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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 did not properly latch and a door that was impeded from closing. This affected 3 of 4 smoke compartments which had the potential to allow the migration of smoke.

Findings:

During the facility tour of the facility with staff members on 11/02/11, the corridor doors were observed. At 10:00 the corridor door to room 32 did not positively latch when closed. Staff confirmed that the door did not latch.

Based on observation, the facility failed to maintain emergency exits, as evidenced by secondary exit doors that were blocked by furniture and by beds that were stored along the corridor. These conditions conditions affected two of two smoke compartments and could result in a delay of egress in the event of an emergency evacuation.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
7.1.10 Means of Egress Reliability.
7.1.10.1* 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.
7.1.10.2.2 There shall be no obstructions by railings, barriers, or gates that divide the open space into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Findings:

During a tour of the facility with maintenance staff, on 11/02/11, the facility emergency exits were observed.

1. At 11:10 a.m., by room 21 and room 24, there were three beds stored along the corridor. The beds were in the corridor for more than two hours without being moved. Staff stated that the beds moved in and out of the corridor between procedures.

Based on interview and document review, the facility failed to maintain the generator as evidenced by the use of a temporary generator due to the failure of the main generator. This deficient condition affected two of two smoke compartments and could result in failure of the generator in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 110 Standard on Stored Electrical Energy Emergency and Standby Power Systems.
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, Health Care Facilities, 1999 Edition
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, Chapter 6.
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.

Findings:

During document review with staff, on 11/02/11, the generator maintenance records were reviewed. At 11:21 a.m., during a tour of the facility, it was disclosed that the facility generator failed during a power outage on 10/03/11. A temporary generator was immediately brought to the facility, connected to the transfer switches, and tested. The hospital will continue to repair their permanent generator as required.

Based on interview and observation, the facility failed to maintain their electrical wiring and equipment, as evidenced by the permanent use of a power strip and by a cover plate that was missing. These deficient practices affected two of two smoke compartments and could result in the ignition of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition
400-7 Uses Permitted
(a) Uses. Flexible cords shall be used only for the following:
1) Pendants
2) Wiring of fixtures
3) Connection of portable lamps, portable and mobile signs or appliances
4)Elevator cables
5) Wiring of cranes and hoists
6) Connection of stationary equipment to facilitate their frequent interchange
7) Prevention of the transmission of noise or vibration
8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection\
9) Data processing cables as permitted by Section 645-5
10) Connection of moving parts
11) Temporary wiring as permitted in Sections 305-4 b)& 305-4 c)
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords 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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

410-56. Rating and Type.
(e) Position of Receptacle Faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a tour of the facility with staff members on 11/02/11, the electrical wiring in the facility was observed.

1. At 10:16 a.m., in room 26, the wall outlet was uncovered. There was no cover plate for the outlet.

2. At 11:00 a.m., in the operating room sterile hallway, there was a 6 unit power strip attached to the cabinet. There were 6 electrical items plugged in and there were not enough wall outlets for the electrical items in the use.