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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 4 of 11 floors in the Main Hospital and 2 of 5 floors in the Childrens Hospital, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 3, Staff 7, and Staff 10, on August 30, 2010 through September 8, 2010, the walls and ceilings were observed.

Main Hospital Sixth Floor on 8/30/10:
At 2:04 p.m., in Room 6438, there was an unsealed penetration around communication wires running through in the left wall.

Main Hospital Second Floor on 8/31/10:
At 9:30 a.m., in the Ultrasound exam room 1 located in Unit 2400, there was an unsealed 1 inch penetration in the left wall where cables wires were removed.

At 10:00 a.m., in the Biohazard room 2625 located in Unit 2600, there was an unsealed 1 inch penetration below the dispenser.

Main Hospital First Floor on 8/31/10:
At 10:43 a.m., in the Scheduling office room 1483, there was a 1 1/2 inch unsealed penetration behind the door where the door handle hit the wall.

Main Hospital Level A on 8/31/10:
At 2:15 p.m., in Locker room A214, there were 1/2 inch unsealed penetrations around two sprinkler pipes located in the back wall.


Main Hospital Level B on 8/31/10:
At 10:40 a.m., in Room B826, there were two, 1/2 inch round penetrations in the back wall.




27961


Children's Hospital on 8/30/10:

During a tour of the facility with Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facility walls and ceilings were observed.

At 11:24 a.m., in the Respiratory Care Room 5729 on the 5th floor there was a 1/2 inch penetration in the wall next to the electrical cover plate that was not secured and hanging sideways on the wall.

At 1:20 p.m., in Room 5829A on the 5th floor, there were four, 1/2 inch round penetrations in the left wall and a pair of scissors stuck into one penetration.

At 1:28 p.m., in Room 5819 "Special Care Unit" on the 5th floor, there were six, 1/4 inch round penetrations in the wall behind the ice maker machine.

At 1:45 p.m., in Nursing Station 2 across from Room 5806 on the 5th floor, there were six, 1/4 inch round penetrations behind the ice maker machine.

At 2:00 p.m., in Room 5216 on the 5th floor, there was a 5 inches x 2 inches penetration in the right wall.

At 4:15 p.m., in Room 3117 "Report Room" on the 3rd floor, there were five, 1/2 inch round penetrations in the wall.

Based on observation and interview, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to positive latch upon closure. This failure affected 1 of 5 floors in the Childrens Hospital and 1 of 1 floors in the Heart and Surgical Hospital. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facilities corridor doors were observed.

Children's Hospital and Main Hospital on 8/31/10:
At 10:10 a.m., the Children's Gift Shop on the 1st floor had a corridor door that failed to positive latch on the right side due to a door wedge that prevented it from closing. When interviewed on August 31, 2010 at 10:10 a.m., Staff 4 stated that the hardware on the door was broken and they were ordering a new self closing device.

Heart and Surgical Hospital on 9/07/10:
At 3:20 p.m., Room "On Call V139/0140 had a door that failed to positive latch due to a door wedge that prevented it from closing.

At 3:43 p.m., the door to the Boiler Room on the lower level failed to positive latch on the right side.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by smoke barrier doors that failed to release from the magnet device during the testing of the fire alarm system. This failure affected 1 of 5 floors in the Children's Hospital and Level A. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facility doors were observed.

Children's Hospital and Main Hospital on 9/2/10:
At 11:14 a.m., the smoke barrier doors to the Lobby in the GI Lab on the 1st floor failed to release from the magnet after testing of a smoke detector.

At 11:40 a.m., the Children's Gift shop corridor doors on the 1st floor failed to release from the magnet on the right side after testing of a smoke detector.

At 1:37 p.m., the smoke barrier doors to A861 on Level A failed to release from the magnet on the left side after testing of a smoke detector.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction as evidenced by unsealed penetrations in the facility smoke barrier walls. This failure affected 1 of 11 floors in the Main Hospital and 1 of 1 floors in the Highland Springs Medical Center and would allow the spread of fire and smoke from one compartment to another, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 3, Staff 4, Staff 7 and Staff 10, on August 30, 2010 through September 8, 2010, the facility smoke barrier walls were observed.

Main Hospital Fourth Floor on 8/30/10:
At 3:45 p.m., the smoke barrier wall in Unit 4700 (Adult side) between patient rooms 4755 and 4756, there was an unsealed 4 inch conduit with blue and purple wires running through.


Highland Springs Medical Plaza on 9/03/10:
At 10:55 a.m., the smoke barrier wall between Suite 105 and the corridor had one penetration approximately 8 inch x 8inch , one penetration approximately 2 inch x 2 inch wide and a 2 inch wide penetration around 3 white pipes.

Based on observation, the facility failed to ensure that smoke barrier doors on magnetic devices latch and resist the passage of smoke as evidenced by smoke barrier doors failure to latch upon activation of the fire alarm system. This failure affected 2 of 5 floors in the Children's Hospital, Level A and B in the Main Hospital and 1 of 2 floors in the Heart and Surgical Hospital, resulting in potential harm to patients, staff and visitors.

Findings:

During the testing of the fire alarm system with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010, through September 8, 2010, the facilities corridor doors were observed.

Children's Hospital and Main Hospital On 9/02/10:
At 10:01 a.m., the smoke barrier doors on the 2nd floor in the Operating Room across from Room 2360 failed to positive latch on the left side after activation of an initiating device.

At 11:18 a.m., the smoke barrier doors to the Lobby/Visitor elevators on the 1st floor failed to positive latch on both sides after activation of an initiating device.

At 11:40 a.m., the Children's Gift shop corridor doors on the 1st floor failed to positive latch on both sides after activation of an initiating device.

At 1:37 p.m., the smoke barrier doors to A861 on Level A failed to positive latch on both sides after activation of an initiating device.

At 2:38 p.m., the smoke barrier door by B406 on Level B failed to positive latch on both sides after activation of an initiating device.





21101


Heart and Surgical Hospital on 9/07/10:

During the testing of the fire alarm system with Staff 4, Staff 10, Staff 11, Staff 14 and Staff 16, on September 7, 2010, the smoke barrier doors were observed.

At 11:56 a.m., on the upper level the smoke barrier door located between the Cafe and Conference room, the leaf next to the Conference room failed to latch during the activation of the fire alarm system.

Based on observation, the facility failed to maintain the exit and directional signs, as evidenced by exit signs that were not fully illuminated. This failure affected two suites in the Out patient Primary Care Services-Professional Plaza, and could result in delayed evacuation in the event of a fire or other emergency causing potential harm to the occupants.

Findings:

During a tour of the facility with Staff 10, Staff 14 and Staff 16, on August 30, 2010, through September 8, 2010, the exit lights were observed.

Professional Plaza Building "A" and "B" on 9/07/10:
At 2:56 p.m., in Suite 204 B the exit light between hall 2 and 3 was not fully illuminated.
At 3:15 p.m., in Suite 207 A the exit light in hall 7 was not fully illuminated.

Based on observation and interview, the facility failed to ensure staff were trained with respect to their duties and emergency procedures and equipment. This failure could create delay and the potential for harm to patients if staff become confused and fail to follow or understand the facility emergency plan.

19.7.1.1 The Administration of every health care occupancy shall have, in effect and available to all personnel, written copies of a plan for protection of all persons in the event of fire, for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with their duties under the plan. A copy of the plan shall be readily available at all times.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010, through September 8, 2010, the facilities staff were interviewed.

Main Hospital and Children's Hospital on 9/02/10:
At 9:46 a.m. in the Recovery/PT Care area on the 3rd floor, Staff 17 was interviewed and stated that she had not participated in a fire drill, only in the fire extinguisher training held every year. When asked how long Staff 17 had worked at the facility, Staff 17 stated 37 years.

Based on observation and interview, the facility failed to maintain a fire alarm system to provide effective warning of fire in any part of the building as evidenced by not being able to hear an audible device (fire alarm) and affected the third floor Recovery Room. This failure would delay staff's response to a fire or other emergency, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facilities fire alarm system was observed.

Main Hospital and Children's Hospital on 9/02/10:
At 9:45 a.m., in the Recovery Room on the 3rd floor, the pull station was activated in the hallway outside the room that could not be heard in the Recovery Room once the fire door released and latched. When a patient and Staff 16 were interviewed on September 2, 2010 at 9:45 a.m., they both stated that they had not heard the first alarm testing. When testing was done again, both stated that they could faintly hear the alarm. The room contained no strobe, chime/bell or speaker.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by missing sprinkler escutcheon rings, sprinklers with penetrations, sprinklers that were impeded and a PIV that failed to send a trouble signal to the fire alarm panel and was not locked as required. This affected 7 of 11 floors in the Main Hospital, 3 of 5 floors in the Children's Hospital, Sleep Diagnostic Center, Radiology Clinic-Sun City, Cancer Center Highland Springs, Ambulatory Rehab Clinic. This failure could result in the fire sprinkler system not functioning as designed in the event of a fire, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 3, Staff 7, Staff 10, Staff 14, and Staff 16, on August 30, 2010 through September 8, 2010, the automatic sprinkler sytem was tested and observed.

Main Hospital - Ninth Floor on 8/30/10:
At 11:20 a.m, in Unit 9100 the sprinkler escutcheon ring was missing in the clean storage room 9114.

Main Hospital - Seventh Floor on 8/30/10:
At 1:25 p.m., in Unit 7100 the sprinkler escutcheon ring was missing in room 7116.

Main Hospital - Sixth Floor on 8/30/10:
At 2:08 p.m., in Unit 6100 the sprinkler escutcheon ring was missing in copy room 6448.

At 2:10 p.m., in Unit 6100 the sprinkler escutcheon ring was missing in soiled linen room 6119.

At 2:15 p.m., in Unit 6100 the sprinkler escutcheon ring was missing above bed 2 in patient room 6101.

At 2:22 p.m., the sprinkler escutcheon ring was missing in the corridor of the Unit 6200 South exit.

Main Hospital - Fifth Floor on 8/30/10:
At 2:41 p.m., the sprinkler escutcheon ring was missing in Physical Therapy room 5428.

Main Hospital - Fourth Floor on 8/30/10:

At 2:50 p.m., 1 of 2 sprinkler escutcheon rings was missing in Cardiac records storage room 4438.

At 3:00 p.m., the sprinkler escutcheon ring across from room 4410 was missing.

At 3:05 p.m., there was an approximately 1/4 inch unsealed penetration next to the sprinkler escutcheon ring in Cardiac waiting room 4006.

At 3:30 p.m., in Unit 4200 the escutcheon ring was missing in the Peds South exit corridor.
At 4:12 p.m., 2 of 3 sprinkler escutcheon rings were missing in Unit 4300, room 4311.

Main Hospital - Second Floor on 8/31/10:
At 10:08 a.m., a sprinkler escutcheon ring was missing in Out Patient Pharmacy.

At 10:20 a.m., the sprinkler in Lab room 2137 had signs of corrosion.

Main Hospital - Level A on 8/31/10:
At 2:18 p.m., the sprinkler escutcheon ring in Peds Emergency Department room 5 was missing.

Sleep Diagnostic Center - on 9/7/10:
At 10:27 a.m., the sprinkler escutcheon ring in the waiting area had an approximately 1/2 inch unsealed penetration.




27961


Childrens' Hospital on 8/30/10:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facilities automatic sprinkler system was observed.

At 2:10 p.m., in the ceiling outside Room 5320 on the 5th floor there was a sprinkler missing an escutcheon ring.

At 2:35 p.m., in the ceiling by the Nursing Station on the 4th floor there was a sprinkler missing an escutcheon ring.

At 4:25 p.m., in the alcove across from 3106 on the 3rd floor, there was a roll of plastic cups within 6 inches of the sprinkler deflector.

O/P Radiology Clinic, Sun City on 9/03/10:
At 9:00 a.m., in the hallway outside X-Ray 1 room there was a sprinkler missing an escutcheon ring.

At 9:00 a.m., in X-Ray 1 room there were 5 escutcheon rings missing.

Cancer Center Highland Springs Medical Center on 9/03/10:
At 12:24 p.m., the Post Indicator Valve (PIV) was closed and failed to send the supervisory signal to the fire alarm panel and monitoring station. The lock was broken and laying on the ground next to the PIV.

Ambulatory Rehab Clinic - 11406 Loma Linda, on 9/07/10:
At 10:28 a.m., there was a sprinkler escutcheon ring missing in Room 159.

Based on observation, the facility failed to ensure oxygen cylinders were secured in accordance with NFPA 99, as evidenced by an unsecured oxygen tank. This failure affected 1 of 11 floors in the Main Hospital.

NFPA 99 Standard for Health Care Facilities (1999 Edition)
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4-3.1.1.2(a) 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a tour of the facility with Staff 3, Staff 7, Staff 10, on August 30, 2010, through September 8, 2010, oxygen storage was observed.

Main Hospital Level A on 8/31/10:
At 2:20 p.m., in the Fast Track Department there was an unsecured oxygen tank located next to a waste bin.

Based on document review, and interview the facility failed to maintain the relative humidity level equal to or greater than 35% as evidenced by documentation that the humidity level for Labor and Delivery Room 3 was below the required level of 35% for a six month period and by no documentation for daily humidity levels for 4 of 4 procedure rooms in the CATH Lab. This failure could result in an increase risk of fire in the operating rooms resulting in potential harm to patients and staff.

Findings:

During document review with facility Staff 1 and Staff 4 on August 30, 2010 through September 8, 2010, the humidity levels of all Operating Rooms were requested for review.


Main Hospital on 8/30/10:

December 2010:
1. On December 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
2. On December 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
3. On December 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
4. On December 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
5. On December 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
6. On December 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
7. On December 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
8. On December 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
9. On December 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
10. On December 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
11. On December 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
12. On December 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33.5%.
13. On December 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
14. On December 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
15. On December 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
16. On December 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
17. On December 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
18. On December 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%. Comments on log state " humidity adjusted " .
19. On December 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
20. On December 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
21. On December 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
22. On December 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%. Comments on log state " humidity turned up " .
23. On December 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 14%. Comments on log state " humidity turned up " .
24. On December 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
25. On December 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
26. On December 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
27. On December 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
28. On December 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
29. On December 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
30. On December 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
31. On December 31, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.

January 2010:
32. On January 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
33. On January 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
34. On January 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
35. On January 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
36. On January 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
37. On January 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
38. On January 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
39. On January 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
40. On January 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
41. On January 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
42. On January 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%. Comments state " humidity (up arrow). "
43. On January 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%. Comments state " humidity " .
44. On January 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
45. On January 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
46. On January 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
47. On January 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
48. On January 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
49. On January 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 46%.
50. On January 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
51. On January 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
52. On January 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
53. On January 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was not listed.
54. On January 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
55. On January 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
56. On January 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
57. On January 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
58. On January 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
59. On January 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
60. On January 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%. Comments state " maintenance called " .
61. On January 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 24%.
62. On January 31, 2010, the humidity level in Labor and Delivery Operating Room 3 was 24%. Comments state " humidity (up arrow). "

February 2010: No comments written on the February log for the days when the humidity level was lower than policy allows.
63. On February 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
64. On February 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
65. On February 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
66. On February 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
67. On February 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
68. On February 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
69. On February 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
70. On February 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
71. On February 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
72. On February 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
73. On February 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
74. On February 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
75. On February 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
76. On February 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
77. On February 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
78. On February 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
79. On February 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 23%.
80. On February 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
81. On February 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
82. On February 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
83. On February 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
84. On February 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
85. On February 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 24%.
86. On February 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 23%.
87. On February 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
88. On February 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
89. On February 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
90. On February 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.

March 2010: Comments section on March 2010 log state " Humidity is fine reader on wall is broken maintenance ordered had held reader. "
1. On March 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
2. On March 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
3. On March 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
4. On March 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
5. On March 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
6. On March 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%. Comments on log state " Maintenance getting per " .
7. On March 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
8. On March 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
9. On March 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was not listed.
10. On March 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
11. On March 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%. Comments on log state " Maintenance checking reader on wall broken humidity @ 37% per hand held by maintenance.
12. On March 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
13. On March 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
14. On March 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
15. On March 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
16. On March 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
17. On March 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
18. On March 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 23%.
19. On March 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
20. On March 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
21. On March 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
22. On March 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
23. On March 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
24. On March 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
25. On March 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.
26. On March 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
27. On March 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
28. On March 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
29. On March 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
30. On March 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
31. On March 31, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.

April 2010:
1. On April 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
2. On April 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%
3. On April 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 36%.
4. On April 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
5. On April 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
6. On April 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
7. On April 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
8. On April 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
9. On April 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
10. On April 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 38%.
11. On April 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
12. On April 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
13. On April 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
14. On April 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
15. On April 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
16. On April 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
17. On April 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
18. On April 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
19. On April 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.
20. On April 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
21. On April 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 41%.
22. On April 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
23. On April 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
24. On April 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
25. On April 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
26. On April 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 49%. Comments on log state " turn temp down recheck in 2hr @ 74 " .
27. On April 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.
28. On April 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%. Comments on log state " temp recheck " .
29. On April 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
30. On April 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.

May 2010:
1. On May 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
2. On May 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
3. On May 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
4. On May 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
5. On May 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
6. On May 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%. Comments on log state " turned temp down re check " .
7. On May 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 36%.
8. On May 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
9. On May 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
10. On May 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%. Comments on log state " called maintenance reader on wall broken, given hand held scanner humidity at 40% " .
11. On May 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 36%.
12. On May 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%. Comments on log state " recheck @ 1015 36 CRH " .
13. On May 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.

Main Hospital First Floor on 8/31/10:

At 10:38 a.m., the four Cath Labs did not have a humidity monitoring device and when staff was asked if the humidity levels were monitored daily staff stated no.

Based on document review, the facility failed to maintain their generators as evidenced by 4 of 4 generators that were not exercised under load for 30 minutes for the month of October 2009 and November 2009. This could result in emergency generator failure and could cause potential harm to patients, staff and visitors in the event of an emergency.


NFPA 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.

(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:
During document review with facility Staff 4 and Staff 12, on August 31, 2010 through September 8, 2010, the facility generator test and inspection logs were reviewed.
Main Hospital on 8/31/10:
At 1:15 p.m., the facility failed to provide documentation of the generators exercised at least once a month under load for 30 minutes for the month of October 2009 and November 2009 for the South Wing generator 1 and, failed to provide documentation of the generators exercised under load for 30 minutes per month for the month of November 2009 for the South Wing generator 2, West Generator 1 and West Generator 2.

Based on observation, the facility failed to maintain its electrical equipment and appliances as evidenced by failing to prevent the use of unauthorized electrical equipment such as extension cords, and adapters, power strips plugged into power strips, electrical appliances plugged into multi-plug power strips and missing and/or broken electrical cover plates. This affected 3 of 11 floors in the Main Hospital, 2 of 5 floors in the Children's Hospital, Ambulatory Rehab Clinic and Out Patient Primary Care. This failure could result in the potential increase risk of an electrical fire resulting in potential harm to patients, staff and visitors.

NFPA 70 National Electrical Code (1999 Edition), Chapter 4 Article 400-Flexible Cords and Cables
Section 400-8.
Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable 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 ceiling, dropped ceiling, 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 buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

NFPA 70, National Electrical Code (1999 Edition) Article 240-4, and HFCA Transmittal Notice 22-99, prohibits the use of extension cords without overcurrent protection.

NFPA 70, National Electrical Code (1999 Edition) Article 110-12(c) states there shall not be damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken.

Findings:

During a tour of the facility with facility Staff 4 and Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the electrical system was observed.

Main Hospital Seventh Floor on 8/30/10:
At 1:20 p.m., the microwave was plugged into a power strip and not directly into the wall outlet in employee break room 7014.

At 1:48 p.m., in Unit 7200 there was a six outlet wall adapter with no overcurrent protection in the Cardiac Transplant Coordinators Office room 7700G.

Main Hospital Fourth floor on 8/30/10:
At 3:34 p.m., in Unit 4700 there was a microwave and refrigerator plugged into a power strip and not directly into the wall outlet in room 4729.

Main Hospital Second Floor on 8/31/10:
At 8:54 a.m., in Unit 2400 there was a surge protector plugged into a surge protector in room 2429, Scheduling office.

At 9:10 a.m., in Unit 2200 there was a microwave and refrigerator plugged into a six outlet adapter in Diagnostic room 5.

At 9:15 a.m., in Unit 2200 there was a microwave and refrigerator plugged into a power strip and not directly into the wall outlet in the employee break room.

At 10:24 a.m., there was a surge protector plugged into a surge protection in room 2143.

Professional Plaza - Out Patient Primary Care Second Floor on 9/7/10:
At 2:50 p.m., in Suite 204B there was a six outlet adapter with no overcurrent protection above the workstation between exam room 13 and 14.

At 3:10 p.m., in Suite 207A there was a six outlet adapter with no overcurrent protection above the workstation between exam room 5 and 6.




27961

Children's Hospital on 8/30/10:

During a tour of the facility with facility Staff 3 and Staff 7 and Staff 10 on August 30, 2010 through September 8, 2010, the electrical system was observed.

At 1:17 p.m., Room 5700F on the 5th floor had a refrigerator plugged into multi-plug surge protection strip.

At 2:08 p.m., Room 5118 on the 5th floor had a refrigerator plugged into multi-plug surge protection strip.

At 4:05 p.m., Room 3348 on the 3rd floor had a refrigerator plugged into multi-plug surge protection strip.

Ambulatory Rehab Clinic - 11406 Loma Linda on 9/07/10:
At 10:32 a.m., in the Hand Center Room there was a refrigerator plugged into multi-plug surge protection strip.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 4 of 11 floors in the Main Hospital and 2 of 5 floors in the Childrens Hospital, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 3, Staff 7, and Staff 10, on August 30, 2010 through September 8, 2010, the walls and ceilings were observed.

Main Hospital Sixth Floor on 8/30/10:
At 2:04 p.m., in Room 6438, there was an unsealed penetration around communication wires running through in the left wall.

Main Hospital Second Floor on 8/31/10:
At 9:30 a.m., in the Ultrasound exam room 1 located in Unit 2400, there was an unsealed 1 inch penetration in the left wall where cables wires were removed.

At 10:00 a.m., in the Biohazard room 2625 located in Unit 2600, there was an unsealed 1 inch penetration below the dispenser.

Main Hospital First Floor on 8/31/10:
At 10:43 a.m., in the Scheduling office room 1483, there was a 1 1/2 inch unsealed penetration behind the door where the door handle hit the wall.

Main Hospital Level A on 8/31/10:
At 2:15 p.m., in Locker room A214, there were 1/2 inch unsealed penetrations around two sprinkler pipes located in the back wall.


Main Hospital Level B on 8/31/10:
At 10:40 a.m., in Room B826, there were two, 1/2 inch round penetrations in the back wall.




27961


Children's Hospital on 8/30/10:

During a tour of the facility with Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facility walls and ceilings were observed.

At 11:24 a.m., in the Respiratory Care Room 5729 on the 5th floor there was a 1/2 inch penetration in the wall next to the electrical cover plate that was not secured and hanging sideways on the wall.

At 1:20 p.m., in Room 5829A on the 5th floor, there were four, 1/2 inch round penetrations in the left wall and a pair of scissors stuck into one penetration.

At 1:28 p.m., in Room 5819 "Special Care Unit" on the 5th floor, there were six, 1/4 inch round penetrations in the wall behind the ice maker machine.

At 1:45 p.m., in Nursing Station 2 across from Room 5806 on the 5th floor, there were six, 1/4 inch round penetrations behind the ice maker machine.

At 2:00 p.m., in Room 5216 on the 5th floor, there was a 5 inches x 2 inches penetration in the right wall.

At 4:15 p.m., in Room 3117 "Report Room" on the 3rd floor, there were five, 1/2 inch round penetrations in the wall.

Based on observation and interview, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to positive latch upon closure. This failure affected 1 of 5 floors in the Childrens Hospital and 1 of 1 floors in the Heart and Surgical Hospital. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facilities corridor doors were observed.

Children's Hospital and Main Hospital on 8/31/10:
At 10:10 a.m., the Children's Gift Shop on the 1st floor had a corridor door that failed to positive latch on the right side due to a door wedge that prevented it from closing. When interviewed on August 31, 2010 at 10:10 a.m., Staff 4 stated that the hardware on the door was broken and they were ordering a new self closing device.

Heart and Surgical Hospital on 9/07/10:
At 3:20 p.m., Room "On Call V139/0140 had a door that failed to positive latch due to a door wedge that prevented it from closing.

At 3:43 p.m., the door to the Boiler Room on the lower level failed to positive latch on the right side.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by smoke barrier doors that failed to release from the magnet device during the testing of the fire alarm system. This failure affected 1 of 5 floors in the Children's Hospital and Level A. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facility doors were observed.

Children's Hospital and Main Hospital on 9/2/10:
At 11:14 a.m., the smoke barrier doors to the Lobby in the GI Lab on the 1st floor failed to release from the magnet after testing of a smoke detector.

At 11:40 a.m., the Children's Gift shop corridor doors on the 1st floor failed to release from the magnet on the right side after testing of a smoke detector.

At 1:37 p.m., the smoke barrier doors to A861 on Level A failed to release from the magnet on the left side after testing of a smoke detector.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction as evidenced by unsealed penetrations in the facility smoke barrier walls. This failure affected 1 of 11 floors in the Main Hospital and 1 of 1 floors in the Highland Springs Medical Center and would allow the spread of fire and smoke from one compartment to another, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 3, Staff 4, Staff 7 and Staff 10, on August 30, 2010 through September 8, 2010, the facility smoke barrier walls were observed.

Main Hospital Fourth Floor on 8/30/10:
At 3:45 p.m., the smoke barrier wall in Unit 4700 (Adult side) between patient rooms 4755 and 4756, there was an unsealed 4 inch conduit with blue and purple wires running through.


Highland Springs Medical Plaza on 9/03/10:
At 10:55 a.m., the smoke barrier wall between Suite 105 and the corridor had one penetration approximately 8 inch x 8inch , one penetration approximately 2 inch x 2 inch wide and a 2 inch wide penetration around 3 white pipes.

Based on observation, the facility failed to ensure that smoke barrier doors on magnetic devices latch and resist the passage of smoke as evidenced by smoke barrier doors failure to latch upon activation of the fire alarm system. This failure affected 2 of 5 floors in the Children's Hospital, Level A and B in the Main Hospital and 1 of 2 floors in the Heart and Surgical Hospital, resulting in potential harm to patients, staff and visitors.

Findings:

During the testing of the fire alarm system with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010, through September 8, 2010, the facilities corridor doors were observed.

Children's Hospital and Main Hospital On 9/02/10:
At 10:01 a.m., the smoke barrier doors on the 2nd floor in the Operating Room across from Room 2360 failed to positive latch on the left side after activation of an initiating device.

At 11:18 a.m., the smoke barrier doors to the Lobby/Visitor elevators on the 1st floor failed to positive latch on both sides after activation of an initiating device.

At 11:40 a.m., the Children's Gift shop corridor doors on the 1st floor failed to positive latch on both sides after activation of an initiating device.

At 1:37 p.m., the smoke barrier doors to A861 on Level A failed to positive latch on both sides after activation of an initiating device.

At 2:38 p.m., the smoke barrier door by B406 on Level B failed to positive latch on both sides after activation of an initiating device.





21101


Heart and Surgical Hospital on 9/07/10:

During the testing of the fire alarm system with Staff 4, Staff 10, Staff 11, Staff 14 and Staff 16, on September 7, 2010, the smoke barrier doors were observed.

At 11:56 a.m., on the upper level the smoke barrier door located between the Cafe and Conference room, the leaf next to the Conference room failed to latch during the activation of the fire alarm system.

Based on observation, the facility failed to maintain the exit and directional signs, as evidenced by exit signs that were not fully illuminated. This failure affected two suites in the Out patient Primary Care Services-Professional Plaza, and could result in delayed evacuation in the event of a fire or other emergency causing potential harm to the occupants.

Findings:

During a tour of the facility with Staff 10, Staff 14 and Staff 16, on August 30, 2010, through September 8, 2010, the exit lights were observed.

Professional Plaza Building "A" and "B" on 9/07/10:
At 2:56 p.m., in Suite 204 B the exit light between hall 2 and 3 was not fully illuminated.
At 3:15 p.m., in Suite 207 A the exit light in hall 7 was not fully illuminated.

Based on observation and interview, the facility failed to ensure staff were trained with respect to their duties and emergency procedures and equipment. This failure could create delay and the potential for harm to patients if staff become confused and fail to follow or understand the facility emergency plan.

19.7.1.1 The Administration of every health care occupancy shall have, in effect and available to all personnel, written copies of a plan for protection of all persons in the event of fire, for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with their duties under the plan. A copy of the plan shall be readily available at all times.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010, through September 8, 2010, the facilities staff were interviewed.

Main Hospital and Children's Hospital on 9/02/10:
At 9:46 a.m. in the Recovery/PT Care area on the 3rd floor, Staff 17 was interviewed and stated that she had not participated in a fire drill, only in the fire extinguisher training held every year. When asked how long Staff 17 had worked at the facility, Staff 17 stated 37 years.

Based on observation and interview, the facility failed to maintain a fire alarm system to provide effective warning of fire in any part of the building as evidenced by not being able to hear an audible device (fire alarm) and affected the third floor Recovery Room. This failure would delay staff's response to a fire or other emergency, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facilities fire alarm system was observed.

Main Hospital and Children's Hospital on 9/02/10:
At 9:45 a.m., in the Recovery Room on the 3rd floor, the pull station was activated in the hallway outside the room that could not be heard in the Recovery Room once the fire door released and latched. When a patient and Staff 16 were interviewed on September 2, 2010 at 9:45 a.m., they both stated that they had not heard the first alarm testing. When testing was done again, both stated that they could faintly hear the alarm. The room contained no strobe, chime/bell or speaker.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by missing sprinkler escutcheon rings, sprinklers with penetrations, sprinklers that were impeded and a PIV that failed to send a trouble signal to the fire alarm panel and was not locked as required. This affected 7 of 11 floors in the Main Hospital, 3 of 5 floors in the Children's Hospital, Sleep Diagnostic Center, Radiology Clinic-Sun City, Cancer Center Highland Springs, Ambulatory Rehab Clinic. This failure could result in the fire sprinkler system not functioning as designed in the event of a fire, resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 3, Staff 7, Staff 10, Staff 14, and Staff 16, on August 30, 2010 through September 8, 2010, the automatic sprinkler sytem was tested and observed.

Main Hospital - Ninth Floor on 8/30/10:
At 11:20 a.m, in Unit 9100 the sprinkler escutcheon ring was missing in the clean storage room 9114.

Main Hospital - Seventh Floor on 8/30/10:
At 1:25 p.m., in Unit 7100 the sprinkler escutcheon ring was missing in room 7116.

Main Hospital - Sixth Floor on 8/30/10:
At 2:08 p.m., in Unit 6100 the sprinkler escutcheon ring was missing in copy room 6448.

At 2:10 p.m., in Unit 6100 the sprinkler escutcheon ring was missing in soiled linen room 6119.

At 2:15 p.m., in Unit 6100 the sprinkler escutcheon ring was missing above bed 2 in patient room 6101.

At 2:22 p.m., the sprinkler escutcheon ring was missing in the corridor of the Unit 6200 South exit.

Main Hospital - Fifth Floor on 8/30/10:
At 2:41 p.m., the sprinkler escutcheon ring was missing in Physical Therapy room 5428.

Main Hospital - Fourth Floor on 8/30/10:

At 2:50 p.m., 1 of 2 sprinkler escutcheon rings was missing in Cardiac records storage room 4438.

At 3:00 p.m., the sprinkler escutcheon ring across from room 4410 was missing.

At 3:05 p.m., there was an approximately 1/4 inch unsealed penetration next to the sprinkler escutcheon ring in Cardiac waiting room 4006.

At 3:30 p.m., in Unit 4200 the escutcheon ring was missing in the Peds South exit corridor.
At 4:12 p.m., 2 of 3 sprinkler escutcheon rings were missing in Unit 4300, room 4311.

Main Hospital - Second Floor on 8/31/10:
At 10:08 a.m., a sprinkler escutcheon ring was missing in Out Patient Pharmacy.

At 10:20 a.m., the sprinkler in Lab room 2137 had signs of corrosion.

Main Hospital - Level A on 8/31/10:
At 2:18 p.m., the sprinkler escutcheon ring in Peds Emergency Department room 5 was missing.

Sleep Diagnostic Center - on 9/7/10:
At 10:27 a.m., the sprinkler escutcheon ring in the waiting area had an approximately 1/2 inch unsealed penetration.




27961


Childrens' Hospital on 8/30/10:

During a tour of the facility with facility Staff 4, Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the facilities automatic sprinkler system was observed.

At 2:10 p.m., in the ceiling outside Room 5320 on the 5th floor there was a sprinkler missing an escutcheon ring.

At 2:35 p.m., in the ceiling by the Nursing Station on the 4th floor there was a sprinkler missing an escutcheon ring.

At 4:25 p.m., in the alcove across from 3106 on the 3rd floor, there was a roll of plastic cups within 6 inches of the sprinkler deflector.

O/P Radiology Clinic, Sun City on 9/03/10:
At 9:00 a.m., in the hallway outside X-Ray 1 room there was a sprinkler missing an escutcheon ring.

At 9:00 a.m., in X-Ray 1 room there were 5 escutcheon rings missing.

Cancer Center Highland Springs Medical Center on 9/03/10:
At 12:24 p.m., the Post Indicator Valve (PIV) was closed and failed to send the supervisory signal to the fire alarm panel and monitoring station. The lock was broken and laying on the ground next to the PIV.

Ambulatory Rehab Clinic - 11406 Loma Linda, on 9/07/10:
At 10:28 a.m., there was a sprinkler escutcheon ring missing in Room 159.

Based on observation, the facility failed to ensure oxygen cylinders were secured in accordance with NFPA 99, as evidenced by an unsecured oxygen tank. This failure affected 1 of 11 floors in the Main Hospital.

NFPA 99 Standard for Health Care Facilities (1999 Edition)
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4-3.1.1.2(a) 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a tour of the facility with Staff 3, Staff 7, Staff 10, on August 30, 2010, through September 8, 2010, oxygen storage was observed.

Main Hospital Level A on 8/31/10:
At 2:20 p.m., in the Fast Track Department there was an unsecured oxygen tank located next to a waste bin.

Based on document review, and interview the facility failed to maintain the relative humidity level equal to or greater than 35% as evidenced by documentation that the humidity level for Labor and Delivery Room 3 was below the required level of 35% for a six month period and by no documentation for daily humidity levels for 4 of 4 procedure rooms in the CATH Lab. This failure could result in an increase risk of fire in the operating rooms resulting in potential harm to patients and staff.

Findings:

During document review with facility Staff 1 and Staff 4 on August 30, 2010 through September 8, 2010, the humidity levels of all Operating Rooms were requested for review.


Main Hospital on 8/30/10:

December 2010:
1. On December 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
2. On December 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
3. On December 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
4. On December 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
5. On December 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
6. On December 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
7. On December 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
8. On December 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
9. On December 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
10. On December 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
11. On December 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
12. On December 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33.5%.
13. On December 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
14. On December 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
15. On December 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
16. On December 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
17. On December 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
18. On December 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%. Comments on log state " humidity adjusted " .
19. On December 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
20. On December 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
21. On December 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
22. On December 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%. Comments on log state " humidity turned up " .
23. On December 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 14%. Comments on log state " humidity turned up " .
24. On December 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
25. On December 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
26. On December 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
27. On December 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
28. On December 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
29. On December 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
30. On December 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
31. On December 31, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.

January 2010:
32. On January 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
33. On January 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
34. On January 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
35. On January 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
36. On January 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
37. On January 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
38. On January 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
39. On January 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
40. On January 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
41. On January 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
42. On January 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%. Comments state " humidity (up arrow). "
43. On January 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%. Comments state " humidity " .
44. On January 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
45. On January 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
46. On January 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
47. On January 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
48. On January 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
49. On January 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 46%.
50. On January 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
51. On January 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
52. On January 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
53. On January 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was not listed.
54. On January 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
55. On January 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
56. On January 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
57. On January 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
58. On January 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
59. On January 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
60. On January 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%. Comments state " maintenance called " .
61. On January 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 24%.
62. On January 31, 2010, the humidity level in Labor and Delivery Operating Room 3 was 24%. Comments state " humidity (up arrow). "

February 2010: No comments written on the February log for the days when the humidity level was lower than policy allows.
63. On February 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
64. On February 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
65. On February 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
66. On February 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
67. On February 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
68. On February 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
69. On February 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
70. On February 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
71. On February 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
72. On February 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
73. On February 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
74. On February 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
75. On February 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
76. On February 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
77. On February 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
78. On February 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
79. On February 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 23%.
80. On February 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
81. On February 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
82. On February 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
83. On February 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
84. On February 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
85. On February 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 24%.
86. On February 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 23%.
87. On February 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
88. On February 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
89. On February 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
90. On February 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.

March 2010: Comments section on March 2010 log state " Humidity is fine reader on wall is broken maintenance ordered had held reader. "
1. On March 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
2. On March 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
3. On March 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
4. On March 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
5. On March 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
6. On March 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%. Comments on log state " Maintenance getting per " .
7. On March 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
8. On March 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
9. On March 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was not listed.
10. On March 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
11. On March 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%. Comments on log state " Maintenance checking reader on wall broken humidity @ 37% per hand held by maintenance.
12. On March 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
13. On March 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
14. On March 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
15. On March 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
16. On March 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
17. On March 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
18. On March 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 23%.
19. On March 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
20. On March 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
21. On March 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 20%.
22. On March 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
23. On March 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
24. On March 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 27%.
25. On March 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.
26. On March 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
27. On March 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 26%.
28. On March 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 17%.
29. On March 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.
30. On March 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
31. On March 31, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.

April 2010:
1. On April 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
2. On April 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%
3. On April 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 36%.
4. On April 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
5. On April 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
6. On April 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 21%.
7. On April 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
8. On April 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 16%.
9. On April 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 22%.
10. On April 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 38%.
11. On April 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
12. On April 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
13. On April 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
14. On April 14, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%.
15. On April 15, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
16. On April 16, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
17. On April 17, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%.
18. On April 18, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
19. On April 19, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.
20. On April 20, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
21. On April 21, 2010, the humidity level in Labor and Delivery Operating Room 3 was 41%.
22. On April 22, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
23. On April 23, 2010, the humidity level in Labor and Delivery Operating Room 3 was 29%.
24. On April 24, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
25. On April 25, 2010, the humidity level in Labor and Delivery Operating Room 3 was 32%.
26. On April 26, 2010, the humidity level in Labor and Delivery Operating Room 3 was 49%. Comments on log state " turn temp down recheck in 2hr @ 74 " .
27. On April 27, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.
28. On April 28, 2010, the humidity level in Labor and Delivery Operating Room 3 was 34%. Comments on log state " temp recheck " .
29. On April 29, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
30. On April 30, 2010, the humidity level in Labor and Delivery Operating Room 3 was 19%.

May 2010:
1. On May 1, 2010, the humidity level in Labor and Delivery Operating Room 3 was 18%.
2. On May 2, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
3. On May 3, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%.
4. On May 4, 2010, the humidity level in Labor and Delivery Operating Room 3 was 25%.
5. On May 5, 2010, the humidity level in Labor and Delivery Operating Room 3 was 28%.
6. On May 6, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%. Comments on log state " turned temp down re check " .
7. On May 7, 2010, the humidity level in Labor and Delivery Operating Room 3 was 36%.
8. On May 8, 2010, the humidity level in Labor and Delivery Operating Room 3 was 35%.
9. On May 9, 2010, the humidity level in Labor and Delivery Operating Room 3 was 31%.
10. On May 10, 2010, the humidity level in Labor and Delivery Operating Room 3 was 30%. Comments on log state " called maintenance reader on wall broken, given hand held scanner humidity at 40% " .
11. On May 11, 2010, the humidity level in Labor and Delivery Operating Room 3 was 36%.
12. On May 12, 2010, the humidity level in Labor and Delivery Operating Room 3 was 33%. Comments on log state " recheck @ 1015 36 CRH " .
13. On May 13, 2010, the humidity level in Labor and Delivery Operating Room 3 was 37%.

Main Hospital First Floor on 8/31/10:

At 10:38 a.m., the four Cath Labs did not have a humidity monitoring device and when staff was asked if the humidity levels were monitored daily staff stated no.

Based on document review, the facility failed to maintain their generators as evidenced by 4 of 4 generators that were not exercised under load for 30 minutes for the month of October 2009 and November 2009. This could result in emergency generator failure and could cause potential harm to patients, staff and visitors in the event of an emergency.


NFPA 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.

(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:
During document review with facility Staff 4 and Staff 12, on August 31, 2010 through September 8, 2010, the facility generator test and inspection logs were reviewed.
Main Hospital on 8/31/10:
At 1:15 p.m., the facility failed to provide documentation of the generators exercised at least once a month under load for 30 minutes for the month of October 2009 and November 2009 for the South Wing generator 1 and, failed to provide documentation of the generators exercised under load for 30 minutes per month for the month of November 2009 for the South Wing generator 2, West Generator 1 and West Generator 2.

Based on observation, the facility failed to maintain its electrical equipment and appliances as evidenced by failing to prevent the use of unauthorized electrical equipment such as extension cords, and adapters, power strips plugged into power strips, electrical appliances plugged into multi-plug power strips and missing and/or broken electrical cover plates. This affected 3 of 11 floors in the Main Hospital, 2 of 5 floors in the Children's Hospital, Ambulatory Rehab Clinic and Out Patient Primary Care. This failure could result in the potential increase risk of an electrical fire resulting in potential harm to patients, staff and visitors.

NFPA 70 National Electrical Code (1999 Edition), Chapter 4 Article 400-Flexible Cords and Cables
Section 400-8.
Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable 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 ceiling, dropped ceiling, 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 buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

NFPA 70, National Electrical Code (1999 Edition) Article 240-4, and HFCA Transmittal Notice 22-99, prohibits the use of extension cords without overcurrent protection.

NFPA 70, National Electrical Code (1999 Edition) Article 110-12(c) states there shall not be damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken.

Findings:

During a tour of the facility with facility Staff 4 and Staff 14 and Staff 16 on August 30, 2010 through September 8, 2010, the electrical system was observed.

Main Hospital Seventh Floor on 8/30/10:
At 1:20 p.m., the microwave was plugged into a power strip and not directly into the wall outlet in employee break room 7014.

At 1:48 p.m., in Unit 7200 there was a six outlet wall adapter with no overcurrent protection in the Cardiac Transplant Coordinators Office room 7700G.

Main Hospital Fourth floor on 8/30/10:
At 3:34 p.m., in Unit 4700 there was a microwave and refrigerator plugged into a power strip and not directly into the wall outlet in room 4729.

Main Hospital Second Floor on 8/31/10:
At 8:54 a.m., in Unit 2400 there was a surge protector plugged into a surge protector in room 2429, Scheduling office.

At 9:10 a.m., in Unit 2200 there was a microwave and refrigerator plugged into a six outlet adapter in Diagnostic room 5.

At 9:15 a.m., in Unit 2200 there was a microwave and refrigerator plugged into a power strip and not directly into the wall outlet in the employee break room.

At 10:24 a.m., there was a surge protector plugged into a surge protection in room 2143.

Professional Plaza - Out Patient Primary Care Second Floor on 9/7/10:
At 2:50 p.m., in Suite 204B there was a six outlet adapter with no overcurrent protection above the workstation between exam room 13 and 14.

At 3:10 p.m., in Suite 207A there was a six outlet adapter with no overcurrent protection above the workstation between exam room 5 and 6.




27961

Children's Hospital on 8/30/10:

During a tour of the facility with facility Staff 3 and Staff 7 and Staff 10 on August 30, 2010 through September 8, 2010, the electrical system was observed.

At 1:17 p.m., Room 5700F on the 5th floor had a refrigerator plugged into multi-plug surge protection strip.

At 2:08 p.m., Room 5118 on the 5th floor had a refrigerator plugged into multi-plug surge protection strip.

At 4:05 p.m., Room 3348 on the 3rd floor had a refrigerator plugged into multi-plug surge protection strip.

Ambulatory Rehab Clinic - 11406 Loma Linda on 9/07/10:
At 10:32 a.m., in the Hand Center Room there was a refrigerator plugged into multi-plug surge protection strip.