HospitalInspections.org

Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by unsecured fixed furniture at one corridor location and obstructed exit doors. This affected two of four floors at the Main Hospital, and one of three floors at the Pavilion. This could result in a delay in evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

7.1.10 Means of Egress Reliability.
7.1.10.1* General. Means of egress shall be continuously
maintained free of all obstructions or impediments to full instant
use in the case of fire or other emergency.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall
obstruct exits or their access thereto, egress therefrom, or visibility
thereof.

Findings:

During a facility tour and interview with the ES, EMS, and NS, the means of egress were observed.

Main Hospital 1st Floor

1. On 3/12/19 at 10:04 a.m., the Emergency Department (ED) means of egress was observed. An Emergency Medical Services (EMS) gurney with an oxygen cylinder protruding out of the bin below, was observed obstructing the cross-corridor doors located in the ED hallway from fully closing when they released during fire alarm activation. Upon interview, EMS1 and NS1 confirmed the finding.

Main Hospital 2nd Floor

2. On 3/12/19 at 3:15 p.m., the Operating Room (OR) means of egress was observed. An OR procedure bed was stationed directly in front of the cross-corridor doors located in the South exit access corridor. Upon interview, ES1 confirmed the finding.

Pavilion 2nd Floor

3. On 3/13/19 at 10:15 a.m., the Neonatal Intensive Care Unit (NICU) exit access corridor was observed. The corridor width measured at 8 feet. Two upholstered arm chairs and a table were stationed on one side of the corridor. The furniture projected approximately 2 feet into the corridor, with corridor clear width at approximately 6 feet. The furniture grouping was unsecured to either the floor or wall. Upon interview, ES2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the sleeping suites. This was evidenced by a suite greater than 1,000 square feet that did not have two designated exits. This affected one of four floors at the Main Hospital, and could result in a delay in evacuation in an emergency.

Findings:

During a facility tour and interview with the ES, the patient sleeping suites were observed.

Main Hospital 3rd Floor

1. On 3/12/19 at 2:05 p.m., the Clinical Decision Unit (CDU) sleeping suite was observed. The suite measured approximately 1,876 square feet in size, and contained eight sleeping rooms. One designated exit from the suite was observed. A door remotely located from the exit, on the opposite side of the suite was located inside a patient room, obstructed from view and access by cubicle curtains and bed equipment. The door was not a designated exit, but lead outside to an adjoining exit access corridor. Upon interview, ES2 confirmed the finding.

Based on observation and interview, the facility failed to maintain a clear and identifiable path of egress. This was evidenced by the failure to identify and post a non-exit guidance sign. This affected one of four floors at the Main Hospital, and could potentially result in entrapment and re-entry into the building during a fire, and egress delay and confusion by staff, residents, and visitors during an emergency evacuation.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with
Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3,
or 19.2.10.4.

7.10.8.3* No Exit.
7.10.8.3.1 Any door, passage, or stairway that is neither an
exit nor a way of exit access and that is located or arranged so
that it is likely to be mistaken for an exit shall be identified by
a sign that reads as follows:
NO
EXIT
7.10.8.3.2 The NO EXIT sign shall have the word NO in letters
2 in. (51 mm) high, with a stroke width of 3?8 in. (9.5 mm),
and the word EXIT in letters 1 in. (25 mm) high, with the
word EXIT below the word NO, unless such sign is an approved
existing sign.

Findings:

During a facility tour and interview with the AS, the path of egress and exits were observed.

Main Hospital 1st Floor

1. On 3/14/19 at 11:45 a.m., the glass and metal framed door equipped with panic bar, that was located in the Main Lobby corridor was observed. The door exited outside into a courtyard enclosed by the building structure. The door did not have signage that indicated it was not an exit. Upon interview, AS1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the kitchen hood fire suppression and ventilation systems. This was evidenced by a dislodged sprinkler nozzle cap and a missing vent filter. This affected one of four floors at the Main Hospital, and could result in the uncontrolled spread of a grease fire.

NFPA 101. Life Safety Code, 2012 Edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
6.2.3 Grease Filters.
6.2.3.1 Grease filters shall be listed and constructed of steel or listed equivalent material.
6.2.3.2 Grease filters shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions.
6.2.3.3 Grease filters shall be arranged so that all exhaust air passes through the grease filters.
6.2.3.4 Grease filters shall be easily accessible and removable for cleaning.
6.2.3.5 Grease filters shall be installed at an angle not less than 45 degrees from the horizontal.

10.2 Types of Equipment.
10.2.1 Fire-extinguishing equipment shall include both automatic
fire-extinguishing systems as primary protection and
portable fire extinguishers as secondary backup.
10.2.2* A placard shall be conspicuously placed near each extinguisher
that states that the fire protection system shall be
activated prior to using the fire extinguisher.
10.2.2.1 The language and wording for the placard shall be
approved by the authority having jurisdiction.
10.2.6 Automatic fire-extinguishing systems shall be installed in
accordance with the terms of their listing, the manufacturer ' s
instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A
NFPA 17A, Standard for Wet Chemical Extinguishing Systems, 2009 edition.
4.3 Discharge Nozzles. (See also Section 5.5.)
4.3.1 Discharge nozzles shall be listed for their intended use.
4.3.1.1 Discharge nozzles shall be provided with an internal
strainer or a separate listed strainer located immediately upstream
of the nozzle.
4.3.1.2 Discharge nozzles shall be of brass, stainless steel, or
other corrosion-resistant materials, or be protected inside and
out against corrosion.
4.3.1.3 Discharge nozzles shall be made of noncombustible
materials and shall withstand the expected fire exposure without
deformation.
4.3.1.4* Discharge nozzles shall be permanently marked for
identification.
4.3.1.5 All discharge nozzles shall be provided with caps or
other suitable devices to prevent the entrance of grease vapors,
moisture, or other foreign materials into the piping.
4.3.1.6 The protection device shall blow off, blow open, or
blow out upon agent discharge.

Findings:

During a facility tour and interview with the ES, the kitchen hood and fire extinguishing systems were observed.

Main Hospital 1st Floor

1. On 3/13/19 at 9:10 a.m., the Kitchen hood located above the cooking kettles, was missing the filter, creating an approximately 12 inch by 8 inch opening in the vent system. A rubber gasket-seal for the vent filter was torn and hanging down over the kettles.

2. On 3/13/19 at 9:15 a.m., one of three red sprinkler nozzle caps located over the tilt skillet, was dislodged and found hanging from the nozzle that it was protecting.

Upon interview, ES2 confirmed the above two findings.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to perform a semi-annual inspection. This affected four of four floors at the Main Hospital, and three of three floors at the Pavilion, and could result in a system malfunction or delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1* General.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually
3. Batteries
4. Transient suppressors
5. Fire alarm control unit trouble signals
7. In- building fire emergency voice/alarm communications equipment
8. Remote annunciators
9. Initiating devices
10. Guard's tour equipment
11. Combination systems (a) Fire extinguisher electronic monitoring device/systems
(b) Carbon monoxide detectors/systems
12. Interface equipment
13. Alarm notification appliances
14. Exit marking audible notification appliances
15. Supervising station alarm systems-transmitters
16. Special procedures
17. Supervising station alarm systems-receivers
18. Public emergency alarm reporting system transmission equipment
20. Mass notification system, non-supervised systems installed prior to adoption of this edition

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(S) tested
(8) Functional test of detectors
(9)*Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' S published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour, document review, and interview with the ES, the FAS was observed and records were requested.

Main Hospital and Pavilion

1. On 3/14/19 at 2:40 p.m., the facility was observed with an automatic FAS. The current Annual Fire Alarm Inspection/Testing Report was dated 1/15/18. No post-semi-annual visual inspection was available for review. Upon interview, ES1 confirmed that the FAS was inspected and tested on an annual basis.

Based on observation, document review, and interview, the facility failed to maintain the automatic fire sprinkler system and components. This was evidenced by the absence of eight of twelve monthly inspections. This affected four of four floors at the Main Hospital, and three of three floors at the Pavilion, and could result in the malfunction of the sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 Edition.
4.3 Records
4.3.1* Records shall be made inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

5.2.4 Gauges
5.2.4.1* Gauges on a wet pipe sprinkler shall be inspected monthly to ensure that they are in good condition and the normal water supply pressure is being maintained.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

Findings:

During a tour of the facility, document review, and interview with the ES, the automatic sprinkler system was observed and records where requested.

Main Hospital and Pavilion

1. On 3/14/19 at 3:20 p.m., records provided indicated that monthly visual inspections for the alarm, system riser check valves, and pressure gauges for the following months were not completed: January, and February 2019, April, may, July, August, October, and November 2018. Upon interview, ES1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by an obstructed corridor door. This affected one of four floors at the Main Hospital, and could result in the inability to contain smoke and/or fire to a room.

Findings:

During a facility tour and interview with the ES, the corridor doors were observed.

Main Hospital 4th Floor

1. On 3/12/19 at 12:01 p.m., the door to Room 447 was observed. An unattended Computer on Wheels (COW) was stored in the swing path of the door, preventing the door from closing. Upon interview, ES2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the smoke barrier walls. This was evidenced a smoke barrier wall penetration. This affected one of four floors at the Main Hospital, and could result in the inter-compartmental spread of smoke in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1)This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a)Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b)Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.
8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.
8.5.6.4 Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/2 in. (13 mm), measured between the edge of the membrane and the sprinkler.
8.5.6.5 Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke.

Findings:

During a facility tour and interview with the ES, the smoke barrier walls were observed.

Main Hospital 2nd Floor

1. On 3/12/19 at 3:30 p.m., the smoke barrier wall located above the cross-corridor doors by CD Services was observed. The wall had a one inch diameter penetration located inside a metal conduit that had blue cables traveling through. The previous fire caulking had been dislodged, and was hanging down on the cables. Upon interview, ES1 confirmed the finding.

Based on observation, record review, and interview, the facility failed to maintain the elevators. This was evidenced by expired permits, and the failure to provide monthly testing for elevators equipped with fire fighters' emergency services. This affected four of four floors at the Main Hospital, and three of three floors at the Pavilion. This could potentially result in an elevator malfunction.

NFPA 101, Life Safety Code, 2012 Edition.
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.

9.4.6 Elevator Testing.
9.4.6.1 Elevators shall be subject to periodic inspections and
tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators
and Escalators.
9.4.6.2 All elevators equipped with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly
operation with a written record of the findings made and kept on the premises as required by ASMEA17.1/CSA B44, Safety Code for Elevators and Escalators.


Findings:

During a facility tour, document review, and interview with the ES, the elevators were observed and records were requested.

Main Hospital and Pavilion

1. On 3/14/19 at 2:40 p.m., the facility was observed with elevators equipped with fire fighters' emergency recall. No documentation was provided to show that the fire fighters' emergency services on the elevators had been tested on a monthly basis for the past 12 months. Upon interview, ES2 confirmed the finding.

2. On 3/14/19 at 3:20 p.m., the facility was observed with approximately 26 elevators. The posted permits inside the elevators had expiration dates of 1/3/19. Documentation titled "Elevators-Preliminary Testing" dated 1/22/19, indicated that there were outstanding preliminary orders for elevators that needed to be addressed prior to inspection compliance and issuing of permits. Upon interview, ES1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the medical gas alarm and shut-off valves. This was evidenced by panels that were obstructed from view and access by nursing staff. This affected one of four floors at the Main Hospital, and could result in a non-detected mal-function of the medical piped-in gas and vacuum systems.

NFPA 99, Health Care Facilities Code 2012 Edition
3.3.4.4 Master Alarm System. A warning system that monitors the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system. (PIP)

5.1.9.2* Master Alarms. A master alarm system shall be provided to monitor the operation and condition of the source of supply, the reserve source (if any), and the pressure in the main lines of each medical gas and vacuum piping system.

5.1.9.2.1 The master alarm system shall consist of two or more alarm panels located in at least two separate locations, as follows:
(1) One master alarm panel shall be located in the office or work space of the on-site individual responsible for the maintenance of the medical gas and vacuum piping systems.
(2) In order to ensure continuous surveillance of the medical gas and vacuum systems while the facility is in operation, the second master alarm panel shall be located in an area of continuous observation (e.g., the telephone switchboard, security office, or other continuously staffed location).
5.1.4.8.5 Zone valve boxes shall not be installed behind normally open or normally closed doors or otherwise hidden from plain view.
5.1.4.8.4 Zone valve boxes shall be installed where they are visible and accessible at all times.

Findings:

During a facility tour and interview with the ES, the medical gas valve and alarm panels were observed.

Main Hospital 3rd Floor

1. On 3/12/19 at 2:25 p.m., the two medical gas and alarm panels located in the Two East Nursing Station corridor were obstructed from view and access by cross-corridor doors that were held in the full-open position in front of the panels by magnetic hold-open devices. The doors blocked access and view of the medical gas valve and alarm panels by the nurses at the adjoining nursing station. Upon interview, ES2 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the piped Gas and Vacuum Systems. This was evidenced by discrepancies on the Annual Inspection. This affected two of four floors at the Main Hospital, and could result in a system malfunction.

NFPA 99, Health Care Facilities Code, 2012 Edition.
Chapter 4 Fundamentals
4.1* Building System Categories. Building systems in health
care facilities shall be designed to meet system Category 1
through Category 4 requirements as detailed in this code.
4.1.1* Category 1. Facility systems in which failure of such equipment
or system is likely to cause major injury or death of patients
or caregivers shall be designed to meet system Category 1 requirements
as defined in this code.

5.1 Category 1 Piped Gas and Vacuum Systems.
5.1.1* Applicability.
5.1.1.1 These requirements shall apply to health care facilities
that require Category 1 systems as referenced in Chapter 4.
5.1.1.4 An existing system that is not in strict compliance with
the provisions of this code shall be permitted to be continued in
use as long as the authority having jurisdiction has determined
that such use does not constitute a distinct hazard to life.
5.1.1.6 Paragraph 5.1.14.4.3 through 5.1.14.4.9 and 5.1.13
through 5.1.15 shall apply to existing health care facilities.
5.1.1.7 Paragraph 5.1.14.3 and 5.1.14.4.1 shall apply to new
and existing health care facilities.
5.1.2 Nature of Hazards of Gas and Vacuum Systems. Potential
fire and explosion hazards associated with positive pressure
gas central piping systems and medical-surgical vacuum
systems shall be considered in the design, installation, testing,
operation, and maintenance of these systems.

Findings:

During observation, document review, and interview with the AS, the piped Gas and Vacuum Systems were observed, and maintenance records were requested.

Main Hospital 2nd and 4th Floors

1. At 4:00 p.m., the facility was observed with a Category 1 Piped Medical Gas and Vacuum System. Documentation titled, "Medical Gas Outlet discrepancies/Repairs" dated 8/30/18, indicated system discrepancies for Main Hospital 2nd and 4th floors, with repairs pending and price quotes obtained for the follow-up repairs. Upon interview, AS2 confirmed the finding stating parts are on order for the necessary repairs, and that an actual repair date has not been scheduled.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by an obstructed electrical panel. This affected one of four floors at the Main Hospital, and could result in delayed access to the panel in the event of an emergency, resulting in an increased risk of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

Chapter 9 Building Service and Fire Protection Equipment
9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
110.32 Work Space About Equipment. Sufficient space shall be provided and maintained about electrical equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall be not less than 2.0 m (61/2 ft) high (measured vertically from the floor or platform) or not less than 914 mm (3 ft) wide (measured parallel to the equipment). The depth shall be as required in 110.34(A). In all cases, the work space shall permit at least a 90 degree opening of doors or hinged panels.

Findings:

During a tour of the facility and interview with the ES, the electrical equipment and wiring were observed.

Main Hospital 4th Floor

1. On 3/12/19 at 11:30 a.m., access to Electrical Panel 4-B was obstructed by medical equipment stacked against the front of the panel. Upon interview, ES1 confirmed the finding.