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Based on observation and interview, the facility failed to maintain a two hour fire barrier between the building and nonconforming buildings with which it shares the barrier. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 5:25 PM observation above the drop down ceiling of the two hour fire barrier between the facility and an extended care facility, as seen from the pulmonary rehabilitation room, revealed a one inch annular space over a heating, ventilation and cooling duct.

On 06/11/15 at 5:25 PM in an interview, Staff R confirmed the observation.

2. On 06/11/15 at 5:30 PM observation of the double doors between the facility and the extended care facility revealed, when tested, the double doors did not close and latch.

On 06/11/15 at 5:30 PM in an interview, Staff Q confirmed the observation.

3. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:45 PM observation of the fire doors, separating new from existing construction, at m18, sk-6, revealed, when tested, they did not close and latch.

On 06/12/15 at 2:45 PM in an interview, Staff Q confirmed the observation.

4. On 06/12/15 at 2:56 PM observation above the drop down ceiling of the two hour rated fire barrier that separates new from existing construction, at L18, sk-6, revealed two copper lines with an annular space surrounding both and a conduit leading from the barrier to a junction with two missing knock-out.

On 06/12/15 at 2:56 PM in an interview, Staff R confirmed the observations.

5. On 06/12/15 at 3:00 PM observation above the drop down ceiling of the two hour rated fire barrier that separates new from existing construction at L18, sk-6, revealed a one inch conduit traveling from the barrier to an open junction box.

On 06/12/15 at 3:00 PM in an interview, Staff R confirmed the observation.

Based on record review and observation, the facility failed to provide construction of a type to accommodate not more than one story in a fully sprinklered building. Census at the time of survey was 6,879 cases performed in the last year.

Findings include

On 06/16/15 a review of the building ' s occupancy permit, dated 09/30/97, revealed it had a construction type of II(000).

Observation of the building on 06/10/15 revealed it had two stories with a radiology department and physician office spaces.

Based on observation and interview, the facility failed to ensure its corridor doors with gaps had astragals, rabbets or bevels covering the gaps and failed to ensure all latching hardware on corridor doors functioned. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. On 06/08/15 at 3:20 PM corridor doors to patient rooms 1006, 1008, 1003, and 1005 were observed to consist of two leafs. Observation of these doors at each of these rooms revealed there was a gap between the leaves of greater than 1/8 of an inch without an astragal, rabbet, or bevel protecting the opening.

On 06/08/15 at 2:41 PM in an interview Staff R and S confirmed the observation.

2. On 06/09/15 at 9:20 AM the tour of the 10th floor of the Renaissance building resumed with Staff Q, R, and S. On 06/09/15 at 9:30 AM observation of corridor doors to patient room 1015 revealed they consisted of two leafs. Observation of these doors revealed there was a gap between the leaves of greater than 1/8 of an inch without an astragal, rabbet, or bevel protecting the opening.

On 06/09/15 at 9:30 AM in an interview, Staff Q and R confirmed the observation.

3. On 06/09/15 at 9:30 AM observation of corridor doors to patient rooms 1013 and 1014 revealed they consisted of two leafs with latching hardware that, when tested, did not positively latch.

On 06/09/15 at 9:30 AM in an interview, Staff Q and R confirmed the observation.

4. On 06/09/15 at 9:41 AM observation of the corridor to the housekeeping closet by stair 01 revealed it did not close and positively latch.

On 06/09/15 at 9:41 AM in an interview, Staff Q and R confirmed the observation.

5. On 06/09/15 at 10:10 AM observation of the corridor door on the soiled utility room (two doors down from the aforementioned housekeeping closet) revealed it did not close and latch.

On 06/09/15 at 10:10 AM in an interview, Staff Q and R confirmed the observation.

6. On 06/09/15 at 10:41 AM observation of the corridor door to soiled utility room 1090 on the east side of Renaissance revealed the door did not close and latch when tested.

On 06/09/15 at 10:41 AM in an interview, Staff Q and R confirmed the observation.

7. On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:45 PM observation of the door to a clean utility room protecting the corridor at m22 revealed its latching hardware did not close and latch the door.

On 06/15/15 at 1:45 PM in an interview, Staff S confirmed the observation.

8. On 06/15/15 at 3:43 PM a tour was taken of the third floor with Staff Q, R, and S. At 4:05 PM observation of the doors to patient rooms 1321, 1329, and 1335, revealed they each had gaps of greater than one quarter of an inch.

On 06/15/15 at 4:05 PM in an interview, Staff S confirmed the observation.

9. On 06/15/15 at 4:41 PM a tour was taken of the second floor with Staff Q, R, and S. At 4:53 PM observation of corridor doors to patient room 1222 revealed they had latching hardware, which, when tested, did not completely close the doors.

On 06/15/15 at 4:53 PM in an interview, Staff R confirmed the observation.

10. On 06/15/15 at 5:01 PM observation of the corridor door to patient room 1207 revealed it was on a self closer that was held open with a wedge.

On 06/15/15 at 5:01 PM Staff W stated he/she places the wedge there to keep the door constantly open so that he/she can see her/his patient.

Based on observation and interview, the facility failed to maintain a two hour fire rating on all shafts and chutes. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/09/15 at 9:20 AM a tour of the 10th floor of the Renaissance building was taken with Staff Q, R, and S. On 06/09/15 at 10:33 AM observation of the two hour protective construction around shaft 04 as seen from the northern hall, revealed a one foot by one foot square cut into the drywall, approximately one foot away where the words " 2HR RATING " are stenciled onto the wall.

On 06/09/15 at 10:33 AM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure access to exits is marked by approved, readily visible signs. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:30 AM observation of the southerly path of egress from the psychiatric unit to stair A revealed a set of double doors used for traffic control visually blocking the exit sign leading to stair A.

On 06/10/15 at 9:30 AM in an interview, Staff Q confirmed the observation.

On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 1:54 PM observation of exit stairwell D as seen from the public corridor revealed it did not have an exit sign.

On 06/12/15 at 1:54 PM in an interview, Staff Q confirmed the observation.

On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 9:45 AM a second path of egress from the endoscopy suites either out of the northwest doors or the northern doors were not marked.

On 06/15/15 at 9:45 AM in an interview, Staff Q confirmed the observation.

Based on observation and staff interview it was determined that the facility failed to have a smoke barrier to form at least two smoke compartments on each floor used by inpatients for sleeping or treatment. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

During the tour, on 06/10/15 form 11:50 Am till 3:10 PM, of the facility, review of the life safety floor plans, and staff interview it was determined that the facility did not have the required smoke barrier to divide the floor into two smoke compartments. This was confirmed by Staff DD at the time of discovery.

Based on observation and interview, the facility failed to ensure the rating of its smoke barriers. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. Observation above the drop down ceiling over smoke barrier doors H building, Floor 10 East revealed two half-inch corrugated conduits open to air, and a cable tray with openings between it and the barrier.

On 06/08/15 at 2:41 PM in an interview, Staff R confirmed the finding.

On 06/09/15 at 9:20 AM the tour of the 10th floor of the Renaissance building resumed with Staff Q, R, and S.

2. On 06/09/15 at 9:25 AM observation above the drop down ceiling over smoke doors H building, Floor 10 West revealed a cable tray in the smoke barrier with gaps between it and the barrier.

On 06/09/15 at 9:25 AM in an interview, Staff R confirmed the finding.

3. On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:54 PM observation of the two hour rated barrier in the clean supply room across from patient room 1512 revealed at the corner where an automated medication dispenser is located a one inch open corrugated conduit traveling from the barrier and having red wires traveling out of it.

On 06/15/15 at2:54 PM in an interview, Staff R confirmed the observation.

4. On 06/15/15 at 3:15 PM observation above the drop down ceiling of the one hour rated barrier over the door to the soiled utility room across from patient room 1524 revealed three open one inch conduits.

On 06/15/15 at 3:15 PM in an interview, Staff R confirmed the observation.

5. On 06/15/15 at 3:18 PM observation above the drop down ceiling of the smoke barrier over the doors labeled H building, floor five east, revealed three open one inch conduits holding grey wiring.

On 06/15/15 at 3:18 PM in an interview, Staff R confirmed the observation.

6. On 06/15/15 at 3:22 PM observation above the drop down ceiling of the smoke barrier perpendicular to the doors labeled H building, floor five east revealed two open one inch conduits traveling from it, with one holding grey wires and the other holding a blue and grey wire.

On 06/15/15 at 3:22 PM in an interview, Staff R confirmed the observation.

7. On 06/15/15 at 3:25 PM observation above the drop down ceiling of the smoke barrier outside the consult room near doors labeled floor 5 east, revealed four open conduits with the annular space surrounding them taking the form of a rectangle.

On 06/15/15 at 3:25 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to ensure all doors in its smoke barriers completely closed and shut and that gaps were covered by rabbets, bevels, or astragals. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/08/15 at 2:41 PM a tour was conducted of the tenth floor of the Renaissance building with Staff Q, R, and S. On 06/08/15 at 3:54 PM observation of smoke barrier doors H, Floor 10 East revealed they did not have rabbets, bevels, or astragals at their meeting edges, which had a gap of one quarter of an inch.

On 06/08/15 at 3:54 PM in an interview, Staff Q and R confirmed the observation.

2. On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:52 PM observation of smoke doors, H building, Floor 7 east, revealed, when tested, the doors did not close and shut.

On 06/15/15 at 1:52 PM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure each hazardous area had a self closing door. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:51 PM observation of a pharmacist ' s office revealed it was packed with combustible items, specifically, texts and multiple boxes of paper such that the only avenue of travel was an alley from the door to the chair at the desk. Representing a hazard greater than that found in patient rooms, this room did not have a door with a self closer.

On 06/15/15 at 2:51 PM in an interview, Staff Q, R, and S confirmed the observation.

2. On 06/15/15 at 3:36 PM observation of the doors to a file room containing combustibles greater than that found in patient rooms revealed the door was not on a self closer.

On 06/15/15 at 3:36 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to maintain the rating of its barriers protecting stairways and other exit components. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 2:01 PM observation above the drop down ceiling of the two hour barrier protecting stair 3 revealed a one inch penetration with a red wire traveling out of it.

On 06/15/15 at 2:01 PM in an interview, Staff R confirmed the observation.

2. On 06/15/15 at 2:33 PM a tour was taken of the fifth floor with Staff Q, R, and S. At 2:33 PM observation above the drop down ceiling of the two hour rating protecting stair 2 revealed three conduits open to air with grey wires traveling through them. The conduit was observed to come from the barrier.

On 06/15/15 at 2:33 PM in an interview, Staff R confirmed the observation.

Based on observation and interview, the facility failed to comply with Chapter 7 of National Fire Protection Association 101, 2000 edition, and 7.2.1.6, special locking arrangements for locked doors in the psychiatric unit. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/10/15 at 8:40 AM a tour was taken of the eighth floor of the Legacy building with Staff Q, R, S and T. On 06/10/15 at 9:30 AM double doors leading to the psychiatric unit were observed to be locked on the egress side.

On 06/10/15 at 9:30 AM Staff Q explained the doors would automatically unlock when the fire alarm system becomes activated.

On 06/10/15 at 9:30 AM and again at 11:45 AM the fire alarm system was activated and at each time the doors were not observed to unlock from the egress side.
On 06/10/15 at 9:30 AM and again at 11:45 AM Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure emergency lighting was provided in accordance with National Fire Protection Association 101, 7.9. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. Observation of operating rooms 38, 39, and 40 revealed they did have battery powered emergency lighting. Observation of the battery powered emergency lighting in operating room 39 revealed they did not work.

On 06/12/15 at 3:40 PM in an interview, Staff Q confirmed the observation saying the battery operated lights had not been tested monthly or yearly.

Based on observation and staff interview it was determined that the facility failed to provide adequate Exit lights to show the path of egress. This had a potential to affect all staff and patients within the building.

Finding:

During the tour of the facility on 06/11/15 it was found that the facility failed to provided the required exit signs to provide direction of the path of egress from the first floor physical therapy rehab room 101. The tour revealed that when standing in the short corridor to the treatments rooms you could not see an Exit signs to either of the two exits. This was confirmed at the time of discovery by Staff CC.

During the tour of the Athletic club dressing rooms it was determined that there were only two exit lights and they were not visible from the locker room or shower stalls. Further, it was found that at the bottom of the stairs leading from the track there was no sign providing direction to the exits. Also, from the track lanes the signs of the exits could not be visualized from the corners of the track. This was confirmed at the time of discovery by Staff CC.

Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process. Based on document review and staff interview it was determined that the facility failed to include the physicians in the fire drill process.

Findings include:

On 06/16/15 a review of the facility ' s fire drill documentation was completed. A review of the drills revealed not one physician participated in the drills.

On 06/16/15 at 4:00 PM in an interview, Staff Q confirmed that of 850 physicians on staff, there wasn ' t evidence any had participated in any fire drills.

Based on record review and interview, the facility failed to ensure its fire alarm system was maintained in accordance with National Fire Protection Association 72. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.


Findings include:

On 06/16/15 a review of the facility ' s fire alarm documentation was completed. The review revealed the system was tested on 10/31/14 and the test showed a battery in the basement failed. The review did not reveal where the battery was changed or otherwise rectified.

On 06/16/15 at 4:00 PM in an interview, Staff X confirmed he/she could not show where the battery had been replaced.

Based on observation and interview, the facility failed to ensure its sprinklers were tested in accordance with National Fire Protection Association 25, 9-3.4.2, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/16/15 a review of the building fire sprinkler system documentation was completed on 06/16/15. The review did not reveal where an annual main drain test at the riser was conducted.

On 06/16/15 at 4:00 PM in an interview, Staff X confirmed the main drain test had not been performed annually.

Based on observation and interview, the facility failed to ensure space heating devices were used appropriately. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/11/15 at 8:30 AM a tour was taken of the sixth floor going from north to south with Staff Q, R, S and T. At 10:41 AM a space heater was observed in a pharmacist office less than three feet from a chair and a rubbish container. Review of the tag on the heater revealed no combustibles or other furnishings were to be kept within three feet of the space heater.

On 06/11/15 at 8:30 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 11:17 AM a tour was conducted of the fifth floor going from north to south, with Staff Q, R, S, and T. At 1:35 PM two sets of oxygen shut off valves were found for pediatric intensive care unit (the north wing) rooms 1-15: one set found in the resource room, and another found in the corridor just outside the pediatric intensive care unit.

On 06/11/15 at 1:35 PM in an interview, Staff Q could not explain which shut off valves were downstream and which were upstream.

2. On 06/11/15 at 1:35 PM the vacuum shut off valves for the west and east wings (two different units) were found behind a computer work station.

On 06/11/15 at 1:30 PM Staff U couldn ' t find any medical gas shut off valves.

3. On 06/12/15 at 9:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 9:45 AM the oxygen shut off valves were observed behind a computer workstation ' s shelving at the nursing station.

On 06/12/15 at 9:45 AM in an interview Staff V said he/she was unable to find the shut off valves for the gases.

4. On 06/12/15 at 9:45 AM in an interview, neither Staff Q, R, nor S could say where the shut off valve for the vacuum system was.

On 06/12/15 at 10:02 AM in an interview, Staff R stated there were multiple vacuum shut off valves located up in the ceiling.

5. On 06/15/15 at 9:00 AM the tour of the second floor resumed with Staff Q, R, and S. At 10:30 AM the medical gas shut off valves for the post anesthesia care unit was located behind two computer carts. They were located across from the patient rooms that had the gas outlets the valves shut off, without any intervening wall in-between.

On 06/15/15 at 10:30 AM in an interview, Staff Q confirmed the observation.

6. On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:15 AM observation of the medical gas shut off valves for the interventional vascular unit revealed the shut off valves for rooms one through 34 were located across from rooms 30, 31, 32, 33, 34, and 8, without any intervening wall between them.

On 06/15/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to comply with National Fire Protection Association 99, 1999 edition, at 4-3.1.2.3(d), for not having an intervening wall between a zone shut off valve and the outlets it serves and for not having zone shut off valves readily accessible at 4-3.2.2.6. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 1:36 PM a tour was taken of the seventh floor with Staff Q, R, and S. At 1:56 PM observation within the supervisors office located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 1:56 PM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 2:00 PM observation of the conference room located within a patient care area revealed three power strips daisy chained together.

On 06/15/15 at 2:00 PM in an interview, Staff Q confirmed the observation.

3.On 06/15/15 at 2:20 PM observation west conference room revealed two power strips daisy chained together.

On 06/15/15 at 2:20 PM in an interview, Staff Q confirmed the observation.

Based on observation and staff interview it was determined that the facility failed to maintain the smoke barriers from penetrations in accordance to NFPA 101 2000 edition 8.3.5. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 6,879 cases performed in the last year.

Findings:

During the tour of the facility above the ceiling in the medical records office in the far left corner it was found that there were two openings in conduit and additionally in the corridor adjacent to the cyto room was found an additional open conduit. The findings were confirmed at the time of discovery by Staff DD.

Based on observation and interview, the facility failed to ensure compliance with National Fire Protection Association 99, 1999 edition, 3-3.2.1.2, by not having battery powered lighting in anesthetizing locations. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

On 06/12/15 at 3:40 PM a tour was taken of the operating room suite on the second floor with Staff Q, R, and S. Observation of the operating rooms revealed all anesthetizing locations except operating rooms 38, 39, and 40 revealed they did not have battery operated emergency lighting.

On 06/12/15 at 3:40 PM in an interview, Staff Q confirmed the observation.

Based on observation, plans review, and staff interview it was determined that the facility failed to maintain the one hour fire resistant rated wall between other tenant spaces. This had a potential to affect all staff and patients within this facility. Census at the time of survey was 12,773 cases performed in the last year.

Findings:

On 06/08/15 at 4:30 PM during the tour of the facility it was determined that the wall above the front entry area did not extend to the outer wall. The fire walls stopped just above the glassed-in enter. The area above the glassed-in door way was found to be open to the adjacent occupancy. Review of the drawings did confirm that the fire wall was to extend to the out wall. Staff AA and Staff BB confirmed the findings at the time of discovery.

On 06/08/15 at 4:50 PM in the mech/elec/telephone room it was noted that the fire wall had two ½ " conduit pipes with blue wire extending through them. The ends of the conduit were not filled with fire stop material, also it was noted that there were two white wires passing through the wall without a sleeve and failed to have fire stop around them. Further, there was a return steam pipe also passing through the wall that a gap was noted around the pipe without fire stop around the pipe. Staff AA and Staff BB confirmed the findings at the time of discovery.

19.2.7 Discharge from Exits.
Discharge from exits shall be arranged in accordance with Section 7.7.

7.7.3
The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means.

Based on observation and interview, the facility failed to ensure compliance with section 7.7 of National Fire Protection Association 101, 2000 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/15/15 at 11:00 AM a tour was taken of the first floor with Staff Q, R, and S. At 11:15 AM observation of stair 1SE revealed the stairs continued more than half a story beyond the level of exit discharge without any effective means of interruption.

On 06/15/15 at 11:15 AM in an interview, Staff Q confirmed the observation.

2. On 06/15/15 at 11:30 AM observation of stair 1SW revealed the stairs continued more than half a story beyond the level of exit discharge without any effective means of interruption.

On 06/15/15 at 11:30 AM in an interview, Staff Q confirmed the observation.

Based on observation and interview, the facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. This has the potential to affect all patients, staff, and visitors to the facility. The facility had a census of 478 patients at the time of the survey.

Findings include:

1.On 06/11/15 at 3:37 PM a tour was conducted of the fourth floor going from north to south, with Staff Q, R, S, and T. At 4:06 PM at the nursing station a daisy chain of three power strips was observed.

On 06/11/15 at 4:06 PM in an interview, Staff Q confirmed the observation.

2. On 06/12/15 at 8:45 AM a tour was conducted of the third floor with Staff Q, R, and S. At 2:00 PM observation of the informatics office at o13, sk-4, revealed three power strips were daisy chained: one with five out of 6 outlets used, and another with four of four outlets used.

On 06/12/15 at 2:00 PM in an interview, Staff Q confirmed the observation.