Downtown Brooklyn Nursing & Rehabilitation Center
June 20, 2017 Certification Survey

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 16, 2017

Citation Details

2011 NFPA 70: 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 2011 NFPA 70: 590.2 All Wiring Installations. (A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (B) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation. 590.3 Time Constraints. (A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. (B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes. (C) Emergencies and Tests. Temporary electric power and lighting installations shall be permitted during emergencies and for tests, experiments, and developmental work. (D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed. Based on observation and staff interview, extension cords and multi outlet adapters were noted in use in the facility. This was observed on two of five floors of the facility. The findings are: On 6/16/17 between 9:30am- 2pm during the recertification survey, extensions cords and multi outlet adapters were noted in use in the facility. Examples are: 1) In the Med Room on the 5th floor, a multi outlet adapter was observed in use. 2) In the Blood Work Room on the 4th floor, an extension cord was plugged into a power strip then plugged into the wall outlet. In an interview on 6/15/17 at approximately 11:15am, the Administrator stated that the Life Safety Consultant had installed the adapters for the med carts to be charged. He also stated will check if he has paperwork to provide that the adapter meets the UL standards. At the time of the exit, no paper work was presented to verify compliance with the regulations. In an interview on 6/15/2017 at approximately 11:25am, the Administrator stated he will have the extension cord removed immediately. 2011 NFPA 70: 400.8, 590.2 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedAugust 31, 2017

Element 1
The Director of Facilities Management and his team will go through every room and look at every outlet to ensure the following:
1. That no surge protectors/extension cords exist in any patient areas
2. If surge protector/extension cord, exist in a non-patient area, that they are affixed to the wall
3. If surge protector/extension cord, exist in a non-patient area, that they are not daisy chained to another surge protector/extension cord
4. That no multi outlet adapters that are in use that are not UL listed
8/8/17
Element 2
All areas of the facility have been inspected and no findings exist.
8/15/17
Element 3
Director of Facilities Management will maintain a log of any non-patient rooms and outlets that contain an extension cord/surge protector. Should an outlet need to be changed from a duplex outlet receptacle to a quad outlet receptacle, it will be hard wired and non-movable.
8/16/17
Element 4
Director of Facilities Management will monitor compliance by auditing the aforementioned log, ensuring that only those identified rooms/outlets have UL listed surge protectors/extension cords.
The maintenance team will conduct monthly audits as part of their safety rounds.
8/16/17
Element 5
Director of Facilities Management will be responsible
8/16/17

K307 NFPA 101:RAMPS AND OTHER EXITS

REGULATION: Ramps and Other Exits Ramps, exit passageways, fire and slide escapes, alternating tread devices, and areas of refuge are in accordance with the provisions 7.2.5 through 7.2.12. 18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 20, 2017
Corrected date: August 18, 2017

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that handrails were provided in the exit ramp leading to outside of the facility. Reference is made to the ramp to prospect avenue. The Finding is: On (MONTH) 16, (YEAR) between the hours of 10:00 am and 3:00 pm during the recertification survey, a ramp was observed on the main floor leading to prospect avenue. Further observation revealed that no handrail was observed in this area. Residents have access to this area in the event of an emergency situation. In an interview with the Maintenance Director and Adminstrator on 06/19/2017 at approximately 2:08 pm, they stated that in a conversation with the Architect, the facility has more than enough exits and that the ramp may not be needed. 2012 NFPA 101: 19.2.2.6 to 19.2.2.10

Plan of Correction: ApprovedAugust 31, 2017

Element 1
The Director of Facilities Management will contact the vendor who will come in and provide a proposal for the installation of handrails down the exit ramp.
8/10/17
Element 2
There are no other areas of the facility that require corrective action
Element 3
Director of Facilities Management will coordinate the design and installation of the permanent handrail that will exist on the exit ramp in accordance with NFPA 101
8/11/17
Element 4
The Director of Facility Management will monitor compliance by ensuring that the exit ramp has hand rails down the length of the exit to Prospect Place.

Element 5
Director of Facilities Management will be responsible