HospitalInspections.org

Based on observation the facility failed to provide acceptable smoker barrier separations.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were penetrations in smoke barriers in the following locations: 1) at the end of the 200 corridor, 2) in the 100 corridor near the physician lounge, 3) in the 100 corridor next to the nurse station, 4) near the physical therapy room, and 5) near the laboratory.

Based on observation the facility failed to provide a complete fire alarm system.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that the FACP did not have the panel/breaker labeled on the door of the unit that supplies power to the FACP.

Based on observation the facility failed to provide an acceptable fire sprinkler installation.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were problems with the sprinkler heads in the following locations: 1) the electrical room at physical therapy had a missing head, 2) the back of the sterilizers had a ceiling tile falling down around a sprinkler head making the head less effective, and 3) the gift shop did not have a sprinkler head.

Based on observation the facility failed to provide an acceptable fire extinguisher.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that the fire extinguisher for the emergency generator was out of date.

Based on observation the facility failed to provide an acceptable medical gas installation.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were the following problems: 1) the bulk oxygen enclosure had combustible plastic slats in the fence, 2) there were combustibles stored adjacent to the bulk oxygen enclosure, and 3) there was a truck parked within 10 feet from the bulk oxygen enclosure, 4) there was only one alarm for the medical gas and that was at the reception desk (there must be two with the second in the maintenance area), and 5) the medical gas zone valve outside of room 307 was difficult to read, the lettering must be legible.

Based on observation the facility failed to provide an acceptable emergency generator space.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were the following problems with the emergency generator: 1) there was corrosion on the battery terminal of the 300 KW generator, 2) there was oil on the floor of the generator room, 3) the generator space did not have an emergency light with 90 minute battery backup on the life safety branch of the EES, and 4) the generator had only one alarm which was at the reception desk (there shall be a second alarm in the maintenance department).

Lack of Grounding System Tests.

NFPA 99, 1999, 3-3.4.2.3(a) states that testing shall be performed after initial installation, replacement or servicing of a device, and that additional testing shall be performed at intervals defined by documented performance data. If the facility has documented performance data for the electrical receptacles in all patient care areas then the schedule defined by this data will be acceptable. In the absence of the data the following schedule shall be maintained by the facility. Receptacle testing shall be performed in all general care areas every 12 months and in critical care areas every 6 months. (NFPA 99, 1984).

Based on observation the facility failed to provide any logs of ground system tests.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were no grounding system tests. The grounding test shall include the following:

NFFA 99, 1999, 3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).


Lack of Line Isolation Monitor Tests.

" The proper functioning of each line isolation monitor (LIM) circuit shall be ensured by the following:
(a) The LIM circuit shall be tested after installation, and prior to being placed in service, by successively grounding each line of the energized distribution system through a resistor of 200 V ohms, where V = measured line voltage. The visual and audible alarms [see 3-3.2.2.3(b)] shall be activated.
(b) The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch [see 3-3.2.2.3(f)]. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.
(c) After any repair or renovation to an electrical distribution system and at intervals of not more than 6 months, the LIM circuit shall be tested in accordance with paragraph (a) above and only when the circuit is not otherwise in use. For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. " - N.F.P.A. 99, 1999, 3-3.3.4.2

Based on observation the facility failed to provide any records of line isolation monitor tests.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were no line isolation test logs.


Lack of HVAC Filter Logs.

Based on observation the facility failed to provide any logs of HVAC filter changes.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were no HVAC filter change logs.

Based on observation the facility failed to provide acceptable generator test data.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there was not any test data for the larger 300 KW generator after the date of 9/6/2010. This was the same generator that showed corrosion on the battery terminals. The second generator was a 90 KW generator and the test data appeared complete.

Based on observation the facility failed to provide an acceptable electrical installation.

The inspector observed while accompanied by the Maintenance Worker during the hours of the inspection from 9:30 am to 2:30 pm that there were the following problems with the electrical system: 1) the electrical room at physical therapy had panels that were without directories and appeared to be unlabeled critical panels, critical panels must have the label " CRITICAL " present on the front of the panel, 2) in the 200 wing the patient rooms and treatment room #1 did not have hospital grade electrical outlets, 3) the PACU and the ORs must have the electrical receptacles labeled with the panel/breaker that supplies power to that receptacle.