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Based on document review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by the failure to provide policy and procedure that addressed Food and emergency lighting. This affected four of four floors and the basement and could result in an ineffective emergency preparedness plan for sheltering in place.

Findings:

During document review and interview with the Disaster Preparedness Coordinator, the emergency preparedness plan was reviewed.

On 4/4/23 at 11:17 a.m., the facility's EPP failed to include a provision of subsistence needs for staff and patients that addressed food in an emergency and a policy and procedure for alternate sources of energy to maintain emergency lighting. Upon interview, the Disaster Preparedness Coordinator confirmed the finding and stated that there were no provisions in the EPP that address food and emergency lighting whether they evacuate or shelter in place.

Based on document review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by a communication plan that did not include contact information. This affected four of four floors and the basement and could result in a delay in response in the event of an emergency.

Findings:

During document review and interview with Disaster Preparedness Coordinator, the emergency preparedness plan was reviewed.

On 4/4/23 at 1:30 p.m., the facility's communication plan failed to include contact information for staff, entities providing services under contract, and patient physicians. Upon interview, the Disaster Preparedness Coordinator stated that the EPP communication plan failed to include the contact information.

Based on document review and interview, the facility failed to maintain the written emergency preparedness plan (EPP). This was evidenced by a communication plan that did not include emergency officials contact information. This affected four of four floors and the basement and could result in a delay in response in the event of an emergency.

Findings:

During document review and interview with the Disaster Preparedness Coordinator, the emergency preparedness plan was reviewed.

On 4/4/23 at 1:32 p.m., the facility's communication plan failed to include emergency officials contact information for Federal, State, tribal, regional, and local emergency preparedness staff. Upon interview, the Disaster Preparedness Coordinator stated that the EPP communication plan failed to include contact information.

Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by unsealed penetrations. This affected one of four floors and basement and could result in the spread of fire and smoke.

Findings:

During a tour of the facility and interview with the interim Plant Operations Director (POD), the ceiling and walls were observed.

1. On 4/3/23 at 3:21 p.m., an unsealed penetration approximately one inch by one inch was observed in the Clean Utility Room in the General Medical Education area on the third floor. Upon interview, the interim POD confirmed the finding and stated that the penetration was caused by a door strike.

2. On 4/5/23 at 11:34 a.m., an unsealed penetration approximately seven inches by five inches was observed in the Environmental Services break room in the basement floor in section 300. The penetration had cold water piping running through the penetration. Upon interview, the interim POD confirmed the finding and stated that the penetration was caused when new piping was installed.

Based on observation and interview, the facility failed to maintain the exit signs. This was evidenced by exit signs that failed to remain illuminated when tested. This affected one of four floors and basement and could result in delayed egress in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance
with 7.9.3.1.3.
7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During observation and interview with the interim Plant Operations Director (POD), the exit signs were observed.


On 4/4/23 at 3:20 p.m., the battery powered exit sign number 175 in building 200 near the courtyard egress failed to remain illuminated when tested. Upon interview, the interim POD confirmed the finding and stated that the battery needed to be replaced.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by a door that was not equipped with a self-closing device. This could result in the passage of smoke in the event of a fire, and affected one of four floors and basement.

Findings:

During a tour of the facility with the interim Plant Operations Director (POD) , the hazardous areas were observed.

On 4/3/23 at 10:17 a.m., the Santa Claus Room in the Pre Anesthesia Services area on the second floor was being used as general purpose storage. The door was not equipped with a self-closing or automatic-closing device. The room was approximately 140 square feet and contained medical equipment for the Operating Rooms.

Based on observation and interview, the facility failed to maintain the cooking facility. This was evidenced by suppression nozzles to the Ansul Kitchen System that were not intact to prevent grease build up. This affected the basement and could result in an inefficient or inoperable Ansul Kitchen System.


NFPA 101 Life Safety Code, 2012 edition
19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 edition.

4.3 Discharge Nozzles
4.3.1.5 All discharge nozzles shall be provided with Caps or other suitable devices to prevent the entrance of grease vapors, moisture, environmental contaminants, or other foreign materials into the piping.
4.3.1.6 The protection device shall blow off, blow open, or blow out upon agent discharge.

Findings:

During a tour of the facility and interview with the interim Plant Operations Director (POD) , the cooking facility was observed.

On 4/5/23 at 10:55 a.m., the kitchen hood Ansul suppression system was observed with 12 nozzles. Two of 12 discharge nozzles were not protected with blow-off caps and were loosely hanging, in the basement kitchen in the 500 area. During an interview, the interim POD confirmed the finding and stated that that he was unaware of why the blow off caps were loosely hanging.

Based on observation, the facility failed to maintain the Alcohol-Based Hand Rub (ABHR) dispensers. This was evidenced by an ABHR that was installed directly above an ignition source. This affected one of four floors and basement, and could result in an electrical fire.

Findings:

During a tour of the facility with the interim Plant Operations Supervisor (POS), the ABHR dispensers were observed.

On 4/4/23 at 10:35 a.m., an ABHR dispenser was observed approximately eight inches above a quadplex receptacle in Operating Room 4 on the second floor.

Based on observation, document review, and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to provide a semiannual inspection of the FAS and no inspection/test of the FAS batteries. This affected four of four floors and the basement and could result in the delay of notification to emergency forces in the event of an emergency.

NFPA 101: Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72: National Fire Alarm and Signaling Code, 2010 Edition
Chapter 14 Inspection, Testing, and Maintenance
14.1 Application.
14.1.1 The inspection, testing, and maintenance of systems, their initiating devices, and notification appliances shall comply with the requirements of this chapter.
14.3 Inspection.
14.3.1 * Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.
14.3.2 Devices or equipment that is inaccessible for safety considerations (e.g., continuous process operations, energized electrical equipment, radiation, and excessive height) shall be permitted to be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
14.3.4 The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Table 14.3.1 Visual Inspection Frequencies-semiannually

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance
with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.
Table 14.4.5 Testing Frequencies.
6. Batteries-fire alarm systems
(d) Sealed lead-acid type
(1) Charger test: Annually
(2) Discharge test (30 minutes): Annually
(3) Load voltage test: Semiannually

14.6.2 Maintenance, Inspection, and Testing Records.
14.6.2.1 Records shall be retained until the next test and for 1 year thereafter.
14.6.2.4 * A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)* Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a tour of the facility, document review, and interview with the interim Plant Operations Director (POD), the FAS was observed, and records requested.

1. On 4/4/23 at 8:35 a.m., the Annual FAS inspection/Testing Report was dated 12/12/22. No semiannual inspection report was available for review. Upon interview, the interim POD stated that he was not aware that a semiannual FAS inspection was required for the FAS.

2. On 4/4/23 at 8:36 a.m., the Annual FAS inspection/Testing Report was dated 12/12/22. The facility failed to provide documentation that indicate an annual charger test, annual discharge test and a semiannual load voltage test were conducted for two of two sealed lead acid (SLA) batteries in the fire alarm control panel (FACP). Upon interview, the interim POD stated that he was not aware of the battery testing requirements.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by the failure to include instructions to notify the authority having jurisdiction (AHJ) in the event of a fire alarm impairment. This affected four of four floors and the basement and could result in the AHJ not having the ability to exercise oversight in an acceptable timeframe if the fire alarm system was to become inoperable.

Findings:

During a document review and interview with the interim Plant Operations Director (POD), the interim fire measures and policies were requested for review.

On 4/4/23 at 9:43 a.m., the fire watch policy was requested. The policy failed to include notification to California Department of Public Health (CDPH) if the fire alarm was out of service for more than 4 hours in a 24-hour period. Upon interview, the interim POD confirmed that the policy did not include instructions to contact CDPH.

Based on observation, the facility failed to maintain the fire sprinklers. This was evidenced by missing identification signs and foreign materials on the sprinkler components. This affected four of four floors and a basement. This could result in the malfunction of the sprinklers in the event of a fire.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.1 Automatic Sprinklers.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.1.1 * Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:

(1) NFPA 13, Standard for the Installation of Sprinkler Systems

NFPA 13: Standard for the Installation of Sprinkler Systems, 2010 Edition
6.7.4 * Identification of Valves.
6.7.4.1 All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs.
6.7.4.2 The identification sign shall be secured with corrosion-resistant wire, chain, or other approved means.
6.7.4.3 The control valve sign shall identify the portion of the building served.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 edition
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Findings:

During a tour of the facility with the interim Plant Operations Supervisor (POS), the automatic sprinkler system was observed.

1. On 4/3/23 at 11:36 a.m., the sprinkler riser in the Basement that served the 500 area was observed without identification sign for a control valve.

2. On 4/3/23 at 11:39 a.m., the sprinkler riser in the Basement that served the 200 and 300 areas were without identification sign for a control valve.

3. On 4/5/23 at 11:18 a.m., the Basement Equipment Room 10 was observed without an identification sign for an auxiliary drain for the 300 area.

4. On 4/5/23 at 1:51 p.m., the fire sprinklers under the canopy in front of the main lobby entrance were observed. Three of the eight sprinklers under the canopy were observed with cobwebs on the deflectors.

Based on document review and interview, the facility failed to maintain interim fire measures. This was evidenced by the failure to include instructions to notify the authority having jurisdiction (AHJ) in the event of a sprinkler system impairment. This affected four of four floors and the basement and could result in the AHJ not having the ability to exercise oversight in an acceptable timeframe if the sprinkler system was to become inoperable.

Findings:

During document review and interview with the interim Plant Operations Director (POD), the interim fire measures and policies were requested for review.

On 4/4/23 at 9:43 a.m., the fire watch policy was requested. The policy failed to include notification to California Department of Public Health (CDPH) if the fire sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, the interim POD confirmed that the policy did not include notification to contact CDPH.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch and were equipped with doors gap. This could result in the passage of smoke in the event of a fire, and affected three of four floors and the basement.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interview with the interim Plant Operations Director (POD), the corridor doors were observed and tested

1. On 4/3/23 at 2:09 p.m., the self-closing corridor door to the Doctor's Dictation Room on the fourth floor by the Ortho Nursing Station was obstructed from closing by a door stopper.

2. On 4/3/23 at 2:55 p.m., the corridor door to the Nourishment Center room 3040 on the third floor by the telemetry area was obstructed from latching by a paper towel that was stuffed in the strike plate. Upon interview, the interim POD confirmed the finding and stated that the paper towel was most-likely placed in the latch by staff.

3. On 4/3/23 at 3:55 p.m., the corridor door to Room 359 on the third floor in the Med/Surge area was observed with a one-inch gap on the top right corner of the door when closed.

4. On 4/3/23 at 3:58 p.m., the corridor door to Room 358 on the third floor in the Med/Surge area failed to latch when tested. Upon interview, the interim POD confirmed the finding and stated that the latch was not lining up to the strike plate.

5. On 4/3/23 at 4 p.m., the corridor door to Room 357 on the third floor in the Med/Surge area failed to latch when tested. Upon interview, the interim POD confirmed the finding and stated that the latch was not lining up to the strike plate.

6. On 4/3/23 at 4:05 p.m., the corridor door to Room 350 on the third floor in the Med/Surge area was observed with a 1/2 inch gap on the top left corner of the door when closed.

7. On 4/3/23 at 4:09 p.m., the corridor door to Room 348 on the third floor in the Med/Surge area failed to latch when tested. Upon interview, the interim POD confirmed the finding and stated that the latch was not lining up to the strike plate.

8. On 4/4/23 at 1:39 p.m., the self-closing corridor door to the Patient Registration 1 office in the lobby area of the first floor failed to latch when tested.

9. On 4/4/23 at 1:47 p.m., the self-closing corridor door to Room 3 in Fast Track area on the first floor failed to latch when tested. The door was tested three times and failed to close and latch on all three occasions.

10. On 4/5/23 at 9:40 a.m., the corridor door to the case management store room on the first floor in the 300 area failed to latch when tested. Upon interview, the interim POD confirmed the finding and stated that the latch was not lining up to the strike plate.

11. On 4/5/23 at 11:37 a.m., the corridor door to the Environmental Services Breakroom on the basement floor in the 300 area failed to latch when tested. Upon interview, the interim POD confirmed the finding and stated that the latch was not lining up to the strike plate.

Based on document review and interview, the facility failed to maintain the Gas and Vacuum Piped Systems. This was evidenced by the failure to correct issues identified during an annual inspection. This affected on of four floors and basement and could result in a malfunction of the Gas and Vacuum Piped Systems.

Findings:

During document review and interview with the interim Plant Operations Director (POD), the annual inspection for Gas and Vacuum Piped Systems was requested and reviewed.

On 4/4/23, At 3:41 p.m., a document titled, "Medical Gas Inspection Report" dated May 2022 was reviewed. The report identified multiple issues including a future use valve that was leaking and needed to be repaired. A repair document indicated the repairs had been made to the medical gas system on 8/10/22, but the leaking future use valve was not repaired or replaced.

Upon interview, the interim POD provided an estimate for repair dated 6/10/22 from a vendor to replace the valve. He stated that the valve replacement had fallen through the cracks and the vendor would be scheduled to replace it.

Based on observation, document review, and interview, the facility failed to maintain the emergency power supply system (EPSS). This was evidenced by missing monthly testing records for the generator batteries. This affected four of four floors and the basement. This could result in a loss of power due to a generator malfunction during an emergency power outage.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.4 Essential Electrical System Requirements - Type 1.
6.4.4.1.3 Maintenance of Batteries. Batteries for on-site generators shall be maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
8.1* General.
8.1.1 The routine maintenance and operational testing program shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established.
8.3.4 A permanent record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained and readily available.
8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer
8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.

Findings:

During a tour of the facility, document review, and interview with the interim Plant Operations Director (POD), the EPSS was observed, and records were requested and reviewed.

1. On 4/3/23 at 2:25 p.m., testing records for the 1200-kilowatt diesel back-up generator were reviewed. The facility failed to provide battery conductance testing records for 12 of 12 months. Upon interview, the interim POD confirmed that the facility was not conducting conductance test on the generator's batteries.

2. On 4/3/23 at 2:41 p.m., testing records for the 250-kilowatt diesel back-up generator were reviewed. The facility failed to provide battery conductance testing records for 12 of 12 months. Upon interview, the interim POD confirmed that the facility was not conducting conductance test on the generator's batteries.

Based on observation, document review, and interview, the facility failed to maintain the electrical wiring and equipment . This was evidenced by an electrical panel that was missing a deadfront cover, electrical outlets that failed to be flushed against the mounting surface, missing identification for individual circuits, and the failure to correct issues identified during an annual inspection. This affected four of four floors and the basement, and could result in an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

408.38 Enclosure. Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead-front.

408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy.

408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

Findings:

During a tour of the facility, document review, and interview with the interim Plant Operations Supervisor (POS) and Interim Plant Operations Director (POD), the electrical wiring and equipment was observed.

1. On 4/3/23 at 11:50 a.m., the Electrical Panel located in the Generator Area was observed without a dead-front cover, exposing live components. Upon interview, the interim POS confirmed the finding and stated that he was not aware that the deadfront cover was missing.

2. On 4/3/23 at 11:50 a.m., the Electrical Panel located in the Generator Area was observed without a circuit directory.

3. On 4/3/23 at 2:20 p.m., Electrical Panel 4LNA located in the electrical room on the fourth floor Ortho area was observed without a circuit directory.

4. On 4/3/23 at 2:31 p.m., a receptacle cover plate in Patient Room 3022 on the third floor Telemetry area was not flushed against the mounting surface that created approximately a one-inch gap, exposing live components.

5. On 4/3/23 at 2:34 p.m., a receptacle cover plate in Patient Room 3019 on the third floor Telemetry area was not flushed against the mounting surface that created approximately a one-inch gap, exposing live components.

6. On 4/3/23 at 2:50 p.m., a receptacle cover plate in Patient Room 3011 on the third floor Telemetry area was not flushed against the mounting surface that created approximately a one-inch gap, exposing live components.

7. On 4/3/23 at 2:59 p.m., electrical panel 3LNB in the electrical room on the third floor Telemetry area was observed with an unprotected opening.

8. On 4/3/23 at 4:26 p.m., circuit breakers 4, 6 and 8 in electrical panel 3LSA in the electrical room on the third floor were not identified on the panel directory.

9. On 4/4/23 at 10:01 a.m., circuit breakers 36 and 38 in electrical panel 2E in the electrical room 2227 on the second floor recovery hallway were not identified on the panel directory.

10. On 4/4/23 at 10:09 a.m., circuit breakers 13, 15, 17, and 23 in electrical panel 2EC in electrical room 2227 on the second floor recovery hallway were not identified on the panel directory.

11. On 4/4/23 at 10:25 a.m., circuit breakers 22, 24, 26, 28, 30, 31, and 32 and in electrical panel 2LNA in electrical room on the second floor Pre Anesthesia Services hallway were not identified on the panel directory.

12. On 4/4/23 at 10:41 a.m., circuit breakers 10 and 12 in electrical panel 2LE in the Operating Room hallway on the second floor were not identified on the panel directory.

13. On 4/4/23 at 10:51 a.m., electrical panel 2EB in the Operating Room (OR) hallway on the second floor was observed obstructed by a surgical cart. Upon interview, the the interim POS confirmed the finding and stated that OR staff placed the cart in the panel work space.

14. On 4/4/23 at 1:57 p.m., a receptacle without a faceplate was observed in Room 27 in the Emergency Room (ER) overflow in section 100.

15. On 4/4/23 at 2 p.m., Electrical Panel GNLD in electrical room 1091 in the ER area in section 100 was observed without a circuit directory.

16. On 4/4/23 at 2 p.m., Electrical Panel GHNA in electrical room 1091 in the ER area in section 100 was observed without a circuit directory.

17. On 4/4/23 at 2:45 p.m., circuit breakers 3 and 4 in electrical panel DP2 in the Angio Control Room suite 4 on the first floor were not identified on the panel directory.

18. On 4/4/23 at 2:58 p.m., circuit breakers 4 and 6 in electrical panel A1 in the X-Ray 2 room in the 200 section on the first floor were not identified on the panel directory.

19. On 4/4/23 at 3:05 p.m., a receptacle was without a faceplate was observed next to an Omnicell machine in the Angio storage room across from the Doctor's Lounge on the first floor in section 200.

20. On 4/4/23 at 3:10 p.m., circuit breakers 2, 4, 6, 16, 18, 33, 36, and 41 in electrical panel GPA in the Lab Room in the 200 section on the first floor were not identified on the panel directory.

21. On 4/5/23 at 9:12 a.m., the Electrical Panel in the Respiratory Break Room in section 300 was observed without a circuit directory.

22. On 4/5/23 at 9:43 a.m., a Light Switch cover plate in Soiled Utility Room number 1332 in the Short Stay area on the first floor was not flushed against the mounting surface that created approximately a one-inch gap, exposing live components.

23. On 4/5/23 at 10:15 a.m., electrical panel DPHA in the Information Systems room in 500 section on the first floor was observed obstructed by a dolly cart. Upon interview, the the interim POS confirmed the finding and stated that Information System's staff placed the cart in the panel work space.

24. On 4/5/23 at 10:20 a.m., electrical panel DPLB in the Information Systems room in 500 section on the first floor was observed without a panel directory.

25. On 4/5/23 at 10:36 a.m., a receptacle cover plate in the Ultra Sound Hallway by the Radiology Waiting Room on the first floor 500 area was not flushed against the mounting surface.

26. On 4/5/23 at 11:47 p.m., circuit breakers 8, 10, 12, 14, 15, 16, 17, 20, 22, 24, 26 and 28 in electrical panel LBEA in section 300 on the Basement floor were not identified on the panel directory.

27. On 4/4/23 at 2:24 p.m., the facility failed to provide documentation that the deficiencies had been repaired for the electrical panels. The document titled, "Infrared Inspection Report" dated 9/29/23 to 9/30/23 listed 13 deficiencies for the electrical components that were over the temperature specification and needed to be addressed. The deficiencies listed the followings:

1. Location: Building 100 3rd Floor Electrical Closet 3033, Breaker Panel- 3LNB. Item: Left neutral connection, check crimp connector and lug connection. Note connection not very hot at the time of inspection but should be checked.
2. Location: Building 200 Roof Equipment Room, Breaker Panel- RE. Item: Fourth neutral over from right.
3. Location: Building 500 Elevator #9 Equipment Room, Elevator #9 (local disconnect switch). Item: A Ø line side lug connecting knife stab & pivot also C Ø load side lug connection & fuse clip.
4. Location: Building 100 2nd Floor Roof Area, MCC E2 Supply fan #2 (feeder disconnect switch). Item: A Ø line side fuse clip.
5. Location: Building 100 2nd Floor Roof Area, MCC E2 Supply fan #1 (feeder disconnect switch). Item: C Ø line side fuse clip.
6. Location: Building 100 2nd Floor Roof Area, MCC E2 Main incoming line. Item: Check All 3 Ø's front lug connections and crimp connectors.
7. Location: Building 200 Roof Area, Mitsubishi Mini Split AC Unit#1. (Local disconnect switch). Item: Note: Not hot now as the unit was not running, noticed right Ø fuse is melted.
8. Location: Building 500 Basement Electrical Room #6, Transformer BLNA, disconnect on the side of the transformer. Item: A Ø line side knife stab.
9. Location: Building 500 Basement Electrical Room #6, MCC - MCNA Return Fan (controller). Item: C Ø load side screw connection on the thermal overload.
10. Location: Building 200 Electrical Room #1, MSB Emergency Switchboard. (feeder disconnect switch). Item B Ø load side lug connection & fuse clip.
11. Location: Building 100 Chiller Equipment Room, MCC-NB. Chiller #1. (main feeder disconnect switch). Item: A Ø load side lug connection & fuse clip.
12. Location: Outside Cooling Tower Area, MCC. Main Incoming Line. Item: A & C Ø line side lug connection also check crimp connectors.
13. Location: Outside Cooling Tower Area, MCC. Condensate circulating pump #1. (controller). Item: C Ø line side lug connection fuse clip.

Upon interview, the interim POD stated that the repairs had not been made.

Based on observation and interview, the facility failed to maintain the electrical equipment and wiring. This was evidenced by the non-compliant use of a power strips and extension cords. This affected two of four floors and basement, and could result in an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

Chapter 9 Building Service and Fire Protection Equipment
9.1 Utilities.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 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
(7) Where subject to physical damage

Findings:

During a facility tour and interview with the interim Plant Operations Director (POD) and the interim Plant Operations Supervisor (POS), the electrical equipment and wiring were observed.

1. On 4/4/23 at 9:18 a.m., a green extension cord was observed in the Cath Lab Operations Office with a mini fridge connected to it on the second floor in the Intensive Care Unit/ Cardiac Intensive Care Unit Hallway. The extension cord was being used as a long term fixture.

2. On 4/4/23 at 9:56 a.m., an extension cord that was connected to a TV and was observed connected to a relocatable power tap in the recovery area break room on the second floor. The extension cord was being used as a long term fixture.

3. On 4/4/23 at 2:43 p.m., the Angio Locker Room on the first floor was observed with a relocatable power tap that was suspended approximately three inches off the ground with a coffee maker connected to it.

4. On 4/4/23 at 3:27 p.m., a relocatable power tap was observed connected to another relocatable power tap in the Health Information Management Office underneath the Privacy Officer's desk on the first floor.

5. On 4/4/23 at 4:01 p.m., Room 162 across Occupational Health in section 400 on the first floor was observed with a relocatable power tap that was suspended approximately two inches off the ground.

6. On 4/5/23 at 9:30 a.m., a relocatable power tap was observed connected to another relocatable power tap in the Case Management Office underneath the the Case Manager's desk on the first floor in section 300.

Upon interview, the interim POD confirmed the findings and stated that it was an oversight by staff.