HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the fire rated construction of its smoke barrier walls. this was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the migration of smoke or fire from one smoke compartment to the next and affected 4 of 6 smoke compartments in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the smoke barrier walls were observed.

Main Hospital:
1. On 11/12/14, at 11:53 a.m., the smoke barrier wall near Imagining had an approximately 1 1/2 inch penetration above a conduit located in the right corner of the smoke barrier wall.

2. On 11/12/14, at 1:44 p.m., the smoke barrier wall next to Intensive Care Unit "ICU" had an approximately 2 1/2 inch penetration in the right corner of the smoke barrier wall. During interview, Engineering staff 1 acknowledged the penetrations and stated the penetrations would be sealed immediately.

Based on observation and interview, the facility failed to maintain and provide battery powered emergency lighting. This was evidenced by an emergency light that failed to illuminate when tested and by no battery back up emergency lights in 2 of 2 operating rooms at Airway Surgery Center and by no battery back up emergency lights in 2 of 2 operating rooms at the main hospital. This could result in failure to provide emergency lighting in the event of a power outage or failure of the emergency power. This affected two operating rooms in the main hospital and two operating rooms at the out patient Airway Surgery Center.

NFPA 101, Life Safety Code 2000 Edition
Section 7.9 Emergency Lighting
7.9.2 Performance of System.
7.9.2.1* Emergency illumination shall be provided for not less than 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 lux)
and, at any point, not less than 0.1 ft-candle (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 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.
7.9.2.2* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

NFPA 99, Standard for Health Care Facilities (1999) Edition
3-3.2.1.2 All Patient Care Areas.
5. Wiring in anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During the facility tour with the Director of Facility Management and Engineering Staff 1, on 11/12/14 through 11/14/14, the emergency lighting was observed.

Out Patient Airway Surgery Center:
1. At 3:09 p.m., on 11/13/14, the battery powered emergency light located in the blood draw room failed to illuminate when tested by engineering staff 1. During an interview, engineering staff 1 stated the lights are tested monthly and annually.

2. At 3:11 p.m., on 11/13/14, the facility failed to provide battery powered emergency lights in operating room 1 and in operating room 2. This was acknowledged by engineering staff 1 during the survey.

Main Hospital:
3. At 4:01 p.m., on 11/13/14, the facility failed to provide battery powered emergency lights in operating room 1 and in operating room 2. This was acknowledged by engineering staff 1 during the survey.

Based on document review and interview, the facility failed to maintain the fire alarm system as evidenced by failure to have the fire alarm system certified annually by a factory trained and certified technician. This could result in failure of the fire alarm system and affected 6 of 6 smoke compartments in the main hospital.

NFPA 101, Life Safety Code (2000) Edition
Section 9.6 Fire Detection, Alarm and Communications Systems
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7* 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 Code.

NFPA 72, National Fire alarm Code 1999 Edition
Chapter 7 Inspection, Testing and Maintenance
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies
fire alarm certified
(3) International Municipal Signal Association fire alarm
certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization
listed by a national testing laboratory for the servicing
of fire alarm systems

Findings:

During document review and interview with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the fire alarm annual certification reports were requested.

At 11:26 a.m., on 11/13/14, the facility failed to provide documentation for the annual certification of the fire alarm system by a certified technician. During interview, engineering staff 1 stated the fire alarm system and all components are maintained by engineering staff and provided a report dated 9/26/14, documenting the fire alarm system was tested and inspected by engineering staff. Engineering staff 1, was ask if the staff who did the testing was factory trained and certified and engineering staff 1 stated he was not certified.

Based on document review and interview, the facility failed to maintain its smoke detectors, as evidenced by two battery powered smoke detectors that failed to activate an alarm when tested and by no documentation of conducting sensitivity testing for six system base smoke detectors. This could result in the smoke detectors not functioning as designed and could result in the failure to alert staff of a fire in the facility. This affected patients and staff at two out patient clinics and the out patient surgery center.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the maintenance and testing records for the smoke detectors were requested.

Health Clinic at 7272-4 29 Palms Hwy., Suite 103, 29 Palms:
1. At 2:54 p.m., on 11/12/14, the smoke detector located in the waiting area failed to activate an audible alarm when sprayed with can smoke by engineering staff 1.

Hi Desert Family Health Clinic, 58375 29 Palms Hwy, Yucca Valley:
2. At 2:37 p.m., on 11/13/14, the smoke detector near treatment room 11, failed to activate an alarm when engineering staff 1, sprayed it with can smoke. During an interview, engineering staff 1 stated all out patient clinic smoke detectors were tested and the batteries were replaced on 9/11/14 and provided documentation.

Out Patient - Airway Surgery Center:
3. At 1:10 p.m., on 11/13/14, the facility failed to provide documentation of conducting sensitivity testing for 6 of 6 smoke detector in the surgery center.

Based on observation and interview, the facility failed to maintain electrical safety in accordance with NFPA 70, as evidenced by the unauthorized use of power strips. This could increase the risk of an electrical fire and affected 2 of 6 smoke compartments.

NFPA 70, National Electrical Code, 1999 Edition.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the Director of Facility Management and Engineering staff 1 on 11/12/14 through 11/14/14, the electrical equipment and wiring was observed.

Main Hospital:
1. On 11/12/14, at 11:20 a.m., in the Health Information Management office, the refrigerator and microwave oven were plugged into a power strip and not directly into the wall receptacle.

2. On 11/12/14, at 12:14 p.m., in the Administration office the microwave was plugged into a power strip and not directly into the wall receptacle.

3. On 11/12/14, at 1:07 p.m., there were power strips plugged into power strips under the desks in the Medical Records office.

4. On 11/12/14, at 1:27 p.m., in the Anesthesiologist sleep room, the microwave and refrigerator was plugged into a power strip and not directly into the wall receptacle. During interview, the Director of Facility Management acknowledged the unauthorized use of the power strips.

Based on observation and interview, the facility failed to ensure the Alcohol Based Hand Rub (ABHR) dispensers were not installed above or adjacent to an ignition source, as evidenced by ABHR dispensers that were installed above electrical outlets. This could increase the risk of an electrical fire and affected 1 of 6 smoke compartments in the main hospital and the outpatient surgery center.

Findings:

During the facility tour with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the Alcohol Based Hand Rub (ABHR) dispensers were observed.

Main Hospital:
1. At 11:53 a.m., the ABHR in Laboratory room 303 was installed approximately 3 feet above an electrical outlet. There was no catch plate under the dispenser and there was evidenced of spills on the wall below the dispenser.

Out Patient Airway Surgery Center:
2. At 3:04 p.m., on 11/13/14, the ABHR in operating room 1 was installed approximately 3 feet above an electrical outlet. There was not catch plate under the dispenser and there was evidenced of spills on the wall below the dispenser.

3. At 3:06 p.m., on 11/13/14, the ABHR in operating room 2 was installed approximately 3 feet above an electrical outlet. There was no catch plate under the dispenser and there was evidenced of spills on the wall below the dispenser.

Based on observation and interview, the facility failed to maintain the integrity of the fire rated construction of its smoke barrier walls. this was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the migration of smoke or fire from one smoke compartment to the next and affected 4 of 6 smoke compartments in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

Section 8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the smoke barrier walls were observed.

Main Hospital:
1. On 11/12/14, at 11:53 a.m., the smoke barrier wall near Imagining had an approximately 1 1/2 inch penetration above a conduit located in the right corner of the smoke barrier wall.

2. On 11/12/14, at 1:44 p.m., the smoke barrier wall next to Intensive Care Unit "ICU" had an approximately 2 1/2 inch penetration in the right corner of the smoke barrier wall. During interview, Engineering staff 1 acknowledged the penetrations and stated the penetrations would be sealed immediately.

Based on observation and interview, the facility failed to maintain and provide battery powered emergency lighting. This was evidenced by an emergency light that failed to illuminate when tested and by no battery back up emergency lights in 2 of 2 operating rooms at Airway Surgery Center and by no battery back up emergency lights in 2 of 2 operating rooms at the main hospital. This could result in failure to provide emergency lighting in the event of a power outage or failure of the emergency power. This affected two operating rooms in the main hospital and two operating rooms at the out patient Airway Surgery Center.

NFPA 101, Life Safety Code 2000 Edition
Section 7.9 Emergency Lighting
7.9.2 Performance of System.
7.9.2.1* Emergency illumination shall be provided for not less than 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 lux)
and, at any point, not less than 0.1 ft-candle (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 lux) and, at any point, not less than 0.06 ft-candle (0.6 lux) at the end of the 11/2 hours. A maximum-to-minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.
7.9.2.2* The emergency lighting system shall be arranged to provide the required illumination automatically in the event of any of the following:
(1) Interruption of normal lighting such as any failure of a public utility or other outside electrical power supply
(2) Opening of a circuit breaker or fuse
(3) Manual act(s), including accidental opening of a switch controlling normal lighting facilities
7.9.2.4* Battery-operated emergency lights shall use only reliable types of rechargeable batteries provided with suitable facilities for maintaining them in properly charged condition. Batteries used in such lights or units shall be approved for their intended use and shall comply with NFPA 70, National Electrical Code®.

NFPA 99, Standard for Health Care Facilities (1999) Edition
3-3.2.1.2 All Patient Care Areas.
5. Wiring in anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During the facility tour with the Director of Facility Management and Engineering Staff 1, on 11/12/14 through 11/14/14, the emergency lighting was observed.

Out Patient Airway Surgery Center:
1. At 3:09 p.m., on 11/13/14, the battery powered emergency light located in the blood draw room failed to illuminate when tested by engineering staff 1. During an interview, engineering staff 1 stated the lights are tested monthly and annually.

2. At 3:11 p.m., on 11/13/14, the facility failed to provide battery powered emergency lights in operating room 1 and in operating room 2. This was acknowledged by engineering staff 1 during the survey.

Main Hospital:
3. At 4:01 p.m., on 11/13/14, the facility failed to provide battery powered emergency lights in operating room 1 and in operating room 2. This was acknowledged by engineering staff 1 during the survey.

Based on document review and interview, the facility failed to maintain the fire alarm system as evidenced by failure to have the fire alarm system certified annually by a factory trained and certified technician. This could result in failure of the fire alarm system and affected 6 of 6 smoke compartments in the main hospital.

NFPA 101, Life Safety Code (2000) Edition
Section 9.6 Fire Detection, Alarm and Communications Systems
9.6.1.4 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 Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.
9.6.1.7* 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 Code.

NFPA 72, National Fire alarm Code 1999 Edition
Chapter 7 Inspection, Testing and Maintenance
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies
fire alarm certified
(3) International Municipal Signal Association fire alarm
certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization
listed by a national testing laboratory for the servicing
of fire alarm systems

Findings:

During document review and interview with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the fire alarm annual certification reports were requested.

At 11:26 a.m., on 11/13/14, the facility failed to provide documentation for the annual certification of the fire alarm system by a certified technician. During interview, engineering staff 1 stated the fire alarm system and all components are maintained by engineering staff and provided a report dated 9/26/14, documenting the fire alarm system was tested and inspected by engineering staff. Engineering staff 1, was ask if the staff who did the testing was factory trained and certified and engineering staff 1 stated he was not certified.

Based on document review and interview, the facility failed to maintain its smoke detectors, as evidenced by two battery powered smoke detectors that failed to activate an alarm when tested and by no documentation of conducting sensitivity testing for six system base smoke detectors. This could result in the smoke detectors not functioning as designed and could result in the failure to alert staff of a fire in the facility. This affected patients and staff at two out patient clinics and the out patient surgery center.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the
detector causes a signal at the control unit where its sensitivity
is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the
authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted
to be either adjusted within the listed and marked sensitivity range and
cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors
referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review with the Director of Facility Management and Engineering staff 1, on 11/12/14 through 11/14/14, the maintenance and testing records for the smoke detectors were requested.

Health Clinic at 7272-4 29 Palms Hwy., Suite 103, 29 Palms:
1. At 2:54 p.m., on 11/12/14, the smoke detector located in the waiting area failed to activate an audible alarm when sprayed with can smoke by engineering staff 1.

Hi Desert Family Health Clinic, 58375 29 Palms Hwy, Yucca Valley:
2. At 2:37 p.m., on 11/13/14, the smoke detector near treatment room 11, failed to activate an alarm when engineering staff 1, sprayed it with can smoke. During an interview, engineering staff 1 stated all out patient clinic smoke detectors were tested and the batteries were replaced on 9/11/14 and provided documentation.

Out Patient - Airway Surgery Center:
3. At 1:10 p.m., on 11/13/14, the facility failed to provide documentation of conducting sensitivity testing for 6 of 6 smoke detector in the surgery center.

Based on observation and interview, the facility failed to maintain electrical safety in accordance with NFPA 70, as evidenced by the unauthorized use of power strips. This could increase the risk of an electrical fire and affected 2 of 6 smoke compartments.

NFPA 70, National Electrical Code, 1999 Edition.
400-8. Uses not permitted.
Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the Director of Facility Management and Engineering staff 1 on 11/12/14 through 11/14/14, the electrical equipment and wiring was observed.

Main Hospital:
1. On 11/12/14, at 11:20 a.m., in the Health Information Management office, the refrigerator and microwave oven were plugged into a power strip and not directly into the wall receptacle.

2. On 11/12/14, at 12:14 p.m., in the Administration office the microwave was plugged into a power strip and not directly into the wall receptacle.

3. On 11/12/14, at 1:07 p.m., there were power strips plugged into power strips under the desks in the Medical Records office.

4. On 11/12/14, at 1:27 p.m., in the Anesthesiologist sleep room, the microwave and refrigerator was plugged into a power strip and not directly into the wall receptacle. During interview, the Director of Facility Management acknowledged the unauthorized use of the power strips.