HospitalInspections.org

At 11:21 a.m., there was an approximately 16 inch by 5 inch penetration, and an approximately 2 inch penetration, around blue and gray Internet lines, in the wall of Room W266. Staff 6 confirmed this finding, and identified the area as W266.

At 1:37 p.m., there was an approximately 5 inch by 5 inch penetration, and an approximately ? inch penetration, in the North wall of Storage Room S454. Staff 6 confirmed the finding, and identified the area as S454.

At 4:31 p.m., there were two approximately 1 inch penetrations in the North wall, and an approximately 1 inch penetration in the South wall near the lighting mount, in Room SB4. Staff 6 confirmed the finding, and identified the area as SB4.

At 4:48 p.m., there were two approximately 4 inch round penetrations above the door to Room 215 in the high rise basement. Staff 6 confirmed the finding, and identified the area as the high rise basement Room 215.






29665

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This affected one of five floors of the Sinatra Tower, one of two floors of the West Tower, one of four floors of the East Tower, and the basement of the main hospital. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with maintenance staff on 1/17/12, the walls and ceilings of the main hospital were observed.

At 4:54 p.m., there was an approximately 1 inch round penetration in the left wall, under the desk, of the rehabilitation department ' s charting room. Maintenance Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain the corridor construction as evidenced by one penetration in a corridor wall. This affected one of two floors in the West Tower of the main hospital, and could result in the spread of smoke and fire, in the event of a fire.

During a tour of the facility with maintenance staff on 1/17/12, the corridor walls were observed.

At 3:22 p.m., there was an approximately 2 inch penetration in the corridor wall above the camera, outside of the PBX office. Staff 6 confirmed the finding, and identified the area as outside of the PBX office.

At 11:15 a.m., the kitchen door, labeled as Room W262, was impeded from closing by a trash can. Staff 6 confirmed the finding, and identified the room as W262.

At 12:02 p.m., the door to the security services office was impeded from closing by a clipboard wedged under the door. Staff 6 confirmed the finding, and identified the room as the security services office.

At 3:14 p.m., the door to K analyst office in the Information Technology (IT) department was impeded from closing by a wedge. Staff 6 confirmed the finding, and the IT manager identified the office as Room K.

At 3:16 p.m., there door to H analyst office in the IT department was impeded from closing by a wedge. Staff 6 confirmed the finding, and the IT manager identified the Room H.







29665

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected one of two floors of the West Tower, one of five floors of the Sinatra Tower, and by one of four floors of the East Tower of the main building. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a facility tour with maintenance staff on 1/17/12, the corridor doors were observed.

At 4:58 p.m., the door to the rehabilitation department ' s waiting room was equipped with a self-closing device. The door closed but failed to latch.

Based on observation, the facility failed to maintain their exits as evidenced by exits that were not marked by readily visible signs. This affected one of two floors of the West Tower, and the basement of the main hospital. This could result in a delay in evacuation, in the event of a fire or other emergency.

During a facility tour with maintenance staff on 1/17/12, the exit signs were observed.

At 3:47 p.m., there was no illuminated exit sign in the egress path from the purchasing department to the exit corridor. Staff 6 confirmed the finding, and identified the room as the purchasing department.

At 4:21 p.m., there was no exit sign to provide a direct egress from the bakery in the kitchen. Staff 6 confirmed the finding, and identified the room as the bakery.

Based on observation, the facility failed to maintain their smoke barrier walls as evidenced by penetrations in the smoke barrier walls. This affected one of two floors of the West Tower and one of five floors of the Sinatra Tower. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
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.

During a facility tour with maintenance staff on 1/17/12, the smoke barrier walls were observed.

At 11:11 a.m., there were three approximately ? inch penetrations above the door frame in the smoke barrier wall near Room W260. Staff 6 confirmed the finding, and identified the wall as near Room W260.

At 2:20 p.m., there were two approximately ? inch penetrations, and an approximately 2 inch by ? inch penetration in the smoke barrier wall outside of Room S137. Staff 6 confirmed the finding, and identified the area as outside of Room S137.

Based on observation, the facility failed to maintain their the doors protecting smoke barriers as evidenced by one smoke barrier door that failed to latch. This affected one of five floors of the Sinatra Tower, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with maintenance staff on 1/18/12, the smoke barrier doors were tested and observed.

At 10:30 a.m., the smoke barrier double doors labeled SU19 were held open by a magnetic hold-open device. Both sides of the smoke barrier double door released from the hold-open device upon activation of the fire alarm system, and the right door failed to latch. Staff 6 and Staff 7 confirmed the finding, and identified door as SU19.

On 1/18/12, the hazardous areas at the main hospital were observed.

At 11:37 a.m., the linen supply room was observed to be greater than 50 square feet, and contained linen supplies on open shelves. The door to the linen supply room was held open by a magnetic hold-open device designed to release upon the activation of the fire alarm system. The door released upon activation of the fire alarm system, but dragged on the concrete floor and failed to latch. Staff 6 and Staff 7 confirmed the finding, and identified the room as the linen supply room.





29665

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self-closing doors. This was evidenced by hazardous areas without self-closing doors. This affected one of two floors of the West Tower in the main hospital, three of five floors of the El Mirador building, and one of three suites at La Quinta Medical Center. This could result in the spread of fire from a hazardous area to other areas of the facility.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During the facility tour with maintenance staff from 1/17/12 to 1/19/12, the hazardous areas were observed. Combustible storage rooms greater than 50 square feet in size are considered hazardous areas.

On 1/18/12, the hazardous areas of the El Mirador Medical Plaza were observed.

At 9:59 a.m., the storage room in the Outpatient Neurology department on the third floor was observed to be approximately 70 square feet in size. The room contained more than 10 cardboard boxes of papers and other combustible supplies. The door to the storage room was not equipped with a self-closing device.

At 10:44 a.m., the film file room on the first floor of the cancer center was observed to be approximately 300 square feet in size. The room contained more than 20 shelves of papers, paper files, and other combustibles. The door to room was not equipped with a self-closing device.

At 11:30 a.m., the medical records office in Suite 201 on the second floor was observed to be approximately 300 square feet in size. The room contained more than 25 shelves of papers, paper files, and other combustibles. The door to room was not equipped with a self-closing device.

At 11:41 a.m., the storage room in Suite 214 on the second floor was observed to be approximately 200 square feet in size. The room contained more than 30 cardboard boxes of supplies. The door to room was not equipped with a self-closing device.

On 1/19/12, the hazardous areas of the La Quinta Medical Center were observed.

At 7:55 a.m., the clean utility room at the Comprehensive Cancer Center (Suite 260) was observed to be approximately 125 square feet in size. The room contained five shelves of linens and a large cardboard box of linens. The door to the room was not equipped with a self-closing device.

On 1/19/12, the hazardous areas of the La Quinta Medical Center were observed.

At 7:55 a.m., the clean utility room at the Comprehensive Cancer Center (Suite 260) was observed to be approximately 125 square feet in size. The room contained five shelves of linens and a large cardboard box of linens. The door to the room was not equipped with a self-closing device.

During fire alarm testing with Staff 6 and Staff 7 on January 18, 2012, the exit doors at the main hospital were observed.

At 10:15 a.m., there was a cart, an approximately 2 foot by 3 foot white bag full of equipment, a wooden tool that was approximately 2 ? feet by 4 inches, a socket wrench and a cordless drill, on the floor, that impeded accessibility to the emergency exit in Pediatrics East. Staff 6 and 7 confirmed the finding and identified the area as Pediatrics exit.







29665

Based on observation and interview, the facility failed to ensure that exits are accessible at all times as evidenced by an exit door that was locked while the building was occupied. This affected one of four floors of the East Tower in the main hospital, and one of five floors of the El Mirador building. This could result in a delay in egress, in the event of a fire or other emergency.

Findings:

During a facility tour on maintenance staff from 1/17/12 to 1/19/12, exits were observed.

On 1/19/12, the exit doors of the El Mirador Medical Plaza were observed.

At 9:25 a.m., the cross corridor door between the East Lobby and the Cancer Center on the first floor was held open by a magnetic hold open device. The magnetic hold open device was designed to release upon activation of the fire alarm system. When the door was released from the magnet, it was locked and could not be opened from the East Lobby to exit into the Cancer Center. The door was labeled as an exit with LED exit signs on both sides.

During an interview at 9:26 a.m., Maintenance Staff 1 confirmed that the door was labeled as an exit from the East Lobby to the Cancer Center and that it was locked. The property manager unlocked the door immediately. Maintenance Staff 1 and the property manager were unsure how long the door had been locked. They stated that most patient care suites in the building operate between 8:00 a.m., and 5:00 p.m.

During a facility tour with maintenance staff on 1/17/12, the emergency lights were observed and tested at the main hospital.

At 4:47 p.m., the battery-powered emergency light in Room 217 in the high rise basement failed to illuminate when tested. Staff 6 confirmed the finding and identified the room as the switch gear room in the high rise basement.






29665

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by battery-powered emergency light fixtures that failed to illuminate when tested. This affected the basement of the main hospital, and one of five floors of El Mirador building. This could result in a lack of illumination during a power outage.

Findings:

During a facility tour with maintenance staff from 1/17/11 to 1/19/12, the emergency lighting was observed.

On 1/18/12, the emergency lighting at El Mirador Medical Plaza was observed.

At 1:41 p.m., the battery-powered emergency bull frog light, on the second floor of Stairway 3, failed to illuminate when tested.

Based on observation, the facility failed to maintain their exit signs as evidenced by exits that were not marked, and by exit signs that failed to illuminate when tested. This affected one of two floors on the East Tower, one of two floors of the West Tower, and one of five floors of the Sinatra Tower. This could result in a delay in evacuation, in the event of a fire or other emergency.

Findings:

During a facility tour with maintenance staff on 1/17/12, the illuminated exit signs were observed and tested in the West and Sinatra Towers.

At 11:35 a.m., there was no exit sign to provide direction of egress in the east direction from Room W282 . Staff 6 and Staff 7 confirmed the finding and identified the area as east of Room W282.

At 3:01 p.m., there was no exit sign to provide direction of egress in the east direction from Bay 13 in the PACU Recovery. Staff 6 and Staff 7 confirmed the finding and identified the area as east from Bay 13.

At 3:08 p.m., there was no exit sign to provide direction of egress in the east direction from Bay 4 in the PACU recovery . Staff 6 and Staff 7 confirmed the finding and identified the area as east from Bay 4.

During a facility tour with maintenance staff on 1/18/12, the illuminated exit signs were observed and tested in the East Tower.

At 8:15 a.m., there was no Exit sign to provide direction of egress above the cross-corridor door labeled S1-1. Staff 6 confirmed the finding and identified the door as S1-1.

At 8:41 a.m., there were eight of eight exit signs that failed to illuminate when tested on the third floor of the East Tower. Staff 6 confirmed the finding and identified the area as the third floor of the East wing.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly on each shift. This was evidenced by no documentation for fire drills conducted during the last quarter of 2011. This affected three of three outpatient suites at the La Quinta Medical Center, and could result in a delay in staff response, in the event of a fire.

Findings:

During record review on 1/17/12, the fire drill records for the main hospital and outpatient facilities were requested.

At 11:50 a.m., there were no records that indicated that fire drills were conducted during the fourth quarter of 2011 at La Quinta Medical Center for three of three outpatient suites.

During an interview at 11:51 a.m., Security Staff 1 stated that drills were scheduled for October 2011 at the La Quinta outpatient suites, but were not conducted.

Based on observation and interview, the facility failed to maintain their fire alarm system as evidenced by one pull station that was obstructed, and by one area where the fire alarm could not be heard. This affected one of four floors of the East Tower, and the basement of the main building. This could result in a delay in notification in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition.
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

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.

Findings:

During fire alarm testing with maintenance staff on 1/18/12, the alarm system components were observed and tested.

At 11:43 a.m., there was no alarm notification device in the washer/dryer room and no alarm could be heard while the dryer was running. Staff 11 confirmed that the fire alarm could not be heard. Staff 6 and Staff 7 confirmed the finding and Staff 6 identified the area as Room SB4.

At 1:38 p.m., there was a pull station activation device near a wall labeled E5, that was impeded from access by a bed near the emergency room. Staff 6 moved the bed right away, and a nurse placed another bed that impeded access to the pull station.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was covered by a plastic cap. This affected one of four floors of the East Tower, and could result in a delay in notification in the event of a fire.

Findings:

During a facility tour with maintenance staff on 1/18/12, the smoke detectors on the second floor of the East Tower were observed.

At 8:45 a.m., the smoke detector, located in the corridor between the Spine and Joint Department and the administration building, was covered with an orange plastic cap that impaired its ability to detect smoke.

During an interview at 8:46 a.m., Maintenance Staff 1 and Maintenance Staff 2 did not know how long the smoke detector had been covered. Maintenance Staff 2 removed the plastic cover immediately.

Based on observation, the facility failed to maintain their sprinkler system. This was evidenced by sprinkler heads that were missing escutcheon rings. This affected the basement of the main hospital, and could result in a delay in extinguishing a fire, in the event of a fire.

Findings:

During a facility tour with maintenance staff on 1/17/12, the sprinkler system components were observed.

At 4:17 p.m., one of three sprinkler heads was missing an escutcheon ring in the bake shop. Staff 6 confirmed the finding and identified the area as the kitchen bake shop.

At 4:28 p.m., one of three sprinkler heads was missing an escutcheon ring in the SB2 closet near the morgue. Staff 6 confirmed the finding and identified the area as the morgue.

On 1/17/12, the fire extinguishers were observed in the main hospital.

At 4:06 p.m., there was a fire extinguisher mounted behind a desk, and impeded from access, in the linen room labeled SB61A. Staff 6 and Staff 7 confirmed the finding and identified the area as Room SB61A.

At 2:52 p.m., there was a fire extinguisher obstructed by an isolation cart near Room 1264. Staff 6 confirmed the finding.

At 2:57 p.m., there was a fire extinguisher, labeled Fire Extinguisher 2 near NU49, mounted approximately 66 inches from the floor to the top of the extinguisher. Staff 6 confirmed the finding and identified the area as near NU49.

On 1/18/2012, the fire extinguishers were observed in the main hospital.

At 10:28 a.m., there was a fire extinguisher obstructed by a workstation on wheels near Room SU-18T. Staff 6 confirmed the finding and identified the area as Room SU-18T.






29665

Based on observation, the facility failed to ensure that fire extinguishers are maintained in accordance with NFPA 10. This was evidenced by fire extinguishers that were obstructed, and by one fire extinguisher that was mounted greater than 5 feet above the floor. This affected two of five floors of the Sinatra Tower, and one of five floors of the El Mirador building. This could result in a delay in extinguishing a fire, in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1.6 General Requirements
1.6.3 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 paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).


Findings:

During a facility tour with maintenance staff from 1/17/12 to 1/19/12, the fire extinguishers were observed.

On 1/18/12, the fire extinguishers at El Mirador Medical Plaza were observed.

At 11:06 a.m., the fire extinguisher in the biohazard room, next to the G.I. Lab on the first floor, was obstructed by a 64-gallon plastic trash bin.

Based on observation, the facility failed to ensure that means of egress are free from obstructions. This was evidenced by equipment stored in the corridor. This affected one of two floors of the West Tower in the main hospital, and could result in a delay in evacuation, in the event of a fire or other emergency.

Findings:

During a facility tour of the facility with maintenance staff from 1/17/12 to 1/18/12, the egress paths were observed.

On 1/18/12, at 11:29 a.m., there were approximately 60 boxes in the analyst corridor of the Information Technology (IT) department. The boxes were observed in the corridor at approximately the same time on 1/17/12. Staff 6 confirmed the finding and the IT manager identified the area as the analyst corridor.

On 1/18/12, at 12:17 p.m., there were two IV pumps on one side of the corridor near Room 4256, and a television that was on a cart and two baby cribs on the other side of the corridor. The equipment was observed in the corridor on 1/17/12. Staff 6 confirmed the finding and identified the area as outside of Room 4256.

At 11:27 a.m., there was an emergency oxygen shutoff valve that was impeded from access by an Isonet, near Room W282. Staff 6 confirmed the finding and identified the area as outside of Room W282.






29665

Based on observation, the facility failed to maintain their piped-in medical gas systems in accordance with NFPA 99. This was evidenced by one emergency shutoff valve that was obstructed. This affected one of two floors on the West Tower, and one of four floors of the East Tower. This could result in a delay in shutting off the medical gas lines in the event of a fire, or other emergency.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a facility tour with maintenance staff on 1/17/12, the piped-in medical gas system was observed.

At 4:09 p.m., there was a coffee machine obstructing the medical gas emergency shutoff valve in the Central 1 Department employee break room.

At 10:41 a.m., there was a snack vending machine near Elevator W2 that was plugged into an outlet without a cover plate. Staff 6 confirmed the finding and identified the area as the W2 Elevator vending machines.

At 2:16 p.m.,10 of 42 circuits were not identified in Electrical Panel CBP2 in Neuro Science ICU. Circuits 27, 33, 36, 37, 38, 39, 40, 41, and 42 were not identified. Staff 6 confirmed the finding and identified the area as ICU.

At 3:34 p.m., there was a refrigerator that was plugged into a multi-plug adaptor in the purchasing department break room. Staff 6 confirmed the finding and identified the area as the purchasing department.







29665

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by appliances that were plugged into surge protectors, by surge protectors that were plugged into other surge protectors, by electrical outlets with no cover plates, and by a circuit board with incomplete labeling. This affected one of two floors of the West Tower, one of five floors of the Sinatra Tower, one of four floors of the East Tower, and one of five floors of the El Mirador building. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.
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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour with maintenance staff on 1/17/12, the electrical wiring was observed.

At 3:14 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the pulmonary department office (Door EW-285).

At 3:16 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the pulmonary department break room.

At 3:38 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the medical records office.

At 3:44 p.m., there was a microwave plugged into a six-plug surge protector in the medical records break room.

At 4:53 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the charting room of the rehabilitation department.

On 1/18/12, the electrical wiring at El Mirador Medical Plaza was observed.

At 10:06 a.m., there was a six-plug surge protector plugged into another six-plug surge protector in the cubicle near Room 3027 on the third floor of the cancer center.

At 11:03 a.m., there was an ABHR dispenser mounted above an electrical outlet, and approximately 1/4 inch adjacent to a light switch, in Equipment Room W227. Staff 6 confirmed the finding and identified the area as Room W227.





29665

Based on observation, the facility failed to maintain their ABHR dispensers, as evidenced by ABHR dispensers that were installed over ignition sources. This affected one of two floors of the West Tower, one of four floors of the East Tower, and one of three suites at the La Quinta Medical Center, and could result in an increased risk of a fire.

Findings:

During a facility tour with maintenance staff from 1/17/12 to 1/19/12, the ABHR dispensers were observed.

On 1/17/12, the ABHR dispensers used on the first floor of the East Tower were observed.

At 2:59 p.m., the ABHR dispenser, in Exam Room 2 of the Maternal Fetal Medicine Wing, was installed approximately 1 inch directly above a light switch.

On 1/19/12, the ABHR dispensers at La Quinta Medical Center were observed.

At 7:30 a.m., the ABHR dispenser, outside the Diagnostic Imaging manager's office in Suite 100, was installed approximately 1 inch directly above a light switch.

At 11:21 a.m., there was an approximately 16 inch by 5 inch penetration, and an approximately 2 inch penetration, around blue and gray Internet lines, in the wall of Room W266. Staff 6 confirmed this finding, and identified the area as W266.

At 1:37 p.m., there was an approximately 5 inch by 5 inch penetration, and an approximately ? inch penetration, in the North wall of Storage Room S454. Staff 6 confirmed the finding, and identified the area as S454.

At 4:31 p.m., there were two approximately 1 inch penetrations in the North wall, and an approximately 1 inch penetration in the South wall near the lighting mount, in Room SB4. Staff 6 confirmed the finding, and identified the area as SB4.

At 4:48 p.m., there were two approximately 4 inch round penetrations above the door to Room 215 in the high rise basement. Staff 6 confirmed the finding, and identified the area as the high rise basement Room 215.






29665

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This affected one of five floors of the Sinatra Tower, one of two floors of the West Tower, one of four floors of the East Tower, and the basement of the main hospital. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with maintenance staff on 1/17/12, the walls and ceilings of the main hospital were observed.

At 4:54 p.m., there was an approximately 1 inch round penetration in the left wall, under the desk, of the rehabilitation department ' s charting room. Maintenance Staff 1 confirmed the finding.

Based on observation, the facility failed to maintain the corridor construction as evidenced by one penetration in a corridor wall. This affected one of two floors in the West Tower of the main hospital, and could result in the spread of smoke and fire, in the event of a fire.

During a tour of the facility with maintenance staff on 1/17/12, the corridor walls were observed.

At 3:22 p.m., there was an approximately 2 inch penetration in the corridor wall above the camera, outside of the PBX office. Staff 6 confirmed the finding, and identified the area as outside of the PBX office.

At 11:15 a.m., the kitchen door, labeled as Room W262, was impeded from closing by a trash can. Staff 6 confirmed the finding, and identified the room as W262.

At 12:02 p.m., the door to the security services office was impeded from closing by a clipboard wedged under the door. Staff 6 confirmed the finding, and identified the room as the security services office.

At 3:14 p.m., the door to K analyst office in the Information Technology (IT) department was impeded from closing by a wedge. Staff 6 confirmed the finding, and the IT manager identified the office as Room K.

At 3:16 p.m., there door to H analyst office in the IT department was impeded from closing by a wedge. Staff 6 confirmed the finding, and the IT manager identified the Room H.







29665

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected one of two floors of the West Tower, one of five floors of the Sinatra Tower, and by one of four floors of the East Tower of the main building. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a facility tour with maintenance staff on 1/17/12, the corridor doors were observed.

At 4:58 p.m., the door to the rehabilitation department ' s waiting room was equipped with a self-closing device. The door closed but failed to latch.

Based on observation, the facility failed to maintain their exits as evidenced by exits that were not marked by readily visible signs. This affected one of two floors of the West Tower, and the basement of the main hospital. This could result in a delay in evacuation, in the event of a fire or other emergency.

During a facility tour with maintenance staff on 1/17/12, the exit signs were observed.

At 3:47 p.m., there was no illuminated exit sign in the egress path from the purchasing department to the exit corridor. Staff 6 confirmed the finding, and identified the room as the purchasing department.

At 4:21 p.m., there was no exit sign to provide a direct egress from the bakery in the kitchen. Staff 6 confirmed the finding, and identified the room as the bakery.

Based on observation, the facility failed to maintain their smoke barrier walls as evidenced by penetrations in the smoke barrier walls. This affected one of two floors of the West Tower and one of five floors of the Sinatra Tower. This could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
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.

During a facility tour with maintenance staff on 1/17/12, the smoke barrier walls were observed.

At 11:11 a.m., there were three approximately ? inch penetrations above the door frame in the smoke barrier wall near Room W260. Staff 6 confirmed the finding, and identified the wall as near Room W260.

At 2:20 p.m., there were two approximately ? inch penetrations, and an approximately 2 inch by ? inch penetration in the smoke barrier wall outside of Room S137. Staff 6 confirmed the finding, and identified the area as outside of Room S137.

Based on observation, the facility failed to maintain their the doors protecting smoke barriers as evidenced by one smoke barrier door that failed to latch. This affected one of five floors of the Sinatra Tower, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with maintenance staff on 1/18/12, the smoke barrier doors were tested and observed.

At 10:30 a.m., the smoke barrier double doors labeled SU19 were held open by a magnetic hold-open device. Both sides of the smoke barrier double door released from the hold-open device upon activation of the fire alarm system, and the right door failed to latch. Staff 6 and Staff 7 confirmed the finding, and identified door as SU19.

On 1/18/12, the hazardous areas at the main hospital were observed.

At 11:37 a.m., the linen supply room was observed to be greater than 50 square feet, and contained linen supplies on open shelves. The door to the linen supply room was held open by a magnetic hold-open device designed to release upon the activation of the fire alarm system. The door released upon activation of the fire alarm system, but dragged on the concrete floor and failed to latch. Staff 6 and Staff 7 confirmed the finding, and identified the room as the linen supply room.





29665

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self-closing doors. This was evidenced by hazardous areas without self-closing doors. This affected one of two floors of the West Tower in the main hospital, three of five floors of the El Mirador building, and one of three suites at La Quinta Medical Center. This could result in the spread of fire from a hazardous area to other areas of the facility.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies
and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During the facility tour with maintenance staff from 1/17/12 to 1/19/12, the hazardous areas were observed. Combustible storage rooms greater than 50 square feet in size are considered hazardous areas.

On 1/18/12, the hazardous areas of the El Mirador Medical Plaza were observed.

At 9:59 a.m., the storage room in the Outpatient Neurology department on the third floor was observed to be approximately 70 square feet in size. The room contained more than 10 cardboard boxes of papers and other combustible supplies. The door to the storage room was not equipped with a self-closing device.

At 10:44 a.m., the film file room on the first floor of the cancer center was observed to be approximately 300 square feet in size. The room contained more than 20 shelves of papers, paper files, and other combustibles. The door to room was not equipped with a self-closing device.

At 11:30 a.m., the medical records office in Suite 201 on the second floor was observed to be approximately 300 square feet in size. The room contained more than 25 shelves of papers, paper files, and other combustibles. The door to room was not equipped with a self-closing device.

At 11:41 a.m., the storage room in Suite 214 on the second floor was observed to be approximately 200 square feet in size. The room contained more than 30 cardboard boxes of supplies. The door to room was not equipped with a self-closing device.

On 1/19/12, the hazardous areas of the La Quinta Medical Center were observed.

At 7:55 a.m., the clean utility room at the Comprehensive Cancer Center (Suite 260) was observed to be approximately 125 square feet in size. The room contained five shelves of linens and a large cardboard box of linens. The door to the room was not equipped with a self-closing device.

On 1/19/12, the hazardous areas of the La Quinta Medical Center were observed.

At 7:55 a.m., the clean utility room at the Comprehensive Cancer Center (Suite 260) was observed to be approximately 125 square feet in size. The room contained five shelves of linens and a large cardboard box of linens. The door to the room was not equipped with a self-closing device.

During fire alarm testing with Staff 6 and Staff 7 on January 18, 2012, the exit doors at the main hospital were observed.

At 10:15 a.m., there was a cart, an approximately 2 foot by 3 foot white bag full of equipment, a wooden tool that was approximately 2 ? feet by 4 inches, a socket wrench and a cordless drill, on the floor, that impeded accessibility to the emergency exit in Pediatrics East. Staff 6 and 7 confirmed the finding and identified the area as Pediatrics exit.







29665

Based on observation and interview, the facility failed to ensure that exits are accessible at all times as evidenced by an exit door that was locked while the building was occupied. This affected one of four floors of the East Tower in the main hospital, and one of five floors of the El Mirador building. This could result in a delay in egress, in the event of a fire or other emergency.

Findings:

During a facility tour on maintenance staff from 1/17/12 to 1/19/12, exits were observed.

On 1/19/12, the exit doors of the El Mirador Medical Plaza were observed.

At 9:25 a.m., the cross corridor door between the East Lobby and the Cancer Center on the first floor was held open by a magnetic hold open device. The magnetic hold open device was designed to release upon activation of the fire alarm system. When the door was released from the magnet, it was locked and could not be opened from the East Lobby to exit into the Cancer Center. The door was labeled as an exit with LED exit signs on both sides.

During an interview at 9:26 a.m., Maintenance Staff 1 confirmed that the door was labeled as an exit from the East Lobby to the Cancer Center and that it was locked. The property manager unlocked the door immediately. Maintenance Staff 1 and the property manager were unsure how long the door had been locked. They stated that most patient care suites in the building operate between 8:00 a.m., and 5:00 p.m.

During a facility tour with maintenance staff on 1/17/12, the emergency lights were observed and tested at the main hospital.

At 4:47 p.m., the battery-powered emergency light in Room 217 in the high rise basement failed to illuminate when tested. Staff 6 confirmed the finding and identified the room as the switch gear room in the high rise basement.






29665

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by battery-powered emergency light fixtures that failed to illuminate when tested. This affected the basement of the main hospital, and one of five floors of El Mirador building. This could result in a lack of illumination during a power outage.

Findings:

During a facility tour with maintenance staff from 1/17/11 to 1/19/12, the emergency lighting was observed.

On 1/18/12, the emergency lighting at El Mirador Medical Plaza was observed.

At 1:41 p.m., the battery-powered emergency bull frog light, on the second floor of Stairway 3, failed to illuminate when tested.

Based on observation, the facility failed to maintain their exit signs as evidenced by exits that were not marked, and by exit signs that failed to illuminate when tested. This affected one of two floors on the East Tower, one of two floors of the West Tower, and one of five floors of the Sinatra Tower. This could result in a delay in evacuation, in the event of a fire or other emergency.

Findings:

During a facility tour with maintenance staff on 1/17/12, the illuminated exit signs were observed and tested in the West and Sinatra Towers.

At 11:35 a.m., there was no exit sign to provide direction of egress in the east direction from Room W282 . Staff 6 and Staff 7 confirmed the finding and identified the area as east of Room W282.

At 3:01 p.m., there was no exit sign to provide direction of egress in the east direction from Bay 13 in the PACU Recovery. Staff 6 and Staff 7 confirmed the finding and identified the area as east from Bay 13.

At 3:08 p.m., there was no exit sign to provide direction of egress in the east direction from Bay 4 in the PACU recovery . Staff 6 and Staff 7 confirmed the finding and identified the area as east from Bay 4.

During a facility tour with maintenance staff on 1/18/12, the illuminated exit signs were observed and tested in the East Tower.

At 8:15 a.m., there was no Exit sign to provide direction of egress above the cross-corridor door labeled S1-1. Staff 6 confirmed the finding and identified the door as S1-1.

At 8:41 a.m., there were eight of eight exit signs that failed to illuminate when tested on the third floor of the East Tower. Staff 6 confirmed the finding and identified the area as the third floor of the East wing.

Based on record review and interview, the facility failed to ensure that fire drills are conducted quarterly on each shift. This was evidenced by no documentation for fire drills conducted during the last quarter of 2011. This affected three of three outpatient suites at the La Quinta Medical Center, and could result in a delay in staff response, in the event of a fire.

Findings:

During record review on 1/17/12, the fire drill records for the main hospital and outpatient facilities were requested.

At 11:50 a.m., there were no records that indicated that fire drills were conducted during the fourth quarter of 2011 at La Quinta Medical Center for three of three outpatient suites.

During an interview at 11:51 a.m., Security Staff 1 stated that drills were scheduled for October 2011 at the La Quinta outpatient suites, but were not conducted.

Based on observation and interview, the facility failed to maintain their fire alarm system as evidenced by one pull station that was obstructed, and by one area where the fire alarm could not be heard. This affected one of four floors of the East Tower, and the basement of the main building. This could result in a delay in notification in the event of a fire.

NFPA 101 Life Safety Code, 2000 Edition.
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

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.

Findings:

During fire alarm testing with maintenance staff on 1/18/12, the alarm system components were observed and tested.

At 11:43 a.m., there was no alarm notification device in the washer/dryer room and no alarm could be heard while the dryer was running. Staff 11 confirmed that the fire alarm could not be heard. Staff 6 and Staff 7 confirmed the finding and Staff 6 identified the area as Room SB4.

At 1:38 p.m., there was a pull station activation device near a wall labeled E5, that was impeded from access by a bed near the emergency room. Staff 6 moved the bed right away, and a nurse placed another bed that impeded access to the pull station.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was covered by a plastic cap. This affected one of four floors of the East Tower, and could result in a delay in notification in the event of a fire.

Findings:

During a facility tour with maintenance staff on 1/18/12, the smoke detectors on the second floor of the East Tower were observed.

At 8:45 a.m., the smoke detector, located in the corridor between the Spine and Joint Department and the administration building, was covered with an orange plastic cap that impaired its ability to detect smoke.

During an interview at 8:46 a.m., Maintenance Staff 1 and Maintenance Staff 2 did not know how long the smoke detector had been covered. Maintenance Staff 2 removed the plastic cover immediately.

Based on observation, the facility failed to maintain their sprinkler system. This was evidenced by sprinkler heads that were missing escutcheon rings. This affected the basement of the main hospital, and could result in a delay in extinguishing a fire, in the event of a fire.

Findings:

During a facility tour with maintenance staff on 1/17/12, the sprinkler system components were observed.

At 4:17 p.m., one of three sprinkler heads was missing an escutcheon ring in the bake shop. Staff 6 confirmed the finding and identified the area as the kitchen bake shop.

At 4:28 p.m., one of three sprinkler heads was missing an escutcheon ring in the SB2 closet near the morgue. Staff 6 confirmed the finding and identified the area as the morgue.

On 1/17/12, the fire extinguishers were observed in the main hospital.

At 4:06 p.m., there was a fire extinguisher mounted behind a desk, and impeded from access, in the linen room labeled SB61A. Staff 6 and Staff 7 confirmed the finding and identified the area as Room SB61A.

At 2:52 p.m., there was a fire extinguisher obstructed by an isolation cart near Room 1264. Staff 6 confirmed the finding.

At 2:57 p.m., there was a fire extinguisher, labeled Fire Extinguisher 2 near NU49, mounted approximately 66 inches from the floor to the top of the extinguisher. Staff 6 confirmed the finding and identified the area as near NU49.

On 1/18/2012, the fire extinguishers were observed in the main hospital.

At 10:28 a.m., there was a fire extinguisher obstructed by a workstation on wheels near Room SU-18T. Staff 6 confirmed the finding and identified the area as Room SU-18T.






29665

Based on observation, the facility failed to ensure that fire extinguishers are maintained in accordance with NFPA 10. This was evidenced by fire extinguishers that were obstructed, and by one fire extinguisher that was mounted greater than 5 feet above the floor. This affected two of five floors of the Sinatra Tower, and one of five floors of the El Mirador building. This could result in a delay in extinguishing a fire, in the event of a fire.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1.6 General Requirements
1.6.3 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 paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).


Findings:

During a facility tour with maintenance staff from 1/17/12 to 1/19/12, the fire extinguishers were observed.

On 1/18/12, the fire extinguishers at El Mirador Medical Plaza were observed.

At 11:06 a.m., the fire extinguisher in the biohazard room, next to the G.I. Lab on the first floor, was obstructed by a 64-gallon plastic trash bin.

Based on observation, the facility failed to ensure that means of egress are free from obstructions. This was evidenced by equipment stored in the corridor. This affected one of two floors of the West Tower in the main hospital, and could result in a delay in evacuation, in the event of a fire or other emergency.

Findings:

During a facility tour of the facility with maintenance staff from 1/17/12 to 1/18/12, the egress paths were observed.

On 1/18/12, at 11:29 a.m., there were approximately 60 boxes in the analyst corridor of the Information Technology (IT) department. The boxes were observed in the corridor at approximately the same time on 1/17/12. Staff 6 confirmed the finding and the IT manager identified the area as the analyst corridor.

On 1/18/12, at 12:17 p.m., there were two IV pumps on one side of the corridor near Room 4256, and a television that was on a cart and two baby cribs on the other side of the corridor. The equipment was observed in the corridor on 1/17/12. Staff 6 confirmed the finding and identified the area as outside of Room 4256.

At 11:27 a.m., there was an emergency oxygen shutoff valve that was impeded from access by an Isonet, near Room W282. Staff 6 confirmed the finding and identified the area as outside of Room W282.






29665

Based on observation, the facility failed to maintain their piped-in medical gas systems in accordance with NFPA 99. This was evidenced by one emergency shutoff valve that was obstructed. This affected one of two floors on the West Tower, and one of four floors of the East Tower. This could result in a delay in shutting off the medical gas lines in the event of a fire, or other emergency.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a facility tour with maintenance staff on 1/17/12, the piped-in medical gas system was observed.

At 4:09 p.m., there was a coffee machine obstructing the medical gas emergency shutoff valve in the Central 1 Department employee break room.

At 10:41 a.m., there was a snack vending machine near Elevator W2 that was plugged into an outlet without a cover plate. Staff 6 confirmed the finding and identified the area as the W2 Elevator vending machines.

At 2:16 p.m.,10 of 42 circuits were not identified in Electrical Panel CBP2 in Neuro Science ICU. Circuits 27, 33, 36, 37, 38, 39, 40, 41, and 42 were not identified. Staff 6 confirmed the finding and identified the area as ICU.

At 3:34 p.m., there was a refrigerator that was plugged into a multi-plug adaptor in the purchasing department break room. Staff 6 confirmed the finding and identified the area as the purchasing department.







29665

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by appliances that were plugged into surge protectors, by surge protectors that were plugged into other surge protectors, by electrical outlets with no cover plates, and by a circuit board with incomplete labeling. This affected one of two floors of the West Tower, one of five floors of the Sinatra Tower, one of four floors of the East Tower, and one of five floors of the El Mirador building. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.
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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During the facility tour with maintenance staff on 1/17/12, the electrical wiring was observed.

At 3:14 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the pulmonary department office (Door EW-285).

At 3:16 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the pulmonary department break room.

At 3:38 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the medical records office.

At 3:44 p.m., there was a microwave plugged into a six-plug surge protector in the medical records break room.

At 4:53 p.m., there was a six-plug surge protector plugged into another six-plug surge protector in the charting room of the rehabilitation department.

On 1/18/12, the electrical wiring at El Mirador Medical Plaza was observed.

At 10:06 a.m., there was a six-plug surge protector plugged into another six-plug surge protector in the cubicle near Room 3027 on the third floor of the cancer center.