers above the drop ceiling of the double doors and other smoke barriers were inspected to assess the integrity of smoke barriers. It was noted that the smoke barriers were penetrated by ducts, pipes, conduits, cables, and wires for light fixtures. None of the penetrations were sealed completely with an approved fire retardant material to prevent passage of smoke from one compartment to the other. Examples include but are not limited to:
a) On 05/26/10 at 10:55 AM, a penetration made by conduit going through the wall to the corridor was noted in the janitorial closet of the Maternity suite (2nd floor).
b) On 05/26/10 at 11:45 AM, a penetration/gap made by a sprinkler pipe was noted above the drop ceiling of the double door between PCU and ICU.
c) On 05/26/10 at 2:15 PM, a HVAC duct was noted penetrating the fire wall near PCU and Chapel.
d) On 05/21/10 at 1:50 PM, during the survey of the ground floor, at the above the ceiling inspection of the fire barrier (above the double door near decontamination room), it was revealed that the penetration in the wall (made by a white conduit) was not sealed by a UL rated material. The penetration around the conduit was filled by a thin layer of joint compound.

This finding was verified with Staff #4, Staff #3 and Staff #29.

A. NFPA 101 2000, Section 19.7.2.1* states:
For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

Based on document review, it was determined that the facility's fire plan 'Code F Procedure' was not written as per the above code.

Findings include:

During document review on 05/27/10 at 11:00 AM, it was noted that the fire alarm policy 'Code F' policy was not written as per NFPA 101 19.7.2.1.
The first bullet of the policy states that "The basic response required of staff shall include transmission of an appropriate fire alarm signal to warn other building occupants, confinement of the effect of the fire by closing doors to isolate the fire area, the removal of all occupants directly involved with the fire emergency and the execution of those evacuation duties as detailed in the Emergency Incident Plan."

Facility has summarized the response as ACRE (Alarm, Confine, Rescue, Evacuation). NFPA 19.7.2.1 requires the response to be RACE/ARACE (Alert & Rescue, Alarm, Confine, Evacuate), in which Rescue may be the first or second step in connection with transmission of alarm either in the case of rescuing the person directly involved with fire, or the person hearing the fire alarm trying to remove others from harm's way.

B. NFPA 101 Section 19.7.2.2 states
A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

Based on document review, it was determined that the facility's fire plan 'Code F Procedure' was not written as per the above code.

Findings include:

During document review on 05/27/10 at 11:00 AM, it was noted that in the fire alarm policy 'Code F', bullet #11 states: 'Extinguish the fire if it is small using portable fire extinguisher'; however, no information or reference is provided in the policy regarding the steps for handling the extinguisher to extinguish the fire.

Based on document review, it was determined that the facility did not ensure that the 'Laboratory Fire Plan' was developed to ensure that plan outlined all specific details to control fire emergency.

Findings include:

Based on document review on 05/26/10 at 10:30 AM, review of 'Laboratory Fire Plan' indicated that Plan did not contain the following:
i) Coded phrase for fire to alert other co-workers
ii) Handling of extinguishers and type of extinguisher to be used in the laboratory.
ii) Any reference to the facility's main Fire Evacuation Plan.

Findings were verified with Staff #4.

Based on observation, it was determined that the facility did not ensure that 'No smoking' signs were installed around the fence where bulk oxygen was stored.

Findings include:

During the tour of the facility grounds on 05/24/10, it was noted that the area where bulk storage was located did not have any no smoking sign installed around the fence. It is to be noted that only one 'No Smoking' imprint was on the bulk storage tank which can be viewed from the front only. Facility has made a parking space by the oxygen bulk storage area and there is no sign of caution.
Findings were verified with Staff #4 and Staff #3.

As per NFPA 99 Section 3-4.2.2.2
(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment:
1. Illumination of means of egress as required in NFPA 101,? Life Safety Code?
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, "Gas and Vacuum Systems."
4. Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery-powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.
No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

Based on document review and staff interview, it was determined that the facility did not ensure that the life safety branch of Type I EES system supplying theWagner building, was maintained as per the above code.

Findings include:

1. During document review on 05/27/10 at 11:30 AM, it was noted that the ATS LS branch diagram of the emergency generator 600 Kw supplying 'Wagner', had its wiring/distribution going to the 'Lab'. Staff #4 had earlier stated that everything in the Lab was on this transfer switch. As per the code 3.4.2.2.2 (b), no other functions apart from life safety could be provided to any electrical outlet/receptacle or equipment.

2. As per the diagram of the 'Wagner' generator, the Elevators 1, 2 and 3 are on the ATS EQ, meaning equipment branch. As per the code 3.4.2.2.2 (b)(6), Elevator cab lighting, control, communication, and signal systems should be on life safety branch and not on the equipment branch. For the equipment branch of Type I EES, the code is:

Section 3.4.2.2.3(e) "Equipment for Delayed-Automatic or Manual Connection. The following equipment shall be arranged for either delayed-automatic or manual connection to the alternate power source [also see A-3-4.2.2.3(d)]:
(2)'Elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power [For elevator cab lighting, control, and signal system requirements, see 3-4.2.2.2(b)(6).]'.

Based on document review, it could not be verified if all three elevator banks in the facility are equipped with fire fighter recall.

Findings include:

Staff #4 was requested to provide information regarding the fire fighter recall feature on all the elevators in the facility. During fire alarm documentation review on 05/27/10 at 11:30 AM, it was noted that the vendor 'Simplex' noted that the recall alarm for elevator was working; however it did not indicate how many elevators were connected and working with the recall feature. Finding was verified with Staff #4.