HospitalInspections.org

Based on observation the facility failed to provide adequate exit signage.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there were the following issues with exit signs. They were: 1) Burkett, first floor, main entry - lamps out, 2) Burkett, sign between the Lounge and Lobby - lamp out, and 3)Burkett, north exit from building - no exit sign.

Based on observation the facility failed to provide adequate hazardous area containment.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there were the following issues with hazardous areas. They were: 1) the Kitchen storage room did not have a closer, and 2) Lewis building, room 128, reading room - had a drainage pipe violating the 1 hour wall fire rating.

Based on observation the facility were not testing the fire alarms in the Activity building, the White House, and the Cafeteria/Pharmacy.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that fire alarms were not being tested in the Activity building, the White House, and the Cafeteria/Pharmacy. This acceptable as long as they are classified as business occupancies. However, if patients use any of these buildings they must be reclassified as Health Care, and the fire alarms must be tested on an appropriate schedule.

Based on observation the facility failed to provide adequate sprinkler system coverage.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there were the following issues with the sprinkler system. They were: 1) Lewis building, Assessment Room #2 - no sprinkler head, and 2) Lewis building, Medical Records Storage Closet - no sprinkler head.

Emergency Water and Fuel:

As a component of emergency preparedness, the facility shall provide letters indicating preferred customers status in case of an emergency situation for water and fuel source. - 81 FR 63859

Based on observation the facility failed to provide an adequate letter from a generator fuel supplier.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there was no letter from a fuel supplier indicating that the facility would be considered a preferred customer in the event of an emergency.

Labeling of Transfer Switches and Panels:

"Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system." - NFPA 70, 2011, 700.10.

Based on observation the facility failed to provide adequate labeling of panels.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that the electrical panels in the Lewis building were not yet labeled.


Segregation of the Essential Electrical System:

"The essential electrical system shall be divided into the following three branches: (1) Life safety, (2) Critical, (3) Equipment." NFPA 99, 2012, 6.4.2.2.1.1

"The life Safety branch shall be limited to circuits essential to life safety." - NFPA 99, 2012, 6.4.2.2.3.1. No functions other than those listed in 6.4.2.2.3.2, 6.4.2.2.3.3, and 6.4.2.2.3.4 shall be connected to the life safety branch, except as specifically permitted in 6.42.2.3." - NFPA 99, 2012, 6.4.2.2.3.5.

The critical system shall serve functions related to patient care. - NFPA 99, 2012, 6.4.2.2.4.2

"The equipment branch shall be connected to equipment described in 6.4.2.2.5.3 through 6.4.2.2.5.4." - NFPA 99, 2012, 6.4.2.2.5.1

Based on observation the facility failed to provide adequate segregation of the essential electrical system.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there were the following issues with improper routing of the essential electrical system in the Lewis building. They were: 1) critical panel on 1st floor at the FACP had a generator battery and heater that must be on a life safety panel, 2) panel L1S in the electrical room had a non-life safety receptacle and lights on the life safety panel, this must be moved, and 3) in Lewis 1S electrical closet circuit #5 was labeled "Rm 40 Main Breaker", this must be moved out of the life safety panel, this is not a life safety function.

Based on observation the facility failed to provide an adequate risk analysis for the essential electrical system.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there was not a risk analysis of the essential electrical system.

Based on observation the facility failed to provide adequate testing and inspection of the essential electrical system.

The inspector observed, while accompanied by the Environment of Care Director, the Materials Manager, and the Maintenance Supervisor during the hours of the inspection from 8:00 am to 6:45 pm on 6/28/2017 that there were the following issues. They were: 1) the main and feeder circuit breakers must be inspected annually, and 2) all panels must be properly labeled.