HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by one penetration in a wall. This affected one of six floors in the main hospital, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the walls and ceilings were observed.

10/24/12 - Main Hospital - First Floor

At 8:30 a.m., there was an approximately 1 1/2 inch penetration in the wall of the closet in the cafeteria.

Based on observation, the facility failed to maintain the corridor doors, as evidenced by coridor doors that failed to latch. This affected three of six floors. This could result in the spread of smoke and fire throughout the facility.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the corridor doors were observed.


29665

10/23/12 - Emergency Department - First Floor

At 11:06 a.m., the door to Treatment Room 12 released from its magnetic automatic-closing device during fire alarm testing. The door failed to latch.

10/24/12 - Tower 2 - Fourth Floor

At 8:34 a.m., the corridor door to the housekeeping closet was equipped with a self-closing device. The door closed, but failed to latch.

10/24/12 - Tower 2 - Third Floor

At 8:56 a.m., the corridor door to the housekeeping closet was equipped with a self-closing device. The door closed, but failed to latch.

Based on observation and interview, the facility failed to ensure that vertical openings were maintained as one-hour fire barriers. This was evidenced by unsealed conduits penetrating more than one floor of the hospital. This affected four of six floors in Tower 2, and could result in the spread of smoke and fire from one floor to the other, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the vertical openings were observed.

10/25/12 - Tower 2 - Fifth Floor

At 4:19 p.m., there were two approximately 3 inch conduits in the floor of the mechanical room. The top of the conduits were covered with red tape. Engineering Staff 2 removed the tape, and the conduits were not sealed.
During an interview at 4:20 p.m., Engineering Staff 2 stated that the conduits penetrated the fifth and fourth floors.

10/24/12 - Tower 2 - Third Floor

At 9:00 a.m., there was an approximately 1 inch unsealed conduit, with a cable going through, in the floor of the mechanical room.
During an interview at 9:01 a.m., Engineering Staff 2 stated that the conduit penetrated the third and second floors.

Based on observation and interview, the facility failed to ensure that doors in smoke barriers automatically close upon activation of the fire alarm system. This was evidenced by smoke barrier doors that failed to close upon activation of the fire alarm system. This affected one of six floors in the main hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with engineering staff, from 10/22/12 to 10/25/12, the smoke barrier doors were observed.

10/23/12 - Emergency Department - First Floor

At 11:04 a.m., a fire alarm pull station was tested in the emergency department. Four of four smoke barrier doors in the department, and the door to Treatment Room 12, were held open by magnetic hold-open devices. The doors failed to release from the magnets, and failed to automatically close, upon activation of the fire alarm manual pull station.

During an interview at 11:05 a.m., Engineering Staff 1 and Engineering Staff 3 stated that the smoke barrier doors in the Emergency Department were designed to release from the magnets and automatically close only upon activation of the smoke detectors. They stated that the doors were not designed to close upon activation of the manual pull stations, or the automatic sprinkler system.



moved from K27-
10/23/12 - Main Building - First Floor

At 11:24 a.m., the smoke barrier double doors to the cafeteria lounge were held open with electronic automatic-closing devices. The left door failed to automatically close upon activation of the fire alarm system.

At 11:26 a.m., the smoke barrier double doors, near the stairs to the administrative offices, were held open with electronic automatic-closing devices. Both doors failed to automatically close upon activation of the fire alarm system.



29665

Based on observation and interview, the facility failed to maintain their smoke barrier walls. This was evidenced by one smoke barrier wall that was lined with fiberglass insulation, and by penetrations in the draft stop at one offsite building. This affected one of six floors in the main hospital, and the Radiology/Oncology Services suite, and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
3.3.47 Draft Stop. A continuous membrane used to subdivide a concealed space to restrict the passage of smoke, heat, and flames.
19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions.
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the smoke barrier walls were observed.

10/23/12 - Main Hospital - First Floor

At 10:46 a.m., the 2 hour smoke barrier wall, into the cafeteria, was observed above the ceiling. There was pink-colored insulation lining approximately 6 feet by 4 feet of the right side of the smoke barrier wall.
During an interview at 10:47 a.m., Engineering Staff 3 stated that the construction of the smoke barrier wall appeared to be incomplete, and that the insulation was fiberglass.

10/25/12 - Radiology/Oncology Services

At 10:01 a.m., there was an approximately 4 inch by 3 inch penetration in the center of the draft stop, above the ceiling of the dosimetry office, with wires going through. There was an approximately 4 inch round penetration in the lower part of the draft stop.

Based on observation, the facility failed to ensure that hazardous areas were protected by smoke resistant partitions and self-closing doors. This was evidenced by a room containing combustible storage, and a mechanical room, with no self-closing doors. This affected two of six floors in the main hospital, and could result in the spread of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft (4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the hazardous areas were observed.

10/23/12 - Main Hospital - Second Floor

At 3:56 p.m., the Surgery and Critical Care Unit storage room was greater than 50 square feet in size, and contained boxes and plastic containers of supplies. The door to the storage room was not equipped with a self-closing device.

10/24/12 - Main Hospital - First Floor

At 9:08 a.m., the corridor door to the electrical/mechanical room in the Emergency Department was not equipped with a self-closing device.

Based on record review and interview, the facility failed to ensure that fire drills were conducted under varying conditions. This was evidenced by fire drills that were conducted at similar times during the evening and night shifts. This affected the Chemical Dependency Unit, and could result in a delay in staff response, in the event of a fire.

Findings:

During document review with engineering staff, from 10/22/12 to 10/25/12, the fire drills records were reviewed.



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10/25/12 - Chemical Dependency Unit

At 9:31 a.m., records showed that fire drills for the overnight shift were not conducted under varying conditions. Three of three fire drills, conducted during the overnight shift in 2012, were held between 12:35 a.m., and 12:39 a.m.

Based on observation and interview, the facility failed to ensure that manual fire alarm boxes were accessible. This was evidenced by one fire alarm pull station that was mounted approximately 6 feet above the floor. This affected one of six floors in the main hospital, and could result in a delay in notification, in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.1 Mounting. Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3 1/2 ft (1.1 m) and not more than 4 1/2 ft (1.37 m) above floor level.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the fire alarm system was observed.

10/24/12 - Main Hospital - First Floor

At 9:45 a.m., Pull Station 12, in the North Wing outside the physical therapy room, was mounted more than 4 1/2 feet above the floor.
During an interview at 9:46 a.m., Engineering Staff 2 stated that the pull station was approximately 5 feet 10 inches above the floor.

10/23/12 - Endoscopy Unit - First floor
At 10:25 a.m., the smoke detector in Treatment Room 2 failed to activate an alarm when sprayed with canned smoke for approximately two minutes.
At 10:28 a.m., the smoke detector in the patient care area failed to activate an alarm when sprayed with canned smoke for approximately two minutes.







29665

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by incomplete documentation for sensitivity testing, by no records for testing one smoke detector, and by smoke detectors that failed during fire alarm testing. This affected six of six floors in the main hospital, and could result in a delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector 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/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the smoke detectors were observed, and maintenance records reviewed.

10/23/12 - Tower 2 - Third Floor

At 9:14 a.m., the self-closing device on the door into the utility area, next to Room 2333, had a built-in smoke detector. No records for testing the device were provided.
During an interview at 10:55 a.m., Engineering Staff 1 stated that the smoke detector in the door closer was not connected to the fire alarm system, and was not tested.

10/23/12 - Main Hospital

At 2:31 p.m., a document titled "Sensitivity Reacceptance Test Results for 2009" was provided. The document showed sensitivity testing of 54 smoke detectors, on 2/3/10 to 2/11/10, that failed sensitivity testing in 2009. Documents titled "Work Order & Installation Report" were provided showing dates during February, 2010, when the heads were replaced and tested for "alarm and trouble conditions." There were no records for testing the smoke detector sensitivity in February, 2012.
During an interview at 2:32 p.m., Engineering Staff 2 stated that there were not other testing records for review.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to maintain an 18 inch clearance from the sprinkler heads, by foreign material on sprinkler heads, and by escutcheon rings that were not flush to the ceiling. This affected two of six floors in the main hospital, and two of six smoke compartments in the Chemical Dependency Unit. This could result in the automatic sprinkler system not functioning as designed in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition
2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the automatic sprinkler system was observed.

10/23/12 - Main Hospital - Second Floor

At 4:05 p.m., there was electrical equipment on the top shelf in the Electrical Equipment Storage, Room 13, that obstructed the sprinkler head.

10/24/12 - Main Hospital - First Floor

At 9:46 a.m., there were boxes on the top shelf, in the Endoscopy Suit supply closet, that were stored approximately 11 inches from the sprinkler head.

At 10:35 a.m., there was foreign material on the sprinkler head in the pharmacy walk-in refrigerator, in the pharmacy department.

10/25/12 - Chemical Dependency Unit

At 10:20 a.m., one of two sprinkler heads, in the kitchen walk-in refrigerator, had foreign material on the deflector and the escutcheon plate.

At 10:40 a.m., there was white paint-like material on the deflector and escutcheon ring of the sprinkler head in the 500 Hallway linen closet.



29665

10/24/12 - Main Hospital - First Floor

At 9:30 a.m., the escutcheon ring, in the linen closet of the Maternity Department, was installed upside down, and was approximately 3 inches from the ceiling, revealing a penetration around the sprinkler pipe.

10/24/12 - Main Hospital

At 11:15 a.m., records for testing of the 556 fire dampers by an outside vendor on 8/12/11, indicated that 56 fire dampers failed, and required repair. The facility failed to provide records of repair for 20 of the 56 dampers that failed on 8/12/11.






29665

Based on record review and interview, the facility failed to maintain their heating, ventilating, and air conditioning systems, as evidenced by fire dampers that were not repaired, and by fire dampers that were not tested. This affected six of six floors in the main hospital, and the chemical dependency unit. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the fire dampers were observed and maintenance records requested. Damper testing records for the Chemical Dependency Unit were requested from Engineering Staff 1 on 10/23/12.

10/25/12 - Chemical Dependency Unit (CDU)

At 10:25 a.m., fire dampers were observed above the ceiling and labels for fire damper service openings were observed throughout the building. No records for testing the fire dampers were provided for review.
During an interview at 10:26 a.m., Engineering Staff 1 stated that they could not locate records for testing the CDU fire dampers.

Based on observation and interview, the facility failed to ensure that portable space heaters meet the temperature requirements for not more than 212?F, for use in non-sleeping staff and employee areas. This was evidenced by no temperature specifications provided for a portable space heater used in an office area. This affected one of six floors in the main hospital, and could result in an increased risk of a fire.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the portable space heaters were observed.

10/24/12 - Main Hospital - First Floor

At 9:35 a.m., a portable space heater was plugged in and turned on, in the medical records office. The portable space heater was located on the floor, between office furniture. The label on the portable space heater read 1500 watts, and no information regarding the maximum temperature was provided.
During an interview at 9:36 a.m., Engineering Staff 3 and a medical records staff member did not know the portable space heater's maximum temperature.

Based on observation, the facility failed to maintain their trash collection receptacles, as evidenced by trash collection receptacles greater than 32 gallons in capacity that were not stored in a room protected as a hazardous area. This affected two of six floors in Tower 2, and could result in an increased risk of a fire.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the trash collection receptacles were observed.

10/23/12 - Tower 2 - Sixth Floor

At 3:40 p.m., there was a 65-gallon trash collection receptacle, that was approximately 90 percent full of paper, stored in the corridor outside the waiting room.


10/23/12 - Tower 2 - Fifth Floor

At 4:04 p.m., there was a 65-gallon trash receptacle, that was approximately 90 percent full of paper and cardboard, stored in the corridor outside the waiting room

10/24/12 - Emergency Department - First Floor
At 9:20 a.m., there were 6 full oxygen E-cylinders, and 3 empty oxygen E-cylinders, stored in an oxygen rack. The rack was stored approximately 3 1/2 feet away from a linen cart, in the oxygen storage room.






29665

Based on observation and interview, the facility failed to maintain their medical gas storage areas. This was evidenced by medical gas cylinders that were stored in a combustible structure, by medical gas cylinders that were stored less than 5 feet from combustible items, and by electrical fixtures in medical gas storage that were installed less than 5 feet from the floor. This affected one of six floors in the main hospital, and the exterior medical gas cylinder storage area. This could result in the increased risk of a fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
3. Enclosures shall be provided for supply systems, cylinders storage or manifold location for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly building materials with a fire resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert)medical gases shall be permitted to stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the medical gas storage was observed.

10/24/12 - Main Hospital - Exterior Medical Gas Storage

At 10:15 a.m., the exterior medical gas storage areas were observed. There were more than 100 oxygen E-cylinders stored outdoors. In the center of the outdoor oxygen storage area was an approximately 12 foot by 12 foot ventilated wooden storage structure. There were more than 75 oxygen E-cylinders, and more than 17 medical gas H-cylinders in the wooden structure. There was a light switch in the structure that was mounted approximately 44 inches above the floor, and three two-plug outlets that were mounted less than 20 inches above the floor. There were combustible plastics stored less than 4 feet away from the oxygen cylinder racks.
During an interview at 10:16 a.m., Engineering Staff 2 and Engineering Staff 3 stated that the structure was made of wood, and was not fire rated.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by electrical appliances that were plugged into multi-plug power strips and not directly into the wall outlets, and by junction boxes with no cover. This affected three of six floors in the main hospital, the MRI Unit, and the Radiation/Oncology Services suite. This could result in an increased risk of fire.

NFPA 70, National Electrical Code, 1999 Edition
110-12 Mechanical Execution of Work. Electrical Equipment shall be installed in a neat and workman like manner,(a) Unused openings, Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
400-8 Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code


Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the electrical wiring and equipment was observed.

10/23/12 - Tower 1 - Third Floor

At 3:40 p.m., there was a refrigerator, a microwave, and a coffee maker plugged into a multi-plug surge protector in the respiratory lounge.

10/25/12 - Exterior MRI Unit

At 10:50 a.m., there was a junction box, in the MRI Unit, with wires exposed and no cover.


29665

10/24/12 - Main Hospital - First Floor

At 9:21 a.m., there was an approximately 2 1/2 inch round electrical junction with no cover, in the Obstetrics (OB) waiting room storage closet.

At 9:50 a.m., there was an approximately 6 inch by 4 inch electrical box with no cover, in the physical therapy closet.

10/24/12 - Radiation/Oncology Services

At 2:59 p.m., there was an approximately 4 inch by 4 inch electrical box with no cover, in the linear accelerator room.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by one penetration in a wall. This affected one of six floors in the main hospital, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the walls and ceilings were observed.

10/24/12 - Main Hospital - First Floor

At 8:30 a.m., there was an approximately 1 1/2 inch penetration in the wall of the closet in the cafeteria.

Based on observation, the facility failed to maintain the corridor doors, as evidenced by coridor doors that failed to latch. This affected three of six floors. This could result in the spread of smoke and fire throughout the facility.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the corridor doors were observed.


29665

10/23/12 - Emergency Department - First Floor

At 11:06 a.m., the door to Treatment Room 12 released from its magnetic automatic-closing device during fire alarm testing. The door failed to latch.

10/24/12 - Tower 2 - Fourth Floor

At 8:34 a.m., the corridor door to the housekeeping closet was equipped with a self-closing device. The door closed, but failed to latch.

10/24/12 - Tower 2 - Third Floor

At 8:56 a.m., the corridor door to the housekeeping closet was equipped with a self-closing device. The door closed, but failed to latch.

Based on observation and interview, the facility failed to ensure that vertical openings were maintained as one-hour fire barriers. This was evidenced by unsealed conduits penetrating more than one floor of the hospital. This affected four of six floors in Tower 2, and could result in the spread of smoke and fire from one floor to the other, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
8.2.5.4 The fire resistance rating for the enclosure of floor openings shall be not less than as follows (see 7.1.3.2.1 for enclosure of exits):
(1) Enclosures connecting four stories or more in new construction - 2-hour fire barriers
(2) Other enclosures in new construction - 1-hour fire barriers
(3) Existing enclosures in existing buildings - 1/2-hour fire barriers

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the vertical openings were observed.

10/25/12 - Tower 2 - Fifth Floor

At 4:19 p.m., there were two approximately 3 inch conduits in the floor of the mechanical room. The top of the conduits were covered with red tape. Engineering Staff 2 removed the tape, and the conduits were not sealed.
During an interview at 4:20 p.m., Engineering Staff 2 stated that the conduits penetrated the fifth and fourth floors.

10/24/12 - Tower 2 - Third Floor

At 9:00 a.m., there was an approximately 1 inch unsealed conduit, with a cable going through, in the floor of the mechanical room.
During an interview at 9:01 a.m., Engineering Staff 2 stated that the conduit penetrated the third and second floors.

Based on observation and interview, the facility failed to ensure that doors in smoke barriers automatically close upon activation of the fire alarm system. This was evidenced by smoke barrier doors that failed to close upon activation of the fire alarm system. This affected one of six floors in the main hospital, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with engineering staff, from 10/22/12 to 10/25/12, the smoke barrier doors were observed.

10/23/12 - Emergency Department - First Floor

At 11:04 a.m., a fire alarm pull station was tested in the emergency department. Four of four smoke barrier doors in the department, and the door to Treatment Room 12, were held open by magnetic hold-open devices. The doors failed to release from the magnets, and failed to automatically close, upon activation of the fire alarm manual pull station.

During an interview at 11:05 a.m., Engineering Staff 1 and Engineering Staff 3 stated that the smoke barrier doors in the Emergency Department were designed to release from the magnets and automatically close only upon activation of the smoke detectors. They stated that the doors were not designed to close upon activation of the manual pull stations, or the automatic sprinkler system.



moved from K27-
10/23/12 - Main Building - First Floor

At 11:24 a.m., the smoke barrier double doors to the cafeteria lounge were held open with electronic automatic-closing devices. The left door failed to automatically close upon activation of the fire alarm system.

At 11:26 a.m., the smoke barrier double doors, near the stairs to the administrative offices, were held open with electronic automatic-closing devices. Both doors failed to automatically close upon activation of the fire alarm system.



29665

Based on observation and interview, the facility failed to maintain their smoke barrier walls. This was evidenced by one smoke barrier wall that was lined with fiberglass insulation, and by penetrations in the draft stop at one offsite building. This affected one of six floors in the main hospital, and the Radiology/Oncology Services suite, and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
3.3.47 Draft Stop. A continuous membrane used to subdivide a concealed space to restrict the passage of smoke, heat, and flames.
19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
Exception: Listed, fire-retardant-treated wood studs shall be permitted within non-load bearing 1-hour fire-rated partitions.
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the smoke barrier walls were observed.

10/23/12 - Main Hospital - First Floor

At 10:46 a.m., the 2 hour smoke barrier wall, into the cafeteria, was observed above the ceiling. There was pink-colored insulation lining approximately 6 feet by 4 feet of the right side of the smoke barrier wall.
During an interview at 10:47 a.m., Engineering Staff 3 stated that the construction of the smoke barrier wall appeared to be incomplete, and that the insulation was fiberglass.

10/25/12 - Radiology/Oncology Services

At 10:01 a.m., there was an approximately 4 inch by 3 inch penetration in the center of the draft stop, above the ceiling of the dosimetry office, with wires going through. There was an approximately 4 inch round penetration in the lower part of the draft stop.

Based on observation, the facility failed to ensure that hazardous areas were protected by smoke resistant partitions and self-closing doors. This was evidenced by a room containing combustible storage, and a mechanical room, with no self-closing doors. This affected two of six floors in the main hospital, and could result in the spread of smoke and fire in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any Hazardous area shall be safe guarded by a fire barrier having a 1 -hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke -resisting partitions and doors. The doors shall be self-closing or automatic closing. Hazardous shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 square ft (9.3 square m)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 square ft (4.6 square m), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction.
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have non-rated, factory-or field -applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the hazardous areas were observed.

10/23/12 - Main Hospital - Second Floor

At 3:56 p.m., the Surgery and Critical Care Unit storage room was greater than 50 square feet in size, and contained boxes and plastic containers of supplies. The door to the storage room was not equipped with a self-closing device.

10/24/12 - Main Hospital - First Floor

At 9:08 a.m., the corridor door to the electrical/mechanical room in the Emergency Department was not equipped with a self-closing device.

Based on record review and interview, the facility failed to ensure that fire drills were conducted under varying conditions. This was evidenced by fire drills that were conducted at similar times during the evening and night shifts. This affected the Chemical Dependency Unit, and could result in a delay in staff response, in the event of a fire.

Findings:

During document review with engineering staff, from 10/22/12 to 10/25/12, the fire drills records were reviewed.



29665


10/25/12 - Chemical Dependency Unit

At 9:31 a.m., records showed that fire drills for the overnight shift were not conducted under varying conditions. Three of three fire drills, conducted during the overnight shift in 2012, were held between 12:35 a.m., and 12:39 a.m.

Based on observation and interview, the facility failed to ensure that manual fire alarm boxes were accessible. This was evidenced by one fire alarm pull station that was mounted approximately 6 feet above the floor. This affected one of six floors in the main hospital, and could result in a delay in notification, in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.1 Mounting. Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3 1/2 ft (1.1 m) and not more than 4 1/2 ft (1.37 m) above floor level.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the fire alarm system was observed.

10/24/12 - Main Hospital - First Floor

At 9:45 a.m., Pull Station 12, in the North Wing outside the physical therapy room, was mounted more than 4 1/2 feet above the floor.
During an interview at 9:46 a.m., Engineering Staff 2 stated that the pull station was approximately 5 feet 10 inches above the floor.

10/23/12 - Endoscopy Unit - First floor
At 10:25 a.m., the smoke detector in Treatment Room 2 failed to activate an alarm when sprayed with canned smoke for approximately two minutes.
At 10:28 a.m., the smoke detector in the patient care area failed to activate an alarm when sprayed with canned smoke for approximately two minutes.







29665

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by incomplete documentation for sensitivity testing, by no records for testing one smoke detector, and by smoke detectors that failed during fire alarm testing. This affected six of six floors in the main hospital, and could result in a delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector 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/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the smoke detectors were observed, and maintenance records reviewed.

10/23/12 - Tower 2 - Third Floor

At 9:14 a.m., the self-closing device on the door into the utility area, next to Room 2333, had a built-in smoke detector. No records for testing the device were provided.
During an interview at 10:55 a.m., Engineering Staff 1 stated that the smoke detector in the door closer was not connected to the fire alarm system, and was not tested.

10/23/12 - Main Hospital

At 2:31 p.m., a document titled "Sensitivity Reacceptance Test Results for 2009" was provided. The document showed sensitivity testing of 54 smoke detectors, on 2/3/10 to 2/11/10, that failed sensitivity testing in 2009. Documents titled "Work Order & Installation Report" were provided showing dates during February, 2010, when the heads were replaced and tested for "alarm and trouble conditions." There were no records for testing the smoke detector sensitivity in February, 2012.
During an interview at 2:32 p.m., Engineering Staff 2 stated that there were not other testing records for review.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to maintain an 18 inch clearance from the sprinkler heads, by foreign material on sprinkler heads, and by escutcheon rings that were not flush to the ceiling. This affected two of six floors in the main hospital, and two of six smoke compartments in the Chemical Dependency Unit. This could result in the automatic sprinkler system not functioning as designed in the event of a fire.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition
2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the automatic sprinkler system was observed.

10/23/12 - Main Hospital - Second Floor

At 4:05 p.m., there was electrical equipment on the top shelf in the Electrical Equipment Storage, Room 13, that obstructed the sprinkler head.

10/24/12 - Main Hospital - First Floor

At 9:46 a.m., there were boxes on the top shelf, in the Endoscopy Suit supply closet, that were stored approximately 11 inches from the sprinkler head.

At 10:35 a.m., there was foreign material on the sprinkler head in the pharmacy walk-in refrigerator, in the pharmacy department.

10/25/12 - Chemical Dependency Unit

At 10:20 a.m., one of two sprinkler heads, in the kitchen walk-in refrigerator, had foreign material on the deflector and the escutcheon plate.

At 10:40 a.m., there was white paint-like material on the deflector and escutcheon ring of the sprinkler head in the 500 Hallway linen closet.



29665

10/24/12 - Main Hospital - First Floor

At 9:30 a.m., the escutcheon ring, in the linen closet of the Maternity Department, was installed upside down, and was approximately 3 inches from the ceiling, revealing a penetration around the sprinkler pipe.

10/24/12 - Main Hospital

At 11:15 a.m., records for testing of the 556 fire dampers by an outside vendor on 8/12/11, indicated that 56 fire dampers failed, and required repair. The facility failed to provide records of repair for 20 of the 56 dampers that failed on 8/12/11.






29665

Based on record review and interview, the facility failed to maintain their heating, ventilating, and air conditioning systems, as evidenced by fire dampers that were not repaired, and by fire dampers that were not tested. This affected six of six floors in the main hospital, and the chemical dependency unit. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the fire dampers were observed and maintenance records requested. Damper testing records for the Chemical Dependency Unit were requested from Engineering Staff 1 on 10/23/12.

10/25/12 - Chemical Dependency Unit (CDU)

At 10:25 a.m., fire dampers were observed above the ceiling and labels for fire damper service openings were observed throughout the building. No records for testing the fire dampers were provided for review.
During an interview at 10:26 a.m., Engineering Staff 1 stated that they could not locate records for testing the CDU fire dampers.

Based on observation and interview, the facility failed to ensure that portable space heaters meet the temperature requirements for not more than 212?F, for use in non-sleeping staff and employee areas. This was evidenced by no temperature specifications provided for a portable space heater used in an office area. This affected one of six floors in the main hospital, and could result in an increased risk of a fire.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the portable space heaters were observed.

10/24/12 - Main Hospital - First Floor

At 9:35 a.m., a portable space heater was plugged in and turned on, in the medical records office. The portable space heater was located on the floor, between office furniture. The label on the portable space heater read 1500 watts, and no information regarding the maximum temperature was provided.
During an interview at 9:36 a.m., Engineering Staff 3 and a medical records staff member did not know the portable space heater's maximum temperature.

Based on observation, the facility failed to maintain their trash collection receptacles, as evidenced by trash collection receptacles greater than 32 gallons in capacity that were not stored in a room protected as a hazardous area. This affected two of six floors in Tower 2, and could result in an increased risk of a fire.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the trash collection receptacles were observed.

10/23/12 - Tower 2 - Sixth Floor

At 3:40 p.m., there was a 65-gallon trash collection receptacle, that was approximately 90 percent full of paper, stored in the corridor outside the waiting room.


10/23/12 - Tower 2 - Fifth Floor

At 4:04 p.m., there was a 65-gallon trash receptacle, that was approximately 90 percent full of paper and cardboard, stored in the corridor outside the waiting room

10/24/12 - Emergency Department - First Floor
At 9:20 a.m., there were 6 full oxygen E-cylinders, and 3 empty oxygen E-cylinders, stored in an oxygen rack. The rack was stored approximately 3 1/2 feet away from a linen cart, in the oxygen storage room.






29665

Based on observation and interview, the facility failed to maintain their medical gas storage areas. This was evidenced by medical gas cylinders that were stored in a combustible structure, by medical gas cylinders that were stored less than 5 feet from combustible items, and by electrical fixtures in medical gas storage that were installed less than 5 feet from the floor. This affected one of six floors in the main hospital, and the exterior medical gas cylinder storage area. This could result in the increased risk of a fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 130?F (54?C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
3. Enclosures shall be provided for supply systems, cylinders storage or manifold location for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly building materials with a fire resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert)medical gases shall be permitted to stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the medical gas storage was observed.

10/24/12 - Main Hospital - Exterior Medical Gas Storage

At 10:15 a.m., the exterior medical gas storage areas were observed. There were more than 100 oxygen E-cylinders stored outdoors. In the center of the outdoor oxygen storage area was an approximately 12 foot by 12 foot ventilated wooden storage structure. There were more than 75 oxygen E-cylinders, and more than 17 medical gas H-cylinders in the wooden structure. There was a light switch in the structure that was mounted approximately 44 inches above the floor, and three two-plug outlets that were mounted less than 20 inches above the floor. There were combustible plastics stored less than 4 feet away from the oxygen cylinder racks.
During an interview at 10:16 a.m., Engineering Staff 2 and Engineering Staff 3 stated that the structure was made of wood, and was not fire rated.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by electrical appliances that were plugged into multi-plug power strips and not directly into the wall outlets, and by junction boxes with no cover. This affected three of six floors in the main hospital, the MRI Unit, and the Radiation/Oncology Services suite. This could result in an increased risk of fire.

NFPA 70, National Electrical Code, 1999 Edition
110-12 Mechanical Execution of Work. Electrical Equipment shall be installed in a neat and workman like manner,(a) Unused openings, Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
400-8 Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code


Findings:

During a tour of the facility with engineering staff, from 10/22/12 to 10/25/12, the electrical wiring and equipment was observed.

10/23/12 - Tower 1 - Third Floor

At 3:40 p.m., there was a refrigerator, a microwave, and a coffee maker plugged into a multi-plug surge protector in the respiratory lounge.

10/25/12 - Exterior MRI Unit

At 10:50 a.m., there was a junction box, in the MRI Unit, with wires exposed and no cover.


29665

10/24/12 - Main Hospital - First Floor

At 9:21 a.m., there was an approximately 2 1/2 inch round electrical junction with no cover, in the Obstetrics (OB) waiting room storage closet.

At 9:50 a.m., there was an approximately 6 inch by 4 inch electrical box with no cover, in the physical therapy closet.

10/24/12 - Radiation/Oncology Services

At 2:59 p.m., there was an approximately 4 inch by 4 inch electrical box with no cover, in the linear accelerator room.