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Based on document review and interview the facility failed to provide documented evidence that emergency preparedness policies and procedures that were developed address the subsistence water needs for staff and patients.

This deficient practice had the potential to result in inadequate supply of drinking water and water for other purposes to all patients and staff during a disaster affecting the hospital and effectively meet the hydration and personal care needs of patients.

Finding:

On 8/2/18 at 1:18 p.m., the review of the facility's disaster preparedness plan indicated that there was no documented evidence that an assessment had been made to determine the quantity of water needed for drinking, cleaning and food preparation.
During the review above, the Disaster Coordinator stated that the Dietary Director had the breakdown of the quantity of water needed.

The review of the documents provided by the Dietary Director revealed that the assessment to determine the quantity of water had not been done.

Based on document review and interview the facility failed to provide documented evidence that emergency preparedness policies and procedures were developed to address a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

This deficient practice had the potential of not securing and ensuring that patient records were readily available to support continuity of care during an emergency.

Findings:

During the review of facility's disaster preparedness plan by the evaluator on 8/2/18 at 1:18 p.m., the evaluator noted that there was no documented evidence that the facility had developed a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records.

During the review above, the Disaster Coordinator stated that policies and procedures that addressed a system of medical documentation, that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records will be placed in the disaster preparedness plan.

Based on document review and interview the facility failed to provide documented evidence that emergency preparedness communication plan that included a method for sharing information and medical documentation for patients under the facility's care, with other health providers to maintain the continuity of care was developed by the facility.

This deficient practice had the potential to create a delay in providing necessary information to the next care provider as regards the provision of effective patient treatment and continuity to evacuated patient.

Finding:

During review of the facility's disaster preparedness plan, by the evaluator noted that there was no documented evidence of a plan that included a method for sharing information and medical documentation for patients under the facility's care, with other health providers to maintain the continuity of care.

During the review, the Disaster Coordinator stated that information for sharing patient medical information and documentation with other health providers was not in the plan.

Based on document review and interview the facility failed to inspect, test, and maintain the emergency power system.

This deficiency had the potential to interfere/disrupt continuity of electricity during the interruption of normal electrical service.

Findings:

1. On 7/31/18 at 10 a.m., the evaluator observed that the sight glass of the fuel gauge at the emergency generator's day tank was weathered opaque, so that the fuel level in the tank could not be read.

During an interview at the same time as the observation, the Mechanical Engineer stated that he did not know how much fuel was in the day tank because he could not read the fuel gauge.

During a second interview at the same time as the observation the Director of Facilities stated that there was no other way to determine how much fuel was in the tank.

2. On 8/2/18 at 11 a.m., during the review of the Emergency Generator Monthly Test Log, the evaluator was unable to find/obtain any documented evidence that transfer time of emergency power was being tested.

During an interview at the same time as the document review, the Director of Facilities stated that the transfer time was between 8 to 10 seconds but that the transfer times were not being documented because there was no place on the log to document the times, and that the log would be recreated to include a place to enter transfer times.


3. On 8/2/18 at 11 a.m., during review of the Emergency Generator Monthly Test Log by the evaluator there was no documented evidence that the transfer switch was being inspected and tested.

During an interview at the same time as the document review, the Director of Facilities stated that the transfer switch was being tested monthly but that there is no documented evidence because the in house engineer was using the wrong form in the log that does not have a place for documenting the test.

Based on observation and interview the facility failed to ensure walls in a Type I construction were constructed of noncombustible or limited-combustible materials.

The deficiency had the potential for the combustible material to not provide the fire-resistive construction level of protection of noncombustible or limited-combustible material.

The deficiency had the potential of not providing the required fire-resistive construction level for combustible material which would provide the fire resistance rating protection for walls where non-combustible or limited-combustible materials were used.

Findings:

On 7/31/18 at 9:30 a.m. the Director of facilities stated the building was a three story Type I construction building with only the basement sprinklered.

1. On 8/1/18 between 12:30 p.m. and 1 p.m., the evaluator observed in non-sprinklered room 341 of the 3rd floor Adult In Patient (AIP 1). The evaluator noted that there was missing paint at a wall. Closer observation of the exposed unfinished surfaces revealed the wall was constructed of plywood.

During an interview and observation, the Director of Facilities stated that the drywall was replaced by plywood because the patients damage the drywall.

2. On 8/1/18 between 12:30 p.m. and 1 p.m., the evaluator observed in non-sprinklered room 345 of the 3rd floor Adult In Patient (AIP 1) that there was missing paint at a wall. Closer observation of the exposed unfinished surfaces revealed the the wall was constructed of plywood.

During an interview and observation, the Director of Facilities acknowledged the plywood wall.

3. On 8/1/18 between 2:01 p.m. and 2:15 p.m., the evaluator observed in non-sprinklered room 212 of the 2nd floor Children In Patient (CIP 2) that there was missing paint at a wall. Closer observation of the exposed unfinished surfaces revealed the wall was constructed of plywood.

During an interview and observation, the Director of Facilities acknowledged the plywood wall.

NFPA 101 Life Safety Code 2012 Edition

7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure unobstructed full instant use of an exit door.

The deficiency had the potential to delay or prevent the rapid evacuation of occupants.

Findings:

On 7/31/18 at 10:43 a.m., the evaluator observed that the medical records room in the basement and noted that the second exit door was obstructed from fully opening by a shredding bin, a storage bin and a wire basket.

During an interview at the same time as the observation the Director of Facilities acknowledged that the exit door was obstructed from closing.

NFPA 101 Life Safety Code 2012 Edition

7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure an exit and directional sign were clearly and correctly displayed.

The deficiency had the potential to delay or prevent the rapid evacuation of occupants.

Findings:

1. On 7/31/18 at 10:43 a.m., the evaluator observed that an exit sign was obstructed from view from the occupied center of the room in the basement.


2. On 8/1/18 at 9:55 a.m., the evaluator observed there was no directional exit sign at the first floor of the Children Out Patient (COP) waiting area. Closer observation revealed there was a paper exit sign posted at a wall where there was not an exit.

During an interview at the same time as the observation, the Director of Facilities stated that paper sign would be removed and that a directional exit sign that points to the exit would be placed at exits.

This is a repeat deficiency. On 5/27/18 during a Life Safety Code survey the facility received a similar deficiency for not providing a directional exit sign at the 3rd floor stairway.

NFPA 80 Standard for Fire Doors and Other Opening Protectives 2010 Edition

4.2.1* Listed items shall be identified by a label.

4.2.2 Labels shall be applied in locations that are readily visible and convenient for identification by the AHJ after installation of the assembly.

5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

This standard was not met as evidenced by:

Based on observation, interview, and document review there was no visible and/or documented evidence of the rating of two vertical fire doors and no documented evidence of annual inspection and testing of the doors.

The label or the listing is considered evidence that samplings of the door assembly has been evaluated for a certain fire resistance rating. Inspection and testing of the doors help ensure that the doors will function as designed during a fire emergency.

Findings:

1. On 8/1/18 at 12:30 p.m., the evaluator observed that there was a drop down fire door in the 3rd floor Adult In Patient (AIP 1) that would separate nurses station one from the day room. There was no label on or around the door of inspection and testing of the door. Closer observation revealed that the fire rating plate on the door was painted over and illegible.

During an interview at the same time as the observation the Director of Facilities stated there was documented record of the door's current inspection and test.

During document review there was no documented evidence presented that the door being inspected and tested.

2. On 8/1/18 at 1 p.m., the evaluator observed there was a drop down fire door in the 3rd floor Adult In Patient (AIP 1) that would separate a nurses station from the charting room. There was no label on or around the door of inspection and testing of the door. Closer observation revealed the fire rating plate on the door was painted over and was illegible.

During an interview at the same time as the observation, the Director of Facilities stated there was documented record of the door's current inspection and test.

During document review there was no documented evidence presented of the door being inspected and tested.

Based on observation and interview the facility failed to maintain the fire and smoke resistance of hazardous areas separations

The deficiency had the potential support the growth/propagation of fire and smoke during a fire emergency.

Findings:

1. On 7/31/18 at 10:17 a.m., the evaluator observed 13 two-inch diameter penetrations through the wall separating the maintenance shop from the main electrical panel room in the basement.

This is a repeat deficiency. During a Life Safety Code survey on 5/27/18, the facility received a deficiency for having penetrations through the electrical room in the basement.

2. On 7/31/18 at 10:27 a.m., the evaluator observed a two-inch diameter penetration through a boiler room wall in the basement.

During interviews at the same time as the observations, the Director of Facilities acknowledged the penetrations.

3. On 7/31/18 at 10:30 a.m., the evaluator observed that the shop storage room corridor door had a missing lockset thereby, creating a two-inch diameter penetration through the door.

During an interview at the same time as the observation, the Director of Facilities stated that the penetration through the door was caused by the removal of a lockset, and that he did not know who removed or when it was removed, and that the penetration should not have been there.

4. On 8/1/18 the evaluator observed seven 1 inch diameter penetrations through the ceiling of the Information Technology (IT) server room at 2nd floor administration, and one 1 inch by 2 inch penetration in the adjoining IT office.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition

10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:

(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A Standard for Wet Chemical Extinguishing Systems 2009 Edition

4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.

7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:

(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.

These Standards were not met as evidenced by:

Based on observation and interview the facility failed to maintain the kitchen's wet chemical fire-extinguishing system's nozzle blowoff caps intact as designed.

The deficiency had the potential to allow grease vapors, moisture, or other foreign materials to enter/penetrate the nozzle piping of the wet chemical fire-extinguishing
system and for the system not to work as designed in the event of a fire.

Findings:

1. On 8/1/18 at 10:05 a.m., the evaluator observed that eight of nine blow off caps were not placed on the nozzles of the suppression system located above the cooking range and deep fryer at the first floor Kitchen.

During an interview at the same time as the observation the Director of Facilities acknowledged the that the caps needed to be placed on the nozzles.

2. On 8/1/18 at 10:21 a.m., the evaluator observed one of one blow off cap was not placed on the nozzle of the suppression system located above the cafeteria grill cooking area.

NFPA 72 National Fire Alarm and Signaling Code 2010 Edition

14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.


14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

This Code was not met as evidenced by.

Based on observation and interview the facility failed to provide documented evidence of sensitivity test of the smoke detectors, results of the test, and corrections if applicable.

The deficiency had the potential that the smoke detectors would not function as designed during a fire emergency.

Finding:

On 8/2/18 at 9:50 p.m., document review, the evaluator noted that there was no documented evidence to show that the facility conducted the sensitivity test of the smoke detectors.

During an interview at the same time as the document review, the Director of Facilities stated that he could not find the smoke detector sensitivity test report.

NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition

8.5.6.1* Unless the requirements of 8.5.6.2, 8.5.6.3, 8.5.6.4, or 8.5.6.5 are met, the clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

This Standard was not met as evidenced by:

Based on observation and interview the facility failed to ensure and 18 inch clearance between sprinkler deflectors and the top of storage.

The deficiency had the potential prevent or delay fire suppression by obstructing sprinkler spray patterns and coverage.

Finding:

On 7/31/18 at 10:46 a.m., the evaluator observed storage of items that etended to the ceiling where the sprinkler is located at the kitchen storage room located in the basement.

During an interview at the same time as the observation, the Director of Facilities acknowledged the deficiency and the Dietary Director stated that the stored items would be removed to allow for the 18 inch clearance between sprinkler deflectors and the top of storage.

NFPA 10 Standard for Portable Fire Extinguishers 2010 Edition

6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:

(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

6.1.3.10.1 Cabinets housing fire extinguishers shall not be locked, except where fire extinguishers are subject to malicious use and cabinets include a means of emergency access.

This Standard was not met as evidenced by:

Based on observation and interview the facility failed to ensure a fire extinguisher was properly secured, and another fire extinguisher was readily accessible.

The deficiency had the potential to delay or prevent the use of a fire extinguisher by causing damage to the fire extinguisher, and preventing immediate access to a fire extinguisher.

Findings:

1. On 7/31/18 at 10:38 a.m., the evaluator observed the weight of a fire extinguisher being sustained by the extinguishers hose on a bracket in the fan room located in the basement.

During an interview at the same time as the observation, the Director of Facilities acknowledged the fire extinguisher was incorrectly secured in a manner that had a potential to damage the hose of the fire extinguisher thereby, hindering its use.

2. On 7/31/18 at 10:54 a.m., the evaluator observed that the cabinet handle was missing at the fire extinguisher and hose cabinet located at the basement corridor by elevator 1 and 2. Further observation revealed that the Director of Facilities had to pry the cabinet door open with a key.

During an interview at the same time as the observation the Director of Facilities stated that a handle would be installed on the cabinet.

NFPA 101 Life Safety Code 2012 Edition

19.3.6.3.13 Dutch doors shall be permitted where they conform to 19.3.6.3 and meet all of the following criteria:

(1) Both the upper leaf and lower leaf are equipped with a latching device.
(2) The meeting edges of the upper and lower leaves are equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous areas, the doors comply with NFPA-80, Standard for Fire Doors and Other Opening Protectives.

This Code was not met as evidenced by:

Based on observation the hospital failed to ensure corridor doors could resist the passage of smoke and that there were no impediments to the latching of corridor doors.

Doors protecting corridor openings play an integral role in interrupting the spread of smoke.

Findings:

1. On 7/31/18 at 10:30 a.m., the evaluator observed that the corridor door of the shop storage room at the basement had a two inch diameter penetration through the door.

During an interview at the same time as the observation the Director of Facilities stated that the penetration was created by a removed lockset, but did not know when the lockset was removed, and that there should not have been a penetration through the door.

2. On 8/1/18 at 12:30 p.m., the evaluator observed that the corridor door of room 352 at 3rd floor Adult In Patient (AIP 1) failed to hold closed when shut.

During an interview at the same time as the observation the Director of Facilities stated that the door failed to hold in the closed position because, the wrong type of strike plate was installed.

3. On 8/1/18 at 12:30 p.m., the evaluator observed that the corridor door of room 347, a treatment room at 3rd floor Adult In Patient (AIP 1), was a Dutch door that did have an astragal where the top and bottom leaves meet.

4. On 8/1/18 the evaluator observed the corridor door of room 345 at 3rd floor Adult In Patient (AIP 1) was missing.

During an interview at the same time as the observation, the Director of Facilities stated that the door was removed about one week ago because it was broken and that they were waiting for the replacement door.

5. On 8/1/18 the evaluator observed that the corridor door of room 22 at 2nd floor Children In Patient (CIP 2) failed to hold closed when shut.

During an interview at the same time as the observation, the Director of Facilities stated the door failed to hold closed because the strike plate was misaligned.

NFPA 101 Life Safety Code 2012 Edition

8.5.3 Fire Barrier Used as Smoke Barrier. A fire barrier shall be permitted to be used as a smoke barrier, provided that it meets the requirements of Section 8.5.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a firebarrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

This Code was not met as evidenced by:

Based on observation the hospital failed to ensure smoke barriers and a fire barrier were maintained to restrict the transfer of smoke.

Smoke barriers assist to limit the spread the movement of smoke, limit the number of occupants exposed to a single fire and create a safe relocation area. If left unsealed, fire, smoke and toxic gases driven by the heat and pressure of a fire may move through the penetrations and travel to other parts of the building.

Findings:

1. On 8/1/18 at 9:18 a.m., the evaluator observed that the fire barrier wall above the cross corridor doors near room 348 at the 3rd floor Adult In Patient (AIP 1) had a 1 inch diameter penetration.

During an interview at the same time as the observation, the Director of Facilities identified the wall as a fire barrier wall.

2. On 8/1/18 at 9:26 a.m., the evaluator observed that the smoke barrier wall above the ceiling separating the corridor from room 325, an office at the 3rd floor Adult In Patient (AIP 2) had a 1 inch diameter penetration.

During an interview at the same time as the observation, the Director of Facilities stated he could see the penetration.

3. On 8/1/18 at 9:37 a.m., the evaluator observed that the smoke barrier wall above the double doors at the 2nd Floor Mezzanine between the elevator and the children hospital had two penetrations that were 2 inch by 3 inch penetration and 1 inch by 3 inch.

During an interview at the same time as the observation, the Director of Facilities acknowledged the penetration.

NFPA 70 National Electrical Code 2011 Edition

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a
recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

This Code were not met as evidenced by:

Based on observation and interview the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by having storage in the main electrical panel room, having an electrical receptacles with a damaged faceplate.

Storage can delay or prevent access to the electrical panel and can act as a conductor. Damaged and or missing electrical receptacle coverplates can expose energized electrical parts thereby, creating a risk of electric shock, burn injuries and fire.

Finding:

1. On 7/31/18 at 10:17 a.m., the evaluator observed the main electrical panel room in the basement was used to store three metal ceiling light fixtures, a ball, and a large 4 foot by 5 foot framed mirror. the items were located between the main electrical panel and the wall.

During an interview at the same time as the observation that the Director of Facilities stated that the storage would be removed from the main electrical panel room.

2. On 7/31/18 at 10:51 a.m., the evaluator observed a broken electrical cover plate at the wall mounted electrical receptacle at the corridor wall across from elevators 1 and 2 in the basement.

During an interview at the same time as the observation, the Director of Facilities acknowledged the broken coverplate.

NFPA 101 Code for Safety to Life from Fire in Buildings and Structures 2000 Edition

19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:

(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.

(2) Smoking by patients classified as not responsible shall be prohibited.

Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.

(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.

(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

A.19.7.4 The most rigid discipline with regard to prohibition of smoking might not be nearly as effective in reducing incipient fires from surreptitious smoking as the open recognition of smoking, with provision of suitable facilities for smoking. Proper education and training of the staff and attendants in the ordinary fire hazards and their abatement is unquestionably essential. The problem is a broad one, varying with different types and arrangements of buildings; the effectiveness of rules of procedure, which need to be flexible, depends in large part on the management.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to adopt smoking regulations for patients that smoke.

Findings:

On 8/2/18 at 11:27 a.m., during document review,the evaluator noted that there was no documented evidence that smoking regulations were adopted for smoking by patients including:
1. Smoking in prohibited areas,
2. Designated smoking areas,
3. Which patients are prohibited from smoking,
4. Which patients are allowed to smoke,
5. Supervision of patients smoking,
6. Providing ashtrays of noncombustible material and safe design in all areas where
smoking is permitted, and
7. Providing metal containers with self-closing cover devices into which ashtrays can
be emptied readily available to all areas where smoking is permitted.

Review of the Smoke Free Environment Policy and Procedure, numbered 7080.7577.53 with a revised date of 3/1/2008, indicated that the purpose of the policy was to provide guidelines for governing a smoke free work environment, and that the scope of the policy was applicable to all employees. The policy had no indications in it for smoking by patients.

During an interview at the same time as the document review, the Director of Facilities stated that there is Smoking Therapy for patients at the AIP 1 smoking patio.

NFPA 99 Health Care Facilities Code 2012 Edition

6.4.1.1.8.1 The EPS shall be installed in a separate room for Level 1 installations. EPSS equipment shall be permitted to be installed in this room. [110:7.2.1]
(A) 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. [110:7.2.1.1]

6.4.4.1.1.1 Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenance parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 6.4.1.1.10 and 6.4.3.1.


NFPA 110 Standard for Emergency and Standby Power Systems 2010 Edition

8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.

8.3.5* Transfer switches shall be subjected to a maintenance and testing program that includes all of the following operations:
(1) Checking of connections
(2) Inspection or testing for evidence of overheating and excessive contact erosion
(3) Removal of dust and dirt
(4) Replacement of contacts when required

8.4.6 Transfer switches shall be operated monthly.

8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.

This Code and Standard were not met as evidenced by:

Based on observation, record review and interview the facility failed to maintain and test the Essential Electric System.

This deficiency had the potential of not ensuring the continuity of electricity to the facility during the interruption of normal electrical service.

Findings:

1) On 7/31/18 at 10 a.m., the sight glass of the fuel gauge at the emergency generator's day tank was weathered opaque, so that the fuel level in the tank could not be read.

During an interview at the same time as the observation the Mechanical Engineer stated that he did not know how much fuel was in the day tank because he could not read the fuel gauge.

During a second interview at the same time as the observation, the Director of Facilities stated that there was no other way to determine how much fuel was in the tank.

2) On 7/31/18 at 10:17 a.m., the transfer switches, components of the emergency power system were located in main electrical panel room. Closer observation revealed that the wall separating the main electrical panel room from the maintenance shop had 13 two-inch diameter penetration through it.

This is a repeat deficiency, on 5/27/18 during a Life Safety Code survey. The facility recieved a deficiency for having penetrations through the electrical room in the basement.

3) On 8/2/18 at 11 a.m., during review of the Emergency Generator Monthly Test Log, the evaluator noted that there was no documented evidence that transfer time of emergency power was being tested.

During an interview at the same time as the document review, the Director of Facilities stated that the transfer time was between 8 to 10 seconds but that the transfer times were not being documented because there was no place on the log to document the times, and that the log would be recreated to include a place to enter transfer times.

4) On 8/2/18 at 11 a.m., during review of the Emergency Generator Monthly Test Log, the evaluator noted that there there was no documented evidence that the automatic transfer switch (ATS) was being inspected and tested.

During an interview at the same time as the document review, the Director of Facilities stated that the ATS was being tested monthly but that there was no documented evidence because the in-house engineer was using the wrong form in the log that does not have a place for documenting the test.

This is a repeat deficiency. On 5/27/18 during a Life Safety Code survey, the facility recieved a deficiency for not having documented evidence that the ATS was being inspected and tested.

NFPA 70 National Electrical Code 2011 Edition

400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:

(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

400.9 Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by 400.7(A). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400.4) 14 AWG and larger shall be permitted if conductors are spliced in accordance with 110.14(B) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by using extension cords as permanent wiring.

To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles, extension cords and/or power strips are often interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire.

Findings:

1. On 7/31/18, 8/1/18 and 8/2/18, the evaluator observed a daisy chain of extension cords that in turn was connected to a second power strip that was connected to a wall mounted electrical receptacle in the conference room of the 2nd Floor Administration.

2. On 8/1/18 at 1:26 p.m., the evaluator observed doctor office 8 on the 3rd floor Adult Out Patient (AOP) with daisy chain of extension cords that was connected to a power strip that was connected to a wall mounted electrical receptacle.

During an interview at the same time as the observation, Director of Facilities acknowledged the daisy chained extension cords.

3. On 8/1/18 at 1:26 p.m., the evaluator observed that in a social worker office on the 3rd floor Adult Out Patient (AOP) with an extension cord that was passed under the carpet across a threshold that was connected to a wall mounted electrical receptacle.

During an interview at the same time as the observation. the Director of Facilities acknowledged the extension cord that was used as permanent wiring that ran across the doorway and concealed under the carpet.

NFPA 99 Health Care Facilities Code 2012 Edition

11.6.2.3 Cylinders shall be protected from damage by means
of the following specific procedures:

(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm - not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure an oxygen cylinder was secure, empty and full cylinders were segregated, and empty cylinders were marked.

The deficiency had the potential of the oxygen cylinder falling. If the valve of the cylinder were knocked off the high potential energy inside the cylinder could render the cylinder a projectile that could penetrate a concrete wall. The deficiency also had the potential for a nurse to pick up an empty oxygen cylinder in an emergency.

Findings:

1. On 8/1/18 at 10:43 a.m., on the 1st Floor of the Administration, in a room identified as Clinic by a paper sign posted on the door, the the evaluator observed one of six oxygen cylinder stored insecurely and left standing on the floor.

During an interview at the same time as the observation, the Director of Facilities stated an oxygen storage rack would be obtained.

2. On 8/1/18 10:43 a.m., on the 1st Floor of the Administration, in a room identified as Clinic by a paper sign posted on the door, the the evaluator observed that there were 5 oxygen cylinders stored together and one cylinder on a crash cart without signaled identifying which cylinders were empty and which were full.

During an interview at the same time as the observation the Director, of Facilities acknowledged there was no signaled, and stated that the crash cart was not functioning.