HospitalInspections.org

Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by unsealed penetrations in the walls and ceiling. This affected two of two floors at the Main Hospital and could result in the spread of fire and smoke in the event of a fire.

NFPA 101 - Life Safety Code, 2012 Edition
8.3 Fire Barriers.
8.3.1 General.
8.5.6 Penetrations.
8.5.6.2
Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.
8.5.6.4
Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 1/ 2 in. (13 mm), measured between the edge of the membrane and the sprinkler.
Findings:

During a tour of the facility and interview with Staff 1 on 12/9/20, the walls and ceilings were observed.

Main Hospital-Level 2

1. At 9:58 a.m., the Storage Room with the door labeled 02-051 was observed. There were two penetrations located on the east wall and one penetration on the west wall. All three penetrations were approximately 1/4 inch diameter in size.

2. At 10:00 a.m., the Storage Room with the door labeled 02-044 was observed with a broken ceiling vent. The vent was missing part of the vent cover plate creating a penetration approximately 1 inch by 1 inch in size.

3. At 10:05 a.m., the Storage Room with the door labeled 02-011 was observed. The pipe below the lavatory was missing an escutcheon plate creating an approximate 3/4 inch penetration around the pipe.

Main Hospital-Level 1

4. At 10:58 a.m., the Dry Food Storage Room in the Dietary Kitchen was observed. There were three penetrations located directly above the portable fire extinguisher labeled 27. All three penetrations were approximately 1/4 inch diameter in size.

5. At 1:52 p.m., the Surgery Storage Room with the door labeled 01-060 was observed. There was one penetration located above electrical panel QEH and a second penetration located above electrical panel LSL. Both penetrations were approximately 1 inch by 1/4 inch in size and were located around conducts that served the electrical panels.

These findings were acknowledged by Staff 1.

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Based on observation, document review, and interview, the facility failed to maintain the emergency lighting equipment. This was evidenced by one emergency light that did not activate when tested and another that was lacking monthly and annually testing. This affected one of two floors at the Main Hospital and the Outpatient Services Building and could result in the malfunction of the battery operated emergency lighting during an emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.2.1* Emergency illumination shall be provided for a minimum of 11.2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft candle (0.65 lux) at the end of 11.2 hours. A maximum-tominimum illumination uniformity ratio of 40 to 1 shall not be exceeded.

7.9.3 Periodic Testing of Emergency Lighting Equipment.

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 1 1/2 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.

7.9.3.1.2 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, self-testing/self-diagnostic battery-operated emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall indicate failures by a status indicator.
(4) A visual inspection shall be performed at intervals not exceeding 30 days.
(5) Functional testing shall be conducted annually for a minimum of 1 1/2 hours.
(6) Self-testing/self-diagnostic battery-operated emergency lighting equipment shall be fully operational for the duration of the 11?2-hour test.
(7) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

7.9.3.1.3 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Computer-based, self-testing/self-diagnostic battery-operated emergency lighting equipment shall be provided.
(2) Not less than once every 30 days, emergency lighting equipment shall automatically perform a test with a duration of a minimum of 30 seconds and a diagnostic routine.
(3) The emergency lighting equipment shall automatically perform annually a test for a minimum of 1 1/2 hours.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.3(2) and (3).
(5) The computer-based system shall be capable of providing a report of the history of tests and failures at all times.

Findings:

During a tour of the facility, document review, and interview with Staff 1 on 12/9/20, the emergency lighting equipment was observed and records were requested.

Outpatient Services Building

1. At 9:30 a.m., the battery and electronically powered emergency light located in the MRI Control Room was observed. Upon interview, Staff 1 stated they were not testing the emergency light. There were no records provided indicating the emergency light was being tested for 30 seconds on a monthly basis or for 90 minutes on an annual basis.

Main Hospital

2. At 11:31 a.m., on the First Floor, the emergency battery backup lighting unit in the Labor and Delivery Operating Room failed to illuminate when the test button was pressed by Staff 1. When interviewed, Staff 1 confirmed the finding.

Based on observation, record review and interview, the facility failed to maintain the exit signs. This was evidenced by the failure to complete an annual and monthly functional test of the battery-powered emergency exit signs, by the failure to provide complete documentation of the required monthly visual inspections of the exit signs and by one exit sign that required a bulb replacement. This could result in a delay in evacuation, in the event of a fire or other emergency. This affected the Outpatient Services Building and one of two floors at the Main Hospital.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10 Marking of Means of Egress
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 Periodic Testing of Emergency Lighting Equipment.
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 1 1/2 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.

7.10.5.2 Continuous Illumination.
7.10.5.2.1 Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2.

Findings:

During a tour of the facility, record review, and interview with Staff 1 on 12/9/20, the exit signs were observed, and records were requested.

OUTPATIENT SERVICES BUILDING

1. At 9:21 a.m., the facility failed to provide complete documentation that indicated the facility had completed an annual 90 minute and monthly 30 seconds functional test for six of six battery-operated emergency exit signs. The Staff 1 confirmed that the annual 90 minutes and monthly 30 seconds functional test was not conducted.

2. At 9:31 a.m., the facility failed to provide complete documentation of the monthly visual inspection for the illumination sources for six of six exit signs. There was no monthly documentation provided for review. The Staff 1 confirmed that the monthly visual inspection was not conducted.

MAIN HOSPITAL

3. At 10:37 a.m., First Floor, the right bulb of the battery-operated exit light-47 in the CT hallway was not illuminated. The Staff 1 confirmed the finding.

Based on document review, observation, and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the failure to maintain appropriate humidity levels and document the cause and correction of humidity range discrepancies for four of four Operating Rooms. This affected one of two floors in the Main Hospital and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings

During document review, a tour of the facility, and interview with Staff 1, the anesthetizing locations were observed and records were requested.

Main Hospital Level 1

1. On 12/8/20 at 4:00 p.m., documents provided indicated the facility implemented guidelines from the Association of periOperative Registered Nurses (AORN) for maintaining humidity range in the operating rooms between 20 and 60 percent. Documents also indicated the humidity and temperature levels in four of four Operating Rooms were being monitored using SensoScientific Monitors located in each of the rooms. The monthly humidity reports indicated four of four Operating Rooms had humidity levels that fell out of the required range in multiple instances.

Operating Room 7H had recorded humidity levels out of range on approximately 15 days during the past six months (6/3/20, 6/21/20, 6/23/20, 6/26/20, 6/27/20, 8/7/20, 8/13/20, 8/14/20, 8/16/20, 8/17/20, 8/18/20, 8/22/20, 10/7/20, 10/26/20, and 11/18/20).

Operating Room 1H had recorded humidity levels out of range on approximately 6 days during the past six months (6/3/20, 6/23/20, 6/26/20, 7/16/20, 8/14/20, and 10/7/20).

Operating Room 2H had recorded humidity levels out of range on approximately 4 days during the past six months (6/3/20, 6/21/20, 6/28/20, and 10/27/20).

Operating Room 3H had recorded humidity levels out of range on approximately 21 days during the past six months (6/3/20, 6/19/20, 6/21/20, 6/24/20, 6/26/20, 6/28/20, 7/16/20, 7/30/20, 8/25/20, 8/29/20, 9/14/20, 9/15/20, 9/16/20, 9/17/20, 9/19/20, 9/20/20, 9/24/20, 9/25/20, 9/27/20, 10/4/20, and 10/26/20).

2. During an interview on 12/9/20 at 11:20 a.m., Staff 1 stated there were no logs kept that provided information on the exact times when the humidity went out of range in the Operating Rooms. Staff 1 also stated they did not keep record of what caused the humidity levels to go out of range and how the issue was corrected.

Based on observation, record review, and interview, the facility failed maintain the fire alarm system and its components. This was evidenced by devices that were not tested during the annual inspection and testing of the fire alarm system and by a manual pull station that was obstructed. This affected the Main Hospital and could result in a delay in notification in the event of a fire.

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.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
Table 14.4.5 Testing Frequencies
15. Initiating Devices*
(F)Manual fire alarm boxes - Initial/Reacceptance; Annually
(h) Smoke detectors - functional test - Initial/Reacceptance; Annually

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)

17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

Findings:

During a tour of the facility, record review, and interview with the Staff 1, the fire alarm system records were reviewed.

1. On 12/8/20, at 9:39 a.m., the document titled Final HFAP Inspection Report 10/2020, indicated that the fire alarm system was inspected and tested quarterly. The inspection and test were conducted on January, April, July and October of 2020. The report indicated 15 out of 262 smoke detectors were not tested. The locations were not tested are as follows:
First Floor
Old ER Exam Rm 113 - 7/22/2020
Old ER Exam Rm 114 - 10/21/2020
Old ER Exam Rm 115 - 10/21/2020
ER Ortho/Suture Beds 111 - 112 - 7/22/2020
ER Pediatric Room 114 and 115 - 7/22/2020
ER OB Rooms 116 and 117 - 7/22/2020
ER Crit Care Treatment Room 107, 106, 105 - 7/22/2020
ER Fastrack Beds 108 - 110 - 7/22/2020
ER Trauma/Crit Care Bed 104 and 102 - 7/22/2020
ER Eye/Ent Room 101 - 7/22/2020

2. On 12/8/20, at 10:02 a.m., the report indicated that 50 manual pull stations were tested. The facility has a total of 53 pull stations. The location of the three manual pull stations that were not tested are as follows:
First Floor:
Old ER Triage, 1-M1-009 - 10/21/2020
Old ER Ambulance Entrance, 1-M1-012 - 7/22/2020
Old ER Admitting Room, 1-M1-013 - 10/21/2020

When interviewed, Staff 1 stated that the devices were inaccessible due to COVID-19 - Waiver 35.

3. On 12/9/20, at 9:51 a.m., Second Floor, the manual pull station by Room 268 was obstructed by a rolling chair. The rolling chair was parked in front of the manual pull station. When interviewed, Staff 1 confirmed the finding.

Based on record review and interview, the facility failed to maintain the fire watch plan. This was evidenced by an incomplete fire watch plan for the fire alarm system (FAS). This affected the Main Hospital and could result in a delay in notification in the event of an emergency with the fire alarm system.

Findings:

During record review and interview with Staff 1 on 12/8/20, the facility's fire watch policy and procedure for the FAS was reviewed and staff was interviewed.

At 11:15 a.m., the facility's fire watch policy and procedure was reviewed. The fire watch plan failed to include the specified timeframe in the event the FAS was out of service and failed to indicate that the facility would contact the California Department of Public Health if the fire alarm system went out of service for more than 4 hours in a 24-hour period. When interviewed, Staff 1 confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the smoke detector devices. This was evidenced by five of five single station battery powered smoke alarms that were not tested on a weekly basis as required per the manufacturer and one smoke alarm that did not activate when tested. This affected the Outpatient Services Building and could result in the delayed notification in the event of a fire.

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.
9.6.1.5 *
To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.
9.6.2.10.1.1 Where required by another section of this Code, single-station and multiple-station smoke alarms shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code, unless otherwise provided in 9.6.2.10.1.2, 9.6.2.10.1.3, or 9.6.2.10.1.4.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published
instructions and this Code.

14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer's published instructions.

Findings:

During a tour of the facility, document review, and interview with Staff 1 on 12/9/20, the smoke detector devices were observed and records were requested.

Outpatient Services Building

1. At 9:17 a.m., the battery powered smoke alarm located in the Employee Breakroom was observed. Staff 1 tested the smoke alarm manually by pressing down on the test button. The smoke alarm did not active. Upon interview, Staff 1 stated they were not aware the Outpatient Services Building was equipped with smoke alarms and they had not been testing them. Staff 1 also confirmed there was a total of five battery powered smoke alarms located in the Outpatient Services Building.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system and it components. This was evidenced by one sprinkler head that was covered in debris, and two sprinkler heads that had penetrations near the escutcheon plates. This was also evidenced by one sprinkler head that did not have the required 18 inch clearance. This affected one of two floors at the Main Hospital and could result in the malfunction of the sprinkler system 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.

9.7.1.1* 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
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

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.

NFPA 13, Standard for the Installation of Sprinkler System. 2010 Edition
8.6.6* Clearance to Storage (Standard Pendent and Upright Spray Sprinklers).

8.6.6.1 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

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).

5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

Findings:

During a tour of the facility and interview with Staff 1 on 12/9/20, the automatic sprinkler system was observed.

Main Hospital-Level 1

1. At 10:42 a.m., the sprinkler heads in the Laboratory were observed. The sprinkler head located above the chemistry machine was covered in debris. The frangible bulb was not visible.

2. At 11:27 a.m., the sprinkler head in the Storage Room with door labeled 01-099 had a penetration located around the escutcheon plate. The penetration was approximately 1 inch by 1/8 inch in size.

3. At 1:40 p.m., the sprinkler head in the Storage Closet for Labor and Delivery was observed. There were two cervical kits stored approximately 6 inches from the sprinkler head.

Upon interview, these findings were confirmed at this time by Staff 1.


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4. At 1:43 p.m., on the First Floor, the sprinkler head in the Labor and Delivery Locker Room, with the door labeled 01-032 had a penetration located at the top right of the escutcheon plate. The penetration was approximately 1/4 inch in size. When interviewed, Staff 1 confirmed the finding.

Based on record review and interview, the facility failed to maintain the fire watch plan. This was evidenced by an incomplete fire watch plan for the automatic fire sprinkler system. This affected the Main Hospital and could result in a delay in notification in the event of an emergency with the automatic fire sprinkler system.

Findings:

During record review and interview with Staff 1 on 12/8/20, the facility's fire watch policy and procedure for the automatic fire sprinkler system was reviewed and staff was interviewed.

At 11:15 a.m., the facility's fire watch policy and procedure was reviewed. The fire watch plan failed to include the specified timeframe in the event the automatic fire sprinkler system was out of service, and failed to indicate that the facility would contact the California Department of Public Health if the automatic fire sprinkler system went out of service for more than 10 hours in a 24-hour period. When interviewed, Staff 1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by four corridor doors that did not latch when tested, one door that had a broken self-closing device, and one door that was obstructed from closing. This affected two of two floors at the Main Hospital and the Outpatient Services Building and could result in the inability to contain smoke and/or fire to a room.

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

Findings:

During a tour of the facility and interview with Staff 1 on 12/9/20, the corridor doors were observed.

Outpatient Services Building

1. At 9:18 a.m., the corridor door to the Employee Breakroom did not latch when tested. The door was equipped with a self-closing device.

2. At 9:27 a.m., the door to the Men's Restroom located in the Lobby was equipped with a broken self-closing device.

These findings were acknowledged by Staff 1.

Main Hospital-Level 2

3. At 9:49 a.m., the corridor door to Room 264 was being held open by a trash receptacle. Upon interview, Staff 1 confirmed this finding and moved the receptacle away from the door.

Main Hospital-Level 1

4. At 10:53 a.m., the door to the Restroom with door labeled 01-147 located in the Lobby did not latch when tested. The door was equipped with a self-closing device.

Based on observation and interview, the facility failed to maintain the electrical system and its components. This was evidenced by four obstructed electrical panels. This affected one of two floors at the Main Hospital and the Outpatient Services Building, and could result in the inability to access the electrical panel during an emergency.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities. Utilities shall comply with the provisions of section 9.1
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.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
(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.

Findings:

During a tour of the facility and interview with Staff 1 on 12/9/20, the electrical system and its components were observed.

Outpatient Services Building

1. At 9:32 a.m., the electrical panel located in the MRI Control Room was observed. There was a rolling table stationed directly in front of the electrical panels. The panel could not be accessed without moving the table. This finding was confirmed by Staff 1, who moved the rolling table to a different location at this time.

Main Hospital-Level 1

2. At 1:44 p.m., two of two electrical panels in the Storage Room with door labeled 01-021 were observed. The electrical panels had a metal ladder stationed directing in front of them and could not be accessed. Upon interview, Staff 1 confirmed this finding.

Based on observation, record review, and interview, the facility failed to maintain the elevators. This was evidenced by the failure to provide monthly testing for elevators equipped with fire fighters' emergency services. This affected the Main Hospital. This could potentially result in an elevator malfunction.

NFPA 101, Life Safety Code, 2012 Edition.
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.

9.4.6 Elevator Testing.
9.4.6.1 Elevators shall be subject to periodic inspections and
tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators
and Escalators.
9.4.6.2 All elevators equipped with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly
operation with a written record of the findings made and kept on the premises as required by ASMEA17.1/CSA B44, Safety Code for Elevators and Escalators.

Findings:

During a facility tour, record review, and interview with the Staff 1, the elevators were observed, and records were requested.

On 12/8/20 at 10:20 a.m., the facility failed to provide complete monthly testing
for two elevators equipped with fire fighters' emergency recall. The ICU/ER elevator was missing the monthly tests for May, June, August and September of 2020 and the Surgery elevator was missing the monthly tests for June, August and September of 2020. When interviewed, Staff 1 confirmed the finding.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by the improper use of a power strip. This affected one of two floors at the Main Hospital. This could result in the increased risk of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition.
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

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
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage.

Findings:

During a tour of the facility and interview with Staff 1 on 12/9/20, the electrical equipment and wiring were observed.

At 10:46 a.m., on the First Floor, there was a refrigerator plugged into a power strip in the Administration Office. When interviewed, Staff 1 confirmed the finding and stated that he was not aware of the refrigerator plugged into a power strip.

Based on observation and interview, the facility failed to maintain oxygen storage. This was evidenced by an oxygen storage room door that did not have the minimal required signage. This affected one of two floors at the Main Hospital and could result in the unsafe storage of oxygen.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.

11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.
11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING

Findings:

During a tour of the facility and interview with Staff 1 on 12/9/20, the oxygen storage was observed.

At 9:57 a.m., on the Second Floor, the Oxygen Storage Room by Room 231 was observed. The room door was not equipped with a No Smoking sign. When interviewed, Staff 1 confirmed the finding.