HospitalInspections.org

Based on observation, document review, and interview, the facility failed to protect all patient care areas by failing to comply with the regulations regarding electrical wiring and utilities.
This was evidenced by the following:
1. Medical equipment such as IV pumps, ventilators, glucometers, ENT scopes, PC monitors as well as assorted low amperage medical devices that were attached to un-listed assemblies which were plugged into Tripp-Lite and Hubbell power strips or Special Purpose Relocatable Power Taps or (SPRPT) in anesthetizing locations.
2. Medical equipment such as IV pumps, ventilators, glucometers, ENT scopes, PC monitors as well as assorted low amperage medical devices that were attached to un-listed assemblies which were plugged into Trip-Lite power strips or Special Purpose Relocatable Power Taps or (SPRPT) in general and critical patient care areas.
3. High wattage electrical equipment such as mini refrigerators, microwave ovens, and coffee machines that were plugged into Tripp-Lite and other brand power strips or Special Purpose Relocatable Power Taps or (SPRPT).
4. Power strips that were plugged into other Tripp-Lite, Belkin, and other brand name power strips or Special Purpose Relocatable Power Taps or (SPRPT).
5. Electrical outlets that were missing covers.
6. The use of Tripp-Lite and other brand name power strips or Special Purpose Relocatable Power Taps or (SPRPT) in a hanging or suspended fashion creating tension in the cable resulting in the plug blades slipping out of the receptacle slits.
These deficient practices affected all staff and patients in the Hospital patient care areas and could potentially result in the ignition of an electrical fire or in electrical shock.
NFPA 101, 2000 Edition, Existing 19.3.2 Protection from Hazards. 19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 99, 1999 Edition.
2-1-Definitions- Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
NFPA 99, 1999 Edition.
2-1-Definitions- Listed. Equipment, materials, or services included in a list published by an organization that is acceptable to the authority having jurisdiction and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets identified standards or has been tested and found suitable for a specified purpose.

NFPA 99, 19993-3.2.1.2, All patient care areas. (d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. NFPA 70, 1999 110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
NFPA 70, 1999 400.8 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.
NFPA 70, 1999
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:
4th floor, ICU
On 11/26/2012 the electrical receptacles inside of the Intensive Care Unit and the Trauma Nursing
Unit on the fourth floor of the main Hospital tower were observed.
1. At 10:15 a.m., at bed 4E16, there was one portable IV Poole with one Tripp-Lite power strip mounted to the pole. The power strip was connected to four Baxter IV pump machines. The power strip was connected to a wall outlet above the patient hospital bed.
2. At 10:20 a.m., at bed 4E9, There were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four Baxter IV pump machines and the other power strip was connected to three Baxter IV pump machines.
3. At 10:30 a.m., at bed 4E14, a Tripp-Lite-model number 27941, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The two plastic ties secured the power strip to the bottom base pole of the ventilator cart and would need scissors or another type of tool to remove. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
4. At 10:33 a.m., there were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to three IV pump machines.
5. At 10:35 a.m., at bed 4E8, a Tripp-Lite-model number 30255, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
6. At 10:38 a.m., in bed 4E8, there were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The second portable IV pole contained two more Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines
7. At 10:40 a.m., at bed 4E5, a Tripp-Lite-model number 30015, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
8. At 10:43 a.m., in bed 4E5, there were three IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The second portable IV pole contained two more Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The third IV pole contained one Tripp-Lite power strip connected to four more IV pump machines. At 10:44 a.m., in an interview with the Bio-medical engineer, he stated that the IV machines were not on but only charging at the moment.
9. At 10:45 a.m., at bed 4E4, a Tripp-Lite-model number 30253, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
10. At 10:47 a.m., at bed 4E4, There were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The second portable IV pole contained two more Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four more IV pump machines.
11. At 10:50 a.m., at bed 4E2, a Tripp-Lite-model number 30413, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
12. At 10:53 a.m., at bed 4E1, a Tripp-Lite-model number 30254, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
13. At 10:55 a.m., at bed 4E15, a Tripp-Lite medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed. At 10:56 a.m., in an interview with the charge nurse at 10:56 a.m., the nurse was asked which receptacle the ventilator was plugged into. The nurse stated that the ventilator should be plugged into the red wall outlet. At 11:57 a.m., in an interview with the Bio-Medical Engineer, the Engineer stated that the patient use ventilators in the ICU should always be connected to the room emergency red outlets directly. At 3:25 p.m., The Bio-Medical Engineer in an interview stated that the new hospital policy allows ventilators to be plugged into Tripp-Lite power strips. He further added that the Savanna Greggor ventilator machines used approximately 2.5 amps when plugged in and in use and all contain a back up battery back up in case of electrical power failure.
During the interview, the Bio-Medical Engineer stated that the Baxter/Sigma IV pumps connected to the Tripp-Lite power strips were low amperage 300 milliamps AC/DC type.
14. At 10:59 a.m., in patient bed 4E15, there were three portable IV "Tree" poles in the room. Two of the IV poles each had two Tripp-Lite power strips with four plugs each that were attached with metal screws on both sides of the poles. Each power strip was then connected to four Baxter IV pump machines. All 16 IV pumps were connected to the four Tripp-Lite power strips which were then plugged into four wall outlets above the patient hospital bed. The Tripp-Lite power strip was the medical grade UL 1363A, PS-415-HG-OEM type.
In an interview with the charge nurse at 11:00 a.m., the nurse stated that the IV pumps were connected to the portable IV poles with power strips for patient transport purposes.
Third Floor
Surgery Center (OR)

On 11/26/2012, the electrical outlets in the Surgery center were observed.
15. At 11:05 a.m., in OR room 5 there was a black six plug Hubbell brand power strip on the floor near the patient bed below the ceiling mounted electrical supply boom above with a twist lock knob. In an interview with the charge nurse, the nurse stated that three medical devices were plugged into the power strip including a compression machine, cardiac monitor and fluid warmer.
16. At 11:20 a.m., in OR room 10 there was a black six plug Hubbell power strip on the floor by the patient bed connected to medical devices. Per an interview with the charge nurse, there was fluid warmer machine, Bear Hugger compression machine, and hospital bed plugged into the Hubbell power strip. The Hubbell power strip was connected to the electrical boom with a twist lock knob.
At 11:23 a.m., In an interview with the charge nurse, the nurse stated that the power strip was used so that all the electrical device cables and cords could be located at one central location so that medical staff would not inadvertently trip or step on other loose cables or power cords and that the sterile field would be maintained. At 11:28 a.m., in an interview with the bio-med engineer, the engineer stated that the Hubbell type power strips are UL listed but could not be changed out for Tripp-Lite power strips because Tripp-Lite does not make the twist lock knob assembly necessary for the OR room use.
17. In the same OR room 10, there was one IV pole with two Tripp-Lite power strips OEM model attached to the pole. There were more than five IV pump machines connected to the two power strips on the IV pole.
18. At 11:40 a.m., OR room 1 contained two black Hubbell six plug power strips on the floor both connected to the electrical boom above the patient bed area with a twist lock knob. One power strip was connected to a cauterize machine and a compressor machine. The other power strip was connected to two fluid warmer machines and one hospital bed.
19. In OR room 1 there were also two Tripp-Lite power strips one on an IV pole. One power strip was the UL 1363 PS-615-HG and the other one was a PS-415-HG type both approved for patient care areas per the manufacturer. 11/27/2012

Fifth floor, Inpatient Nursing
20. At 11:00 a.m., in the Inpatient Nursing wing room closet SD 22, there was a medical device
monitor on a cart that was plugged into a Tripp-Lite OEM power strip on the floor. Staff unplugged the machine and rolled the cart away.
21. At 11:05 a.m., in the main corridor in the Inpatient nursing unit nurse's station, there was a glucometer connected to a Tripp-Lite power strip model PS-415-HGULTRA on the counter top.
There was also a clock connected to the power strip.
11/27/2012
Third floor, GI Wing or Endoscopy Surgery Center

22. At 11:30 a.m., in room 3D15 there was one Tripp-Lite power strip, OEM type with Velcro straps tied to a metal and wood food tray table. The power strip was connected to a vital signs monitor and capro stat air machine standing on the food tray table.
23. At 11:35 a.m., in room 3D13, there was a PC monitor connected to a Tripp-Lite OEM type power strip attached to an IV pole.
11/28/2012
In an interview with the Bio-medical Engineer at 11:00 a.m., the Engineer was asked if the IV
Poles, the IV pump machines, and the Tripp-Lite power strips or Special Purpose Relocatable Power Taps or (SPRPT) all came assembled together as an assembled product or in the same container from the manufacturer. The Engineer stated that the three devices above all came from different suppliers and were hand assembled at the hospital by hospital staff.
Findings:
During a tour of the facility on 11/26/12, electrical equipment and devices were observed.
24. At 10:12 a.m., there was a medical equipment pole stand in Respiratory Medical Intensive Care Room 5R6 that had three IV pumps attached to the stand. These IV pumps were plugged into a four outlet power strip that was attached to the side of the pole stand. When asked, Engineering Staff 1 stated that the power strip was a Tripp-Lite model PL 415-HG-OEM.
25. At 10:15 a.m., there were three medical equipment pole stands in Respiratory Medical Intensive Care Room 5R4 that had IV pumps attached to the stands. These IV pumps were plugged into 2 four outlet Tripp-Lite power strips that were attached to both sides of the pole stands.
26. At 10:20 a.m., there were two medical equipment pole stands in Respiratory Medical Intensive Care Room 5R4 that had two IV pumps attached to them. Each IV stand had two Tripp-Lite four outlet powerstrips attached to the sides of the pole stand.

27. At 10:32 a.m., there was a medical equipment pole stand in Respiratory Medical Intensive Care Room 5E15 that had four IV pumps attached to it. These pumps were plugged into a Tripp-Lite four outlet power strip attached to the side of the pole stand.
28. At 10:38 a.m., there was a medical equipment pole stand in Respiratory Medical Intensive Care Room 5E8 that had a IV pump attached to it. The IV pump was plugged into a Tripp-Lite power strip that was attached to the side of the pole stand.
29. At 10:44 a.m., there was a six outlet Tripp-Lite power strip attached to the wall by the Telemetry Nurses' Station near Room 5D16A.
30. At 10:45 a.m., there was a six outlet Tripp-Lite power strip attached to the wall by the Telemetry Nurses' Station near Room 5D16A that had two glucometers plugged into it.
31. At 10:58 a.m., Emergency Resuscitation Room 1E93 had a Tripp-Lite power strip mounted to a linen cabinet. A blanket warmer, a computer, and a transplant pack were plugged into it. One of the plug ends had become partially unplugged from the outlet exposing the terminals due to the tension in the line.
32. At 11:12 a.m., Emergency Room 1E64 had a Tripp-Lite six outlet power strip that was suspended above the floor under a desk causing tension on the electrical plugs.
33. At 11:20 a.m., Emergency Resuscitation Room 1E89 had a medical equipment pole stand with an IV pump that was attached to a Tripp-Lite power strip on the side of the pole stand.
34. At 11:25 a.m., Emergency Room Bays 11 and 12 had a medical equipment pole stand with an IV pump attached to it. The IV pump was plugged into a four outlet Tripp-Lite power strip attached to the side of the pole.
During a tour of the facility on 11/27/12, electrical equipment and devices were observed.
35. At 9:55 a.m., Room 7B20 had a microwave oven plugged into a six outlet Tripp-Lite power strip.
36. At 10:45 a.m., Room 5A18 had an IV pump and a PCA pump attached to a medical pole stand. These pumps were plugged into a Tripp-Lite power strip attached to the side of the medical equipment pole.
37. At 2:25 p.m., there was a plate cover missing from an outlet receptacle in the Sterile Processing.
Assembly Room on the Basement Floor.
38. At 2:32 p.m., there was a hospital grade outlet adapter from single gang to double gang outlets
with no over current protection in the Sterile Processing Room.
39. At 2:35 p.m., there were three ventilators in Sterile Processing on the Basement Floor that were not in use. These ventilators also had humidifiers as part of the assembly. The pedestal to the ventilator had a power strip that was zip tied to it.
40. At 3:35 p.m., there was a hospital grade outlet adapter increasing the number of outlets from a single gang outlet to a double gang outlet with no over current protection in Building 80 on the Sixth
Floor Treatment Room.
During a tour of the facility on 11/27/12, electrical equipment and devices were observed.

San Francisco General Hospital - Main Hospital,
6th Floor, Surgical Clinic, Oncology/Pediatric Nursing, Psychiatry nursing, offices, Labor and
delivery, and Women's Option Center.

41. At 9:55 a.m., in Room 6B18, a temperature reading machine was plugged into a Tripp-Lite 6-outlet power strip.
42. At 10:25 a.m., in Room 6M25 (Lab), a Tripp-Lite 6-outlet power strip was mounted to a desk.
43. At 10:30 a.m., in Room 6M49, a Tripp-Lite 6-outlet power strip was mounted to a desk.
44. At 10:35 a.m., in Room 6M68, 4 Tripp-Lite 6-outlet power strips were mounted to the desks in the room.
45. At 10:52 a.m., in Room 6A25, a water cooler was plugged into an extension cord that was plugged into another extension cord.
46. At 10:57 a.m., in Room 6A (Medication Room), a stainless steel refrigerator was plugged into a Tripp-Lite power strip.
San Francisco General Hospital - Main Hospital,
4th Floor Surgical Clinic, Progressive Care Unit, Pharmacy,
and offices.

47. At 11:26 a.m., in Room 4J3 (Staff Room), a microwave was plugged into a Tripp-Lite power strip.
48. At 11:44 a.m., in Room 4B7 Bed 1, a television and compressor were plugged into a Curtis SP700 power strip.
49. At 1:32 p.m., by Room 4D4 in the corridor, a Tripp-Lite power strip was mounted to the wall.
50. At 1:35 p.m., by Room 4D6 in the corridor, a Tripp-Lite power strip was mounted to the wall.
51. At 1:36 p.m., by Room 4D7 in the corridor, a Tripp-Lite power strip was mounted to the wall.
52. San Francisco General Hospital - Avon Breast Center
53. At 3:28 p.m., in Room 44, a space heater was plugged into a Belkin power strip. During a tour of the facility on 11/27/12, electrical equipment and devices were observed.
Main Building, 6th Floor
54. At 10:58 a.m., in Room 6F8, there was an extension cord plugged into a Belkin power strip with computer system, printer, speaker, and a microwave plugged into the power strip.
4th Floor
55. At 11:19 a.m., in Room 4M61, there was a Belkin power strip with a PC monitor, eye test light, and a sound bar plugged into the power strip, non medical grade power strip.

56. At 11:31 a.m., in Room 4M35, there were two Tripp-Lite SPS-415 power strips, non medical grade plugged to each other with two computer systems, imaging module, and a printer plugged into the power strips.
57. At 11:44 a.m., in Room 4C1, there was a 3 plug multi-plug adapter plugged into a Tripp-Lite SPS-615 power strip with a printer, two computer systems, and speaker plugged into the power strip and the multi-plug adapter. Building 90 5th Floor
58. At 3:21 p.m., in Room 513, there was a microwave and coffee maker plugged into a Tripp-Lite SPS- 615 power strip.
4th Floor
59. At 3:31 p.m., in the Phlebotomy area near
Room 409G, a lamp was plugged into a Tripp-Lite Model RS 206-2 power strip with an extension cord daisy chained to the power strip. An electric fan was plugged into the other extension cord.
3rd Floor
60. At 3:41 p.m., in Room 329, there was an ENT scope plugged into a Tripp-Lite SPS-615 power
strip, non medical grade power strip.
2nd Floor
61. At 3:50 p.m., in Room 206, there was a lamp, ENT scope, VMI machine, and computer system plugged into a Tripp-Lite SPS-615 power strip, non medical grade power strip.

62. At 3:52 p.m., in Room 230, there was a computer system, exam light, and Hyfrecator Plus machine, plugged into a Tripp-Lite SPS-615 power strip, non medical grade power strip.

Based on observation, document review, and interview, the facility failed to protect all patient care areas by failing to comply with the regulations regarding electrical wiring and utilities.
This was evidenced by the following:
1. Medical equipment such as IV pumps, ventilators, glucometers, ENT scopes, PC monitors as well as assorted low amperage medical devices that were attached to un-listed assemblies which were plugged into Tripp-Lite and Hubbell power strips or Special Purpose Relocatable Power Taps or (SPRPT) in anesthetizing locations.
2. Medical equipment such as IV pumps, ventilators, glucometers, ENT scopes, PC monitors as well as assorted low amperage medical devices that were attached to un-listed assemblies which were plugged into Trip-Lite power strips or Special Purpose Relocatable Power Taps or (SPRPT) in general and critical patient care areas.
3. High wattage electrical equipment such as mini refrigerators, microwave ovens, and coffee machines that were plugged into Tripp-Lite and other brand power strips or Special Purpose Relocatable Power Taps or (SPRPT).
4. Power strips that were plugged into other Tripp-Lite, Belkin, and other brand name power strips or Special Purpose Relocatable Power Taps or (SPRPT).
5. Electrical outlets that were missing covers.
6. The use of Tripp-Lite and other brand name power strips or Special Purpose Relocatable Power Taps or (SPRPT) in a hanging or suspended fashion creating tension in the cable resulting in the plug blades slipping out of the receptacle slits.
These deficient practices affected all staff and patients in the Hospital patient care areas and could potentially result in the ignition of an electrical fire or in electrical shock.
NFPA 101, 2000 Edition, Existing 19.3.2 Protection from Hazards. 19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1. 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 99, 1999 Edition.
2-1-Definitions- Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
NFPA 99, 1999 Edition.
2-1-Definitions- Listed. Equipment, materials, or services included in a list published by an organization that is acceptable to the authority having jurisdiction and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets identified standards or has been tested and found suitable for a specified purpose.

NFPA 99, 19993-3.2.1.2, All patient care areas. (d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. NFPA 70, 1999 110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
NFPA 70, 1999 400.8 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.
NFPA 70, 1999
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

Findings:
4th floor, ICU
On 11/26/2012 the electrical receptacles inside of the Intensive Care Unit and the Trauma Nursing
Unit on the fourth floor of the main Hospital tower were observed.
1. At 10:15 a.m., at bed 4E16, there was one portable IV Poole with one Tripp-Lite power strip mounted to the pole. The power strip was connected to four Baxter IV pump machines. The power strip was connected to a wall outlet above the patient hospital bed.
2. At 10:20 a.m., at bed 4E9, There were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four Baxter IV pump machines and the other power strip was connected to three Baxter IV pump machines.
3. At 10:30 a.m., at bed 4E14, a Tripp-Lite-model number 27941, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The two plastic ties secured the power strip to the bottom base pole of the ventilator cart and would need scissors or another type of tool to remove. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
4. At 10:33 a.m., there were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to three IV pump machines.
5. At 10:35 a.m., at bed 4E8, a Tripp-Lite-model number 30255, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
6. At 10:38 a.m., in bed 4E8, there were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The second portable IV pole contained two more Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines
7. At 10:40 a.m., at bed 4E5, a Tripp-Lite-model number 30015, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
8. At 10:43 a.m., in bed 4E5, there were three IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The second portable IV pole contained two more Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The third IV pole contained one Tripp-Lite power strip connected to four more IV pump machines. At 10:44 a.m., in an interview with the Bio-medical engineer, he stated that the IV machines were not on but only charging at the moment.
9. At 10:45 a.m., at bed 4E4, a Tripp-Lite-model number 30253, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
10. At 10:47 a.m., at bed 4E4, There were two IV poles in the room. One portable IV pole contained two Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four IV pump machines. The second portable IV pole contained two more Tripp-Lite 4 plug power strips. One power strip was connected to four IV pump machines and the other power strip was connected to four more IV pump machines.
11. At 10:50 a.m., at bed 4E2, a Tripp-Lite-model number 30413, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
12. At 10:53 a.m., at bed 4E1, a Tripp-Lite-model number 30254, medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed.
13. At 10:55 a.m., at bed 4E15, a Tripp-Lite medical grade UL 1363A, PS415-HG-OEM power strip was connected to the ventilator and heater/humidifier machine. The Tripp-lite power strip was tied to the bottom of the ventilator movable cart with plastic zip ties. The Power strip was then connected to the red plug emergency receptacle on the upper wall behind the patient hospital bed. At 10:56 a.m., in an interview with the charge nurse at 10:56 a.m., the nurse was asked which receptacle the ventilator was plugged into. The nurse stated that the ventilator should be plugged into the red wall outlet. At 11:57 a.m., in an interview with the Bio-Medical Engineer, the Engineer stated that the patient use ventilators in the ICU should always be connected to the room emergency red outlets directly. At 3:25 p.m., The Bio-Medical Engineer in an interview stated that the new hospital policy allows ventilators to be plugged into Tripp-Lite power strips. He further added that the Savanna Greggor ventilator machines used approximately 2.5 amps when plugged in and in use and all contain a back up battery back up in case of electrical power failure.
During the interview, the Bio-Medical Engineer stated that the Baxter/Sigma IV pumps connected to the Tripp-Lite power strips were low amperage 300 milliamps AC/DC type.
14. At 10:59 a.m., in patient bed 4E15, there were three portable IV "Tree" poles in the room. Two of the IV poles each had two Tripp-Lite power strips with four plugs each that were attached with metal screws on both sides of the poles. Each power strip was then connected to four Baxter IV pump machines. All 16 IV pumps were connected to the four Tripp-Lite power strips which were then plugged into four wall outlets above the patient hospital bed. The Tripp-Lite power strip was the medical grade UL 1363A, PS-415-HG-OEM type.
In an interview with the charge nurse at 11:00 a.m., the nurse stated that the IV pumps were connected to the portable IV poles with power strips for patient transport purposes.
Third Floor
Surgery Center (OR)

On 11/26/2012, the electrical outlets in the Surgery center were observed.
15. At 11:05 a.m., in OR room 5 there was a black six plug Hubbell brand power strip on the floor near the patient bed below the ceiling mounted electrical supply boom above with a twist lock knob. In an interview with the charge nurse, the nurse stated that three medical devices were plugged into the power strip including a compression machine, cardiac monitor and fluid warmer.
16. At 11:20 a.m., in OR room 10 there was a black six plug Hubbell power strip on the floor by the patient bed connected to medical devices. Per an interview with the charge nurse, there was fluid warmer machine, Bear Hugger compression machine, and hospital bed plugged into the Hubbell power strip. The Hubbell power strip was connected to the electrical boom with a twist lock knob.
At 11:23 a.m., In an interview with the charge nurse, the nurse stated that the power strip was used so that all the electrical device cables and cords could be located at one central location so that medical staff would not inadvertently trip or step on other loose cables or power cords and that the sterile field would be maintained. At 11:28 a.m., in an interview with the bio-med engineer, the engineer stated that the Hubbell type power strips are UL listed but could not be changed out for Tripp-Lite power strips because Tripp-Lite does not make the twist lock knob assembly necessary for the OR room use.
17. In the same OR room 10, there was one IV pole with two Tripp-Lite power strips OEM model attached to the pole. There were more than five IV pump machines connected to the two power strips on the IV pole.
18. At 11:40 a.m., OR room 1 contained two black Hubbell six plug power strips on the floor both connected to the electrical boom above the patient bed area with a twist lock knob. One power strip was connected to a cauterize machine and a compressor machine. The other power strip was connected to two fluid warmer machines and one hospital bed.
19. In OR room 1 there were also two Tripp-Lite power strips one on an IV pole. One power strip was the UL 1363 PS-615-HG and the other one was a PS-415-HG type both approved for patient care areas per the manufacturer. 11/27/2012

Fifth floor, Inpatient Nursing
20. At 11:00 a.m., in the Inpatient Nursing wing room closet SD 22, there was a medical device
monitor on a cart that was plugged into a Tripp-Lite OEM power strip on the floor. Staff unplugged the machine and rolled the cart away.
21. At 11:05 a.m., in the main corridor in the Inpatient nursing unit nurse's station, there was a glucometer connected to a Tripp-Lite power strip model PS-415-HGULTRA on the counter top.
There was also a clock connected to the power strip.
11/27/2012
Third floor, GI Wing or Endoscopy Surgery Center

22. At 11:30 a.m., in room 3D15 there was one Tripp-Lite power strip, OEM type with Velcro straps tied to a metal and wood food tray table. The power strip was connected to a vital signs monitor and capro stat air machine standing on the food tray table.
23. At 11:35 a.m., in room 3D13, there was a PC monitor connected to a Tripp-Lite OEM type power strip attached to an IV pole.
11/28/2012
In an interview with the Bio-medical Engineer at 11:00 a.m., the Engineer was asked if the IV
Poles, the IV pump machines, and the Tripp-Lite power strips or Special Purpose Relocatable Power Taps or (SPRPT) all came assembled together as an assembled product or in the same container from the manufacturer. The Engineer stated that the three devices above all came from different suppliers and were hand assembled at the hospital by hospital staff.
Findings:
During a tour of the facility on 11/26/12, electrical equipment and devices were observed.
24. At 10:12 a.m., there was a medical equipment pole stand in Respiratory Medical Intensive Care Room 5R6 that had three IV pumps attached to the stand. These IV pumps were plugged into a four outlet power strip that was attached to the side of the pole stand. When asked, Engineering Staff 1 stated that the power strip was a Tripp-Lite model PL 415-HG-OEM.
25. At 10:15 a.m., there were three medical equipment pole stands in Respiratory Medical Intensive Care Room 5R4 that had IV pumps attached to the stands. These IV pumps were plugged into 2 four outlet Tripp-Lite power strips that were attached to both sides of the pole stands.
26. At 10:20 a.m., there were two medical equipment pole stands in Respiratory Medical Intensive Care Room 5R4 that had two IV pumps attached to them. Each IV stand had two Tripp-Lite four outlet powerstrips attached to the sides of the pole stand.

27. At 10:32 a.m., there was a medical equipment pole stand in Respiratory Medical Intensive Care Room 5E15 that had four IV pumps attached to it. These pumps were plugged into a Tripp-Lite four outlet power strip attached to the side of the pole stand.
28. At 10:38 a.m., there was a medical equipment pole stand in Respiratory Medical Intensive Care Room 5E8 that had a IV pump attached to it. The IV pump was plugged into a Tripp-Lite power strip that was attached to the side of the pole stand.
29. At 10:44 a.m., there was a six outlet Tripp-Lite power strip attached to the wall by the Telemetry Nurses' Station near Room 5D16A.
30. At 10:45 a.m., there was a six outlet Tripp-Lite power strip attached to the wall by the Telemetry Nurses' Station near Room 5D16A that had two glucometers plugged into it.
31. At 10:58 a.m., Emergency Resuscitation Room 1E93 had a Tripp-Lite power strip mounted to a linen cabinet. A blanket warmer, a computer, and a transplant pack were plugged into it. One of the plug ends had become partially unplugged from the outlet exposing the terminals due to the tension in the line.
32. At 11:12 a.m., Emergency Room 1E64 had a Tripp-Lite six outlet power strip that was suspended above the floor under a desk causing tension on the electrical plugs.
33. At 11:20 a.m., Emergency Resuscitation Room 1E89 had a medical equipment pole stand with an IV pump that was attached to a Tripp-Lite power strip on the side of the pole stand.
34. At 11:25 a.m., Emergency Room Bays 11 and 12 had a medical equipment pole stand with an IV pump attached to it. The IV pump was plugged into a four outlet Tripp-Lite power strip attached to the side of the pole.
During a tour of the facility on 11/27/12, electrical equipment and devices were observed.
35. At 9:55 a.m., Room 7B20 had a microwave oven plugged into a six outlet Tripp-Lite power strip.
36. At 10:45 a.m., Room 5A18 had an IV pump and a PCA pump attached to a medical pole stand. These pumps were plugged into a Tripp-Lite power strip attached to the side of the medical equipment pole.
37. At 2:25 p.m., there was a plate cover missing from an outlet receptacle in the Sterile Processing.
Assembly Room on the Basement Floor.
38. At 2:32 p.m., there was a hospital grade outlet adapter from single gang to double gang outlets
with no over current protection in the Sterile Processing Room.
39. At 2:35 p.m., there were three ventilators in Sterile Processing on the Basement Floor that were not in use. These ventilators also had humidifiers as part of the assembly. The pedestal to the ventilator had a power strip that was zip tied to it.
40. At 3:35 p.m., there was a hospital grade outlet adapter increasing the number of outlets from a single gang outlet to a double gang outlet with no over current protection in Building 80 on the Sixth
Floor Treatment Room.
During a tour of the facility on 11/27/12, electrical equipment and devices were observed.

San Francisco General Hospital - Main Hospital,
6th Floor, Surgical Clinic, Oncology/Pediatric Nursing, Psychiatry nursing, offices, Labor and
delivery, and Women's Option Center.

41. At 9:55 a.m., in Room 6B18, a temperature reading machine was plugged into a Tripp-Lite 6-outlet power strip.
42. At 10:25 a.m., in Room 6M25 (Lab), a Tripp-Lite 6-outlet power strip was mounted to a desk.
43. At 10:30 a.m., in Room 6M49, a Tripp-Lite 6-outlet power strip was mounted to a desk.
44. At 10:35 a.m., in Room 6M68, 4 Tripp-Lite 6-outlet power strips were mounted to the desks in the room.
45. At 10:52 a.m., in Room 6A25, a water cooler was plugged into an extension cord that was plugged into another extension cord.
46. At 10:57 a.m., in Room 6A (Medication Room), a stainless steel refrigerator was plugged into a Tripp-Lite power strip.
San Francisco General Hospital - Main Hospital,
4th Floor Surgical Clinic, Progressive Care Unit, Pharmacy,
and offices.

47. At 11:26 a.m., in Room 4J3 (Staff Room), a microwave was plugged into a Tripp-Lite power strip.
48. At 11:44 a.m., in Room 4B7 Bed 1, a television and compressor were plugged into a Curtis SP700 power strip.
49. At 1:32 p.m., by Room 4D4 in the corridor, a Tripp-Lite power strip was mounted to the wall.
50. At 1:35 p.m., by Room 4D6 in the corridor, a Tripp-Lite power strip was mounted to the wall.
51. At 1:36 p.m., by Room 4D7 in the corridor, a Tripp-Lite power strip was mounted to the wall.
52. San Francisco General Hospital - Avon Breast Center
53. At 3:28 p.m., in Room 44, a space heater was plugged into a Belkin power strip. During a tour of the facility on 11/27/12, electrical equipment and devices were observed.
Main Building, 6th Floor
54. At 10:58 a.m., in Room 6F8, there was an extension cord plugged into a Belkin power strip with computer system, printer, speaker, and a microwave plugged into the power strip.
4th Floor
55. At 11:19 a.m., in Room 4M61, there was a Belkin power strip with a PC monitor, eye test light, and a sound bar plugged into the power strip, non medical grade power strip.

56. At 11:31 a.m., in Room 4M35, there were two Tripp-Lite SPS-415 power strips, non medical grade plugged to each other with two computer systems, imaging module, and a printer plugged into the power strips.
57. At 11:44 a.m., in Room 4C1, there was a 3 plug multi-plug adapter plugged into a Tripp-Lite SPS-615 power strip with a printer, two computer systems, and speaker plugged into the power strip and the multi-plug adapter. Building 90 5th Floor
58. At 3:21 p.m., in Room 513, there was a microwave and coffee maker plugged into a Tripp-Lite SPS- 615 power strip.
4th Floor
59. At 3:31 p.m., in the Phlebotomy area near
Room 409G, a lamp was plugged into a Tripp-Lite Model RS 206-2 power strip with an extension cord daisy chained to the power strip. An electric fan was plugged into the other extension cord.
3rd Floor
60. At 3:41 p.m., in Room 329, there was an ENT scope plugged into a Tripp-Lite SPS-615 power
strip, non medical grade power strip.
2nd Floor
61. At 3:50 p.m., in Room 206, there was a lamp, ENT scope, VMI machine, and computer system plugged into a Tripp-Lite SPS-615 power strip, non medical grade power strip.

62. At 3:52 p.m., in Room 230, there was a computer system, exam light, and Hyfrecator Plus machine, plugged into a Tripp-Lite SPS-615 power strip, non medical grade power strip.