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Based on record review and staff interview, the facility failed to inspect all emergency electrical system (EES) circuit breakers annually, and to exercise the circuit breakers periodically associated for the emergency generator. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 3/15/23, at 11:41 am revealed documentation was not provided to verify emergency electrical system (EES) circuit breakers were inspected annually, and exercised periodically.

In an interview on 3/15/23, at 11:41 am, Maintenance A confirmed the testing was not conducted, so documentation was not available.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

Based on observation, record review and staff interview, the facility failed to provide a secondary means of unlocking magnetic locks with activation of the fire alarm system. This condition had the potential to prevent occupants from exiting the facility during a fire.

Findings are:
Observation on 3/15/23, from 11:47 am to 12:30 pm revealed newly installed magnetic locks for the following doors: ER, Central Supply, and the Johnson Control Room.

Record review on 3/15/23, at 12:30 pm revealed testing documentation of the magnetic locks was not available for review to verify the locks released with the activation of the fire alarm.

In an interview on 3/15/23, from 11:47 am to 12:30 pm, Maintenance A confirmed the locks were recently installed, and called the installation company during to verify the locks were not tied to the fire alarm system to deactivate the locks with activation of the fire alarm.

7.2.1.6.2* Access-Controlled Egress Door Assemblies. Where permitted in Chapters 11 through 43, door assemblies in the means of egress shall be permitted to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met: (4) Activation of the building fire-protective signaling system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset. (5) The activation of manual fire alarm boxes that activate the building fire-protective signaling system specified in 7.2.1.6.2(4) shall not be required to unlock the door leaves. (6) Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.

Based on observation and staff interview, the facility failed to separate hazardous areas with smoke resistive doors and partitions. This condition would allow smoke to migrate into the exit corridors.

Findings are:
Observation on 3/15/23, from 12:06 pm to 12:40 pm revealed:
1. The Boiler Room door did not positively latch when self-closed.
2. In the East Boiler Room wall, penetrations were unsealed, and spray foam was used to seal penetrations, rather than a listed fire caulking.
3. Combustible storage was observed in the Old Recovery Room that exceeded 50 square feet, which was open to the OR Suite.
4. The fire-rated Chief Nursing Office door did not positively latch when self-closed.

In an interview on 3/15/23, from 12:06 pm to 12:40 pm, Maintenance A acknowledged the findings.

Based on observation, record review and staff interview, the facility failed to provide a Category 1 Warning System in a continuously monitored area. This condition would not reliably notify staff of a fault within the system.

Findings are:
Record review on 3/15/23, at 11:39 am revealed the bulk oxygen medical gas inspection report from 1/30/23 cited there was not an alarm panel hooked up, and that the low-pressure alarm was in the basement.

Observation on 3/15/23, at 11:45 am revealed the only medical gas alarm was a bell to monitor low-pressure, located in the basement - which was not a continuously monitored area.

In an interview on 3/15/23, from 11:39 am to 11:45 am, Maintenance A acknowledged the findings of the medical gas inspection report. Maintenance A confirmed the alarm in the basement was the only alarm from the original system install. Maintenance A stated that only scope procedures were performed in the OR.

NFPA 99, 2012, 5.2.9 Warning Systems (Category 2). Warning systems associated with Category 2 systems shall provide the master, area, and local alarm functions of a Category 1 system as required in 5.1.9, except as follows: (1) Warning systems shall be permitted to be a single alarm panel. (2) The alarm panel shall be located in an area of continuous surveillance while the facility is in operation. (3) Pressure and vacuum switches/sensors shall be mounted at the source equipment with a pressure indicator at the master alarm panel.
5.1.9* Category 1 Warning Systems. 5.1.9.1 General. All master, area, and local alarm systems used for medical gas and vacuum systems shall include the following: (1) Separate visual indicators for each condition monitored, except as permitted in 5.1.9.5.2 for local alarms that are displayed on master alarm panels (2) Visual indicators that remain in alarm until the situation that has caused the alarm is resolved (3) Cancelable audible indication of each alarm condition that produces a sound with a minimum level of 80 dBA at 0.92 m (3 ft) (4) Means to visually indicate a lamp or LED failure (5) Visual and audible indication that the communication with an alarm-initiating device is disconnected (6) Labeling of each indicator, indicating the condition monitored (7) Labeling of each alarm panel for its area of surveillance (8) Reinitiation of the audible signal if another alarm condition occurs while the audible alarm is silenced (9) Power for master, area alarms, sensors, and switches from the life safety branch of the emergency electrical system as described in Chapter 6 (10) Power for local alarms, dew point sensors, and carbon monoxide sensors permitted to be from the same essential electrical branch as is used to power the air compressor system (11) Where used for communications, wiring from switches or sensors that is supervised or protected as required by 517.30(C)(3) of NFPA 70, National Electrical Code, for life safety and critical branches circuits in which protection is any of the following types: (a) Conduit (b) Free air (c) Wire (d) Cable tray (e) Raceways (12) Communication devices that do not use electrical wiring for signal transmission will be supervised such that failure of communication shall initiate an alarm. (13) Assurance by the responsible authority of the facility that the labeling of alarms, where room numbers or designations are used, is accurate and up-to-date (14) Provisions for automatic restart after a power loss of 10 seconds (e.g., during generator start-up) without giving false signals or requiring manual reset (15) Alarm switches/sensors installed so as to be removable

Based on record review and staff interview, the facility failed to inspect all emergency electrical system (EES) circuit breakers annually, and to exercise the circuit breakers periodically associated for the emergency generator. This practice increased the potential that emergency power would not be supplied to the facility.

Findings are:
Record review on 3/15/23, at 11:41 am revealed documentation was not provided to verify emergency electrical system (EES) circuit breakers were inspected annually, and exercised periodically.

In an interview on 3/15/23, at 11:41 am, Maintenance A confirmed the testing was not conducted, so documentation was not available.

NFPA 99, 2012, 6.6.4.1.2 Maintenance and Testing Circuitry. Circuitry shall be
maintained and tested in accordance with 6.4.4.1.2.

6.4.4.1.2 Maintenance and Testing of Circuitry.
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers
shall be inspected annually, and a program for periodically
exercising the components shall be established according to
manufacturer's recommendations.

Based on record review and staff interview, the facility failed to implement the following: documentation of inspection as well as an inspection program for all non-PCREE equipment located within the patient care vicinity of all patient rooms and; documentation of an audit, testing and inspection as well as written procedures and policies for audits, testing and inspection of power strips throughout the facility. This practice increased the potential of electrical equipment throughout the facility causing injury or a fire.

Findings are:
Record review on 3/15/23, at 11:11 am revealed:
1. Written policies and procedures for conducting audits and testing of power strips, and non-PCREE devices was not provided.
2. Documentation of initial testing for power strips, and non-PCREE devices was not provided for review.

In an interview on 3/15/23, at 11:11 am, Maintenance A confirmed the testing was not conducted and policies not provided.