HospitalInspections.org

Based on observation and interview the facility failed to provide two-hour fire rated separation between the hospital and the attached business occupancy and the attached long term care facility by not having listed wall assemblies and by not having walls that are complete from exterior wall to exterior wall and from floor to floor or floor to roof deck and by having non-rated windows in the wall assemblies and by having doors in openings that do not have the required minimum one and one-half hour fire rating. The facility also allowed unsealed penetrations of portions of the walls that were designed to a two-hour fire-rated design. This deficiency has the potential to allow a fire to spread beyond the compartment of origin and extends travel distances beyond the required limits. The deficient practice affects all residents, staff and visitors of the facility.
Findings are:
Observation on February 25, 2014 at 9:30am revealed that there was a penetration of the two-hour fire wall above doors 1159A that was not fire-stopped to a listed design for a two-hour fire rating.
An interview with Maintenance B on February 25, 2014 at 9:30am revealed that doors 1159A and the adjacent wall were to be part of the two-hour fire-rated separation and that the hole around a communications cable was not fire-stopped.
Observation on February 25, 2014 at 9:39am revealed that there were several unsealed penetrations of the two-hour fire-rated wall above the ceiling in room 1159 and that the wall was not complete from floor to roof deck.
An interview with Maintenance B on February 25, 2014 at 9:39am revealed that the north wall of room 1159 was part of the two-hour fire rated separation and that there were several unsealed penetrations and that the wall was not complete from floor to roof deck.
Observation on February 25, 2014 at 9:43am revealed that the two-hour fire wall in room 1231 had several penetrations that were not fire-stopped and that the wall was not complete from floor to roof deck and the joints in the fire code drywall were not taped.
An interview with Maintenance B on February 25, 2014 at 9:43am revealed that the wall in room 1231 was to be part of the two-hour fire-rated separation and that there were several unsealed penetrations of the wall and that the drywall did not extend from floor to roof deck and that the joints in the outer layer of drywall were not taped.
Observations on February 25, 2014 between 9:45am and 10:15am revealed that the rest of the wall between the facility and the Outpatient rehab area was not a two-hour fire-rated assembly and that the wall contained windows that were not fire-rated.
An interview with Maintenance B on February 25, 2014 between 9:45 and 10:15 revealed that rest of the wall between the facility and the outpatient rehab building was not a listed two-hour assembly and that the window was not fire-rated.

Based on documentation review and interview, the facility failed to provide documentation on the corridor finish materials that verify the products meet interior finish requirements. This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96.
Findings include:

1. Documentation review on 2/25/2014 at 11:32 a.m. revealed that the rigid vinyl sheets indicate that the information will be provided to verify the flame spread rating of the material, but no documentation of the actual flame spread can be found.
2. Documentation review on 2/25/2014 at 2:25 p.m. revealed that the paperwork for the carpet in the facility is over 10 years old and gives no location to where the product was installed in the facility.
Maintenance A confirmed the findings.

Based on observation and staff interview, the facility failed to maintain positive latching of corridor doors. This condition had the potential to allow smoke and fire to migrate into the exit corridor. Facility census was 49.

Findings are:
Observation during the facility tour on 3/5/14, from 8:59 am to 9:04 am revealed
1. The Patient Room 202 door failed to latch. A wheel chair obstructed the door.
2. The Gym Double Doors failed to latch when self-closed.
In an interview conducted at the time of observation, (3/5/14, from 8:59 am to 9:04 am), Maintenance B acknowledged that the doors failed to latch.

Based on observation and staff interview, the facility failed to mark exits by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. This condition would not allow occupants to efficiently evacuate the facility during a fire or other emergency. Facility census was 49.

Findings are:
Observations during the facility tour on 3/5/14, at 8:44 am revealed an exit sign failed to be installed over the 2300C Smoke Doors by Room 226.
In an interview conducted at the time of observations (3/5/14, at 8:44 am), Maintenance B acknowledged that an exit sign was not visible in these areas.

Based on observation and staff interview, the facility failed to ensure that smoke separation doors would prevent smoke from escaping into other smoke compartments. Facility census was 49.

Findings are:
Observations during the facility tour on 3/5/14, at 8:51 am revealed a gap between the meeting edges of the 2260A Smoke Doors failed to be sealed.
In an interview conducted at the time of observations, (3/5/14, at 8:51 am), Maintenance B acknowledged the condition of the doors.

Based on interview and observation the facility failed to provide smoke protection for hazard areas, by not assuring doors would latch within the door frame. This practice affected all patients, visitors and staff that use the second floor. The facility census was 49 and capacity of 96.

Findings are:
Observations on 3-5-14 at 10:28 am revealed, the door to Locker Room 2321 failed to latch within the door frame.

During an interview on 3-5-14 at 10:28 am, Maintenance A confirmed the door failed to latch.

Based on observation and interview, the facility failed to prevent an exit stairwell to be free of the storage of combustibles. This deficient practice has the potential to interfere and delay egress in the stair, which affects occupants during an emergency. The facility census was 49 and capacity of 96.

Findings are:
Observations on 3-5-14 at 9:18 am revealed, east stair enclosure contained a chair stored within the exiting enclosure.

During an interview on 3-5-14 at 9:18 am, Maintenance A confirmed the items within the stair in the exit stair enclosure.

NFPA Standard:
There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. 2000 NFPA 101, 7.2.2.5.3

Based on documentation review and interview, the facility failed to provide documentation that emergency lighting is tested per NFPA requirements. This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96
Findings include:

1. Documentation review on 2/25/2014 at 10:55 a.m. revealed that the weekly emergency light test papers showed very little information.
2. Documentation review on 2/25/2014 at 10:56 a.m. revealed that no documentation was provided to indicate emergency lighting had been tested to the 1 ? hour annual requirement.
Maintenance A confirmed the findings.

Based on observation and interview the facility failed to have the fire alarm system installed and maintained in accordance with NFPA 72, The National Fire Alarm Code, by not providing the required minimum sound levels of 60dba throughout the facility, by not having the electrical branch circuits identified at the fire alarm control units and by not providing mechanical protection for the fire alarm electrical branch circuits. This deficient practice has the potential to delay response to a fire alarm by not providing notification to the staff and by allowing parts of the fire alarm to shut off inadvertently and by preventing rapid access to fire alarm circuits in an emergency. The facility failed to provide documentation that the fire alarm system is tested and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72 National Fire Alarm Code. This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96
A. Findings are:
Observation on February 25, 2014 at 10:46am revealed that the fire alarm electrical branch circuit for the main fire alarm control panel was not mechanically protected to prevent it from being accidentally being turned off.
An interview with Maintenance B on February 25, 2014 at 10:46am revealed that there was no mechanical protection for the electrical circuit that supplied the main fire alarm control panel.
Observation on February 25, 2014 at 10:47am revealed that the location of the dedicated branch circuit for the main fire alarm panel was not identified at the main fire alarm control panel.
An interview with Maintenance B on February 25, 2014 at 10:47am revealed that there were no markings on the main fire alarm control panel to indicate the location of the electrical circuit supplying it.
Observation on March 3, 2014 between 9:50am and 9:56am during a test of the fire alarm system revealed that there was not 60 dba of audible notification in the corridors outside the ambulance bay and outside room 0148.
An interview with Maintenance B on March 3, 2014 between 9:50am and 9:56am during a test of the fire alarm system revealed that the fire alarm could barely be heard in the corridors outside the ambulance bay and outside room 0148 and that the reading on the meter was not at least 60 dba.
NFPA 72, 1999ed. 1-5.2.5.2
Connections to the light and power service shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit.



27394

B. Findings are:
1. Documentation review on 2/25/2014 at 10:56 a.m. revealed the fire alarm inspection reports show no calibration testing.
2. Documentation review on 2/25/2014 at 10:57 a.m. revealed that the inspection report from April, 2012 indicate deficiencies in the notes and no documentation can be found to show those deficiencies have been corrected.
3. Documentation review on 2/25/2014 at 10:59 a.m. reveal that the in a one year time frame, no smoke detectors were tested for functionality.
4. Documentation review on 2/25/2014 at 1:38 p.m. revealed that no documentation was provided indicating central receiving station is receiving fire alarms and no daily dialer test.
5. Documentation review on 2/25/2014 at 2:00 p.m. revealed that no documentation was provided for the testing and maintenance on the smoke control system.
Maintenance A confirmed the findings.

Based on observation and interview the facility failed to identify the multiple fire department connections and multiple post indicating valves as to the areas of the facility that are served by them. This deficient practice has the potential to delay fire department suppression response in the event of a fire by possibly not connecting the correct sprinkler system for the area of the building. This deficient practice would affect all residents, staff and visitors of the facility.
Findings are:
Observation on February 27, 2014 between 9:50am and 10:15am during a tour of the exterior of the building revealed that there were three post indicating valves and five fire department connections on the exterior of the building and none of them were marked to indicate the areas of the building served.
An interview with Maintenance E on February 27, 2014 between 9:50am and 10:15 am during a tour of the exterior of the building revealed that there was no signage at any of the post indicating valves or any of the fire department connections on the building.
NFPA 13, 1999ed. 3-8.3* Identification of Valves.
All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.
NFPA 13, 1999ed. 5-15.2.3.4
Where a fire department connection services only a portion of a building, a sign shall be attached indicating the portions of the building served.
NFPA 13,1999ed. 5-15.2.3.5
Fire department connections shall be on the street side of buildings and shall be located and arranged so that hose lines can be readily and conveniently attached to the inlets without interference from any nearby objects including buildings, fences, posts, or other fire department connections.
Each fire department connection to sprinkler systems shall be designated by a sign having raised or engraved letters at least 1 in. (25.4 mm) in height on plate or fitting reading service design - for example,
AUTOSPKR., OPEN SPKR. AND STANDPIPE
A sign shall also indicate the pressure required at the inlets to deliver the greatest system demand.

Based on observation, documentation review and interview, the facility failed to provide documentation that the automatic sprinkler system is being tested and maintained per the requirements of NFPA 13. This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96.

A. Findings are:
1. Documentation review on 2/25/2014 at 11:00 a.m. revealed that the only sprinkler reports that were provided were for the St. James building and for the year 2013.
2. Documentation review on 2/25/2014 at 2:40 p.m. revealed that only 1 internal five year pipe inspection was provided. No other systems had documentation to show this test has been completed.
Maintenance A confirmed the findings.



27395

B. Findings are:
Observation during the facility tour on 3/5/14, at 8:49 am revealed the shower curtain in the Patient Room 2293 Bathroom failed to be installed so that it did not obstruct the sprinkler head.
In an interview conducted at the time of observation, (3/5/14, at 8:49 am), Maintenance B confirmed the findings.

Actual NFPA Standard:
5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

Based on observation and interview, the facility failed to maintain portable fire extinguishers in accordance with NFPA 10 by doing a monthly inspection of the extinguisher, which has the potential to impact the operation of fire extinguisher in the event of a fire and allow smoke to spread to other compartments on the second floor. The facility census was 49 and capacity of 96.

Findings are:
Observations on 2-5-14 at 9:39 am revealed, the fire extinguishers in the corridor near Room 2318 failed to have a current monthly inspection.

During an interview on 3-5-14 9:39 am, Maintenance A confirmed the lack of inspections

NFPA Standard:
Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require. 2002, NFPA10, 4-3.1
Periodic inspection of fire extinguishers shall include a check of at least the following items: 2002, NFPA 10, 4-3.2
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Based on observation and interview, the facility failed to provide documentation that the kitchen hood and suppression system is being inspected and maintained per the requirements of NFPA 96.
This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96.

Findings are:
1. Documentation review on 2/25/2014 at 10:50 a.m. revealed that the kitchen hood inspection report cites holes in the hood that need to be sealed and no documentation to show that has been completed.
Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to provide documentation that all draperies, curtains and other loosely hanging materials comply with flame spread requirements of NFPA. This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96.

Findings are:
1. Documentation review on 2/25/2014 at 11:30 a.m. revealed that the paperwork for the privacy curtains shows no proof that the curtains are flame retardant. The paperwork only states that the curtains have been tested, but does not state to what standard and the results.
2. Documentation review on 2/25/2014 at 12:07 p.m. reveal that the paperwork for the vinyl blinds in patient rooms is very faded and unable to be read to verify if the blinds meet all code requirements.
3. Documentation review on 2/25/2014 at 2:20 p.m. revealed that the paperwork for the mattresses does not specify that it meets the NFPA code requirements.
Maintenance A confirmed the findings.

Based on observation and interview the facility failed to maintain the bulk liquid oxygen system in accordance with NFPA 99 by not having the required signage on the tanks and by allowing parking within ten feet of the tank. This deficient practice has the potential of rendering the oxygen supply system for both the normal and reserve systems inoperable in the case of an accident or fire around the bulk oxygen tanks. This deficient practice could affect all residents on oxygen within the facility.
Findings are:
Observation on February 26, 2014 between 9:15am and 10:00am revealed that the bulk oxygen tanks were not permanently placarded with " OXYGEN-NO SMOKING-NO OPEN FLAMES " signs.
An interview with Maintenance B on February 26, 2014 between 9:15am and 10:00am revealed that there was no such placarding on the bulk oxygen tanks.
Observation on February 26, 2014 between 9:15am and 10:00am revealed that there was a facility vehicle parked on the south side of the main bulk oxygen tank within 10 feet of the tank.
An interview with Maintenance B on February 26, 2014 between 9:15am and 10:00am revealed that the vehicle did belong to the facility and that it was parked less than 10 feet from the tank.
NFPA 50, 2001ed. 2.2.12
The minimum distance from any bulk oxygen system to any public sidewalk or parked vehicle shall be 10 ft (3 m).
NFPA 50, 2001ed. 3.5.8.
The bulk oxygen storage location shall be permanently placarded to indicate " OXYGEN - NO SMOKING - NO OPEN FLAMES. "

Based on observation and interview the facility failed to install and maintain the emergency generator in accordance with NPFA 110 by not having the generator room separated from the remainder of the building by a minimum of two-hour fire-rated construction and by not having a remote shut-down for the generator outside the generator room itself. This deficient practice has the potential for a problem with the emergency generator to spread outside the generator room and limit the ability to control the problem with the generator in an emergency. This deficient practice would affect all residents, staff and visitors of the facility.
Findings are:
Observation on February 25, 2014 at 10:16am revealed that the generator room was not separated from the remainder of the building by a minimum of two-hour fire-rated construction by having many penetrations of the walls that were not fire-stopped to listed design to maintain the fire resistance rating of the wall.
An interview with Maintenance B on February 25, 2014 at 10:16am revealed that the penetrations of the walls of the emergency generator room were not sealed at all.
Observation on February 25, 2014 at 10:23am revealed that the door to the emergency generator room, while rated, was not self-closing and positive latching in accordance with NFPA 80.
An interview with Maintenance B on February 25, 2014 at 10:23am revealed that the door to the emergency generator room was not self-closing and positive latching when opened.
Observation on February 25, 2014 at 10:44am revealed that there was no remote shutdown for the emergency generator other than the one located on the generator itself.
An interview with Maintenance B on February 25, 2014 at 10:44am revealed that there was no other shutdown device for the emergency generator other than the device on the generator itself.

NFPA 110, 2002ed. 7.2.1.1
The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes.
NFPA 110, 2002ed. 5.6.5.6
All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

Based on observation and interview, the facility failed to provide documentation that the laboratory has fire and evacuation policies in place and practices those procedures. This practice has the potential to affect all staff, patients and visitors of the facility. Facility had a census of 49 and a capacity of 96.

Findings are:
1. Documentation review on 2/25/2014 at 10:30 a.m. revealed that no documentation was provided to show that special fire drills and evacuation drills were being conducted in the laboratory area.
Maintenance A confirmed the findings.

Based on observation and interview, the facility failed to post oxygen signage on Storage Room 3233. This deficient practice was located on the second level and would affect all patients in the area. The facility census was 49 and capacity of 96.

Findings are:
Observations on 3-5-14 at 8:42 am revealed, oxygen stored in Room 2322, the facility failed to provide oxygen in use signage.

During an interview on 3-5-14 at 8:42 am, Maintenance A confirmed the lack of signage on the door.

NFPA Standard:
Precautionary signs, readable from a distance of 5 feet, shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. 1999 NFPA 99, 8-6.4.2

Based on observation and staff interview, the facility failed to provide mechanical ventilation for an oxygen transfer room in accordance with the National Fire Protection Association 99. This condition had the potential to create an oxygen enriched atmosphere. Facility census was 49.

Findings are:
Observation during the facility tour on 3/5/14, at 8:53 am revealed the vent fan for the Oxygen Transfer Room was shut off. The fan failed to run continuously.
In an interview conducted at the time of observation, (3/5/14, at 8:53 am), Maintenance B confirmed that a switch turned the fan on and off.

Nebraska State Fire Marshal Official Interpretation 01-01

Based on observation and interview, the facility failed to provide documentation that the generator is properly tested at weekly intervals and under load on a monthly basis. This practice has the potential to affect all staff, patients and visitors to the facility. Facility had a census of 49 and a capacity of 96.

Findings are:
1. Documentation review on 2/25/2014 at 10:33 a.m. revealed that no documentation was provided that showed the generator monthly load testing.
2. Documentation review on 2/25/2014 at 10:34 a.m. revealed that no documentation was provided to show the time of transfer for the generator.
3. Documentation review on 2/25/2014 at 10:41 a.m. revealed that no documentation was provided to show the annual load bank test.
Maintenance A confirmed 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.
Findings are:
Observation on February 25, 2014 at 10:33am revealed that the Life Safety panel EWSB contained Critical branch loads for the Nurse Call system.
An interview with Maintenance B on February 25, 2014 at 10:33am revealed that circuits #2 and #6 were labeled as nurse call power and are not permitted on the life safety branch.
Observation on February 25, 2014 at 10:41am revealed that the Critical branch panel ECWB contained non-critical loads for television systems and boiler controls.
An interview with Maintenance B on February 25, 2014 at 10:41am revealed that circuit #7 was labeled for CATV/Tel Elec. Rm. 004 and circuit #11 was labeled Boiler level control and that these were not permitted on the critical branch.
Observation on February 25, 2014 at 11:03am revealed that the Critical Branch panel ECXB contained loads that are required to be on the Life Safety branch.
An interview with Maintenance B on February 25, 2014 at 11:03am revealed that circuit #13 was labeled FACP PAD and that this was a fire alarm circuit and is required to be connected to the Life Safety branch.
Observation on February 25, 2014 at 11:20am revealed that the Life Safety branch panel ESH2 contained non-life safety loads for some procedure room lighting.
An interview with Maintenance B on February 25, 2014 at 11:20am revealed that circuit #6 was labeled as Procedure 2320 lights and that this task lighting was not permitted on the life safety branch.

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 interview the facility failed to identify the multiple main disconnects and to identify the type, size and location of the emergency power supply system at the main service disconnect for the building to alert responding personnel that there is an alternate source of power in the building and that shutting off the main service disconnect will not turn off all power in the building in the case of an emergency. The facility also failed to correctly identify all feeders and branch circuits and failed to maintain the integrity of the electrical equipment. The facility failed to assure power strips and extension cords were used as permanent wiring for mobile television carts on the second floor. This deficient practice would affect residents in the event of an electrical fire. The facility census was 49 and capacity of 96.

A. Findings are:
Observations on 3-5-14 at 9:34 am revealed, two mobile television carts with extension cords and power strips which are used within patient rooms.

During an interview on 3-5-14 at 9:34 am, Maintenance A confirmed the mobile carts with the power strips and extension cords.

Regulation:
Nebraska State Fire Marshal Official Interpretation 08-01
Nebraska State Fire Marshal Official Interpretation 87-11




20404

B. Findings are:
Observation on February 25, 2014 at 10:27am revealed that there were unidentified loads being served from the equipment system panel EQH.
An interview with Maintenance B on February 25, 2014 at 10:27am revealed that there was a 60 amp three pole breaker in slots 34, 36, & 38 that was in the on position and that the circuit directory indicated these as open spaces.
Observation on February 25, 2014 at 10:41am revealed that the Critical branch panel ECWB was not dead front.
An interview with Maintenance B on February 25, 2014 at 10:41am revealed that slots 8, 10, & 12 in critical branch panel ECWB were open to exposed live buss and that the cover was not dead front.
Observation on February 25, 2014 at 10:42am revealed that there was no signage installed at the main electrical service disconnect to indicate the presence of an emergency power system.
An interview with Maintenance B on February 25, 2014 at 10:42am revealed that there was no signage at the main service disconnect to indicate the presence and type of emergency system installed for the facility.
Observation on February 25, 2014 at 10:58am revealed that the circuit directory for the equipment system panel ECXC was not complete.
An interview with Maintenance B on February 25, 2014 at 10:58am revealed that there were circuits in the equipment system panel ECXC were not identified to their use.
Observation on February 25, 2014 at 11:03am revealed that the circuit directory for the critical branch panel ECXB was not complete and accurate.
An interview with Maintenance B on February 25, 2014 at 11:03am revealed that there was a 30 amp three pole breaker in slots 7,9, & 11 that was not identified as to its use.
Observation on February 25, 2014 at 11:17am revealed that the normal panel HW2 was not dead front.
An interview with Maintenance B on February 25, 2014 at 11:17am revealed that the high voltage panel HW2 had two openings that were just covered with duct tape and not dead front.
NFPA 70, 1999ed. 700-8(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.
NFPA 70, 1999ed. 110-22 Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.
NFPA 70, 1999ed. 384-18 Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.

Based on observation and interview the facility failed to have Alcohol Based Hand Rub (ABHR) dispensers installed so that they are not above or immediately adjacent to an electrical ignition source. This deficient practice affected all residents, staff, and visitors in the areas of the ABHR. The facility capacity is 49 and the census was 96.


A. Findings are:
Observations on 3-5-14 between 8:18 am and 8:25 am revealed:
1. ABHR dispenser installed adjacent to light switch in Room 250.
2. ABHR dispenser installed adjacent to light switch in Room 248.
3. ABHR dispenser installed adjacent to light switch in Room 243.

During an interview on 3-5-14 between 8:18 am and 8:25 am, Maintenance A confirmed the ABHR dispensers were installed immediately adjacent or above to electrical sources.

Regulation:
Nebraska State Fire Marshal Official Interpretation 05-04



27395

B. Findings are:
Observations on 3/5/14, at 9:02 am revealed an ABHR failed to be installed so that it was not directly over a light switch in Patient Room 203.
In an interview conducted at the time of observation, (3/5/14, at 9:02 am), Maintenance B confirmed the location of the ABHR.