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Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to latch and corridor doors that were impeded from closing. This affected 3 of 7 smoke compartments which could allow the migration of smoke and fire.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14 through 4/23/14, the corridor doors were observed and tested.

4/21/14
1. At 9:51 a.m., the corridor door to Room 314 near Bed A, was impeded from closing with medical equipment attached to the bed frame. The door failed to close with the equipment blocking the door.

2. At 9:54 a.m., the corridor door to Room 319 near Bed A, was impeded from closing with medical equipment attached to the bed frame. The door failed to close with the equipment blocking the door.

3. At 9:57 a.m., the self-closing corridor to the Staff Lounge near Room 319, was not self closing with the door fully opened. The door was dragged on the floor and failed to close approximately 1/3 of the way and stop.

4. At 9:59 a.m., the corridor door to Room 320 near Bed A, was impeded from closing with an extension to the bed frame. The door failed to close with extension to the frame blocking the door.

5. At 10:22 a.m., the corridor door to Room 12 was impeded from closing with a trash can in front of the door.

6. At 10:26 a.m., the corridor door to Room 16 was impeded from closing with a trash can in front of the door.

4/22/14

7. At 9:20 a.m., the self-closing corridor door to the Decontamination Room was not latching when tested.

8. At 9:28 a.m., the corridor door to Operating Room 4 was not latching when tested.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls in accordance with 8.3.6.1 as evidenced by penetrations. The penetrations could result in the reduction in staff ability to protect in place due to smoke and fire. This affected 3 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* 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 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/22/14, the smoke barrier walls were observed.

1. At 9:38 a.m., there were two approximately 1/2 inch unsealed penetrations in the south smoke barrier wall and two approximately 1 inch unsealed penetrations in the east wall, above the door closure device of the main entrance to the Operating Rooms.

2. At 10:06 a.m., there were two unsealed penetrations in the smoke barrier wall on the third floor, south side near elevators 2 and 3. One penetration was approximately 2 inches by 1/4 inch between the elevators and the other was approximately 4 inches by 3 inches west of the elevators.

3. At 10:21 a.m., there was an approximately 1/2 inch unsealed conduit pipe in the smoke barrier wall of the third floor ICU on the north side.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to latch. This affected 5 of 7 smoke compartments. This could fail to contain smoke during a fire. This affected 5 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/22/14, the facility smoke barrier doors were observed and tested.

1. At 8:48 a.m., the smoke barrier doors near Room 16 in ICU failed to latch when tested. One door was hitting the other door which prevented the doors from closing.

2. At 8:53 a.m., the east smoke barrier door near the stairs, 1DH31, failed to latch when tested.

3. At 9:04 a.m., the main entrance smoke barrier doors failed to latch when tested. The coordinator prevented both doors from latching.

4. At 9:55 a.m., the north smoke barrier door near the Sequoia Room failed to latch when tested.

Based on observation, the facility failed to maintain their exit components to provide protection from fire or smoke. This was evidenced by an exit door that failed to latch. This could allow smoke and fire to migrate into a stairwell in a fire emergency. This affected 3 of 7 smoke compartments.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14, the exit corridors were observed.

At 12:14 p.m., the exit stairwell door near Room 221 was not latching when tested. The door was hitting the door frame and not closing.

Based on document review, and interview, the facility failed to maintain their exit signs equipped with an internal power source. This was evidenced by the failure to perform monthly thirty second tests, and an annual ninety minute test on 18 of 18 exit signs. This affected 3 of 7 smoke compartments, and could result in a delay in egress due to limited exit sign visibility.

NFPA 101, Life Safety Code, 2000 edition
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During document review with the Senior Facilities Manager, and the Operations Manager, on 4/23/14, the exit sign testing documents were requested, and a staff person was interviewed.

1. At 8:51 a.m., there was no documented evidence of testing the 18 exit signs monthly for thirty seconds, and annually for 90 minutes as required.

2. At 8:53 a.m., the Operations Manager said during an interview that he could not find any documentation for testing the exit signs equipped with an internal battery supply.

Based on document review, and interview, the facility failed to prepare staff members to respond to emergency situations as evidenced by no disaster drills conducted for 2013. This affected 7 of 7 smoke compartments, and could result in staff not being prepared to respond to an emergency situation.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center. The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

Findings:

During document review with the Senior Facilities Manager, and the Operations Manager, on 4/23/14, the emergency drill records were reviewed, and a staff person was interviewed.

1. At 2:08 p.m., there was no documented evidence of a disaster drill being conducted during 2013. The facility provided one disaster drill for 2014 that was dated 1/29/14 for an active shooter at the facility.

2. At 2:11 p.m., the Operations Manager said during an interview that he could not find any any disaster drills for 2013.

Based on document review, and interview, the facility failed to prepare staff members to respond to emergency situations as evidenced by no fire drills conducted during the fourth quarter of 2013. This affected 7 of 7 smoke compartments, and could result in facility staff not being prepared to respond to an emergency fire situation.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During document review with the Senior Facilities Manager, and the Operations Manager, on 4/23/14, the fire drill records were reviewed, and a staff person was interviewed.

1. At 2:06 p.m., there was no documented evidence of an emergency fire drill being conducted during the fourth quarter, October, November, and December of 2013. There were two 12 hour shifts of personnel.

2. At 2:11 p.m., the Operations Manager said during an interview that he could not find any fire drills for the fourth quarter of 2013.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the failure to keep impediments from obstructing a manual pull station from access. This could delay activating the fire alarm system in the event of a fire. This affected 1 of 7 smoke compartments.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14, the manual pull stations were observed.

At 10:09 a.m., the manual pull station near 3rd west stairwell, Alarm 12, was impeded from immediate access with a patient lift in front of the device.

Based on observation, document review, and interview, the facility failed to ensure that smoke detectors are maintained. This was evidenced by 1 of 191 smoke detectors that failed to activate the fire alarm system, and no documented evidence that 8 smoke detectors were being maintained (7-5.2.2 number 15). This affected 7 of 7 smoke compartments. This could delay response to a fire in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72,National Fire Alarm Code, 1999 Edition
7-7.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the information regarding tests and all the applicable information requested in figure 7-5.2.2.
(1) Date
(2) Test Frequency
(3) Name of Property
(4) Address
(5) Name of person performing the 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, for example, "Tests performed in accordance with Section_____ ."
(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) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem, corrected/success-fully retested, device abandoned in place)

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/22/14 through 4/23/14, the smoke detectors were tested, maintenance records were reviewed, and a staff person was interviewed.

4/22/14
1. At 9:23 a.m., the smoke detector, 1SD105, near Operating Room 1 was not activating the fire alarm system when tested. Three attempts were made with canned smoke without activating the fire alarm.

4/23/14
2. At 1:18 p.m., there was no documented evidence of maintaining the 8 smoke detectors near the elevator lobbies. There was one smoke detector on each side of the elevator and a total of two on each floor (total of 8).

At 1:22 p.m., the Senior Facilities Manager said during an interview that the smoke detectors were abandoned in place and he could not find any documentation.

Based on observation, the facility failed to maintain the automatic sprinkler system. This was evidenced by a sprinkler escutcheon ring that was missing. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL (Underwriter Laboratory) listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly and a missing escutcheon ring could allow heat and smoke to affect other areas in the building. This affected 1 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14, the sprinkler system was examined.

At 12:57 p.m., there was a sprinkler missing an escutcheon ring in the Narcotic Room in the Pharmacy.

Based on observation, and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by a fire extinguisher that was obstructed from access, a fire extinguisher that was missing a safety tab, unsecured fire extinguishers, and no fire extinguisher available near the bulk oxygen. This affected 3 of 7 smoke compartments which could delay access to a fire extinguisher.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

3-4.4 Travel distances for portable fire extinguishers shall not exceed 50 ft (15.25 m).

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14 through 4/23/14, the fire extinguishers were observed.

4/21/14
1. At 9:42 a.m., the fire extinguisher in the Chiller Room was sitting on a bracket that was not fastened (clipped). The fastening clip was missing and the fire extinguisher was unsecured.

2. At 12:29 p.m., the fire extinguisher near Room 236 was impeded from access with a linen cart in front of the device.

3. At 2:07 p.m., the K class fire extinguisher in the kitchen was missing a safety tab (a tab to hold the pin from falling out).

4. At 2:34 p.m., there was no fire extinguisher near the bulk oxygen room. The bulk oxygen room was greater than 100 feet from a fire extinguisher.

Based on document review, and interview, the facility failed to maintain the Fire Suppression System on their cooking appliance as evidenced by the failure to have the appliance service at intervals of 6 months. The fire suppression unit could fail. This affected 1 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
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 existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Ventilation Control and Fire Protection of Commercial Cooking, 1998 Edition
8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

During document review with the Senior Facilities Manager, and the Operations Manager, on 4/23/14, the cooking appliance maintenance documents were reviewed, and a staff person was interviewed.

1. At 9:48 a.m., the facility provided documentation for 11/8/13 and 1/7/13. There was no documented evidence of the kitchen fire suppression system being serviced on or near 7/1/13.

At 9:53 a.m., the Senior Facilities Manager said during an interview that he could not find any documentation for a service being done during the month of July 2013.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its walls as evidenced by unsealed pipes in the walls. this could result in afire spreading from on smoke compartment to the next smoke compartment due to smoke and fire. This affected 1 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* 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 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve 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.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14, the construction was observed.

At 10:02 a.m. there were three approximately 4 inch unsealed pipes above the server in the north wall and two approximately 3 inch unsealed pipes in the east wall of the Server Room near Room 320.

Based on document review and interview, the facility failed to educate staff with spill procedures as evidenced by a staff person that did not know how to utilize a spill kit. The could result in a fire in the event of an uncontrolled spill. This affected 1 of 7 smoke compartments.

NFPA 99, Standard for Healthcare Facilities, 1999 Edition
10-2.1.1.1 An evaluation shall be made of hazards that may be encountered during laboratory operations before such operations are begun. The evaluation shall include hazards associated with the properties of the chemicals used, hazards associated with the operation of the equipment, and hazards associated with the nature of the proposed reactions (e.g. evolution of acid vapors or flammable gases).
10-2.1.1.2 Periodic reviews of laboratory operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.
10-2.1.3.1 Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.

Findings:

During a tour of the facility with the Senior Facilities Manager, and the Operations Manager, on 4/21/14 through 4/23/14, a lab employee was interviewed, and training records were reviewed.

4/21/14
1. At 1:18 p.m., the Clinical Lab Scientist said during an interview that he did not know how to use a spill kit in the event of a chemical spill.

4/23/14
2. At 1:02 p.m., there was no documented evidence that the Clinical Lab Scientist was trained to utilize a spill kit and that specific training was reviewed annually.

Based on document review, the facility failed to provide written documentation of weekly visual inspections of the emergency generator for 2 of 52 weeks. This could cause loss of power in the event of an emergency. This affected 7 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.3 Emergency Generators. Emergency generators, where
required for compliance with this Code, shall be tested and
maintained in accordance with NFPA 110, Standard for Emergency
and Standby Power Systems.

NFPA 99, Standard for Healthcare Facilities, 1999 Edition
3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with
NFPA 110, Standard for Emergency and Standby Power Systems,
Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer The date and time of day for required testing shall be decided by the owner, based on facility operations.

Findings:

During document review with the Senior Facilities Manager, and the Operations Manager, on 4/23/14, the generator maintenance records were reviewed.

1. At 9:29 a.m., the generator weekly inspection records were reviewed and there was no documented evidence of inspections provided for the weeks of 11/1/13 to 11/12/13, and 10/9/13 to 10/22/13.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances plugged into a multi-plug power strip, multi-outlet power strip plugged into an extension cord, multi-outlet power strips plugged into multi-outlet power strips, uncovered electrical boxes, utilizing an extension cord as permanent wiring, and impeded electrical panels. This could cause delay in access to electrical panels, and an increased risk of an electrical fire. This affected 3 of 7 smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 99, Health Care Facilities, 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 70, National Electrical Code, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

Article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14 through 4/22/14, the facility's electrical equipment and wiring were observed.

4/21/14
1. At 10:18 a.m., there was a microwave oven plugged into a multi-plug power strip and not directly into an electrical outlet in the ICU Nursing Lounge near Room 10 on the 3rd floor.

2. At 10:29 a.m., there was a multi-outlet power strip plugged into another multi-outlet power strip in the ICU Nursing Supervisor Office on the 3rd floor.

3. At 10:36 a.m., there was a refrigerator plugged into a multi-plug power strip in the Respiratory Managers Office on the 3rd floor.

4. At 10:44 a.m., there was a white extension cord in use near Bed B in Room 220.

5. At 10:53 a.m., there was a multi-outlet power strip plugged into another multi-outlet power strip in the IT closet near Room 204.

6. At 1:05 p.m., there was a yellow extension cord plugged into a multi-outlet power strip near the southeast desk in the Pharmacy.

7. At 1:43 p.m., there was a four plex outlet box that was uncovered in the southwest wall of the elevator room.

4/22/14
8. At 9:34 a.m., there were two electrical panels in the storage Room near the Procedure Room in the Operating Room area, that was impeded with two carts in front of the them.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by an alcohol based hand rub dispenser mounted over an ignition source. This affected 1 of 7 smoke compartments, and could result in an alcohol based hand rub ignited fire.

Findings:

During a tour of the facility with the Lead Engineer, the Senior Facilities Manager, and the Operations Manager, on 4/21/14, the alcohol based hand rub dispensers in the facility were observed.

At 10:20 a.m., there was an alcohol based hand rub dispenser mounted above a four plug electrical outlet box in Room 10.