HospitalInspections.org

Based on observation the facility failed to maintain the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This has the potential to allow the passage of smoke and flames in the event of a fire.

Findings:

On a tour of the facility with staff, on 7/27/10 through 7/28/10, the walls and ceilings were observed. Unsealed penetrations were observed in the following areas:

July 27, 2010
1. At 9:18 a.m., there were two approximately 1/4 inch unsealed penetrations in the wall, in Housekeeping 4-88.
2. At 9:31 a.m., there was an approximately 6 inch unsealed penetration in the Pantry Room 4-100, at the bottom of the back wall.
3. At 11:05 a.m., there was an approximately 1/4 inch penetration on the back wall, in room 354-B. There were two approximately 1/4 inch penetrations on the right wall.
4. At 11:01 a.m., there were two approximately 1/4 inch penetrations on the back wall in Room 3-98 housekeeping.
5. At 11:19 a.m., there was an approximately 1 inch penetration in the tower 1 dictation room, in the north wall above the light switch.
6. At 11:26 a.m., there was an approximately 1 inch penetration in the charting station by exit R 3-68 A.

July 28, 2010
7. At 10:23 a.m., there was an approximately 3 inch penetration in the ceiling above the door, in the surgery materials management room.
8. At 2:30 p.m., there were three approximately 1/4 inch unsealed penetrations in the housekeeping closet 1-27.

Based on observation, the facility failed to maintain corridor doors to close and latch and to prevent impediments to closing the doors in the event of a fire. This could result in the spread of smoke and flames in the event of a fire. This effects 1 of 5 smoke compartments on the 5th floor, 1 of 5 smoke compartments on the 4th floor, and 1 of 5 smoke compartments on the 2nd floor. The number of patients affected on each floor is variable.

Findings:

On a tour of the facility with staff, from 7/26/10 through 7/29/10, the doors were observed.

July 27, 2010
5th floor-
1. At 9:19 a.m., the door to the Director of Telemetry's office was held open with a wedge.
4th floor-
2. 9:48 a.m., the door to Room 4124 was obstructed from closing by an L cart (supply).

July 28, 2010
3. At 8:45 a.m., the corridor door, to the first floor interventional suite 4, was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing due to air pressure.
4. At 8:46 a.m., the corridor doors to the first floor imaging department were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of two doors failed to close and latch. The door was obstructed from latching by the astragal.
5. At 8:48 a.m., the corridor door to the first floor CT scan control room was equipped with a magnetic hold open device. The door was released from it's magnetic hold open device and allowed to close. The door failed to close. The door was not equipped with a self-closing device.
6. At 8:50 a.m., the corridor door to the first floor radiologist reading room was equipped with a self-closing device and a magnetic hold open device. The door was released from its magnetic hold open device and allowed to close. The door failed to latch. The door was obstructed from latching by the smoke seal on the door frame.
7. At 8:54 a.m., the corridor door to the first floor observation room (R1-53A) was equipped with a self-closing device and a magnetic hold open device. The door was released from its magnetic hold open device and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
8. At 9:17 a.m., two of two corridor doors, to the first floor x-ray room 5, were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. Two of two door failed to latch. The doors were obstructed from latching by the door frames.
9. At 10:22 a.m., the corridor door to the basement level small laundry room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by a linen barrel that was in the swing path of the door.
10. At 1:23 p.m., in Endoscopy the door failed to latch upon closure.



27893

Based on observation, the facility failed to maintain their exits. This was evidenced by one door leading to an emergency exit that did not have any identifying signs indicating that the door was an exit. This affected one of six floors in one of three buildings and could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff on 7/28/10, the exit doors in the facility were observed.

Main Hospital:

At 9:23 a.m., the door leading from the first floor cath lab to an emergency exit ramp was observed. There was no sign on or above the door indicating that the door was an emergency exit door.

Based on observation, document review, and interview, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in nine smoke barrier walls, and by one 2 hour rated smoke compartment that was not constructed to provide the 2 hour rating. This affected five of six floors in one of three buildings, and could result in the expedited spread of smoke or fire to other smoke compartments.

NFPA 101, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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 for 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 conditions:
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 a facility tour with staff on 7/27/10, the facility's smoke barrier walls were observed.

Main Hospital:

1. At 11:01 a.m., there was an approximately one inch wide unsealed penetration in the fifth floor smoke barrier wall near Room 5113.

2. At 11:05 a.m., the fifth floor smoke barrier wall by Room 5115 was observed. There was one approximately one inch wide unsealed penetration, and one approximately one half inch wide unsealed penetration around a one inch wide metal conduit in the smoke barrier wall.

3. At 11:35 a.m., there was an approximately one half inch wide unsealed penetration surrounding four pipes running through the third floor smoke barrier wall near Room 3226.

4. At 11:48 a.m., there was an approximately one inch wide unsealed penetration in the second floor smoke barrier wall near the main entrance to surgery. A blue cable was running through the penetration.

5. At 11:53 a.m., there was an approximately one inch wide unsealed penetration in the second floor smoke barrier wall near the main entrance to the surgical intensive care unit. A blue cable was running through the penetration.

6. At 12:07 p.m., there was an approximately 24 inch by 18 inch unsealed penetration in the second floor smoke barrier wall near the entrance to medical intensive care unit II. There were seventeen approximately 1 inch wide unsealed penetrations in the smoke barrier wall.

7. At 12:08 p.m., the smoke barrier wall separating the medical intensive care unit II from the corridor was observed. According to the building plans stamped 3/6/84, the wall was designed to be a 2 hour rated smoke barrier wall. The smoke barrier wall above the ceiling was observed. There was a single sheet of sheet rock extending from the ceiling to the deck above. There was one approximately two inch by three inch unsealed penetration and one approximately one inch wide unsealed penetration in the sheet rock. Plant Operations Staff 1 was interviewed at that time. Plant Operations Staff 1 indicated that the wall at that location should have been sealed and four layers of sheet rock in place. On 7/28/10 at 11:05 a.m., that area of the facility was revisited with Architect 1. Architect 1 was interviewed at that time. Architect 1 confirmed that the medical intensive care unit II did not have a 2 hour separation. Plant Operations Staff 1 indicated that Architect 1 would draw up plans to correct the smoke barrier, and those plans would be submitted for proper approvals as soon as possible.
8. At 12:29 p.m., the smoke barrier wall in the electrical room near the first floor overflow emergency department was observed. There was one approximately two and one half inch wide unsealed penetration around a one inch wide metal conduit and one approximately one and one half inch wide unsealed penetration around a two and one half inch wide metal conduit in the smoke barrier wall.

9. At 12:39 p.m., there was an approximately one inch wide unsealed penetration in the basement level smoke barrier wall near the engineering department and dietary storage.

10. At 12:43 p.m., there was an approximately one quarter inch wide unsealed penetration surrounding a cluster of eight pipes in the basement level smoke barrier wall near the housekeeping room by the elevators.

11. At 12:48 p.m., the smoke barrier wall near the south entrance to the kitchen was observed. There was an approximately twelve inch by twelve inch unsealed penetration, four approximately five inch by three inch unsealed penetrations, and an approximately two and one half inch wide unsealed penetration with a blue cable running through it, in the smoke barrier wall.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by two smoke barrier doors that were obstructed from latching or closing. This affected two locations in two of three buildings, and could result in the inability to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 7/7/27/10 to 7/28/10, the facility's smoke barrier doors were observed.

Main Hospital:

1. On 7/28/10 at 8:41 a.m., the smoke barrier doors by the first floor nuclear medicine department were equipped with self-closing devices and magnetic hold open devices. The doors were released from their magnetic hold open devices and allowed to close. One of two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

Cardiac Rehabilitation Wellness Center:

1. On 7/27/10 at 3:19 p.m., the smoke barrier door leading from the classroom to the corridor was observed. The door was held open to the fullest extent and allowed to close. The door remained fully open. The door was not equipped with a self-closing or automatic closing device.

Based on observation, the facility failed to maintain the doors to a hazardous area to shut and latch upon closure. This could result in the spread of smoke and flames in the event of a fire. This effected one of five smoke compartments on the 3rd floor.

Findings:

On July 27, 2010 during a tour of the facility with staff, the remodel area on the 3rd floor of Tower 1 Burn Unit was observed. At 11:29 a.m., the north door failed to self-close and latch.

Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by one fire alarm strobe that failed to flash when the fire alarm system was activated. This affected one of three buildings, and could result in a delayed notification of a fire in the event of a fire emergency.

Findings:

During a facility tour with staff on 7/28/10, the fire alarm system components were observed.

Cardiac Rehabilitation Wellness Center:

At 7:53 a.m., the fire alarm strobe in the corridor outside the classroom was observed. The fire alarm strobe failed to flash when the fire alarm system was activated.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25 and NFPA 13. This was evidenced by three sprinkler heads that were missing escutcheon rings, and by one sprinkler head that did not have eighteen inches of clearance around its deflector plate. This affected one of six floors in one of three buildings, and could result in a delayed response of the automatic sprinkler system.

NFPA 25, 1998 edition
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

NFPA 13, 1999 edition
5-5.6* The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During a facility tour with staff on 7/28/10, the sprinklers in the facility were observed.

Main Hospital:

1. At 8:58 a.m., two of five sprinklers in the first floor lab office space were missing escutcheon rings.

2. At 9:25 a.m., the sprinkler head in the first floor cath lab break room was missing an escutcheon ring.

3. At 9:27 a.m., the sprinkler head in the first floor cath lab storage closet did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by boxes stored approximately two inches directly below the sprinkler head.

Based on observation, the facility failed to maintain the fire extinguishers in accordance with NFPA 10, Standard for Fire Extinguishers, 1998 edition. This was evidenced by fire extinguishers that were obstructed. This effected one of five smoke compartments on the second floor, and may delay access to the fire extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers (1998 edition)

4-3.2 * Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose and nozzle checked (for wheeled units)
( i) HMIS label is in place

Findings:
On July 27, 2010 during a tour of the facility with staff the fire extinguishers were observed.

The fire extinguisher in Surgical ICU had access to and visibility obstructed by a temperature machine placed in front of the fire extinguisher.

Based on observation and interview, the facility failed to maintain the kitchen hood exhaust system, and the grill hood exhaust system, in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. This was evidenced by kitchen equipment with an accumulation of grease, and affected two of five smoke compartments.

NFPA 96
11.2.4 Fusible links (including fusible links on fire damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary where required by the manufacturer.

11.4 Cleaning of Exhaust Systems

11.4.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 11.3.
11.4.2 Hoods, grease removal devices, fans ducts and other appurtenances shall be cleaned to bare metal prior to surfaces becoming heavily contaminated with grease or oily sludge.
11.4.8 After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance.
11.4.13 After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company and areas not cleaned.

NFPA 96
11.3 Inspection of Exhaust System. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 11.3.
Table 11.3 Exhaust System Inspection Schedule

Type of Volume of Cooking Frequency Frequency

Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations such as Quarterly
24 hour-cooking, charbroiling, or wok cooking

Systems serving moderate-volume cooking operations Semiannually

Systems serving low-volume cooking operations, such as Annually
churches, day camps, seasonal businesses, or senior centers

Findings:
On July 28, 2010 during a tour of the kitchen and grill area with staff the exhaust hoods and filters were observed.

1. At 9.21 a.m. during a tour of the kitchen the kitchen hood was observed. The filters had grease on them. During an interview with staff 4 at 9:21 a.m., staff stated that the filters are cleaned on a weekly basis, but it had been 2 weeks ago this past Sunday ( July 11, 2010) that they were last cleaned.

2. At 9:30 a.m. the grill area in the cafeteria was observed. The filters were heavily soiled with grease, and the hood exhaust had a large amount of grease accumulated on it, and the fusible link was covered with grease. The exhaust was last steamed cleaned in May, 2010.

Based on observation, the facility failed to prevent the use of portable space heating devices within patient care areas. This was evidenced by the use of a portable space heating device in one location. This affected one of five smoke compartments on one floor, and could result in an increased risk of fire.

Findings:

On July 27, 2010 during a tour of the facility with staff at 9:13 a.m., there was a portable space floor heater in the Director of Step Down Unit Office, located on the 5th floor. The office is located on the unit, in the area of patient rooms.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This was evidenced by chairs being placed in the hallways, and by gurneys obstructing the means of egress. This effected two of five smoke compartments on the 2nd floor, and one of five smoke compartments on the 1st floor. This could result in a delay in egress from the area in the event of fire or other emergency.

Findings:
On a tour of the facility on July 26, 2010 through July 29, 2010 with staff the means of egress were observed.
1. On July 27, 2010 at 1:38 p.m., there were eight chairs for use by visitors, in the corridor outside the Surgery/ICU waiting area
2. On July 27, 2010 at 1:49 p.m., at the back entrance corridor to surgery, there was a Laserscope and two black trunks on the left side of the hallway, and on the right side there was a two-tier stainless steel cart on wheels.
3. On July 28, 2010, at 3:09 p.m., during a tour of the emergency room there were fourteen gurneys and four chairs in the path of egress. In some areas the means of egress was reduced to approximately three feet or less. At 3:10 p.m., during an interview with staff 1 and 2, both staff acknowledged the gurneys in the corridor, but stated they had no other options at this time. During an interview at 3:09 p.m., with staff 6, staff acknowledged that the gurneys were in the path of egress, but that all the hospitals in Bakersfield were like this. Staff stated that the emergency room was closed today, July 28, 2010, at approximately 12:00 p.m. for 1 to 1 1/2 hours, due to the amount of people. Staff 6 stated that although the emergency room is closed they still accept walk in patients. At 3:22 p.m., staff 6 quoted the census in the emergency room at that time was 33 patients. When asked what the policy is for closing the emergency room, staff stated that they have to call EMS (Emergency Medical Services) to get approved for closure. Staff stated that there is a policy for the emergency room. This policy was requested.
At 3:27 p.m. during an interview with staff 7, when asked how they would evacuate in the event of a fire, staff stated they would move the patients into the rooms.
At 3:33 p.m., the fourteen gurneys and four chairs remained in the path of egress in the emergency room.
At 3:58 p.m., during document review of a fire drill conducted in the emergency room on February 3, 2010, it was noted that the new staff had no knowledge of what to do. No documentation was provided showing another drill was done.
At 4:05 p.m., the policy "Analysis & Management of Patient Flow" was reviewed. The policy indicates that patients will not be housed in fire egress corridors except as a temporary measure, and that they will be immediately (within 30 minutes) moved into an interior corridor or bed. The policy also stated each patient in the corridor location will have their specific location clearly delineated (e.g. "Corridor Bed 1", Corridor Bed 2" , etc).

The fourteen gurneys and four chairs were observed in the corridor from 3:09 p.m., to 3:33 p.m.

Based on observation, the facility failed to maintain their storage of oxygen gas. This was evidenced by two locations housing oxygen cylinders that did not have signs indicating oxygen was being stored in those rooms. This affected two locations in two of three buildings, and could result in confusion for emergency forces on the oxygen storage locations.

NFPA 99, 1999 edition
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a facility tour with staff on 7/27/10 to 7/28/10, the facility's oxygen storage locations were observed.

Main Hospital:

On 7/28/10 at 2:33 p.m., there were four oxygen E cylinders stored in the second floor equipment storage room near operating Room 6. There was no sign on the door to the room indicating oxygen was being stored at that location.

Cardiac Rehabilitation Wellness Center:

On 7/27/10 at 3:22 p.m., there were two oxygen E cylinders stored in the physical therapy storage room. There was no sign on the door to the room indicating oxygen was being stored at that location.

Based on observation and interview the facility failed to maintain the medical gas system in accordance with NFPA 99, Health Care Facilities, 1999 edition. This was evidenced by area alarm panel that failed to have operating LED light. This effected one of five smoke smoke compartments, and could result in the oxygen being out of range, and the ICU (Intensive Care Unit) not being aware of the range.

Findings:
On a tour of the facility July 26, 2010 through July 29, 2010 with staff the area alarm panels for the Medical Gases were observed.

1. On July 27, 2010 at 1:36 p.m., the Area Alarm Panel outside MICU (Medical Intensive Care Unit) 2 was observed to have the green light not working.
2. On July 28, 2010 at 2:29 p.m., the Area Alarm Panel outside MICU 2 was again observed and had cardboard placed over the top portion of the panel, and only the vacuum and air gauges were visible.
At 2:39 p.m., during an interview with staff 2, staff stated that when they replaced the light it burnt the transformer out. Per staff 2 they have ordered a new transformer.

Based on observation, the the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code, 1999 edition. This was evidenced by equipment stored in front of electrical panels, appliances plugged into surge protectors, and by missing electrical face plates. This could result in an increased risk of fire, and affected four of five floors in the main building, and two off-site buildings.

NFPA 70, National Electrical Code,
110-26. Spaces about Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) #2 Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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 the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
NFPA 70, 1999 edition
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:
On a tour of the facility with staff on July 26, 2010 through July 29, 2010, the electrical wiring and equipment was observed.
1. At 9:09 a.m., there was a trash can placed in front of the electrical panel, on the nurse staff lounge on the 5th floor.
2. At 9:11 a.m., there was a refrigerator plugged into a surge protector, in the respirator office on the 5th floor.
3. At 9:21 a.m., there was a refrigerator plugged into a surge protector, in the staff lounge on the 4th floor, in Tower 2.
4. At 9:34 a.m., there was an isolation cart placed in front of electrical panel E 4 A, on the 4th floor.
5. At 9:42 a.m., there was a refrigerator plugged into surge protector, in the Kaiser office on the 4th floor.
6. At 9:45 a.m., there was a medication refrigerator, a warmer, and an L cart placed in front of electrical panel 4 B, in the room R4-76, Central Supply in Tower 1.
7. At 11:06 a.m., there was an electrical outlet face plate missing in the Photo Room 3-80, on the 3rd floor.
8. At 11:21 a.m., there was a warmer cabinet, and a medication refrigerator placed in front of electrical panel 3 B, on the 3rd floor.
9. At 2:18 p.m., there was a computer on wheels, and a chair placed in front of electrical panel LIA, in the 1st floor emergency admitting.

Burn/Bariatric Center:
At 2:50 p.m., there was computer equipment in the program nurse's office plugged into a grey non-surge protected extension cord.

Cardiac Rehabilitation Wellness Center:
1. At 3:16 p.m., there was a water cooler in the hallway near the classroom which was plugged into a grey non-surge protected multi-outlet extension cord.
2. At 3:20 p.m., there was a coffee maker in the classroom which was plugged into a black non-surge protected multi-outlet extension cord.
3. At 3:25 p.m., there was an electrical receptacle in the physical therapy room which was missing a faceplate. The electrical receptacle was located on the upper right hand corner of the wall shared with the women's locker room. Electrical wiring was exposed.



27893

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of three alcohol based hand rub dispensers over or adjacent to ignition sources. This affected three locations in two of three buildings, and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff on 7/27/10 to 7/28/10, the facility's alcohol based hand rub dispensers were observed.

Main Hospital:

On 7/28/10 at 9:29 a.m., an alcohol based hand rub dispenser in the first floor cath lab 2 was mounted approximately three inches to the left of a light switch. The hand rub was 62 percent ethyl alcohol by volume.

Burn/Bariatric Center:

1. On 7/27/10 at 2:38 p.m., an alcohol based hand rub dispenser in the department assistant's office was mounted approximately twenty-eight inches above an electrical receptacle. The hand rub was 62 percent ethyl alcohol by volume.

2. On 7/27/10 at 2:47 p.m., an alcohol based hand rub dispenser in the data center for bariatrics was mounted approximately two inches to the left of a light switch. The hand rub was 62 percent ethyl alcohol by volume.

Based on observation the facility failed to maintain the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This has the potential to allow the passage of smoke and flames in the event of a fire.

Findings:

On a tour of the facility with staff, on 7/27/10 through 7/28/10, the walls and ceilings were observed. Unsealed penetrations were observed in the following areas:

July 27, 2010
1. At 9:18 a.m., there were two approximately 1/4 inch unsealed penetrations in the wall, in Housekeeping 4-88.
2. At 9:31 a.m., there was an approximately 6 inch unsealed penetration in the Pantry Room 4-100, at the bottom of the back wall.
3. At 11:05 a.m., there was an approximately 1/4 inch penetration on the back wall, in room 354-B. There were two approximately 1/4 inch penetrations on the right wall.
4. At 11:01 a.m., there were two approximately 1/4 inch penetrations on the back wall in Room 3-98 housekeeping.
5. At 11:19 a.m., there was an approximately 1 inch penetration in the tower 1 dictation room, in the north wall above the light switch.
6. At 11:26 a.m., there was an approximately 1 inch penetration in the charting station by exit R 3-68 A.

July 28, 2010
7. At 10:23 a.m., there was an approximately 3 inch penetration in the ceiling above the door, in the surgery materials management room.
8. At 2:30 p.m., there were three approximately 1/4 inch unsealed penetrations in the housekeeping closet 1-27.

Based on observation, the facility failed to maintain corridor doors to close and latch and to prevent impediments to closing the doors in the event of a fire. This could result in the spread of smoke and flames in the event of a fire. This effects 1 of 5 smoke compartments on the 5th floor, 1 of 5 smoke compartments on the 4th floor, and 1 of 5 smoke compartments on the 2nd floor. The number of patients affected on each floor is variable.

Findings:

On a tour of the facility with staff, from 7/26/10 through 7/29/10, the doors were observed.

July 27, 2010
5th floor-
1. At 9:19 a.m., the door to the Director of Telemetry's office was held open with a wedge.
4th floor-
2. 9:48 a.m., the door to Room 4124 was obstructed from closing by an L cart (supply).

July 28, 2010
3. At 8:45 a.m., the corridor door, to the first floor interventional suite 4, was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing due to air pressure.
4. At 8:46 a.m., the corridor doors to the first floor imaging department were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of two doors failed to close and latch. The door was obstructed from latching by the astragal.
5. At 8:48 a.m., the corridor door to the first floor CT scan control room was equipped with a magnetic hold open device. The door was released from it's magnetic hold open device and allowed to close. The door failed to close. The door was not equipped with a self-closing device.
6. At 8:50 a.m., the corridor door to the first floor radiologist reading room was equipped with a self-closing device and a magnetic hold open device. The door was released from its magnetic hold open device and allowed to close. The door failed to latch. The door was obstructed from latching by the smoke seal on the door frame.
7. At 8:54 a.m., the corridor door to the first floor observation room (R1-53A) was equipped with a self-closing device and a magnetic hold open device. The door was released from its magnetic hold open device and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.
8. At 9:17 a.m., two of two corridor doors, to the first floor x-ray room 5, were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. Two of two door failed to latch. The doors were obstructed from latching by the door frames.
9. At 10:22 a.m., the corridor door to the basement level small laundry room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by a linen barrel that was in the swing path of the door.
10. At 1:23 p.m., in Endoscopy the door failed to latch upon closure.



27893

Based on observation, the facility failed to maintain their exits. This was evidenced by one door leading to an emergency exit that did not have any identifying signs indicating that the door was an exit. This affected one of six floors in one of three buildings and could result in a delayed evacuation in the event of an emergency.

Findings:

During a facility tour with staff on 7/28/10, the exit doors in the facility were observed.

Main Hospital:

At 9:23 a.m., the door leading from the first floor cath lab to an emergency exit ramp was observed. There was no sign on or above the door indicating that the door was an emergency exit door.

Based on observation, document review, and interview, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in nine smoke barrier walls, and by one 2 hour rated smoke compartment that was not constructed to provide the 2 hour rating. This affected five of six floors in one of three buildings, and could result in the expedited spread of smoke or fire to other smoke compartments.

NFPA 101, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service 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 for 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 conditions:
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 a facility tour with staff on 7/27/10, the facility's smoke barrier walls were observed.

Main Hospital:

1. At 11:01 a.m., there was an approximately one inch wide unsealed penetration in the fifth floor smoke barrier wall near Room 5113.

2. At 11:05 a.m., the fifth floor smoke barrier wall by Room 5115 was observed. There was one approximately one inch wide unsealed penetration, and one approximately one half inch wide unsealed penetration around a one inch wide metal conduit in the smoke barrier wall.

3. At 11:35 a.m., there was an approximately one half inch wide unsealed penetration surrounding four pipes running through the third floor smoke barrier wall near Room 3226.

4. At 11:48 a.m., there was an approximately one inch wide unsealed penetration in the second floor smoke barrier wall near the main entrance to surgery. A blue cable was running through the penetration.

5. At 11:53 a.m., there was an approximately one inch wide unsealed penetration in the second floor smoke barrier wall near the main entrance to the surgical intensive care unit. A blue cable was running through the penetration.

6. At 12:07 p.m., there was an approximately 24 inch by 18 inch unsealed penetration in the second floor smoke barrier wall near the entrance to medical intensive care unit II. There were seventeen approximately 1 inch wide unsealed penetrations in the smoke barrier wall.

7. At 12:08 p.m., the smoke barrier wall separating the medical intensive care unit II from the corridor was observed. According to the building plans stamped 3/6/84, the wall was designed to be a 2 hour rated smoke barrier wall. The smoke barrier wall above the ceiling was observed. There was a single sheet of sheet rock extending from the ceiling to the deck above. There was one approximately two inch by three inch unsealed penetration and one approximately one inch wide unsealed penetration in the sheet rock. Plant Operations Staff 1 was interviewed at that time. Plant Operations Staff 1 indicated that the wall at that location should have been sealed and four layers of sheet rock in place. On 7/28/10 at 11:05 a.m., that area of the facility was revisited with Architect 1. Architect 1 was interviewed at that time. Architect 1 confirmed that the medical intensive care unit II did not have a 2 hour separation. Plant Operations Staff 1 indicated that Architect 1 would draw up plans to correct the smoke barrier, and those plans would be submitted for proper approvals as soon as possible.
8. At 12:29 p.m., the smoke barrier wall in the electrical room near the first floor overflow emergency department was observed. There was one approximately two and one half inch wide unsealed penetration around a one inch wide metal conduit and one approximately one and one half inch wide unsealed penetration around a two and one half inch wide metal conduit in the smoke barrier wall.

9. At 12:39 p.m., there was an approximately one inch wide unsealed penetration in the basement level smoke barrier wall near the engineering department and dietary storage.

10. At 12:43 p.m., there was an approximately one quarter inch wide unsealed penetration surrounding a cluster of eight pipes in the basement level smoke barrier wall near the housekeeping room by the elevators.

11. At 12:48 p.m., the smoke barrier wall near the south entrance to the kitchen was observed. There was an approximately twelve inch by twelve inch unsealed penetration, four approximately five inch by three inch unsealed penetrations, and an approximately two and one half inch wide unsealed penetration with a blue cable running through it, in the smoke barrier wall.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by two smoke barrier doors that were obstructed from latching or closing. This affected two locations in two of three buildings, and could result in the inability to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 7/7/27/10 to 7/28/10, the facility's smoke barrier doors were observed.

Main Hospital:

1. On 7/28/10 at 8:41 a.m., the smoke barrier doors by the first floor nuclear medicine department were equipped with self-closing devices and magnetic hold open devices. The doors were released from their magnetic hold open devices and allowed to close. One of two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

Cardiac Rehabilitation Wellness Center:

1. On 7/27/10 at 3:19 p.m., the smoke barrier door leading from the classroom to the corridor was observed. The door was held open to the fullest extent and allowed to close. The door remained fully open. The door was not equipped with a self-closing or automatic closing device.

Based on observation, the facility failed to maintain the doors to a hazardous area to shut and latch upon closure. This could result in the spread of smoke and flames in the event of a fire. This effected one of five smoke compartments on the 3rd floor.

Findings:

On July 27, 2010 during a tour of the facility with staff, the remodel area on the 3rd floor of Tower 1 Burn Unit was observed. At 11:29 a.m., the north door failed to self-close and latch.

Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by one fire alarm strobe that failed to flash when the fire alarm system was activated. This affected one of three buildings, and could result in a delayed notification of a fire in the event of a fire emergency.

Findings:

During a facility tour with staff on 7/28/10, the fire alarm system components were observed.

Cardiac Rehabilitation Wellness Center:

At 7:53 a.m., the fire alarm strobe in the corridor outside the classroom was observed. The fire alarm strobe failed to flash when the fire alarm system was activated.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25 and NFPA 13. This was evidenced by three sprinkler heads that were missing escutcheon rings, and by one sprinkler head that did not have eighteen inches of clearance around its deflector plate. This affected one of six floors in one of three buildings, and could result in a delayed response of the automatic sprinkler system.

NFPA 25, 1998 edition
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

NFPA 13, 1999 edition
5-5.6* The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During a facility tour with staff on 7/28/10, the sprinklers in the facility were observed.

Main Hospital:

1. At 8:58 a.m., two of five sprinklers in the first floor lab office space were missing escutcheon rings.

2. At 9:25 a.m., the sprinkler head in the first floor cath lab break room was missing an escutcheon ring.

3. At 9:27 a.m., the sprinkler head in the first floor cath lab storage closet did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by boxes stored approximately two inches directly below the sprinkler head.

Based on observation, the facility failed to maintain the fire extinguishers in accordance with NFPA 10, Standard for Fire Extinguishers, 1998 edition. This was evidenced by fire extinguishers that were obstructed. This effected one of five smoke compartments on the second floor, and may delay access to the fire extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers (1998 edition)

4-3.2 * Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose and nozzle checked (for wheeled units)
( i) HMIS label is in place

Findings:
On July 27, 2010 during a tour of the facility with staff the fire extinguishers were observed.

The fire extinguisher in Surgical ICU had access to and visibility obstructed by a temperature machine placed in front of the fire extinguisher.

Based on observation and interview, the facility failed to maintain the kitchen hood exhaust system, and the grill hood exhaust system, in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 edition. This was evidenced by kitchen equipment with an accumulation of grease, and affected two of five smoke compartments.

NFPA 96
11.2.4 Fusible links (including fusible links on fire damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary where required by the manufacturer.

11.4 Cleaning of Exhaust Systems

11.4.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Section 11.3.
11.4.2 Hoods, grease removal devices, fans ducts and other appurtenances shall be cleaned to bare metal prior to surfaces becoming heavily contaminated with grease or oily sludge.
11.4.8 After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance.
11.4.13 After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company and areas not cleaned.

NFPA 96
11.3 Inspection of Exhaust System. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person (s) acceptable to the authority having jurisdiction in accordance with Table 11.3.
Table 11.3 Exhaust System Inspection Schedule

Type of Volume of Cooking Frequency Frequency

Systems serving solid fuel cooking operations Monthly

Systems serving high-volume cooking operations such as Quarterly
24 hour-cooking, charbroiling, or wok cooking

Systems serving moderate-volume cooking operations Semiannually

Systems serving low-volume cooking operations, such as Annually
churches, day camps, seasonal businesses, or senior centers

Findings:
On July 28, 2010 during a tour of the kitchen and grill area with staff the exhaust hoods and filters were observed.

1. At 9.21 a.m. during a tour of the kitchen the kitchen hood was observed. The filters had grease on them. During an interview with staff 4 at 9:21 a.m., staff stated that the filters are cleaned on a weekly basis, but it had been 2 weeks ago this past Sunday ( July 11, 2010) that they were last cleaned.

2. At 9:30 a.m. the grill area in the cafeteria was observed. The filters were heavily soiled with grease, and the hood exhaust had a large amount of grease accumulated on it, and the fusible link was covered with grease. The exhaust was last steamed cleaned in May, 2010.

Based on observation, the facility failed to prevent the use of portable space heating devices within patient care areas. This was evidenced by the use of a portable space heating device in one location. This affected one of five smoke compartments on one floor, and could result in an increased risk of fire.

Findings:

On July 27, 2010 during a tour of the facility with staff at 9:13 a.m., there was a portable space floor heater in the Director of Step Down Unit Office, located on the 5th floor. The office is located on the unit, in the area of patient rooms.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This was evidenced by chairs being placed in the hallways, and by gurneys obstructing the means of egress. This effected two of five smoke compartments on the 2nd floor, and one of five smoke compartments on the 1st floor. This could result in a delay in egress from the area in the event of fire or other emergency.

Findings:
On a tour of the facility on July 26, 2010 through July 29, 2010 with staff the means of egress were observed.
1. On July 27, 2010 at 1:38 p.m., there were eight chairs for use by visitors, in the corridor outside the Surgery/ICU waiting area
2. On July 27, 2010 at 1:49 p.m., at the back entrance corridor to surgery, there was a Laserscope and two black trunks on the left side of the hallway, and on the right side there was a two-tier stainless steel cart on wheels.
3. On July 28, 2010, at 3:09 p.m., during a tour of the emergency room there were fourteen gurneys and four chairs in the path of egress. In some areas the means of egress was reduced to approximately three feet or less. At 3:10 p.m., during an interview with staff 1 and 2, both staff acknowledged the gurneys in the corridor, but stated they had no other options at this time. During an interview at 3:09 p.m., with staff 6, staff acknowledged that the gurneys were in the path of egress, but that all the hospitals in Bakersfield were like this. Staff stated that the emergency room was closed today, July 28, 2010, at approximately 12:00 p.m. for 1 to 1 1/2 hours, due to the amount of people. Staff 6 stated that although the emergency room is closed they still accept walk in patients. At 3:22 p.m., staff 6 quoted the census in the emergency room at that time was 33 patients. When asked what the policy is for closing the emergency room, staff stated that they have to call EMS (Emergency Medical Services) to get approved for closure. Staff stated that there is a policy for the emergency room. This policy was requested.
At 3:27 p.m. during an interview with staff 7, when asked how they would evacuate in the event of a fire, staff stated they would move the patients into the rooms.
At 3:33 p.m., the fourteen gurneys and four chairs remained in the path of egress in the emergency room.
At 3:58 p.m., during document review of a fire drill conducted in the emergency room on February 3, 2010, it was noted that the new staff had no knowledge of what to do. No documentation was provided showing another drill was done.
At 4:05 p.m., the policy "Analysis & Management of Patient Flow" was reviewed. The policy indicates that patients will not be housed in fire egress corridors except as a temporary measure, and that they will be immediately (within 30 minutes) moved into an interior corridor or bed. The policy also stated each patient in the corridor location will have their specific location clearly delineated (e.g. "Corridor Bed 1", Corridor Bed 2" , etc).

The fourteen gurneys and four chairs were observed in the corridor from 3:09 p.m., to 3:33 p.m.

Based on observation, the facility failed to maintain their storage of oxygen gas. This was evidenced by two locations housing oxygen cylinders that did not have signs indicating oxygen was being stored in those rooms. This affected two locations in two of three buildings, and could result in confusion for emergency forces on the oxygen storage locations.

NFPA 99, 1999 edition
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a facility tour with staff on 7/27/10 to 7/28/10, the facility's oxygen storage locations were observed.

Main Hospital:

On 7/28/10 at 2:33 p.m., there were four oxygen E cylinders stored in the second floor equipment storage room near operating Room 6. There was no sign on the door to the room indicating oxygen was being stored at that location.

Cardiac Rehabilitation Wellness Center:

On 7/27/10 at 3:22 p.m., there were two oxygen E cylinders stored in the physical therapy storage room. There was no sign on the door to the room indicating oxygen was being stored at that location.

Based on observation and interview the facility failed to maintain the medical gas system in accordance with NFPA 99, Health Care Facilities, 1999 edition. This was evidenced by area alarm panel that failed to have operating LED light. This effected one of five smoke smoke compartments, and could result in the oxygen being out of range, and the ICU (Intensive Care Unit) not being aware of the range.

Findings:
On a tour of the facility July 26, 2010 through July 29, 2010 with staff the area alarm panels for the Medical Gases were observed.

1. On July 27, 2010 at 1:36 p.m., the Area Alarm Panel outside MICU (Medical Intensive Care Unit) 2 was observed to have the green light not working.
2. On July 28, 2010 at 2:29 p.m., the Area Alarm Panel outside MICU 2 was again observed and had cardboard placed over the top portion of the panel, and only the vacuum and air gauges were visible.
At 2:39 p.m., during an interview with staff 2, staff stated that when they replaced the light it burnt the transformer out. Per staff 2 they have ordered a new transformer.

Based on observation, the the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code, 1999 edition. This was evidenced by equipment stored in front of electrical panels, appliances plugged into surge protectors, and by missing electrical face plates. This could result in an increased risk of fire, and affected four of five floors in the main building, and two off-site buildings.

NFPA 70, National Electrical Code,
110-26. Spaces about Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) #2 Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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 the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
NFPA 70, 1999 edition
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:
On a tour of the facility with staff on July 26, 2010 through July 29, 2010, the electrical wiring and equipment was observed.
1. At 9:09 a.m., there was a trash can placed in front of the electrical panel, on the nurse staff lounge on the 5th floor.
2. At 9:11 a.m., there was a refrigerator plugged into a surge protector, in the respirator office on the 5th floor.
3. At 9:21 a.m., there was a refrigerator plugged into a surge protector, in the staff lounge on the 4th floor, in Tower 2.
4. At 9:34 a.m., there was an isolation cart placed in front of electrical panel E 4 A, on the 4th floor.
5. At 9:42 a.m., there was a refrigerator plugged into surge protector, in the Kaiser office on the 4th floor.
6. At 9:45 a.m., there was a medication refrigerator, a warmer, and an L cart placed in front of electrical panel 4 B, in the room R4-76, Central Supply in Tower 1.
7. At 11:06 a.m., there was an electrical outlet face plate missing in the Photo Room 3-80, on the 3rd floor.
8. At 11:21 a.m., there was a warmer cabinet, and a medication refrigerator placed in front of electrical panel 3 B, on the 3rd floor.
9. At 2:18 p.m., there was a computer on wheels, and a chair placed in front of electrical panel LIA, in the 1st floor emergency admitting.

Burn/Bariatric Center:
At 2:50 p.m., there was computer equipment in the program nurse's office plugged into a grey non-surge protected extension cord.

Cardiac Rehabilitation Wellness Center:
1. At 3:16 p.m., there was a water cooler in the hallway near the classroom which was plugged into a grey non-surge protected multi-outlet extension cord.
2. At 3:20 p.m., there was a coffee maker in the classroom which was plugged into a black non-surge protected multi-outlet extension cord.
3. At 3:25 p.m., there was an electrical receptacle in the physical therapy room which was missing a faceplate. The electrical receptacle was located on the upper right hand corner of the wall shared with the women's locker room. Electrical wiring was exposed.



27893