HospitalInspections.org

This facility is a seven story structure, with patient treatment is located on the first floor and patient care is located on floor three through six. Administration occupies a portion of the first level and entire second level.
This facility is automatic sprinkler protected.

The 1969 portion Type I (332)
The 1998 and 2008 portion Type II (000)
The 1991,1996 & 2003 portion Type I (332)



Based on observation and interview, the facility failed to maintain a fire barrier having a fire resistance rating of at least two hours between two different occupancies, the sprinkled healthcare facility and the sprinkled business facility. This deficient practice would allow smoke and fire to migrate between the two separate occupancies. Facility census was 36.

Findings Include:

Observations on 4-25-11 at 8:47 am revealed a data cable that penetrates a 2 hour fire rated separation between occupancies on the west side of door #1015 above the ceiling. Observations was acknowledged and verified by Facility Personnel B.

Observations on 4-25-11 at 9:10 am revealed a wire that penetrates a 2 hour fire rated separation between occupancies on the south side of door #1092SE above the ceiling. Observations was acknowledged and verified by Facility Personnel B.


NFPA Standard:
Health care occupancies in buildings housing other occupancies shall be completely separated from them by construction having a fire resistance rating of not less than 2 hours. 2000 NFPA 101, 19.1.2.3, 19.1.1.4


Based on observation and staff interview, the facility failed to two hour separate a health care occupancy from business occupancy of a less constrictive construction type. This failure had the potential to allow smoke and fire to migrate to two different occupancies. Facility census was 36.
Findings are:
Observations on 4/26/2011 at 9:10 am on the main floor in the east hallway the two hour wall separating Merrick Manor, above the doors three areas were covered with acoustical tiles caulked to the wall. No information was offered as to the rating of these tiles. During interview with Facility personnel C, confirmed the tiles at time of the observation.

NFPA Standard:
Additions shall be separated from any existing structure not conforming to the provisions with Chapter 19 by a fire barrier having not less than a 2-hour fire resistance rating and constructed of materials as required for the addition. 2000 NFPA 101, 19.1.1.4

Based on observation and staff interview, the facility failed to separate use areas from the corridors by construction of at least ½ hour. In sprinkled buildings partitions are only required to resist the passage of smoke. This practice affected all patients, visitors and staff that use the facility. The facility census was 36 and a capacity of 90.

1) On 4/25/2011 at 1:37 pm an inspection, in the west corridor of the 6th floor above the doors in the middle by Room 616 had one penetration of one inch in diameter with wires passing through it about two feet from the east wall. Facility personnel C confirmed this at the time of the inspection.
2) On 4/25/2011 at 1:41 pm an inspection, in the east corridor of the 6th floor above the doors in the middle by Room 607 had one penetration of two inch in diameter tube with wires passing through it, with no pillow or insulation in it, about two feet from the east wall. Facility personnel C confirmed this at the time of the inspection.
3) On 4/25/2011 at 1:46 pm an inspection, in the west corridor of the 6th floor above the doors between the elevator lobby and the patient hallway had one penetration of one inch in diameter with wires passing through it about two feet from the east wall. Facility personnel C confirmed this at the time of the inspection.
4) On 4/26/2011 at 9:35 am an inspection, in the west corridor (cafeteria hallway) of the 1st floor above the doors south of the service hallway had two wire penetrations through the wall that were not sealed.. Facility personnel C confirmed this at the time of the inspection.



NFPA Standard: When pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment penetrate through fire barriers, the space between the penetrating item and the fire barrier shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier or protected by an approved device that is designed for the specific purpose. 2000 NFPA 101, 8.2.3.2.4.2



Observation on 4/25/2011 at 1:49 PM in room 2508 on the second floor of the HPP Bldg, revealed a hole in the separation wall to the corridor. This observation was confirmed in an interview with Facility Personnel A at the above date and time.

Findings are:
Observation on 4/25/2011 at 2:01 PM in room 3524 on the third floor of the HPP Bldg, revealed a hole in the separation wall to the corridor. This observation was confirmed in an interview with Facility Personnel A at the above date and time.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. This practice affected all residents, staff, and visitors of the facility. The facility capacity is 90 and the census was 36.
Findings include:

Observations on 4/25/2011 at 3:00 pm the door to Room 3374 had a kick-down hold open on it preventing it from shutting. During an interview, at time of observation, with Facility personnel C confirmed this finding.

Observations on 4/26/2011 at 10:47 in the out-patient area Room 1238 the door to the corridor failed to shut and latch. During an interview with Facility personnel C at time of the observation confirmed the finding.

Based on observation and interview, the facility failed to provide separation of a hazardous area from other compartments. This deficient practice would allow fire and smoke to migrate out of the hazard area. The facility census was 36 residents.

Findings Include:

Observations on 4-26-11 at 9:27 am revealed that the door to the hyperbaric chamber lacked a self closure device. Observations was acknowledged and verified by Facility Personnel B.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Observation on 4/25/2011 at 1:25 PM in electrical room 1562 on the first floor of the NPP Bldg, revealed an unsealed Electrical conduit penatration in the separation wall to the corridor. This observation was confirmed in an interview with Facility Personnel A at the above date and time.


Observation on April 26, 2011 at 1:08pm revealed that the door to the large sterile storage room with a rolling shelving system by OR1 was not self-closing and positive latching. This observation was confirmed in an interview with Facility Personnel E at the above date and time.

Observation on April 26, 2011 at 9:36am revealed that the door to the elevator equipment room B002 in the basement of Health Park Plaza was not self-closing and positive latching. This observation was confirmed in an interview with Facility Personnel E at the above date and time.

Based on observation and interview, this facility does not maintain required exit stairwells to be separated by one-hour fire rated construction and to prevent the storage of combustibles. This deficient practice affects all occupants of the facility. This facility has a capacity of 90 and a census of 36.
Findings include:

Observation on 4/25/2011 at 3:03 PM on the second floor Administration Area above door #254 in a Two hour rated stair tower revealed an unsealed Electrical conduit penatration as well as two 1/2 inch holes. This observation was confirmed in an interview with Facility Personnel A at the above date and time.

Based on observation and staff interview, the facility failed to provide delayed release devices in required exits that released upon activation of the fire alarm. Facility census was 36.
Findings are:
1.) Observations on 4/27/2011 at 10:10 am the north stair exit door on the 6th floor failed to release the magnetic locks from the pediatric monitor when the fire alarm was activated. During an interview with Facility personnel C at time of the observation confirmed this.
2.) Observations on 4/27/2011 at 10:11 am the south stair exit door on the 6th floor failed to release the magnetic locks from the pediatric monitor when the fire alarm was activated. During an interview with Facility personnel C at time of the observation confirmed this.

Observation 4/25/2011 at 3:12 pm an inspection, in the east corridor of the 3rd floor, the doors north of the elevator lobby , the west door had no latch release on the outside of the door. The east door had to be opened first to open the west door. Facility personnel C confirmed this at the time of the inspection.

Obsevation 4/26/2011 at 10:42 am an inspection, in the out-patient area the east doors to the corridor failed to shut. When the doors are latched the north door must be open for the south door to open. Facility personnel C confirmed this at the time of the inspection.

Based on observation and interview, the facility failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 72, which requires audible and visual devices in all common use areas. This deficient practice affected all patients, staff, and visitors in those areas. The facility census was 36. Findings Include:

Observations on 4-25-10 at 2:57 pm on the third floor revealed the lack of smoke detection in staff sleeping room. Facility Personnel B confirmed and acknowledges the findings.

Based on observation, the facility failed to provide a properly tested and maintained fire alarm system. The deficient practice would affect all of the building smoke compartments, residents, and staff. The facility has 90 certified beds and at the time of the survey the census was 36. Findings include:

Fire alarm records review and staff interview on 4-26-11 at 2:05 p.m. revealed two of the facility FM-200 fire suppression. The first floor MRI system, reports to the main fire alarm panel as a trouble and a supervisory signal and the second floor Main computer room reports to the main panel as a supervisory signal. Neither of the two systems activates the facility ' s fire alarm system. Observation acknowledged and verified by Personnel Staff A.

Observation and fire alarm test on 4-27-11 between 9:00 a.m. and 12:00 p.m. revealed:

1. Strobe near door 1527 failed to operate during the buildings fire alarm test.
2. On the second level in North stair tower in the HPP build the fire alarm strobe near the door failed to operate during the fire alarm test.

Observation on 4-27-11 at 10:00 a.m. revealed a smoke detector mounted too close to an air duct on the fourth floor near room 411. Observation acknowledged and verified by Personnel Staff E.


Observations on 4-27-10 between 10:34 am and 10:50 pm revealed:
The audible and visual fire alarm in room # 1497 failed to activate.

The audible and visual fire alarm in north corridor of the Imaging Center failed to activate.

The audible and visual fire alarm in south corridor of the Imaging Center failed to activate.

The audible and visual fire alarm in corridor by the dining hall failed to activate.

The visual fire alarm in corridor in the dining hall failed to activate.

The Dankau Conference lacked a visual fire alarm device.

The visual alarm devices in the kitchen area failed to be synchronized.

During an interview on all dates and times of observations, Facility Personnel B confirmed and acknowledges all the findings.

NFPA Standard:
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 feet from each other or they shall flash in synchronization. 1999, NFPA 72, 4-4.4.2.3


Based on observation and interview, the facility failed to assure that the fire alarm system is installed and maintained in accordance with NFPA 72, which requires audible and visual devices in all common use areas and failed to ensure when two or more strobes devices are in view, that they are synchronized. This deficient practice affected all patients, staff, and visitors in those areas. The facility census was 36.
Findings are:
1. Observations on 4/27/2011 at 10:25 am in the Emergency Department the strobe by the vending machines failed to light when activated. During an interview with Facility personnel C at time of the observation confirmed the finding.
2. Observations on 4/27/2011 at 10:45 am in the Rehab Department the strobe in the southwest corner failed to light when activated. During an interview with Facility personnel C at time of the observation confirmed the finding.
3. Observations on 4/27/2011 at 10:12 am on the 6th floor the strobe in the east lobby of the elevator failed to light when activated. During an interview with Facility personnel C at time of the observation confirmed the finding.
4. Observations on 4/27/2011 at 10:13 am in the Joint Center conference room failed to light when activated. During an interview with Facility personnel C at time of the observation confirmed the finding.
5. Observations on 4/27/2011 at 10:30 am in the Administration area the south strobe failed to light when activated. During an interview with Facility personnel C at time of the observation confirmed the finding.

NFPA Standard:
In corridors where there are more than two visible notification appliances in any field of view, they shall be spaced a minimum of 55 feet from each other or they shall flash in synchronization. 1999, NFPA 72, 4-4.4.2.3




29212

Based on observation and interview, the facility failed to install the automatic sprinkler system to provide complete coverage for all portions of the building in accordance with NFPA 13. This deficient practice affected all patients, visitors and staff that are in the area of those areas without sprinkler protection. The facility census was 36.
Findings are:
1.) Observations on 4/25/2011 at 1:15 pm in the stairwell to the 7th floor (penthouse), there was no sprinkler head at the top of the stairs. In interview with Facility personnel C at the time of observation, they confirmed the observation.
2.) Observations on 4/25/2011 at 3:20 pm on the third floor, the bathroom connected to Room 3366, there was no sprinkler head. In interview with Facility personnel C at the time of observation, they confirmed the observation.

Based on observation and interview the facility failed to maintain the sprinkler system in accordance with NFPA 25 and in a reliable operating condition by having missing flush trims for concealed sprinklers and by having missing sprinkler escutcheons and not maintaining ceilings for proper sprinkler activation. This deficient practice has the potential to affect all residents, staff, and visitors of the facility. Facility census was 36 and has a capacity of 90.
Findings Include:

1. Observations on 4/26/2011 at 10:40 am on the first floor in the Administration area, Room 1244 the sprinkler head was missing an escutcheon ring. In interview with Facility personnel C at the time of observation, they confirmed the observation.
2. Observations on 4/26/2011 at 10:55 am on the first floor in the Gift Shop area, the northeast sprinkler head was missing an escutcheon ring. In interview with Facility personnel C at the time of observation, they confirmed the observation.

Based on observation and staff interview, the facility failed to continuously maintain means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. The facility census was 36
.
Findings Include:

Observations on 4-26-11 at 2:24 pm at Wound Care Clinic revealed a cart in the corridor that leaves approximately 2 feet of clearance. Facility Personnel B confirmed and acknowledges all the findings.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branch of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 90 and the census was 36.

Findings Are:

Observation on April 26, 2011 at 10:14am revealed that there was the following non-life safety loads connected to the Life Safety panel M9E: #13 Outlets and Lights at Nurses station 200,300,400 MM. This observation was confirmed in an interview with Facility Personnel E at the above date and time.

Observation on April 26, 2011 at 9:55am revealed that there was the following non-critical loads connected to the Critical Branch panel B116E: #1 Surgery Waiting Doors; #3 Surgery Doors; #4 Door Power Surgery; #5 Surgery Doors. This observation was confirmed in an interview with Facility Personnel E at the above date and time.

Observation on April 26, 2011 at 10:31am revealed that there was the following Life Safety load connected to the Equipment System branch panel 167E: #20 Clean Agent Fire Alarm System. This observation was confirmed in an interview with Facility Personnel E at the above date and time.


NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7°C (20°F).
(b) The outside design temperature is lower than -6.7°C (20°F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on observation and staff interview, the facility failed to use electrical wiring and equipment in accordance with the National Fire Protection Association, 70. This failure increased the probability of electrical equipment and wiring causing an electrical fire or shock in the therapy room. Facility census was 36.

Findings Include:

Observations on 4-26-11 at 9:27 am revealed in room #1068 had an outlet by the mop sink that failed to be GFCI protected. Facility Personnel B confirmed and acknowledges all the findings.

Observations on 4-26-11 at 9:34 am revealed in emergency room at the nurses station had an unapproved surge protector for the printer and fax machine.
Facility Personnel B confirmed and acknowledges all the findings.

NFPA Standard:
NFPA 70, 210-8(a) Ground-Fault Circuit-Interrupter Protection for Personnel. (a) Dwelling Units, All 125-volt, single-phase, 15- and 20-ampere receptacles installed in the locations specified below shall have ground-fault circuit-interrupter protection for personnel.
(1) Bathrooms.
(2) Garages, and also accessory buildings that have a floor located at or below grade level not intended as habitable rooms and limited to storage areas, work areas and areas of similar use.
NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NE State Fire Marshal Official Interpretation: Relocatable power taps are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas. General care areas include patient bedrooms, examining rooms, treatment rooms, clinics and similar areas where it is intended that the patient will come in contact with ordinary appliances such as nurse call systems, electrical beds, examining lamps, telephones and entertainment devices such as radios, televisions and computers. This will also include common spaces such as corridors, lounges, dining rooms and similarly occupied spaces where electrical appliances noted above may be found. Critical patient care areas are: intensive care units, coronary care units, angiography labs, cardiac catheterization labs, delivery rooms, operating rooms, post anesthesia recovery rooms and emergency rooms. In areas not occupied by patients, properly listed portable power taps are permitted. This can include business offices and staff lounges and similar spaces.