HospitalInspections.org

Based on observation and staff interview, the facility failed to provide doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants in the lower level and Surgery suite. This facility has a capacity of 25 with a census of 13 patients. Findings are:

1. Observations on 11/26/12 at 2:10 pm revealed the corridor double doors to the EEG room failed to have an automatic flush bolt installed on the inactive leaf.

2. Observations on 11/28/12 at 1:42 pm revealed the corridor door to the Board Room failed to close and latch as the door failed to have a positive latching device installed.

3. Observations on 11/28/12 at 1:42 pm revealed the corridor door to the Classroom failed to close and latch as the door failed to have a positive latching device installed.

4. Observations on 11/28/12 at 3:56 pm revealed the PACU to Surgery door failed to close and latch.

All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interviews the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects most occupants in this facility with a capacity of 25 and a census of 13. Findings are:

1. Observations on 11/26/12 at 2:12 pm revealed the RT Storage room failed to have self-closure devices installed on the three doors. In addition the RT Storage failed to be separated with doors and self-closing devices from the RT waiting area.

2. Observations on 11/26/12 at 2:29 pm revealed unsealed penetrations in the ceiling of the Chiller Room.

3. Observations on 11/26/12 at 2:32 pm revealed unsealed penetrations in the ceiling of the Shop Air Handler room.

4. Observations on 11/26/12 at 2:40 pm revealed the corridor doors to the Maintenance Shop failed to have an automatic flush bolt installed on the inactive leaf of the double doors. The doors could be pulled open without turning the door knob.

5. Observations on 11/26/12 from approximately 2:00 pm through 4:30 pm revealed numerous corridor double doors failed to have automatic flush bolts on the inactive leafs installed. Also, numerous corridor double doors failed to have an astragal installed as the gap between leafs exceeded 1/8th inch.

6. Observations on 11/26/12 at 2:51 pm revealed the corridor double doors to Materials Management Storage room failed to close and latch when tested.

7. Observations on 11/26/12 at 2:53pm through 3:00 pm, revealed the corridor double doors to Materials Management Storage room/Offices failed to close and latch when tested. In addition no self-closing devices were installed on the doors.

8. IS Tech rooms failed to be separated from the exit corridor on 11/26/12 at 3:04 pm.

9. Observation on 11/26/12 at 3:25 pm revealed the North Mechanical room corridor doors failed to have an automatic flush bolt installed on the inactive leaf of the double doors. The doors could be pulled open without turning the door knob.

10.Observations on 11/26/12 at 3:33 pm revealed the Old Incinerator Storage room contained unsealed penetrations and holes in the walls and ceiling.

11.Observations on 11/28/12 at 1:39 pm revealed the double doors to the Boardroom Storage failed to have an automatic flush bolt installed on the inactive leaf of the double doors. The doors could be pulled open without turning the door knob.

12.Observations on 11/28/12 at 1:45 pm revealed the Dietary electrical room contained unsealed penetrations in the walls.

13.Observations on 11/28/12 at 1:49 pm revealed the Dietary Server room contained unsealed penetrations in the walls.

14.Observations on 11/28/12 at 3:19 pm revealed the Temporary IS Storage room failed to have a self-closing device installed on the corridor door.

15.Observations on 11/28/12 at 3:22 pm revealed the Laboratory Electrical room contained 2 holes in the wall that were unsealed.

16.Observations on 11/28/12 at 3:28 pm revealed the OPS Janitors closet failed to have a self-closure installed on the door.

17.Observations on 11/28/12 at 3:59 pm revealed the PACU Storage room door failed to have a self-closure installed on the door.


All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide exit access from an egress corridor without the use of a special tool or knowledge from the egress side. The deficient practice affected all visitors, staff and residents who would use the exit corridor outside of the New Cafeteria/Kitchen area in the event of an emergency evacuation.. The facility has a capacity of 25 patients and at the time of the survey the census was 13.
Findings are:

1. Observation on 11/28/12 at 2:15 pm revealed the 90 minute fire rated doors into the MOB building from the exit corridor outside the New Cafeteria/Kitchen area and Specialty Clinic were magnetically locked. Interview with Maintenance Staff A on 11/28/12 revealed these doors are locked in the evening and throughout the night to keep anyone from entering into the MOB building for security reasons. Maintenance Staff A confirmed the doors were marked as an exit and that having these doors locked created a greater than 50 foot dead in the exit corridor.

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. NFPA 101, 7.2.1.5.1
Not less than two separate exits shall meet the following criteria:
(1) They shall be provided on every story.
(2) They shall be accessible from every part of every story and mezzanine.
NFPA 101, 39.2.4.2
Dead-end corridors shall not exceed 50 ft (15 m). NFPA 101, 39.2.5.2
NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1
NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1

Based on observation and interview the facility failed to provide horizontal exits with a two-hour fire resistance rating by sealing all penetrations through the barriers. This would allow the passage of smoke from one smoke zone to another, affecting all occupants.
Findings are:
1. Observation on 11/28/12 at 1:15 pm revealed a 4 inch by 8 inch hole in the two hour wall located by the Nursing Administration office.

2. Observation on 11/28/12 at 3:26 pm revealed the failure of the door between OPS and PACU to close and latch when tested.

3. Observations on 11/28/12 at 3:30 pm revealed the failure of the double doors in the two hour wall between OPS and the Soiled Utility & restroom failed to close and latch as the latch was inoperable.

All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

Based on observation and staff interview, the facility failed to maintain sprinkler coverage in accordance with the National Fire Protection Association 13 This condition had the potential for heat to escape from around sprinkler heads and to go above the partial ceiling, slowing the activation of the sprinklers and allowing fire to spread outside of the room, which would affect all 13 patients, visitors, and staff, should the sprinkler activation be delayed.
Findings are:

1. Observations on 11/26/12 at 2:47 pm revealed a sprinkler head located in the Materials Management/Paper room to b\have a white foreign material or paint on the sprinkler head.

2. Observation on 11/28/12, at 1:45 pm revealed the Dietary Electrical room ' s suspended ceiling tiles were not installed, which exposed the ceiling deck. With no ceiling and pendent sprinklers installed designed for a ceiling, the heat of a fire would go above the sprinkler heads and delay the operation of the sprinkler system in the event of a fire in the Dietary Electrical room.

3. Observation on 11/28/12, at 1:45 pm revealed the Dietary Server room ' s suspended ceiling tiles were not installed, which exposed the ceiling deck. With no ceiling and pendent sprinklers installed designed for a ceiling, the heat of a fire would go above the sprinkler heads and delay the operation of the sprinkler system in the event of a fire in the Dietary Electrical room.


4. Observation on 11/26/12 and 11/28/12, at 3:19 pm revealed the Temporary IS Storage room ' s suspended ceiling tiles had been removed, which exposed the ceiling deck. Approximately 2 foot by 4 foot sections of suspended ceiling tiles had been left out above the pendant sprinkler heads. With the large hole in the design features of the suspended ceiling the heat of a fire would go above the sprinkler heads located in the remaining suspended ceiling and delay the operation of the sprinkler system in the event of a fire in the Temporary IS Storage room.


All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

NFPA Standard: 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. 1998 NFPA 25, 2-2.1.1
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, this facility failed to enclose vertical openings in compliance with NFPA 82 and NFPA 101, 8.4. The linen chute did not have a one-hour enclosure with a self-closing door, which put patients and staff in the lower level at risk.
Findings are:

Observation on 11/26/12 at 2:35 pm revealed the Soiled Laundry chute bottom door failed to be self-closing. The spring on the door was disconnected.
Maintenance Staff A confirmed the failure of the bottom chute door to be self-closing at the time of the observation.
NFPA Standard: Requires a minimum one-hour fire resistance rating in shafts between floors. 2000 NFPA 101, 18/19.3.1.1 and 8.2.5
NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with 8.2, protect the area with automatic extinguishing systems in accordance with 9.7, or both where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.1

Based on observation and staff interview the facility failed to maintain the one hour fire rating of the oxygen supply room in the MOB. This deficient practice has the potential to affect all staff and patients in the MOB second floor.
Findings are:

Observation on 11/28/12 at 2:23 pm revealed unsealed penetrations around the oxygen lines in the ceiling of the oxygen storage/supply room in the MOB building.

Maintenance Staff A confirmed the failure of the supply lines to be sealed around the piping at the time of the observation.
NFPA Standard:
(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.
Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of 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 may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose. 1999 NFPA 99, 4-3.1.1.2

Based on observation and staff interview, the facility failed to prohibit the use of power strips as a substitute for adequate wiring or to use them in a proper manner and to provide covers for all junction boxes.
Findings are:

1. Observation on 11/26/12 at 3:31 pm revealed three open junction boxes without covers in the Electrical Vault room.

2. Observation on 11/26/12 at 3:35 pm revealed two open junction boxes without covers in the Switchgear room.

3. Observation on 12/28/12 at 4:40 pm revealed a power strips in use in the Sleep Studies patient rooms.

Maintenance Staff A confirmed the failure of the supply lines to be sealed around the piping at the time of the observation.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NSFM Interpretation Number: 0801: Relocatable power taps not properly listed are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.

Based on observation and staff interview, the facility failed to provide doors to the corridor that stay latched tightly within the doorframes. This deficient practice would not prevent the spread of smoke, affecting all occupants in the lower level and Surgery suite. This facility has a capacity of 25 with a census of 13 patients. Findings are:

1. Observations on 11/26/12 at 2:10 pm revealed the corridor double doors to the EEG room failed to have an automatic flush bolt installed on the inactive leaf.

2. Observations on 11/28/12 at 1:42 pm revealed the corridor door to the Board Room failed to close and latch as the door failed to have a positive latching device installed.

3. Observations on 11/28/12 at 1:42 pm revealed the corridor door to the Classroom failed to close and latch as the door failed to have a positive latching device installed.

4. Observations on 11/28/12 at 3:56 pm revealed the PACU to Surgery door failed to close and latch.

All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors shall be provided with positive latching hardware. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3

Based on observation and staff interviews the facility failed to provide separation of hazardous areas from other compartments. The area of deficient practice affects most occupants in this facility with a capacity of 25 and a census of 13. Findings are:

1. Observations on 11/26/12 at 2:12 pm revealed the RT Storage room failed to have self-closure devices installed on the three doors. In addition the RT Storage failed to be separated with doors and self-closing devices from the RT waiting area.

2. Observations on 11/26/12 at 2:29 pm revealed unsealed penetrations in the ceiling of the Chiller Room.

3. Observations on 11/26/12 at 2:32 pm revealed unsealed penetrations in the ceiling of the Shop Air Handler room.

4. Observations on 11/26/12 at 2:40 pm revealed the corridor doors to the Maintenance Shop failed to have an automatic flush bolt installed on the inactive leaf of the double doors. The doors could be pulled open without turning the door knob.

5. Observations on 11/26/12 from approximately 2:00 pm through 4:30 pm revealed numerous corridor double doors failed to have automatic flush bolts on the inactive leafs installed. Also, numerous corridor double doors failed to have an astragal installed as the gap between leafs exceeded 1/8th inch.

6. Observations on 11/26/12 at 2:51 pm revealed the corridor double doors to Materials Management Storage room failed to close and latch when tested.

7. Observations on 11/26/12 at 2:53pm through 3:00 pm, revealed the corridor double doors to Materials Management Storage room/Offices failed to close and latch when tested. In addition no self-closing devices were installed on the doors.

8. IS Tech rooms failed to be separated from the exit corridor on 11/26/12 at 3:04 pm.

9. Observation on 11/26/12 at 3:25 pm revealed the North Mechanical room corridor doors failed to have an automatic flush bolt installed on the inactive leaf of the double doors. The doors could be pulled open without turning the door knob.

10.Observations on 11/26/12 at 3:33 pm revealed the Old Incinerator Storage room contained unsealed penetrations and holes in the walls and ceiling.

11.Observations on 11/28/12 at 1:39 pm revealed the double doors to the Boardroom Storage failed to have an automatic flush bolt installed on the inactive leaf of the double doors. The doors could be pulled open without turning the door knob.

12.Observations on 11/28/12 at 1:45 pm revealed the Dietary electrical room contained unsealed penetrations in the walls.

13.Observations on 11/28/12 at 1:49 pm revealed the Dietary Server room contained unsealed penetrations in the walls.

14.Observations on 11/28/12 at 3:19 pm revealed the Temporary IS Storage room failed to have a self-closing device installed on the corridor door.

15.Observations on 11/28/12 at 3:22 pm revealed the Laboratory Electrical room contained 2 holes in the wall that were unsealed.

16.Observations on 11/28/12 at 3:28 pm revealed the OPS Janitors closet failed to have a self-closure installed on the door.

17.Observations on 11/28/12 at 3:59 pm revealed the PACU Storage room door failed to have a self-closure installed on the door.


All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

NFPA Standard: Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide exit access from an egress corridor without the use of a special tool or knowledge from the egress side. The deficient practice affected all visitors, staff and residents who would use the exit corridor outside of the New Cafeteria/Kitchen area in the event of an emergency evacuation.. The facility has a capacity of 25 patients and at the time of the survey the census was 13.
Findings are:

1. Observation on 11/28/12 at 2:15 pm revealed the 90 minute fire rated doors into the MOB building from the exit corridor outside the New Cafeteria/Kitchen area and Specialty Clinic were magnetically locked. Interview with Maintenance Staff A on 11/28/12 revealed these doors are locked in the evening and throughout the night to keep anyone from entering into the MOB building for security reasons. Maintenance Staff A confirmed the doors were marked as an exit and that having these doors locked created a greater than 50 foot dead in the exit corridor.

Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side. NFPA 101, 7.2.1.5.1
Not less than two separate exits shall meet the following criteria:
(1) They shall be provided on every story.
(2) They shall be accessible from every part of every story and mezzanine.
NFPA 101, 39.2.4.2
Dead-end corridors shall not exceed 50 ft (15 m). NFPA 101, 39.2.5.2
NFPA Standard: Exits and exit access shall be located and arranged so that exits are readily accessible at all times. 2000 NFPA 101, 7.5.1.1
NFPA Standard: 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. 2000 NFPA 101, 7.1.10.1

Based on observation and interview the facility failed to provide horizontal exits with a two-hour fire resistance rating by sealing all penetrations through the barriers. This would allow the passage of smoke from one smoke zone to another, affecting all occupants.
Findings are:
1. Observation on 11/28/12 at 1:15 pm revealed a 4 inch by 8 inch hole in the two hour wall located by the Nursing Administration office.

2. Observation on 11/28/12 at 3:26 pm revealed the failure of the door between OPS and PACU to close and latch when tested.

3. Observations on 11/28/12 at 3:30 pm revealed the failure of the double doors in the two hour wall between OPS and the Soiled Utility & restroom failed to close and latch as the latch was inoperable.

All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

Based on observation and staff interview, the facility failed to maintain sprinkler coverage in accordance with the National Fire Protection Association 13 This condition had the potential for heat to escape from around sprinkler heads and to go above the partial ceiling, slowing the activation of the sprinklers and allowing fire to spread outside of the room, which would affect all 13 patients, visitors, and staff, should the sprinkler activation be delayed.
Findings are:

1. Observations on 11/26/12 at 2:47 pm revealed a sprinkler head located in the Materials Management/Paper room to b\have a white foreign material or paint on the sprinkler head.

2. Observation on 11/28/12, at 1:45 pm revealed the Dietary Electrical room ' s suspended ceiling tiles were not installed, which exposed the ceiling deck. With no ceiling and pendent sprinklers installed designed for a ceiling, the heat of a fire would go above the sprinkler heads and delay the operation of the sprinkler system in the event of a fire in the Dietary Electrical room.

3. Observation on 11/28/12, at 1:45 pm revealed the Dietary Server room ' s suspended ceiling tiles were not installed, which exposed the ceiling deck. With no ceiling and pendent sprinklers installed designed for a ceiling, the heat of a fire would go above the sprinkler heads and delay the operation of the sprinkler system in the event of a fire in the Dietary Electrical room.


4. Observation on 11/26/12 and 11/28/12, at 3:19 pm revealed the Temporary IS Storage room ' s suspended ceiling tiles had been removed, which exposed the ceiling deck. Approximately 2 foot by 4 foot sections of suspended ceiling tiles had been left out above the pendant sprinkler heads. With the large hole in the design features of the suspended ceiling the heat of a fire would go above the sprinkler heads located in the remaining suspended ceiling and delay the operation of the sprinkler system in the event of a fire in the Temporary IS Storage room.


All observations were confirmed by Maintenance Staff A on 11/26/12 and 11/28/12 at the times of the observations.

NFPA Standard: 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. 1998 NFPA 25, 2-2.1.1
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1

Based on observation and interview, this facility failed to enclose vertical openings in compliance with NFPA 82 and NFPA 101, 8.4. The linen chute did not have a one-hour enclosure with a self-closing door, which put patients and staff in the lower level at risk.
Findings are:

Observation on 11/26/12 at 2:35 pm revealed the Soiled Laundry chute bottom door failed to be self-closing. The spring on the door was disconnected.
Maintenance Staff A confirmed the failure of the bottom chute door to be self-closing at the time of the observation.
NFPA Standard: Requires a minimum one-hour fire resistance rating in shafts between floors. 2000 NFPA 101, 18/19.3.1.1 and 8.2.5
NFPA Standard: Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means: Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with 8.2, protect the area with automatic extinguishing systems in accordance with 9.7, or both where the hazard is severe or where otherwise specified by Chapters 12 through 42. 2000 NFPA 101, 8.4.1.1

Based on observation and staff interview the facility failed to maintain the one hour fire rating of the oxygen supply room in the MOB. This deficient practice has the potential to affect all staff and patients in the MOB second floor.
Findings are:

Observation on 11/28/12 at 2:23 pm revealed unsealed penetrations around the oxygen lines in the ceiling of the oxygen storage/supply room in the MOB building.

Maintenance Staff A confirmed the failure of the supply lines to be sealed around the piping at the time of the observation.
NFPA Standard:
(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.
Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of 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 may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose. 1999 NFPA 99, 4-3.1.1.2

Based on observation and staff interview, the facility failed to prohibit the use of power strips as a substitute for adequate wiring or to use them in a proper manner and to provide covers for all junction boxes.
Findings are:

1. Observation on 11/26/12 at 3:31 pm revealed three open junction boxes without covers in the Electrical Vault room.

2. Observation on 11/26/12 at 3:35 pm revealed two open junction boxes without covers in the Switchgear room.

3. Observation on 12/28/12 at 4:40 pm revealed a power strips in use in the Sleep Studies patient rooms.

Maintenance Staff A confirmed the failure of the supply lines to be sealed around the piping at the time of the observation.

NFPA Standard: Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8
NSFM Interpretation Number: 0801: Relocatable power taps not properly listed are not permitted in areas of health care occupancies regularly occupied by patients. This includes general patient care areas and critical patient care areas.