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Based on observation, record review, and interview it was determined the facility failed to ensure portable heaters were used according to National Fire Protection Association (NFPA). The deficiency had the potential to affect patients, staff and visitors.

The findings include:

Observation on 11/26/19 at 9:45AM , with the Director of Maintenance (DOM) during a Life Safety Tour, revealed a portable heater in the Registration Area. The heater was Titan Model UNK. Portable heaters used in non-patient care areas should be inspected for compliance with NFPA 19.7.8 and be accounted for in the organization's equipment inventory.

A record review on 11/26/19 at 12:30 PM revealed the facility had a policy addressing space heaters (PolicyStat ID 5695569) that directed the following: The hospital prohibited space heaters within smoke compartments containing patient sleeping area and treatment areas. (For full text and any exceptions, refer to NFPA 101-2012:18/19.7.8.)

Interview, with the DOM at the time of observation, revealed he was unaware of the heating element rating of the space heater that was discovered.

The findings were acknowledged by the Administrator and verified by the DOM during the exit conference.

NFPA 101 (2012 Edition)
19.7.8 Portable Space-Heating Devices. Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C)

Based on observation, record review, and interview it was determined the facility failed to ensure electrical wiring was maintained in accordance with National Fire Protection Association (NFPA) standards. The deficiency had the potential to affect patients, staff, and visitors.

The findings include:

Observation during the life safety tour, on 11/26/19 at 9:40 AM, with the Director of Maintenance (DOM), revealed an extension cord on the exterior of the facility powering a pipe heater in an overhang near the front of the building. The extension cord was covered with debris and cobwebs evidencing its permanent use in lieu of permanent wiring. An additional extension cord was observed to be powering a power strip in the Bio Med area. The extension cord extended from the Bio Med Storage area to a desk in the next room creating an electrical hazard. The cord was observed to have been run under a door and created a tripping hazard.

Interview, on 11/26/19 at 10:00 AM, with the DOM revealed he was aware of the NFPA standard prohibiting the use of extension cords in the manner observed. In addition, he was aware that extension cords could not be utilized in lieu of permanent wiring due to the increased danger of an electrical hazard.

A record review on 11/26/19 at 12:30 PM, revealed the facility had a policy (PolicyStat ID 5695596) that prohibited the use of extension cords in the manner observed.

The findings were acknowledged by the Administrator and verified by the DOM at the exit interview.

Actual NFPA Standard:

Reference: NFPA 101 (2012 Edition)

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.

Reference: NFPA 70 (2011 Edition).

400.8 Uses Not Permitted. Unless specifically permitted in 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 to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage.