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Based on observation and interview, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 3 of 7 smoke compartments in the Main Hospital and 1 of 2 smoke compartments in the RHC building.

Findings:

During the facility tour with the Hospital Staff on 3/18/2013 through 3/21/2013, the facility walls and ceilings were observed.

On 3/19/2013

1. At 2:12 p.m., there was an approximately 2 inch unsealed circular penetration in the center of the wall above the bed in the Old OB.

2. At 2:14 p.m., there were four approximately 1/4 inch unsealed circular penetrations in the center of the wall by the soap dispenser in Room 132.

3. At 3:48 p.m., there were penetrations in the north wall of the Fire Alarm Control Panel Room in the RHC building. There was an approximately 3 inch by 4 inch penetration on the bottom right bottom of the north wall and an approximately 2 inch circular penetration surrounding a 1 inch pipe in the top right of the north wall abutting Suite C. The Plant Manager Coordinator confirmed the penetrations in the north wall of the 721 building.






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Building A, Main HospitalOn 3/19/13:

4. At 11:01 A.M., in the "OR Manager Office", there were 4 penetrations approximately 1/2 inches round each in diameter in the wall over the desk and 2 penetrations approximately 1/2 inch round each in the wall next to the door.

5. At 11:08 A.M., in the Chaplain's Office Storage Room, there were 2 penetrations approximately 1 inch round each in the left wall by the door with wires running through it and a 2 inch round penetration in the wall with a wire through it. When interviewed, the Plant Manager Coordinator stated that it was a data line put in for the Diagnostic Imaging center.

6. At 1:30 P.M., in the Kitchen, there was a 1 inch round penetration with a wire through it in the wall next to the door that provided wiring for the speaker located in the corridor.

7. At 1:33 P.M., in the Kitchen, there were 4 penetrations approximately 1/2 inch round each in the wall by the mop closet.

8. At 1:45 P.M., in the Mail Room, there was a penetration in the wall approximately 1/2 inch round in diameter with a white phone wire through it.

Based on observation, the facility failed to maintain the integrity of the construction of the corridor wall. This was evidenced by a penetration in the corridor wall. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 7 smoke compartments in the Main Hospital.

Findings:

During the facility tour with the Hospital Staff on 3/18/2013 through 3/21/2013, the facility corridor walls were observed.

On 3/19/2013:

At 10:45 a.m., there was an approximately 1/2 inch unsealed penetration in the center of the right corridor wall by the Hospital Operator Office.

Based on observation, the facility failed to maintain their doors to resist the passage of smoke and fire as evidenced by doors that failed to positive latch and were blocked from closing. This had the potential to allow the migration of smoke causing harm to patients and staff. This affected 7 of 7 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the doors were observed.

On 3/19/2013:

1. At 10:53 a.m., the right side of the double door failed to latch shut to the Doctor's Lounge.

2. At 11:15 a.m., the self-closing door failed to latch shut to the bathroom by Outpatient Surgery.

3. At 11:25 a.m., the self-closing door failed to latch shut to the janitor's closet next to the ER Doctors' Sleeping Room.

On 3/20/2013:




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On 3/19/13:

4. At 10:50 A.M., the door to "Fluoroscopy" could not be closed due to computer equipment and cable cords extending into the doorway.

5. At 11:15 A.M., the door to the IT Office "Old Ultrasound Room" failed to positive latch upon closure.

6. At 11:20 A.M., the door to Room 2 in the Emergency Department was held open with a metal surgical table with supplies stacked on it.

7. At 11:25 A.M., the door to Registration in the Emergency Department was impeded from closing by a door wedge placed under the door.

8. At 1:43 P.M., the door to room 110B failed to latch due to the latching mechanism stuck in the door.

9. At 2:30 P.M., the door to the Storage Room by Room 103 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

10. At 2:50 P.M., the door the Soiled Utility room in the Infusion Services area was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls as evidenced by penetrations in the smoke barrier walls. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 4 of 7 smoke compartments in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with Hospital Staff on 3/18/2013 through 3/21/2013, the smoke barrier walls were observed and staff were interviewed.

On 3/20/2013:

1. At 10:16 a.m., there were two penetrations in the smoke barrier wall, one approximately 2 inch circular penetration surrounding a 1 inch conduit in the left center and an approximately 4 inch cutout parallel to the right of the first penetration. These penetrations were observed in the left center of the smoke barrier wall above the drop down ceiling abutting patient room 123. The Plant Maintenance Coordinator confirmed the penetrations in the smoke barrier wall located above the drop down ceiling abutting Patient Room 123 and stated that the penetrations would be repaired immediately with fire retardant material.













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On 3/20/13:

2. At 9:43 A.M., in the smoke barrier corridor wall by Room 133, there was an unsealed penetration approximately 5 inches wide by 6 inches long in the wall.

3. At 9:55 A.M., in the smoke barrier wall across from the Cardio-Pulmonary entrance there was a 2 foot long by 1 1/2 inch wide penetration between the smoke barrier wall over the fire doors and the corridor wall.

4. At 10:15 A.M., in the smoke barrier ceiling between the main hospital and the new Patient Services area, there was a 2 1/2 inch by 2 1/2 inch junction box with a 1/2 inch wide penetration around it and an electrical conduit tube with a 1/2 inch wide penetration around it.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to positive latch upon closure. This could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 5 of 7 smoke compartments in the Main Hospital.

Findings:

During fire alarm testing and observation with the Hospital Staff on 3/18/2013 through 3/21/2013, the smoke barrier doors were observed.

On 3/20/2013:

1. At 1:55 p.m., the right leaf of the smoke barrier double door failed to latch shut between the OR suite and the GI room.



On 3/21/2013:

2. At 9:45 a.m., the left leaf of the smoke barrier double door failed to fully close and latch shut at the entrance to the Operating Room Suite.






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On 3/19/13:

3. At 12:00 P.M., the smoke barrier door to the Lab failed to positive latch. When interviewed, the Plant Maintenance Coordinator stated that the employees had deactivated the hardware so they did not have to punch in their code when entering and leaving the Lab.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by gurneys and medical equipment blocking smoke barrier doors. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This affected 2 of 7 smoke compartments in the Main Hospital.

Findings:

During the tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the corridors and exits were observed.

On 3/19/13:

1. At 11:03 A.M., in the Operating Room suite corridor before the red sterile line, there was a gurney placed 1 foot from the smoke barrier doors leading out of the Operating Room.

On 3/20/13:

2. At 2:15 P.M., in the corridor outside of the Operating Room suite, there was a digital process fluoroscopy machine placed 2 feet from the privacy doors which prevented the left side from opening fully and reduced the corridor width to 5 feet.

NFPA 101®, Life Safety Code®, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, the facility failed to maintain their emergency lighting as evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation causing injury to patients and staff. This affected the 1 of 7 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the emergency lighting was observed and tested.

3/19/13:

At 2:10 P.M., emergency lighting unit 15 in the Simulation/Training Room/Operating Room failed to illuminate when tested.

Based on observation and interview, the facility failed to ensure an evacuation map was posted in the Diagnostic Imaging center as evidenced by the facility not posting an evacuation map in the Diagnostic Imaging Center to direct patients and visitors to a path leaidng to a safe location. This failure could delay patients, staff and visitors from utilizing the correct escape path in an emergency evacuation. This affected 1 of 7 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the Diagnostic Imaging center was observed and the Lab Manager and Plant Maintenance Coordinator was interviewed.

3/20/13:

At 10:00 A.M., there was no evacuation map posted in the Diagnostic Imaging Center, which measured approximately 8,552 square feet. When interviewed, the Plant Maintenance Coordinator stated that the building had been opened about a year and they must have forgotten to post an evacuation map. Documentation was requested and provided stating the fire clearance was granted on 3/17/11. The "Temporary Certificate of Occupancy" was provided and stated the "Temporary Occupancy is granted until August 31, 2011". When interviewed, the Lab Manager was asked if the facility had a final permit from the City of Fort Bragg and he stated that they did not. The Lab Manager stated that he had just called the city to come out and perform the final inspection and the City stated that they would be out by Monday, 3/25/13.

The Lab Manager stated that evacuation maps would be posted throughout the Diagnostic Imaging Center. An evacuation map was observed in one of the exam rooms.

Based on document review and interview, the facility failed to conduct fire drills at least quarterly for each shift of personnel as evidenced by 4 of 4 quarterly fire drills missing in Building B, Suite B, Outpatient Clinics - RHC at North Coast Family Health Center. This failure could result in the staff's inability to respond to fire and/or disaster and affected 1 of 1 smoke compartments.

Findings:

During document review with the Hospital Staff on 3/18/13 through 3/21/13, the facility's fire drill records were reviewed.

Building B, Suite B Outpatient Clinics - RHC at North Coast Family Health Center
On 3/18/13:
At 3:00 P.M., no documentation for 4 of 4 quarterly fire drills was provided. When interviewed, the Plant Maintenance Coordinator stated that he conducts fire drills in that building between 8:00 A.M. and 8:30 A.M. and Suite B did not come into work until 10:00 A.M.

Based on testing and observation, the facility failed to provide effective warning of fire as evidenced by strobes that failed to activate and manual pull stations that were impeded from access. This could result in potential harm if the alarms failed to notify patients, visitors and staff of a fire in the facility. This affected 3 of 7 smoke compartments in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72 National Fire Alarm Code®, (1999 Edition)
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

During the facility tour and fire alarm testing with the Hospital Staff on 3/18/13 through 3/21/13, the facility's fire drill records were reviewed.

On 3/19/2013:

1. 10:40 a.m., the manual pull station was blocked from access by a chair in the Main Hospital Lobby.

2. 10:59 a.m., the manual pull station was blocked from access by a trash container at the front entrance to the Surgical Suite.



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On 3/20/13:

3. At 1:39 P.M., in the Med Surge area, the fire alarm notification devices were activated and 4 chimes failed to activate after testing of a manual pull station.

Based on document review and observation, the facility failed to maintain their fire alarm system in accordance with NFPA 101, 2000 edition and NFPA 72, 1999 edition. This was evidenced by the batteries not tested and replaced according to NFPA 72 and NFPA 101 specifications,and no annual certification for the Fire Alarm Control Panel (FACP) and the failure to post the correct time on the FACP. This could cause harm to patients and staff in the event of a fire. This affected 7 of 7 smoke compartments in Building A, Main Hospital and 1 of 1 smoke compartments in Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center.

NFPA 101, Life Safety Code, 2000 Edition
9.6.5 Emergency Control.
9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)

NFPA 72, National Fire Alarm Code®, 1999 Edition
Table 7-3.2 Testing Frequencies.
6. Batteries -- Fire Alarm Systems
d. Sealed Lead-Acid Type,
1. Charger Test (Replace battery every 4 years.)

Findings:

During document review and a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the battery in the FACP was observed and the documentation was reviewed.

On 3/19/2013:

1. 10:35 a.m., there was no date posted on the batteries for the Fire Alarm Control Panel in the Electrical/Mechanical Room 136 to Diagnostic Imaging.

2. 1:48 p.m., the time on the fire alarm control Panel was posted as 12:48 p.m. The actual time was verified as 1:48 p.m. by the Plant Maintenance Coordinator who stated that the time was not corrected from the time change.




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Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center
On 3/18/13:
3. At 2:30 P.M., the facility failed to provide an annual certification for their Fire Alarm Control Panel. The last documentation provided was dated 12/22/11.

Building A, Main Hospital
On 3/19/13:
4. At 11:30 A.M., in the Emergency Department, two lead acid batteries in the FACP were dated 2/25/09.

Based on observation, record review and interview, the facility failed to maintain the smoke detectors as evidenced by the facility failure to provide a current record for sensitivity testing for 100 of 100 system-based smoke detectors, the failure to provide an installation date and testing logs per manufacturer instructions for 6 of 6 battery-operated smoke detectors, and the failure of a smoke detector to activate when tested with aerosol smoke. This could result in the failure of the smoke detectors to operate in the event of a fire and increase the risk of injury to patients, visitors, and staff due to smoke and fire. This affected 7 of 7 smoke compartments in the Main Building and Suite A and Suite B of the RHC Building.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7.3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction.

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.


During the facility tour, record review and interview with the Hospital Staff on 3/18/2013 through 3/21/2013 the facility smoke detectors were observed and tested and maintenance records were reviewed and staff interviewed.

Findings:

On 3/18/2013:

1. At 3:30 p.m., there was no smoke detector sensitivity tests conducted for the 100 of 100 system-based smoke detectors listed on the fire alarm certification report dated December 12, 2013. Maintenance Staff stated that the facility was not aware that a sensitivity test was required and that there were no previous sensitivity tests.

2. At 3:45 p.m., there were no records for the weekly testing of the 6 of 6 battery-operated smoke detectors and no record of the installation date. The manufacturer instructions provided by the facility stated "Test at least once a week" and "NFPA recommends replacing the alarms every 10 years". The Maintenance staff stated that the smoke detectors were installed when the facility leased the building in 2007.



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Building A, Main Hospital
On 3/20/13:
3. At 1:53 P.M., smoke detector L1-30 in the baby unit failed to activate an alarm when tested with canned smoke.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Based on document review, observation and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by the failure to provide documentation of quarterly automatic sprinkler test/inspection for 4 of 4 quarters, and failure of 2 of 4 Inspector Test Valve's (ITV) to activate the alarm within 90 seconds and, by failing to ensure the Tampers for the Diagnostic Imaging Center were locked. This failure could cause injury to patients and staff in the event of a fire and the sprinkler system failed. This affected 2 of 7 smoke compartments in Building A, Main Hospital and Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center.

Findings:

During document review and alarm testing with the Hospital Staff on 3/18/13 through 3/21/13, the facility's maintenance records were reviewed, the automatic sprinkler system was tested and the Plant Maintenance Coordinator was interviewed.

Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center
On 3/18/13:
1. At 4:00 P.M., the maintenance records were reviewed and the facility failed to provide documentation that the sprinkler test/inspections were conducted for 4 of 4 quarters. When interviewed, the Plant Maintenance Coordinator stated that the hospital did not own that building so they had never conducted sprinkler testing.

Building A, Main Hospital
On 3/20/13:
2. At 11:27 A.M., the ITV for the Patient Services area was opened and the alarm failed to occur within 90 seconds. The ITV was timed for approximately 3 minutes, 21 seconds and failed to activated any devices at the facility. The trouble alarm was received at the panel. When interviewed, the Plant Maintenance Coordinator stated that the facility would implement a fire watch and he would contact the vendor to repair the system.

3. At 11:51 A.M., the ITV for the main hospital was opened and the alarm failed to activate within 90 seconds. The ITV was timed for approximately 2 minutes, 45 seconds and failed to activated any devices at the facility. The ITV failed to transmit a trouble signal to the panel. When interviewed, the Plant Maintenance Coordinator stated that the facility would implement a fire watch and he would contact the vendor to repair the system.

4. At 3:10 P.M., the Tamper valves for the Diagnostic Imaging Center were tested and observed to be unlocked.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers that did not have escutcheon rings. This could result in the fire sprinkler system not functioning as designed and increased risk of injury to residents and staff. This affected 1 of 7 smoke compartments.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the sprinkler system was observed.

Building A, Main Hospital
On 3/19/13:
At 4:45 P.M., in the overhang outside the hospital, there was 4 of 4 sprinklers missing the escutcheon rings.

Based on observation, the facility failed to ensure that portable fire extinguishers were easily accessible as evidenced by portable fire extinguishers that were impeded from access. This could delay the ability to extinguish a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 7 smoke compartments in the Main Hospital and Suite B in the 721 Building.

NFPA 10 Standard for Portable Fire Extinguishers, 2002 Edition
1.5.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition and shall be kept in their designated places at all times when they are not being used.
1.5.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal path of travel, including exits from area.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
Findings:

During the facility tour with the Hospital Staff on 3/18/2013 through 3/21/2013, the fire extinguishers were observed.

On 3/19/2013:

1. At 1:30 p.m., the fire extinguisher was blocked by a cart in the Kitchen of the Main Hospital.

2. At 3:25 p.m., the fire extinguisher was blocked by a portable space heater (not in use) and a trash can on the side of the refrigerator in the employee kitchen, Suite B of the RHC Building.

Based on document review, observation and interview, the facility failed to ensure that smoking was allowed in designated smoking areas. This was evidenced by a container of cigarette butts in a non designated smoking area. This affected 1 of 1 smoke compartments in Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center.

Findings:

During document review with the Hospital Staff on 3/18/13 through 3/21/13, the facility's smoking policy was reviewed and the Plant Maintenance Coordinator and Administrator was interviewed.

Building B, Outpatient Clinics - RHC at North Coast Family Health Center
On 3/19/13:
At 4:30 P.M., a coffee can 1/3 full of used cigarette butts was placed up against the corner of Suite A. When interviewed, the Administrator was asked if that was a designated smoking area and she stated that it was not and that the hospital had a no smoking policy. The facility's smoking policy was reviewed and stated the hospital was a smoke free campus. The Plant Maintenance Coordinator confirmed it was a no smoking facility.

Based on record review and interview, the facility failed to ensure that the kitchen cooking facilities were inspected and serviced ar least every six months, as evidenced by one record of the degreasing of the kitchen hood and exhaust system. This could result in a fire and increase the risk of injury to patients, visitors and staff due to a fire. This affected 1 of 7 smoke compartments in the Main Hospital.

NFPA 96 (1998 Edition) 8-2 Inspection. An inspection and servicing of the fire-extinguishing system and listed exhausted hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

During record review and interview with the Hospital Staff on 3/18/2013 through 3/21/2013,The kitchen hood suppression system records were reviewed and staff interviewed.

On 3/18/2013:

At 4:00 p.m., there was one record for the the degreasing of the kitchen hood and exhaust system dated January 25, 2013. The Plant Maintenance Coordinator stated that the facility was not aware until recently that cleaning of the entire kitchen hood exhaust was required. The filters were cleaned in house but no records were available for review.

Based on observation and interview, the facility failed to maintain a safe environment as evidenced by the presence of portable space heaters. This could result in a fire and increase the risk of injury to patients, visitors and staff. This affected 3 of 7 smoke compartments in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.7.8 Portable space heating devices are prohibited in all health care occupancies, except in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F. (100 degrees C)

During the facility tour and interview with the Hospital Staff on 3/18/2013 through 3/21/2013, the rooms were observed and staff were interviewed.

On 3/19/13:

1. At 11:30 a.m., there was a portable space heater in the Doctors Sleeping Room. The portable space heater was plugged in at the time of the survey but was not turned on. The Plant Maintenance Coordinator stated that the portable space heater was not part of the hospital inventory and was not supposed to be in the room.

2. At 1:40 p.m., there was a portable space heater in the Cardiac Echo Room. The portable space heater was not plugged in at the time of the survey. Cardiac Echo Staff 1 stated that the portable space heater was used to warm up the room for the patients.

3. At 3:00 p.m., there were two portable space heaters backed up to the bookcase in the Billing Office. The portable space heaters were plugged in and on at the time of the survey. The space heaters stated 3 feet from the wall on the top of the heaters. There was a patient observed in the billing office paying a bill.

Based on observation, document review and interview, the facility failed to maintain the humidity levels at 35% or greater in accordance with NFPA 99. This was evidenced by documentation of humidity levels less than 35% in two hospital operating rooms (OR) and no documentation for the GI Procedure Room. This could result in fire in an oxygen enriched environment in an operating room and increase the risk of injury to patients, visitors and staff. This affected 2 of 7 smoke compartments.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During observation, record review and interview with the Hospital Staff on 3/18/2013 through 3/21/2013, the operating rooms were observed, humidity documents were reviewed, and staff were interviewed.

On 3/20/2013:

1. At 8:15 a.m., the Nurse Manager was interviewed and humidity logs were requested for the 2 operating rooms and the GI Procedure Room. The Nurse Manager stated that the range for humidity levels was 30% - 60% per hospital guidelines, there was no documentation for the GI procedure room and there was no humidity reader in the GI procedure room. The humidity was logged one time early in the morning before operating procedures and there was no follow-up during the day. There was no procedure in effect to ensure humidity levels were monitored daily and adjusted when needed.

2. During record review, the facility provided humidity level documentation for OR 1 and OR 2 once in the morning between 7 a.m. and 9 a.m. A sample of the humidity levels were noted to be below the 35 percent in March 2013 and February 2013 in Operating Room 1- February 6, 2013 at 31%, February 11, 2013 at 30%, February 21, 2013 at 30%, February 22, 2013 at 31%, March 5, 2013 at 32%, March 18, 2013 at 31%, March 19, 2013 at 32% and Operating Room 2-February 11, 2013 at 31%, February 18, 2013 at 32%, February 20, 2013 at 31%, February 21, 2013 at 33%, February 25, 2013 at 31%, February 27, 2013 at 33%, March 5, 2013 at 32%, March 7, 2013 at 33%, March 8, 2013 at 31%, and March 18, 2013 at 32%. On the log provided by the facility, the acceptable ranges were notes as 30% to 60%. There was no notation of out of range corrections. The Plant Maintenance Coordinator stated that ranges were corrected when observed.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 6.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.3 Load tests of generator sets shall include complete cold starts.

Based on document review and interview, the facility failed to maintain their emergency back up power in accordance with NFPA 110 and NFPA 99. This was evidenced by failure to provide a written record of inspection for 4 of 4 generators, including but not limited to performance, seconds to transfer and exercising period as stated in NFPA 99 and NFPA 110. This could result in generator failure during power outage. This affected 7 of 7 smoke compartments in the Main Hospital.

Findings:

During document review and interview with the Hospital Staff on 3/18/13 through 3/21/13, the generator test and inspection logs were reviewed and the Plant Maintenance Coordinator was interviewed.

Building A, Main Hospital
On 3/18/13:
At 3:30 P.M., the generator records were reviewed and failed to provide the required information as stated in NFPA 99 and NFPA 110. The daily visual log provided listed information for one generator. When interviewed, the Plant Maintenance Coordinator stated that they looked at all 4 generators but only logged "ok" in one field to indicate all 4 generators were visually inspected.

Based on observation, the facility failed to maintain electrical safety as evidenced by the use of extension cords, the use of high wattage appliances plugged into surge protectors, surge protector plugged into each other, and electrical ground ports that were broken or missing. This could result in an electrical fire and increase the risk of injury to patients, visitors and staff. This affected 4 of 7 smoke compartments in the Main Hospital.

Code of Federal Regulations §483.25(h) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.
NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
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 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

During the facility tour, record review and interview with the Hospital Staff on 3/18/2013 through 3/22/2013, the facility's electrical appliances and equipment were observed.

On 3/19/2013:

1. At 1:35 p.m., there were two orange extension cords in use in the IT Room.

2. At 2:00 p.m., there was a microwave, a toaster oven, a coffee maker and a toaster plugged into a surge protector and not directly into the wall in the Station 1 Clean Utility Room.

3. At 2:10 p.m., there was a refrigerator and a microwave plugged into a surge protector and not directly into the wall in the Employee Pantry.

4. At 2:45 p.m., there was a a microwave and a refrigerator plugged into a surge protector and not directly into the wall in File Infusion Oncology Room 4.




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On 3/19/13:

4. At 10:43 A.M., in the Medical Records office, there was a multi-plug power strip used to extend power to a microwave and a toaster oven.

5. At 11:14 A.M., there was a 2 plug electrical outlet with two broken ground ports in the old ultrasound room.

6. At 11:30 A.M., in the Lab, there was a refrigerator in the hallway in front of the door to the Pathologist office that was plugged into a multi-plug power strip that was plugged into two other multi-plug power strips inside the office.

Based on observation and interview, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 3 of 7 smoke compartments in the Main Hospital and 1 of 2 smoke compartments in the RHC building.

Findings:

During the facility tour with the Hospital Staff on 3/18/2013 through 3/21/2013, the facility walls and ceilings were observed.

On 3/19/2013

1. At 2:12 p.m., there was an approximately 2 inch unsealed circular penetration in the center of the wall above the bed in the Old OB.

2. At 2:14 p.m., there were four approximately 1/4 inch unsealed circular penetrations in the center of the wall by the soap dispenser in Room 132.

3. At 3:48 p.m., there were penetrations in the north wall of the Fire Alarm Control Panel Room in the RHC building. There was an approximately 3 inch by 4 inch penetration on the bottom right bottom of the north wall and an approximately 2 inch circular penetration surrounding a 1 inch pipe in the top right of the north wall abutting Suite C. The Plant Manager Coordinator confirmed the penetrations in the north wall of the 721 building.






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Building A, Main HospitalOn 3/19/13:

4. At 11:01 A.M., in the "OR Manager Office", there were 4 penetrations approximately 1/2 inches round each in diameter in the wall over the desk and 2 penetrations approximately 1/2 inch round each in the wall next to the door.

5. At 11:08 A.M., in the Chaplain's Office Storage Room, there were 2 penetrations approximately 1 inch round each in the left wall by the door with wires running through it and a 2 inch round penetration in the wall with a wire through it. When interviewed, the Plant Manager Coordinator stated that it was a data line put in for the Diagnostic Imaging center.

6. At 1:30 P.M., in the Kitchen, there was a 1 inch round penetration with a wire through it in the wall next to the door that provided wiring for the speaker located in the corridor.

7. At 1:33 P.M., in the Kitchen, there were 4 penetrations approximately 1/2 inch round each in the wall by the mop closet.

8. At 1:45 P.M., in the Mail Room, there was a penetration in the wall approximately 1/2 inch round in diameter with a white phone wire through it.

Based on observation, the facility failed to maintain the integrity of the construction of the corridor wall. This was evidenced by a penetration in the corridor wall. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 1 of 7 smoke compartments in the Main Hospital.

Findings:

During the facility tour with the Hospital Staff on 3/18/2013 through 3/21/2013, the facility corridor walls were observed.

On 3/19/2013:

At 10:45 a.m., there was an approximately 1/2 inch unsealed penetration in the center of the right corridor wall by the Hospital Operator Office.

Based on observation, the facility failed to maintain their doors to resist the passage of smoke and fire as evidenced by doors that failed to positive latch and were blocked from closing. This had the potential to allow the migration of smoke causing harm to patients and staff. This affected 7 of 7 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the doors were observed.

On 3/19/2013:

1. At 10:53 a.m., the right side of the double door failed to latch shut to the Doctor's Lounge.

2. At 11:15 a.m., the self-closing door failed to latch shut to the bathroom by Outpatient Surgery.

3. At 11:25 a.m., the self-closing door failed to latch shut to the janitor's closet next to the ER Doctors' Sleeping Room.

On 3/20/2013:




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On 3/19/13:

4. At 10:50 A.M., the door to "Fluoroscopy" could not be closed due to computer equipment and cable cords extending into the doorway.

5. At 11:15 A.M., the door to the IT Office "Old Ultrasound Room" failed to positive latch upon closure.

6. At 11:20 A.M., the door to Room 2 in the Emergency Department was held open with a metal surgical table with supplies stacked on it.

7. At 11:25 A.M., the door to Registration in the Emergency Department was impeded from closing by a door wedge placed under the door.

8. At 1:43 P.M., the door to room 110B failed to latch due to the latching mechanism stuck in the door.

9. At 2:30 P.M., the door to the Storage Room by Room 103 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

10. At 2:50 P.M., the door the Soiled Utility room in the Infusion Services area was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls as evidenced by penetrations in the smoke barrier walls. This could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 4 of 7 smoke compartments in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with Hospital Staff on 3/18/2013 through 3/21/2013, the smoke barrier walls were observed and staff were interviewed.

On 3/20/2013:

1. At 10:16 a.m., there were two penetrations in the smoke barrier wall, one approximately 2 inch circular penetration surrounding a 1 inch conduit in the left center and an approximately 4 inch cutout parallel to the right of the first penetration. These penetrations were observed in the left center of the smoke barrier wall above the drop down ceiling abutting patient room 123. The Plant Maintenance Coordinator confirmed the penetrations in the smoke barrier wall located above the drop down ceiling abutting Patient Room 123 and stated that the penetrations would be repaired immediately with fire retardant material.













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On 3/20/13:

2. At 9:43 A.M., in the smoke barrier corridor wall by Room 133, there was an unsealed penetration approximately 5 inches wide by 6 inches long in the wall.

3. At 9:55 A.M., in the smoke barrier wall across from the Cardio-Pulmonary entrance there was a 2 foot long by 1 1/2 inch wide penetration between the smoke barrier wall over the fire doors and the corridor wall.

4. At 10:15 A.M., in the smoke barrier ceiling between the main hospital and the new Patient Services area, there was a 2 1/2 inch by 2 1/2 inch junction box with a 1/2 inch wide penetration around it and an electrical conduit tube with a 1/2 inch wide penetration around it.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to positive latch upon closure. This could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 5 of 7 smoke compartments in the Main Hospital.

Findings:

During fire alarm testing and observation with the Hospital Staff on 3/18/2013 through 3/21/2013, the smoke barrier doors were observed.

On 3/20/2013:

1. At 1:55 p.m., the right leaf of the smoke barrier double door failed to latch shut between the OR suite and the GI room.



On 3/21/2013:

2. At 9:45 a.m., the left leaf of the smoke barrier double door failed to fully close and latch shut at the entrance to the Operating Room Suite.






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On 3/19/13:

3. At 12:00 P.M., the smoke barrier door to the Lab failed to positive latch. When interviewed, the Plant Maintenance Coordinator stated that the employees had deactivated the hardware so they did not have to punch in their code when entering and leaving the Lab.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by gurneys and medical equipment blocking smoke barrier doors. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This affected 2 of 7 smoke compartments in the Main Hospital.

Findings:

During the tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the corridors and exits were observed.

On 3/19/13:

1. At 11:03 A.M., in the Operating Room suite corridor before the red sterile line, there was a gurney placed 1 foot from the smoke barrier doors leading out of the Operating Room.

On 3/20/13:

2. At 2:15 P.M., in the corridor outside of the Operating Room suite, there was a digital process fluoroscopy machine placed 2 feet from the privacy doors which prevented the left side from opening fully and reduced the corridor width to 5 feet.

NFPA 101®, Life Safety Code®, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, the facility failed to maintain their emergency lighting as evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation causing injury to patients and staff. This affected the 1 of 7 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the emergency lighting was observed and tested.

3/19/13:

At 2:10 P.M., emergency lighting unit 15 in the Simulation/Training Room/Operating Room failed to illuminate when tested.

Based on observation and interview, the facility failed to ensure an evacuation map was posted in the Diagnostic Imaging center as evidenced by the facility not posting an evacuation map in the Diagnostic Imaging Center to direct patients and visitors to a path leaidng to a safe location. This failure could delay patients, staff and visitors from utilizing the correct escape path in an emergency evacuation. This affected 1 of 7 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the Diagnostic Imaging center was observed and the Lab Manager and Plant Maintenance Coordinator was interviewed.

3/20/13:

At 10:00 A.M., there was no evacuation map posted in the Diagnostic Imaging Center, which measured approximately 8,552 square feet. When interviewed, the Plant Maintenance Coordinator stated that the building had been opened about a year and they must have forgotten to post an evacuation map. Documentation was requested and provided stating the fire clearance was granted on 3/17/11. The "Temporary Certificate of Occupancy" was provided and stated the "Temporary Occupancy is granted until August 31, 2011". When interviewed, the Lab Manager was asked if the facility had a final permit from the City of Fort Bragg and he stated that they did not. The Lab Manager stated that he had just called the city to come out and perform the final inspection and the City stated that they would be out by Monday, 3/25/13.

The Lab Manager stated that evacuation maps would be posted throughout the Diagnostic Imaging Center. An evacuation map was observed in one of the exam rooms.

Based on document review and interview, the facility failed to conduct fire drills at least quarterly for each shift of personnel as evidenced by 4 of 4 quarterly fire drills missing in Building B, Suite B, Outpatient Clinics - RHC at North Coast Family Health Center. This failure could result in the staff's inability to respond to fire and/or disaster and affected 1 of 1 smoke compartments.

Findings:

During document review with the Hospital Staff on 3/18/13 through 3/21/13, the facility's fire drill records were reviewed.

Building B, Suite B Outpatient Clinics - RHC at North Coast Family Health Center
On 3/18/13:
At 3:00 P.M., no documentation for 4 of 4 quarterly fire drills was provided. When interviewed, the Plant Maintenance Coordinator stated that he conducts fire drills in that building between 8:00 A.M. and 8:30 A.M. and Suite B did not come into work until 10:00 A.M.

Based on testing and observation, the facility failed to provide effective warning of fire as evidenced by strobes that failed to activate and manual pull stations that were impeded from access. This could result in potential harm if the alarms failed to notify patients, visitors and staff of a fire in the facility. This affected 3 of 7 smoke compartments in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72 National Fire Alarm Code®, (1999 Edition)
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

During the facility tour and fire alarm testing with the Hospital Staff on 3/18/13 through 3/21/13, the facility's fire drill records were reviewed.

On 3/19/2013:

1. 10:40 a.m., the manual pull station was blocked from access by a chair in the Main Hospital Lobby.

2. 10:59 a.m., the manual pull station was blocked from access by a trash container at the front entrance to the Surgical Suite.



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On 3/20/13:

3. At 1:39 P.M., in the Med Surge area, the fire alarm notification devices were activated and 4 chimes failed to activate after testing of a manual pull station.

Based on document review and observation, the facility failed to maintain their fire alarm system in accordance with NFPA 101, 2000 edition and NFPA 72, 1999 edition. This was evidenced by the batteries not tested and replaced according to NFPA 72 and NFPA 101 specifications,and no annual certification for the Fire Alarm Control Panel (FACP) and the failure to post the correct time on the FACP. This could cause harm to patients and staff in the event of a fire. This affected 7 of 7 smoke compartments in Building A, Main Hospital and 1 of 1 smoke compartments in Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center.

NFPA 101, Life Safety Code, 2000 Edition
9.6.5 Emergency Control.
9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)

NFPA 72, National Fire Alarm Code®, 1999 Edition
Table 7-3.2 Testing Frequencies.
6. Batteries -- Fire Alarm Systems
d. Sealed Lead-Acid Type,
1. Charger Test (Replace battery every 4 years.)

Findings:

During document review and a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the battery in the FACP was observed and the documentation was reviewed.

On 3/19/2013:

1. 10:35 a.m., there was no date posted on the batteries for the Fire Alarm Control Panel in the Electrical/Mechanical Room 136 to Diagnostic Imaging.

2. 1:48 p.m., the time on the fire alarm control Panel was posted as 12:48 p.m. The actual time was verified as 1:48 p.m. by the Plant Maintenance Coordinator who stated that the time was not corrected from the time change.




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Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center
On 3/18/13:
3. At 2:30 P.M., the facility failed to provide an annual certification for their Fire Alarm Control Panel. The last documentation provided was dated 12/22/11.

Building A, Main Hospital
On 3/19/13:
4. At 11:30 A.M., in the Emergency Department, two lead acid batteries in the FACP were dated 2/25/09.

Based on observation, record review and interview, the facility failed to maintain the smoke detectors as evidenced by the facility failure to provide a current record for sensitivity testing for 100 of 100 system-based smoke detectors, the failure to provide an installation date and testing logs per manufacturer instructions for 6 of 6 battery-operated smoke detectors, and the failure of a smoke detector to activate when tested with aerosol smoke. This could result in the failure of the smoke detectors to operate in the event of a fire and increase the risk of injury to patients, visitors, and staff due to smoke and fire. This affected 7 of 7 smoke compartments in the Main Building and Suite A and Suite B of the RHC Building.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7.3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction.

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.


During the facility tour, record review and interview with the Hospital Staff on 3/18/2013 through 3/21/2013 the facility smoke detectors were observed and tested and maintenance records were reviewed and staff interviewed.

Findings:

On 3/18/2013:

1. At 3:30 p.m., there was no smoke detector sensitivity tests conducted for the 100 of 100 system-based smoke detectors listed on the fire alarm certification report dated December 12, 2013. Maintenance Staff stated that the facility was not aware that a sensitivity test was required and that there were no previous sensitivity tests.

2. At 3:45 p.m., there were no records for the weekly testing of the 6 of 6 battery-operated smoke detectors and no record of the installation date. The manufacturer instructions provided by the facility stated "Test at least once a week" and "NFPA recommends replacing the alarms every 10 years". The Maintenance staff stated that the smoke detectors were installed when the facility leased the building in 2007.



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Building A, Main Hospital
On 3/20/13:
3. At 1:53 P.M., smoke detector L1-30 in the baby unit failed to activate an alarm when tested with canned smoke.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Based on document review, observation and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by the failure to provide documentation of quarterly automatic sprinkler test/inspection for 4 of 4 quarters, and failure of 2 of 4 Inspector Test Valve's (ITV) to activate the alarm within 90 seconds and, by failing to ensure the Tampers for the Diagnostic Imaging Center were locked. This failure could cause injury to patients and staff in the event of a fire and the sprinkler system failed. This affected 2 of 7 smoke compartments in Building A, Main Hospital and Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center.

Findings:

During document review and alarm testing with the Hospital Staff on 3/18/13 through 3/21/13, the facility's maintenance records were reviewed, the automatic sprinkler system was tested and the Plant Maintenance Coordinator was interviewed.

Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center
On 3/18/13:
1. At 4:00 P.M., the maintenance records were reviewed and the facility failed to provide documentation that the sprinkler test/inspections were conducted for 4 of 4 quarters. When interviewed, the Plant Maintenance Coordinator stated that the hospital did not own that building so they had never conducted sprinkler testing.

Building A, Main Hospital
On 3/20/13:
2. At 11:27 A.M., the ITV for the Patient Services area was opened and the alarm failed to occur within 90 seconds. The ITV was timed for approximately 3 minutes, 21 seconds and failed to activated any devices at the facility. The trouble alarm was received at the panel. When interviewed, the Plant Maintenance Coordinator stated that the facility would implement a fire watch and he would contact the vendor to repair the system.

3. At 11:51 A.M., the ITV for the main hospital was opened and the alarm failed to activate within 90 seconds. The ITV was timed for approximately 2 minutes, 45 seconds and failed to activated any devices at the facility. The ITV failed to transmit a trouble signal to the panel. When interviewed, the Plant Maintenance Coordinator stated that the facility would implement a fire watch and he would contact the vendor to repair the system.

4. At 3:10 P.M., the Tamper valves for the Diagnostic Imaging Center were tested and observed to be unlocked.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers that did not have escutcheon rings. This could result in the fire sprinkler system not functioning as designed and increased risk of injury to residents and staff. This affected 1 of 7 smoke compartments.

Findings:

During a tour of the facility with the Hospital Staff on 3/18/13 through 3/21/13, the sprinkler system was observed.

Building A, Main Hospital
On 3/19/13:
At 4:45 P.M., in the overhang outside the hospital, there was 4 of 4 sprinklers missing the escutcheon rings.

Based on observation, the facility failed to ensure that portable fire extinguishers were easily accessible as evidenced by portable fire extinguishers that were impeded from access. This could delay the ability to extinguish a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 7 smoke compartments in the Main Hospital and Suite B in the 721 Building.

NFPA 10 Standard for Portable Fire Extinguishers, 2002 Edition
1.5.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition and shall be kept in their designated places at all times when they are not being used.
1.5.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal path of travel, including exits from area.
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place
Findings:

During the facility tour with the Hospital Staff on 3/18/2013 through 3/21/2013, the fire extinguishers were observed.

On 3/19/2013:

1. At 1:30 p.m., the fire extinguisher was blocked by a cart in the Kitchen of the Main Hospital.

2. At 3:25 p.m., the fire extinguisher was blocked by a portable space heater (not in use) and a trash can on the side of the refrigerator in the employee kitchen, Suite B of the RHC Building.

Based on document review, observation and interview, the facility failed to ensure that smoking was allowed in designated smoking areas. This was evidenced by a container of cigarette butts in a non designated smoking area. This affected 1 of 1 smoke compartments in Building B, Suite A and B, Outpatient Clinics - RHC at North Coast Family Health Center.

Findings:

During document review with the Hospital Staff on 3/18/13 through 3/21/13, the facility's smoking policy was reviewed and the Plant Maintenance Coordinator and Administrator was interviewed.

Building B, Outpatient Clinics - RHC at North Coast Family Health Center
On 3/19/13:
At 4:30 P.M., a coffee can 1/3 full of used cigarette butts was placed up against the corner of Suite A. When interviewed, the Administrator was asked if that was a designated smoking area and she stated that it was not and that the hospital had a no smoking policy. The facility's smoking policy was reviewed and stated the hospital was a smoke free campus. The Plant Maintenance Coordinator confirmed it was a no smoking facility.

Based on record review and interview, the facility failed to ensure that the kitchen cooking facilities were inspected and serviced ar least every six months, as evidenced by one record of the degreasing of the kitchen hood and exhaust system. This could result in a fire and increase the risk of injury to patients, visitors and staff due to a fire. This affected 1 of 7 smoke compartments in the Main Hospital.

NFPA 96 (1998 Edition) 8-2 Inspection. An inspection and servicing of the fire-extinguishing system and listed exhausted hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

During record review and interview with the Hospital Staff on 3/18/2013 through 3/21/2013,The kitchen hood suppression system records were reviewed and staff interviewed.

On 3/18/2013:

At 4:00 p.m., there was one record for the the degreasing of the kitchen hood and exhaust system dated January 25, 2013. The Plant Maintenance Coordinator stated that the facility was not aware until recently that cleaning of the entire kitchen hood exhaust was required. The filters were cleaned in house but no records were available for review.

Based on observation and interview, the facility failed to maintain a safe environment as evidenced by the presence of portable space heaters. This could result in a fire and increase the risk of injury to patients, visitors and staff. This affected 3 of 7 smoke compartments in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.7.8 Portable space heating devices are prohibited in all health care occupancies, except in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees F. (100 degrees C)

During the facility tour and interview with the Hospital Staff on 3/18/2013 through 3/21/2013, the rooms were observed and staff were interviewed.

On 3/19/13:

1. At 11:30 a.m., there was a portable space heater in the Doctors Sleeping Room. The portable space heater was plugged in at the time of the survey but was not turned on. The Plant Maintenance Coordinator stated that the portable space heater was not part of the hospital inventory and was not supposed to be in the room.

2. At 1:40 p.m., there was a portable space heater in the Cardiac Echo Room. The portable space heater was not plugged in at the time of the survey. Cardiac Echo Staff 1 stated that the portable space heater was used to warm up the room for the patients.

3. At 3:00 p.m., there were two portable space heaters backed up to the bookcase in the Billing Office. The portable space heaters were plugged in and on at the time of the survey. The space heaters stated 3 feet from the wall on the top of the heaters. There was a patient observed in the billing office paying a bill.

Based on observation, document review and interview, the facility failed to maintain the humidity levels at 35% or greater in accordance with NFPA 99. This was evidenced by documentation of humidity levels less than 35% in two hospital operating rooms (OR) and no documentation for the GI Procedure Room. This could result in fire in an oxygen enriched environment in an operating room and increase the risk of injury to patients, visitors and staff. This affected 2 of 7 smoke compartments.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During observation, record review and interview with the Hospital Staff on 3/18/2013 through 3/21/2013, the operating rooms were observed, humidity documents were reviewed, and staff were interviewed.

On 3/20/2013:

1. At 8:15 a.m., the Nurse Manager was interviewed and humidity logs were requested for the 2 operating rooms and the GI Procedure Room. The Nurse Manager stated that the range for humidity levels was 30% - 60% per hospital guidelines, there was no documentation for the GI procedure room and there was no humidity reader in the GI procedure room. The humidity was logged one time early in the morning before operating procedures and there was no follow-up during the day. There was no procedure in effect to ensure humidity levels were monitored daily and adjusted when needed.

2. During record review, the facility provided humidity level documentation for OR 1 and OR 2 once in the morning between 7 a.m. and 9 a.m. A sample of the humidity levels were noted to be below the 35 percent in March 2013 and February 2013 in Operating Room 1- February 6, 2013 at 31%, February 11, 2013 at 30%, February 21, 2013 at 30%, February 22, 2013 at 31%, March 5, 2013 at 32%, March 18, 2013 at 31%, March 19, 2013 at 32% and Operating Room 2-February 11, 2013 at 31%, February 18, 2013 at 32%, February 20, 2013 at 31%, February 21, 2013 at 33%, February 25, 2013 at 31%, February 27, 2013 at 33%, March 5, 2013 at 32%, March 7, 2013 at 33%, March 8, 2013 at 31%, and March 18, 2013 at 32%. On the log provided by the facility, the acceptable ranges were notes as 30% to 60%. There was no notation of out of range corrections. The Plant Maintenance Coordinator stated that ranges were corrected when observed.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA110, Standard for Emergency and Standby Power Systems, Chapter 6.
3-4.4.2 Recordkeeping. A written record of inspection, performance, exercising period, and repairs shall be regularly maintained and available for inspection by the authority having jurisdiction.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.
6-4.3 Load tests of generator sets shall include complete cold starts.

Based on document review and interview, the facility failed to maintain their emergency back up power in accordance with NFPA 110 and NFPA 99. This was evidenced by failure to provide a written record of inspection for 4 of 4 generators, including but not limited to performance, seconds to transfer and exercising period as stated in NFPA 99 and NFPA 110. This could result in generator failure during power outage. This affected 7 of 7 smoke compartments in the Main Hospital.

Findings:

During document review and interview with the Hospital Staff on 3/18/13 through 3/21/13, the generator test and inspection logs were reviewed and the Plant Maintenance Coordinator was interviewed.

Building A, Main Hospital
On 3/18/13:
At 3:30 P.M., the generator records were reviewed and failed to provide the required information as stated in NFPA 99 and NFPA 110. The daily visual log provided listed information for one generator. When interviewed, the Plant Maintenance Coordinator stated that they looked at all 4 generators but only logged "ok" in one field to indicate all 4 generators were visually inspected.

Based on observation, the facility failed to maintain electrical safety as evidenced by the use of extension cords, the use of high wattage appliances plugged into surge protectors, surge protector plugged into each other, and electrical ground ports that were broken or missing. This could result in an electrical fire and increase the risk of injury to patients, visitors and staff. This affected 4 of 7 smoke compartments in the Main Hospital.

Code of Federal Regulations §483.25(h) Accidents.
The facility must ensure that -
(1) The resident environment remains as free from accident hazards as is possible; and
(2) Each resident receives adequate supervision and assistance devices to prevent accidents.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.
NFPA 70 (1999 Edition), 400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
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 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

During the facility tour, record review and interview with the Hospital Staff on 3/18/2013 through 3/22/2013, the facility's electrical appliances and equipment were observed.

On 3/19/2013:

1. At 1:35 p.m., there were two orange extension cords in use in the IT Room.

2. At 2:00 p.m., there was a microwave, a toaster oven, a coffee maker and a toaster plugged into a surge protector and not directly into the wall in the Station 1 Clean Utility Room.

3. At 2:10 p.m., there was a refrigerator and a microwave plugged into a surge protector and not directly into the wall in the Employee Pantry.

4. At 2:45 p.m., there was a a microwave and a refrigerator plugged into a surge protector and not directly into the wall in File Infusion Oncology Room 4.




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On 3/19/13:

4. At 10:43 A.M., in the Medical Records office, there was a multi-plug power strip used to extend power to a microwave and a toaster oven.

5. At 11:14 A.M., there was a 2 plug electrical outlet with two broken ground ports in the old ultrasound room.

6. At 11:30 A.M., in the Lab, there was a refrigerator in the hallway in front of the door to the Pathologist office that was plugged into a multi-plug power strip that was plugged into two other multi-plug power strips inside the office.