HospitalInspections.org

The Hospital is out of compliance with the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to to provide care in a safe setting for patients during a water pipe burst where potentially contaminated kitchen and food products were used and during the clean up where there was a risk for asbestos exposure.

Refer To TAG: A-144.

The Hospital is out of compliance with the Condition of Participation for Food and Dietetic Services.

Findings included:

The Hospital failed to have an organized dietary service, Registered Dietician on staff, and failed to ensure that the nutritional needs of the patients were met in accordance with practitioners' orders and acceptable standards of practice.

Refer To TAG: A-0621 & 0629.

The Hospital is out of compliance with the Condition of Physical Environment.

Findings included:

The Hospital failed to provide and maintain an environment where asbestos exposure risks were minimized for patients, employees and visitors and failed to ensure the proper storage and disposal of trash.

Refer To TAG: A-701 & 713.

Based on observation, interview and record review the Hospital failed to provide care in a safe setting for all patients.

1. The Surveyors interviewed the Chief Executive Officer (CEO) on 4/3/19 at 8:00 A.M. The CEO said that the Facility had experienced a burst pipe in one of the patient rooms which flooded most of the first floor patient care area. The CEO said that the area was evacuated by the local Fire Department and 23 patients were transferred to area hospitals. The CEO said that 11 out of the 23 patients returned to the second floor of the hospital within a day. The CEO said that all water damaged coving was removed and was being replaced.

The Surveyors toured the facility on 4/3/19 at 8:15 A.M. The Surveyors noted that the entire 1st floor patient care area and patients' rooms were empty. The Surveyors observed multiple construction workers removing large pieces of wood and plaster molding and placing them in trash bins on wheels. The Surveyors observed visible dust in the air while multiple drying fans were blowing the walls and flooring in an attempt to dry them. The Surveyors observed that there were plastic sheets covering the entrance to the area and noted that the hallways on the other side of the plastic sheets on the first floor had visible dust in the air and on the floors, walls, and hand rails. The Surveyors noted that the base coving was removed along the bottom of the walls on both sides of the hallway and there was a fan running blowing dust into the air. The Surveyors observed, at the end of the hall, there was a door with a sign on the wall next to it reading "Dialysis". The Surveyors observed the walls on the left and right side of the door had the base coving removed and there was a visible hole in the wall next to the door and the door frame was loose.

The Surveyors opened the door to the Dialysis unit and observed Patient #17 and Patient #18 actively being dialyzed in close proximity to the construction area on the first floor and from the inside of the Dialysis unit you could see the hall outside through the hole in the wall.

The Surveyors interviewed the CEO on 4/4/19 at 8:00 A. M. The CEO said that testing was performed on 4/3/19 in the areas that were effected by the pipe burst and that the tests results showed that the first floor and basement kitchen areas had tested positive for asbestos (a toxic material/carcinogen). The area around the first floor which was visibly covered in dust and debris was not tested for asbestos prior to Patient #17 and Patient #18's dialysis treatment on 4/1/19 and 4/3/19. This area was taped off and not allowed access by the Department of Environmental Protection pending further asbestos testing.

2. The Surveyors toured the Hospital's kitchen on 4/3/19 at 8:30 A.M. The CEO said that water from a burst pipe flooded the first floor and collapsed the ceiling in the basement where the kitchen was located. The CEO said the kitchen was closed could not be used. The CEO said that the refrigerators were not affected by the water and were still being used to serve patient meals. The Surveyors inspected all three refrigerators and the walk in deep freezer. The Surveyors observed evidence of water infiltration in all three refrigerators. The Surveyors observed large brown puddles of water inside the refrigerators and light fixtures on the ceiling were filled with brown rust colored water. The Surveyors observed that the walk in freezer's floor was covered in a half inch of brownish grey frozen water and there were multiple visible icicles where the water had come through the ceiling and a large frozen brown colored ice flow extending down through the food shelves onto boxes of food and frozen turkeys. At 8:00 A.M. on 4/4/19 the CEO told the Surveyors that areas within and above the kitchen tested positive for asbestos.

Review of the document titled "Phase I Environmental Site Assessment" dated September 2016, indicated that previous asbestos testing was performed on the Hospital and asbestos was identified in the vinyl floor tiles and associated mastic, some areas were "suspect" to contain asbestos including drywall and associated joint compound, thermal system insulation (TSI), pipe wrap, and dropped ceiling tiles.

Based on observation, interview and record review the Hospital failed to provide a qualified dietician to supervise the nutritional aspects of patient care for all patients in the hospital.

The Surveyors interviewed the Chief Executive Officer (CEO) for the Hospital at 9:00 A.M. on 4/3/19. The CEO informed the Surveyors that on 3/31/19 the Hospital experienced a major flood on the 1st floor which collapsed the ceiling of the kitchen beneath rendering the kitchen unusable.

The CEO said that there was no dietitian on staff in the Hospital. The CEO said that the Food Service Director, who is not a dietitian, was responsible for patient diets. The CEO said that the lunch served to all patients in the hospital on 4/3/19 was takeout cheese pizza from a local pizza shop and when asked about the patients who were on low salt diets or other dietary restrictions the CEO acknowledged that there was not a dietitian on staff and said "We are doing the best that we can" or words to that effect.

Based on observation, interview and record review the Hospital failed to provide patient diets, including therapeutic diets, in accordance with physician orders for 12 Sampled (Patient #1, #5, #6, #7, #9, #10, #12, #13, #14, #16, #17, and #18) Patients and ten Non-Sampled (NS1-NS10) Patients.

The Surveyors interviewed the Chief Executive Officer (CEO) for the Hospital at 12:00 P.M. on 4/3/19. The CEO said that on 3/31/19, the Hospital experienced a major flood on the 1st floor which collapsed the ceiling of the kitchen beneath rendering the kitchen unusable. The CEO said that the lunch served to all patients in the Hospital on 4/3/19 was takeout cheese pizza from a local pizza shop. The CEO was unable to provide a nutritional plan for all inpatients for the week of 3/31/19-4/6/19.

Review of the Hospital's Dietary Order Summary on 4/3/19 for all 44 inpatients indicated that 22 patients (12 Sampled Patients and 10 Non-Sampled Patients) were ordered therapeutic diets which required salt restrictions, fat restrictions, and potassium restrictions.

The Surveyor observed Patient #1, by him/herself on 1:40 P.M. on 4/3/19, with a tray containing two pieces of pizza with a drink containing a straw. Review of Patient #1's dietary orders indicated that Patient #1 was a 1:1 for feeding, required honey thickened liquids and a diabetic mechanical soft diet. A review of Patient #1's Physician Progress Notes, dated 4/2/19 at 7:00 A.M., indicated that Patient #1 was hyperglycemic (high blood sugar) with a critical glucose of 824 (normal 70 to 100) and required frequent monitoring of blood sugars with "tight control".

The Surveyors interviewed Patient #16 on 4/3/19 at 1:40 P.M. Patient #16 said that the Hospital was not providing him/her with appropriate meals. Patient #16 said that he/she was not supposed to eat deli meat or pizza due to his/her diabetes and sodium restriction and that the Hospital offered him/her a turkey cold cut sandwich for dinner and pizza for lunch. Patient #16 said that when he/she does not follow his/her diet he/she feels terrible and his/her choice was to either eat and feel bad or starve.

The Surveyors interviewed Patient #17's daughter on 4/4/19 at 1:05 P.M. Patient #17's daughter said that she requested to have Patient #17 transferred because the Hospital was not providing adequate therapy and has been providing the wrong food. Patient #17's daughter said that Patient #17 is on dialysis and has not been offered an appropriate dialysis diet and is not supposed to be eating pizza or cold cuts.

The Surveyors interviewed the Chief Clinical Officer (CCO) at 2:00 P.M. on 4/3/19. The CCO said that Patient #1 should never have been left by him/herself during mealtime and the use of a straw was contraindicated for patients on a honey thickened diet. The CCO acknowledged that patients were not receiving meals that met therapeutic diets, salt restrictions, and/or potassium restrictions but that the staff was "doing the best we can".

Based on observation and interview the Hospital failed to maintain and ensure risks were minimized for patients as well as for employees and visitors of the Hospital.

Findings include:

The Surveyors interviewed the Chief Executive Officer (CEO) at 8:00 A.M. on 4/3/19. The CEO said that the Facility had experienced a burst pipe in one of the patient rooms which proceeded to flood most of the first floor patient care area. The CEO said that the area was evacuated by the local Fire Department and 23 patients were transferred to area hospitals. The CEO said that 11 out of the 23 patients returned to the second floor of the hospital the next day. The CEO said that all water damaged coving was removed and was being replaced.

The Surveyors toured the facility at 8:15 A.M. on 4/3/19. The Surveyors observed construction personnel, not wearing masks, pushing a large utility cart over-filled with large boards covered with dust and plaster and wheeling the cart onto the patient elevators on the first floor. The Surveyors observed visible dust and debris in the patient elevator. The CEO confirmed that the construction material was being removed from the first floor using the patient elevator. The Surveyors observed white colored dust on the hand rails and floors of the second floor outside of the elevators and hallways outside the patient rooms. The Surveyors observed several visitors and patients using the elevators throughout the day.

The Surveyors interviewed the CEO at 8:00 A.M. on 4/4/19. The CEO said that testing was performed on 4/3/19 in the areas that were affected by the pipe burst and that the tests results showed that the first floor and basement kitchen areas had tested positive for asbestos (a toxic material/carcinogen).

Review of the document titled "Phase I Environmental Site Assessment" dated September 2016, indicated that previous asbestos testing was performed on the Hospital and asbestos was identified in the vinyl floor tiles and associated mastic, some areas were "suspect" to contain asbestos including drywall and associated joint compound, thermal system insulation (TSI), pipe wrap, and dropped ceiling tiles.

Based on observation the Hospital failed to have a system for prompt disposal of trash in accordance with Federal, State and local laws and regulations (i.e., EPA, OSHA, CDC, state environmental, health and safety regulations).

Surveyors toured the Hospital's kitchen at 8:15 A.M. on 4/3/19. Surveyors observed two kitchen push carts with ten trays of half eaten food, pudding. apple sauce and milk containers. The kitchen carts were next to large food trucks containing trays of food inside. The Director of Plant Operation confirmed that the kitchen was inoperable and that no food was delivered to the patient care areas and there were no kitchen staff working in the kitchen since 3/31/19.

The Surveyors requested food and kitchen policies on 4/9/19 and the Hospital was unable to provide the information due to the area being taped off because of asbestos exposure.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's Director of Maintenance and Chief Executive Officer (CEO), the Facility failed to annually review the Emergency Preparedness Program. The emergency preparedness program must include an Emergency Plan that must be developed and maintained. The plan must be evaluated and updated at least annually.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings Include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was observed that the Facility failed to conduct an annual review of the Emergency Preparedness Plan. The plan was not dated as to when it was reviewed nor did interview indicate that an annual evaluation of the Emergency Preparedness Plan had been conducted.

As a result, the Facility failed to comply with Emergency Preparedness development and annual review requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance (DOM), the Facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Program addressing the resident population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Facility-based Emergency Preparedness Program failed to provide the following in the written emergency plan:

1. Strategies the Facility has put in place to address the needs of at-risk or vulnerable patient populations;
2. Services the Facility would be able to provide during an emergency;
3. How the Facility plans to continue operations during an emergency;
4. Delegations of authority and succession plans.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance (DOM), the Facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Program addressing a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide documentation of the Facility's efforts to contact emergency officials, and its participation in collaborative and cooperative planning efforts.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on documentation review and staff interview, the Facility failed to ensure that policies and procedures of the emergency preparedness plan include a system to track the location of sheltered patients in the Facility's care during an emergency. If the the sheltered patients are relocated during the emergency, the Facility must document the specific name and location of the receiving facility or other location.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings Include:

Although the Facility did have a procedure to track on-duty staff during an emergency, a review of the Facility's emergency preparedness policies and procedures documentation, conducted on 4/3/19, indicates that the policies and procedures do not include a system to track the location of sheltered patients if they are relocated to another location during an emergency. The Facility must document the specific name and location of the receiving facility or other location.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance (DOM), the Facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Program policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide policies and procedures that document the medical record documentation system the Facility has developed to preserve resident information, protect confidentiality of resident information, and secure and maintains availability of records.

During the evacuation of the LTAC unit on 3/31/19, the Director of Nursing stated the paper medical records were transported with the patients to the receiving facility.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish and maintain a Emergency Preparedness Program policies and procedures for the arrangements the facility has with other facilities and other providers to receive patients in the event of limitations or cessations of operations to maintain the continuity of services to facility patients.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide updated policies and procedures that documents the arrangements and/or any agreements the facility has with other facilities to receive patients in the event the Facility is not able to care for them during an emergency. In addition, there was no arrangement for transportation in the event of an evacuation.

Interview with the CEO indicated that the Facility does have an arrangement with two hospitals; however, the agreement was not available for review. It was also stated that the Facility routinely contracts with a few ambulance companies for transportation and these companies would be utilized in event of emergency.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Program policies and procedures for the role of the Facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide policies and procedures that documents the role of the Facility in providing care and treatment at alternate care sites under an 1135 waiver.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's Administrator, Director of Nurses, and Director of Maintenance (DOM), the facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Program policies and procedures for the Facility's written communication plan.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide any policies and procedures that documents the Facility's written communication plan.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish and maintain a comprehensive Emergency Preparedness Program policies and procedures for the Facility's written communication plan to include names and contact information for all of the following:
1. Federal, State, tribal, regional, or local emergency preparedness staff.
2. Other sources of assistance.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide a policy and procedure that documents the Facility has a written communication plan that includes names and contact information for all Federal, State, tribal, regional, or local emergency preparedness staff.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish, review, and maintain updated at least annually, a comprehensive Emergency Preparedness Program policies and procedures for methods for sharing information

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program's communication plan failed to provide policies and procedures that documents:

1. A method for sharing information and medical documentation for patients under the Facility's care, as necessary, with other health providers to maintain the continuity of care.
2. A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1).
3. A means of providing information about the general condition and location of patients under the Facility's care as permitted under 45 CFR 164.510(b)(4).

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish, review, and maintain updated at least annually, an Emergency Preparedness Program policy and procedure for providing information about the facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Emergency Preparedness Program failed to provide policies and procedures that document the Facility's method for providing information about the Facility's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish, review, and maintain updated at least annually, a facility Emergency Preparedness Program training and testing program.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Facility-based Emergency Preparedness Program failed to provide written policies and procedures that document the Facility's method for Emergency Preparedness Program training and testing that meets that requirements of the regulation.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on plan review and interview with the Facility's CEO and Director of Maintenance, the Facility failed to develop, establish, review, and maintain a facility Emergency Preparedness Program training program meeting all requirements.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of an actual emergency.

Findings include:

On 4/3/19 while reviewing the Emergency Preparedness Program, it was revealed that the Facility-based Emergency Preparedness Program failed to provide a written policies and procedures that document the Facility's method for Emergency Preparedness Program training including all of the following:

1. Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role.
2. Provide emergency preparedness training at least annually.
3. Maintain documentation of the training.
4. Demonstrate staff knowledge of emergency procedures.

As a result, the Facility failed to comply with Emergency Preparedness requirements.

This was acknowledged by and reviewed with the CEO and the Director of Maintenance during the exit conference.

This Standard is not met as evidenced by:

Based on observation and staff interview with the Director of Maintenance (DOM) , the Facility failed to ensure compliance with the requirements of the 2012 edition of NFPA 99, Health Care Facilities Code.

This Facility is licensed for 198-beds. This deficient practice could affect the current census of 43 patients, as well as an undetermined amount of staff and visitors in the event of a loss of normal power.

As a result of a flood and evacuation of the LTAC unit on the first floor and the basement level, the remote common audible alarms for the emergency generators are no longer located in a location readily observed by operating personnel at a regular work station in compliance with NFPA 110, 2010 edition, Section 5.6.5.2 and NFPA 99.

NFPA 110, 2010 edition
5.6.6 Remote Controls and Alarms. A remote, common audible alarm shall be provided as specified in 5.6.5.2(4) that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel.

5.6.6.1 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again.

5.6.6.2 In lieu of the requirement in 5.6.6.1, a manual alarm silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

NFPA 99, 6.4.1.1.16 Requirements for Safety Devices.
6.4.1.1.16.1 Internal Combustion Engines. Internal combustion engines serving generator sets shall be equipped with the following:
(1) Sensor device plus visual warning device to indicate a water-jacket temperature below that required in 6.4.1.1.11
(2) Sensor devices plus visual pre-alarm warning device to indicate the following:
(a) High engine temperature (above manufacturer's recommended safe operating temperature range)
(b) Low lubricating oil pressure (below manufacturer's recommended safe operating range)
(c) Low water coolant level
(3) Automatic engine shutdown device plus visual device to indicate that a shutdown took place due to the following:
(a) Overcrank (failed to start)
(b) Overspeed
(c) Low lubricating oil pressure
(d) Excessive engine temperature
(4) Common audible alarm device to warn that one or more of the pre-alarm or alarm conditions exist.

6.4.1.1.16.2 Safety indications and shutdowns shall be in accordance with Table 6.4.1.1.16.2.

6.4.1.1.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning

(2) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 6.4.1.1.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
(f) Overspeed

6.4.1.1.17.1* A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6]

6.4.1.1.17.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm has been silenced, it reactivates after the fault condition has been cleared and has to be restored to its normal position to be silenced again. [110:5.6.6.1]

6.4.1.1.17.3 In lieu of the requirement of 5.6.6.1 of NFPA110, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action. [110:5.6.6.2]

FINDINGS INCLUDE:

The Hospital currently has four operable emergency generators serving the buildings. They are as follows:
#1 - 115 kW natural gas generator serving the non-operable operating rooms and associated areas.
#2 - 85 kW natural gas generator also serving the non-operable operating rooms and associated areas.
The #3 -250 kW diesel & #4 -300 kW diesel generator that are currently not functioning. Two portable diesel fueled emergency generators have been wired through the existing generators to provide the required emergency power. The portable generator serving as Generator # 3 is rated for 200 kW. The portable generator serving as Generator #4 is rated for 400 kW. It was stated that generators #3 and #4 are the sole generators serving all occupied areas, associated equipment, and support spaces.

The annunciator panel for generator #3 is located in the electric room in the basement level near the kitchen. The annunciator for generator #4 is located in the basement mechanical room. Remote, common audible alarms indicating the generators #1, 2, 3, & 4 had a warning, pre-alarm or alarm condition, were located at the nurses station of the LTAC unit. Since the LTAC unit is no longer occupied, the generator annunciator panels are not located in an area readily observed by operating personnel at a regular work station

As a result, the emergency generator annunciator panels are not in accordance with NFPA 99, Section 6.4.1.1.17.

This was acknowledged by and reviewed with the Director of Maintenance by telephone after completion of the onsite Emergency Preparedness survey.