HospitalInspections.org

Based on observation, the facility failed to ensure that the 2-hour fire rated wall was maintained between the medical arts and the hospital buildings. This deficiency had the potential to affect more than a very limited number of occupants in the building.

Findings include:

During observation of the 2-hour fire barrier between the medical arts and the hospital buildings at 11:33 a.m. on 7/30/13, the surveyor observed several electrical wires extending through the open end of a conduit penetrating through the 2-hour wall.

Based on observations, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction. This deficiency had the potential to affect a very limited number of patients, staff and visitors in the building.

Findings include:

1. On 7/29/13 at 1:15 p.m., water damaged fire rated ceiling tiles were observed in the basement, in the maintenance Shop.

2. On 7/29/13 at 1:53 p.m., two fire rated ceiling tiles in Central Processing were bowed with water damage.

3. On 7/30/13 at 9:09 a.m., two small fire rated ceiling tiles were stained dark brown and damaged in the janitor's closet on the business corridor.

Based on observations, the facility failed to maintain the fire resistive construction of all corridor walls to resist the passage of smoke. This deficiency had potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

1. The room called Floor Storage 30 was examined at 4:15 p.m. on 7/29/13. Two cables were extending through an unsealed penetration through the corridor wall, above the room door. One cord was blue and one was beige.

2. The phone closet on the business corridor was examined at 9:15 a.m. on 7/30/13. A tube extended through an unsealed penetration in the floor between this room and the basement.

Based on observations, the facility failed to ensure a corridor was protected from impediments that prevented the doors from closing and latching. This deficiency had the potential to affect a very limited number of patients, staff and visitors.

Findings include:

In accordance with NFPA 101 and Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.19.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

The corridor door to the radiology technician sleeping room was held open with a small couch that was placed in front of the door at 10:12 a.m. on 7/30/13. The couch impeded the door from closing easily.

Based on observations, the facility failed to ensure that the between floor construction rating in a building of Type II (111) was maintained. This deficiency had the potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

1. The room called Floor Storage 30 was examined at 4:19 p.m. on 7/29/13. A hanger was extending through an unsealed penetration through the ceiling surface in the room near the entrance, next to an uncovered junction box.

2. The laboratory was examined at 9:30 a.m. on 7/30/13. Several tubes for two instruments were extending through a PVC pipe that penetrated through the floor into the basement, near the blood bank. The penetrations were unsealed at the floor surface in the lab.

3. The radiology medical record room was examined at 10:11 a.m. on 7/30/13. An unsealed penetration was observed extending through the ceiling around a hanger above the filing cabinets numbered "20-29".

Based on observations, the facility failed to maintain the 2-hour rating of fire/smoke barriers. This deficiency could affect more than a very limited number of patients, staff and visitors in two of the six smoke compartments on the main level.

Findings include:

The 90-minute fire rated door to the nursing home dining room found in the 2-hour fire/smoke barrier was exercised at 11:45 a.m. on 7/30/13. The door was held by a magnetic hold device that was interfaced with the fire alarm control panel. The door failed to latch positively when it was released from the magnetic hold.

Based on observations, the facility failed to ensure doors protecting hazardous areas closed and latched with the efforts of the self-closing mechanism. This deficiency had the potential to affect more than a very limited number of patients, staff and visitors in one smoke compartment of the building.

Findings include:

Three exterior doors to the boiler room with self closures were observed held open with a two by four inch wood piece and cement blocks at 1:19 p.m. on 7/29/13. The doors to hazardous areas shall not be held open by any means other than an approved device arranged to release the door for automatic closing.

Based on observations, the facility failed to maintain all fire suppression systems in accordance with the standards of NFPA 72, 1999 Edition. This deficiency had potential to affect a very limited number of patients, staff and visitors in the building.

Findings include:

1. The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 Edition.

A Chemetron fire suppression control panel for the pre-action automatic sprinklers (for the MRI room) located in the Data Processing room was observed at 4:52 p.m. on 7/29/13. The disconnect means for the normal power serving this control panel was not identified at this panel.

2. On 7/29/13 at 1:15 p.m., the fire alarm pull device was observed hidden behind a stack of tool boxes in the maintenance shop.

Based on observations and staff interview, the facility failed to ensure that smoke detection devices interconnected to the fire alarm system were maintained in operational condition. This deficiency had potential to affect a very limited number of patients, staff and visitors in the building.

Findings include:

The Magnetic Resonance Imaging (MRI) equipment room was examined at 10:19 a.m. on 7/30/13. The smoke detector and the fire detector in this room, which were interconnected to the fire alarm system, were covered over by plastic and duct tape. Staff member A stated staff forgot to remove the plastic and the duct tape from the units when they completed installation of a piece of equipment in this room in the spring.

Based on observation, the facility failed to ensure all portions of the building were protected by the automatic sprinkler system. This deficient practice had the potential to affect a very limited number of patients, staff and visitors in the basement portion of the building.

Findings include:

Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors per section 5-5.5.3.1 of NFPA 13, 1999 Edition.

Mechanical Room 1 was inspected at 3:04 p.m. on 7/29/13. The space under Air Conditioning Unit (ACU) #4 lacked automatic sprinkler coverage under the 7 feet wide duct system.

Based on observations and staff interview, the facility failed to ensure that the sprinkler system and its components were maintained and capable of operating in accordance with the NFPA 13 (1999 Edition) standards. This deficiency had the potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

1. In accordance with 5-1.1(3) of NFPA 13 (1999 Edition) sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. Removal of one or more panels in a lay-in ceiling can hinder the ability of the sprinkler installed in that type of assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire or the fire alarm system to activate.

A couple of facility areas were observed to have suspended ceiling tiles out of place. Although the suspended ceiling assembly does not need to be a rated assembly, it is part of the design considerations of the sprinkler system to contain and hold the heat necessary to activate the sprinkler heads under this assembly. The areas where these conditions were noted include the following:

a.) A ceiling tile was found removed from its tracks in the kitchen staff locker room in the basement at 1:45 p.m. on 7/29/13. During the observation, one unidentified kitchen staff and staff member A could not answer how long the ceiling tile was missing from its location.

b.) A ceiling tile was found removed from its tracks in the space between the autoclave room and radiology at 10:16 a.m. on 7/30/13.

2. Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below.

Two empty cardboard boxes, on a top shelf in the janitor's closet on the business corridor, were observed within 18" of the sprinkler head and directly below the deflector at 9:09 a.m. on 7/30/13.

3. An escutcheon ring around an automatic sprinkler head was loose and not flush with the ceiling tile surface in the anesthesia store room of the Operating Room at 11:55 a.m. on 7/30/13.

Based on observation, the facility did not maintain a portable fire extinguisher component in accordance with the standards of NFPA 10, 1998 Edition. This deficiency had the potential to affect a very limited number of patients, staff and visitors.

Findings include:

In accordance with NFPA 10, section 1-6.9, fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately repaired and protected.

The fire extinguisher storage box on the business corridor was examined at 9:25 a.m. on 7/30/13. The surveyor could not open the box when applied 5 pounds or more pressure to open to box to retrieve the fire extinguisher. Staff member A assisted the surveyor and opened the box. The box cover was shifted and didn't fit in the frame of the box properly.

Based on observations, the facility failed to store oxygen in accordance with the standards of NFPA 99 (1999 Edition). This deficiency had potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99, 1999 Edition and Section 8-3.1.11.2, storage for nonflammable gases less than 3000 ft 3 (85 3); subsection (h) requires that cylinder or container restraint shall meet 4-3.5.2.1(b)27. Further, Section 4-3.5.2.1(b)27 states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

The oxygen storage area was examined at 1:30 p.m. on 7/29/13. Both size D and K size oxygen cylinders were observed to be standing upright and unsecured on the floor. Additionally, three carbon dioxide cylinders were standing upright and unsecured on the floor.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of patients, staff and visitors in the basement of the building.

Findings include:

In accordance with NFPA 70 and Article 384-13, all panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. Further in accordance with 110-22 of NFPA 70 ,1999 Edition, each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident.

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power strips is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

NFPA 70 Chapter 3 Section 305-4(h): Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protection shall be provided to avoid damage.

In accordance with Article 110-26 of NFPA 70 (1999 Edition) sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

Finally, in accordance with NFPA 70 and Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

1. Electrical panel PK I, located in the basement hallway across from the laundry services, was inspected at 1:55 p.m. on 7/29/13. Circuit breakers #12 and #38 were in on positions; however, they were not addressed on the panel directory.

2. The refrigerator observed in the clean laundry folding room was plugged into a surge protector at 2:01 p.m. on 7/29/13.

3. An electrical panel found in the dirty linen room in the main laundry services was inspected at 3:02 p.m. on 7/29/30. Circuit #10 was not addressed on the panel directory and was in an on position.

4. Two bins of liquid laundry detergents, weighing approximately 100 pounds per unit, were stored directly in front of two electrical panels in the dirty linen room in the main laundry services at 3:10 p.m. on 7/29/13.

5. A refrigerator was plugged into a surge protector in the Hospice room at 3:52 p.m. on 7/29/13.

6. The electrical junction box found in room called Floor Storage 30 had a missing cover at 4:18 p.m. on 7/29/13.

7. The electrical cord to the Defibrillator machine was pinched between two chairs in ER at 9:01 a.m. on 7/30/13.

8. A microwave was plugged into a surge protector in the Medical Records room at 9:20 a.m. on 7/30/13.

9. The laboratory was examined starting at 9:29 a.m. on 7/30/13. The following concerns were observed:

a.) A surge protector was taped on to the receptionist's desk while it was placed on top of another surge protector. Both of the units were used and 6 cords were plugged into them. Additionally, the bottom surge protector had two additional adaptors (with circuit breakers) plugged into it, creating daisy chain affect.

b.) An extension cord was found in the blood bank. The extension cord connected a florescent light fixture to a surge protector.

c.) There was a missing outlet cover near the wall where the drain tubes for two instruments penetrated the floor.

Based on observation, the facility failed to ensure that the 2-hour fire rated wall was maintained between the medical arts and the hospital buildings. This deficiency had the potential to affect more than a very limited number of occupants in the building.

Findings include:

During observation of the 2-hour fire barrier between the medical arts and the hospital buildings at 11:33 a.m. on 7/30/13, the surveyor observed several electrical wires extending through the open end of a conduit penetrating through the 2-hour wall.

Based on observations, the facility failed to maintain the fire and smoke resistance rating of wall assemblies in a building of Type II (111) construction. This deficiency had the potential to affect a very limited number of patients, staff and visitors in the building.

Findings include:

1. On 7/29/13 at 1:15 p.m., water damaged fire rated ceiling tiles were observed in the basement, in the maintenance Shop.

2. On 7/29/13 at 1:53 p.m., two fire rated ceiling tiles in Central Processing were bowed with water damage.

3. On 7/30/13 at 9:09 a.m., two small fire rated ceiling tiles were stained dark brown and damaged in the janitor's closet on the business corridor.

Based on observations, the facility failed to maintain the fire resistive construction of all corridor walls to resist the passage of smoke. This deficiency had potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

In accordance with Section 19.3.6.2.1 of NFPA 101, corridor walls shall be continuous from the floor to the underside of the floor or roof deck above, through any concealed spaces, such as those above suspended ceilings, and through interstitial structural and mechanical spaces, and they shall have a fire resistance rating of not less than 1/2 hour.

1. The room called Floor Storage 30 was examined at 4:15 p.m. on 7/29/13. Two cables were extending through an unsealed penetration through the corridor wall, above the room door. One cord was blue and one was beige.

2. The phone closet on the business corridor was examined at 9:15 a.m. on 7/30/13. A tube extended through an unsealed penetration in the floor between this room and the basement.

Based on observations, the facility failed to ensure a corridor was protected from impediments that prevented the doors from closing and latching. This deficiency had the potential to affect a very limited number of patients, staff and visitors.

Findings include:

In accordance with NFPA 101 and Section 19.3.6.3.3, hold-open devices that release when the door is pushed or pulled shall be permitted. Further, Annex A.19.3.6.3.3 states that doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

The corridor door to the radiology technician sleeping room was held open with a small couch that was placed in front of the door at 10:12 a.m. on 7/30/13. The couch impeded the door from closing easily.

Based on observations, the facility failed to ensure that the between floor construction rating in a building of Type II (111) was maintained. This deficiency had the potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

1. The room called Floor Storage 30 was examined at 4:19 p.m. on 7/29/13. A hanger was extending through an unsealed penetration through the ceiling surface in the room near the entrance, next to an uncovered junction box.

2. The laboratory was examined at 9:30 a.m. on 7/30/13. Several tubes for two instruments were extending through a PVC pipe that penetrated through the floor into the basement, near the blood bank. The penetrations were unsealed at the floor surface in the lab.

3. The radiology medical record room was examined at 10:11 a.m. on 7/30/13. An unsealed penetration was observed extending through the ceiling around a hanger above the filing cabinets numbered "20-29".

Based on observations, the facility failed to maintain the 2-hour rating of fire/smoke barriers. This deficiency could affect more than a very limited number of patients, staff and visitors in two of the six smoke compartments on the main level.

Findings include:

The 90-minute fire rated door to the nursing home dining room found in the 2-hour fire/smoke barrier was exercised at 11:45 a.m. on 7/30/13. The door was held by a magnetic hold device that was interfaced with the fire alarm control panel. The door failed to latch positively when it was released from the magnetic hold.

Based on observations, the facility failed to ensure doors protecting hazardous areas closed and latched with the efforts of the self-closing mechanism. This deficiency had the potential to affect more than a very limited number of patients, staff and visitors in one smoke compartment of the building.

Findings include:

Three exterior doors to the boiler room with self closures were observed held open with a two by four inch wood piece and cement blocks at 1:19 p.m. on 7/29/13. The doors to hazardous areas shall not be held open by any means other than an approved device arranged to release the door for automatic closing.

Based on observations, the facility failed to maintain all fire suppression systems in accordance with the standards of NFPA 72, 1999 Edition. This deficiency had potential to affect a very limited number of patients, staff and visitors in the building.

Findings include:

1. The connections to the light and power service for the Fire Alarm Control Panel (FACP) shall be on a dedicated branch circuit(s). The circuit(s) and connections shall be mechanically protected. Circuit disconnecting means shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as FIRE ALARM CIRCUIT CONTROL or equivalent lettering. The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit per section 1-5.2.5.2 of NFPA 72, 1999 Edition.

A Chemetron fire suppression control panel for the pre-action automatic sprinklers (for the MRI room) located in the Data Processing room was observed at 4:52 p.m. on 7/29/13. The disconnect means for the normal power serving this control panel was not identified at this panel.

2. On 7/29/13 at 1:15 p.m., the fire alarm pull device was observed hidden behind a stack of tool boxes in the maintenance shop.

Based on observations and staff interview, the facility failed to ensure that smoke detection devices interconnected to the fire alarm system were maintained in operational condition. This deficiency had potential to affect a very limited number of patients, staff and visitors in the building.

Findings include:

The Magnetic Resonance Imaging (MRI) equipment room was examined at 10:19 a.m. on 7/30/13. The smoke detector and the fire detector in this room, which were interconnected to the fire alarm system, were covered over by plastic and duct tape. Staff member A stated staff forgot to remove the plastic and the duct tape from the units when they completed installation of a piece of equipment in this room in the spring.

Based on observation, the facility failed to ensure all portions of the building were protected by the automatic sprinkler system. This deficient practice had the potential to affect a very limited number of patients, staff and visitors in the basement portion of the building.

Findings include:

Sprinklers shall be installed under fixed obstructions over 4 feet wide such as ducts, decks, open grate flooring cutting tables, and overhead doors per section 5-5.5.3.1 of NFPA 13, 1999 Edition.

Mechanical Room 1 was inspected at 3:04 p.m. on 7/29/13. The space under Air Conditioning Unit (ACU) #4 lacked automatic sprinkler coverage under the 7 feet wide duct system.

Based on observations and staff interview, the facility failed to ensure that the sprinkler system and its components were maintained and capable of operating in accordance with the NFPA 13 (1999 Edition) standards. This deficiency had the potential to affect more than a very limited number of patients, staff and visitors in the building.

Findings include:

1. In accordance with 5-1.1(3) of NFPA 13 (1999 Edition) sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. Removal of one or more panels in a lay-in ceiling can hinder the ability of the sprinkler installed in that type of assembly to activate by allowing heat and smoke to enter into interstitial spaces and collect there, delaying the activation of the sprinkler to control the fire or the fire alarm system to activate.

A couple of facility areas were observed to have suspended ceiling tiles out of place. Although the suspended ceiling assembly does not need to be a rated assembly, it is part of the design considerations of the sprinkler system to contain and hold the heat necessary to activate the sprinkler heads under this assembly. The areas where these conditions were noted include the following:

a.) A ceiling tile was found removed from its tracks in the kitchen staff locker room in the basement at 1:45 p.m. on 7/29/13. During the observation, one unidentified kitchen staff and staff member A could not answer how long the ceiling tile was missing from its location.

b.) A ceiling tile was found removed from its tracks in the space between the autoclave room and radiology at 10:16 a.m. on 7/30/13.

2. Unacceptable obstructions to spray patterns shall be corrected per section 2-2.1.2 of NFPA 25. Obstructions to spray patterns include horizontal obstructions near the ceiling, vertical obstructions, suspended or floor-mounted obstructions, and clearances between sprinklers and storage below.

Two empty cardboard boxes, on a top shelf in the janitor's closet on the business corridor, were observed within 18" of the sprinkler head and directly below the deflector at 9:09 a.m. on 7/30/13.

3. An escutcheon ring around an automatic sprinkler head was loose and not flush with the ceiling tile surface in the anesthesia store room of the Operating Room at 11:55 a.m. on 7/30/13.

Based on observation, the facility did not maintain a portable fire extinguisher component in accordance with the standards of NFPA 10, 1998 Edition. This deficiency had the potential to affect a very limited number of patients, staff and visitors.

Findings include:

In accordance with NFPA 10, section 1-6.9, fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately repaired and protected.

The fire extinguisher storage box on the business corridor was examined at 9:25 a.m. on 7/30/13. The surveyor could not open the box when applied 5 pounds or more pressure to open to box to retrieve the fire extinguisher. Staff member A assisted the surveyor and opened the box. The box cover was shifted and didn't fit in the frame of the box properly.

Based on observations, the facility failed to store oxygen in accordance with the standards of NFPA 99 (1999 Edition). This deficiency had potential to affect more than a very limited number of patients, staff, and visitors.

Findings include:

In accordance with NFPA 99, 1999 Edition and Section 8-3.1.11.2, storage for nonflammable gases less than 3000 ft 3 (85 3); subsection (h) requires that cylinder or container restraint shall meet 4-3.5.2.1(b)27. Further, Section 4-3.5.2.1(b)27 states that freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

The oxygen storage area was examined at 1:30 p.m. on 7/29/13. Both size D and K size oxygen cylinders were observed to be standing upright and unsecured on the floor. Additionally, three carbon dioxide cylinders were standing upright and unsecured on the floor.

Based on observations, the facility failed to maintain the electrical system and/or its components in accordance with the standards of the National Electrical Code, NFPA 70, 1999 Edition or interpretations from the Centers for Medicare and Medicaid Services (CMS). These deficiencies have the potential to affect more than a limited number of patients, staff and visitors in the basement of the building.

Findings include:

In accordance with NFPA 70 and Article 384-13, all panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors. Further in accordance with 110-22 of NFPA 70 ,1999 Edition, each disconnecting means and each service at the point where it originates shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident.

In accordance with 240-4 of the NFPA 70 (1999 Edition), 7-5.1.2.6 and 7-6.2.1.5 of NFPA 99 (1999 Edition) and previous interpretations from CMS (transmittal notice dated 3-30-99) extension cords or multiple adaptors used in health care shall be protected against over-current conditions by means acceptable to the National Electrical Code or the Authority Having Jurisdiction (CMS), one means of which is by providing surge strips or multiple adaptors that have built-in circuit breakers with either 15 or 20 ampere ratings. The limited use of circuit breaker protected power strips is acceptable, provided that no major appliances such as air conditioners, refrigerators, microwaves, heating units and oxygen concentrators are connected to a power strip. These items must be directly connected to an appropriate receptacle.

NFPA 70 Chapter 3 Section 305-4(h): Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protection shall be provided to avoid damage.

In accordance with Article 110-26 of NFPA 70 (1999 Edition) sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches, whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels. The work space shall be clear and extend from the grade, floor, or platform to the height required by Section 110-26. Working space required by this Article shall not be used for storage.

Finally, in accordance with NFPA 70 and Article 370-25, in completed installations, each box shall have a cover, faceplate, or fixture canopy.

1. Electrical panel PK I, located in the basement hallway across from the laundry services, was inspected at 1:55 p.m. on 7/29/13. Circuit breakers #12 and #38 were in on positions; however, they were not addressed on the panel directory.

2. The refrigerator observed in the clean laundry folding room was plugged into a surge protector at 2:01 p.m. on 7/29/13.

3. An electrical panel found in the dirty linen room in the main laundry services was inspected at 3:02 p.m. on 7/29/30. Circuit #10 was not addressed on the panel directory and was in an on position.

4. Two bins of liquid laundry detergents, weighing approximately 100 pounds per unit, were stored directly in front of two electrical panels in the dirty linen room in the main laundry services at 3:10 p.m. on 7/29/13.

5. A refrigerator was plugged into a surge protector in the Hospice room at 3:52 p.m. on 7/29/13.

6. The electrical junction box found in room called Floor Storage 30 had a missing cover at 4:18 p.m. on 7/29/13.

7. The electrical cord to the Defibrillator machine was pinched between two chairs in ER at 9:01 a.m. on 7/30/13.

8. A microwave was plugged into a surge protector in the Medical Records room at 9:20 a.m. on 7/30/13.

9. The laboratory was examined starting at 9:29 a.m. on 7/30/13. The following concerns were observed:

a.) A surge protector was taped on to the receptionist's desk while it was placed on top of another surge protector. Both of the units were used and 6 cords were plugged into them. Additionally, the bottom surge protector had two additional adaptors (with circuit breakers) plugged into it, creating daisy chain affect.

b.) An extension cord was found in the blood bank. The extension cord connected a florescent light fixture to a surge protector.

c.) There was a missing outlet cover near the wall where the drain tubes for two instruments penetrated the floor.