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Based on observation the facility failed to provide complete fire sprinkler head assembly.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there was the following issue: the sprinkler head in room A-1 did not have an escutcheon plate.

Escutcheons are part of the listed assembly per 1999 NFPA 13 §3-2.7.2.

Receptacle Testing in Patient Care Areas - NFFA 99, 1999, 3-3.3.3

(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. Since data is not typically available from the manufacturer, the facility may document the failure rates of the receptacles and provide a testing schedule that will safeguard their patients. This shall be done by the Safety Committee, approved by the Governing Board, and written into the safety policies and procedures. H.L.R. 2007, §133.142. Until this assessment has been done, receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide a current record for receptacle testing per NFPA 99: 3-3.3.3. for patient care areas.

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that record for current year receptacle testing was not available.

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

The inspector observed, while accompanied by the Chief Operating Officer and the Mechanic during the hours of the inspection from 9:30 am to 4:45 pm on 12/2/2014 that there were the following issues. They were: 1) The breaker for the main Fire Alarm panel was not colored red, 2) There were not directories in the back of the electrical panel doors, 3) There were no labels on the electrical panels indicating, and 4) The receptacles in the patient rooms were not hospital grade.

" A dedicated electrical circuit to the life safety branch of the EES shall be provided. The circuit shall be identified with a red marking and identified as "FIRE ALARM CIRCUIT CONTROL". - NFPA 72, 1999: 1-5.2.5.2

Circuit Directories: Room numbers and areas were not identified on the circuit directory of the panels. All circuits and circuit modifications shall be legibly identified as to purpose of use on the circuit directory located on the face or inside of the panel door in the case of a panel board, and at each switch on a switchboard. - NEC 1999, 384-13.

" Panelboards. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. " - NFPA 70, 1999, 384-13

All receptacles, whether four or more, shall be listed " hospital grade " and so identified. Each receptacle shall be grounded by means of an insulted copper conductor sized in accordance the Table 250-122. NFPA 70, 1999, 517-18 (b).