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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff, in the event of a fire. This affected three of eight floors in the Main Hospital.

Findings:

During the facility tour with Facility Director 1, Facility Director 2, Facility Manager and Facility Staff 1 on January 9, 2012 and January 10, 2012, the facility walls and ceilings were observed.

On January 9, 2012: - 3rd Floor in the Main Hospital Building.

1. At 2:35 p.m., there were two approximately one inch penetrations behind a wall clock over the entry door in Room 3E-9.

On January 10, 2012 - 1st Floor in the Main Hospital Building.

1. At 9:50 a.m., in Room B-108, there was an approximately two inch penetration in the ceiling above the escutcheon ring in Room B-108.

2. At 9:55 a.m., there was no escutcheon ring around the sprinkler, exposing an approximately one inch penetration in the ceiling in Room B-158.

3. At 10:00 a.m., the wall in the CT Scan Room had a penetration that measured approximately 1 inch. The penetration was located adjacent to the door labeled 1-H-5. The penetration was at the height of the door knob.

Based on observation, the facility failed to maintain the facility doors, as evidenced by doors that failed to latch, by penetrations in the doors and by a door that was obstructed from opening completely. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected two of eight floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with Facility Director 2 on January 9, 2012, the facility doors were observed.

Eighth Floor -
1. At 10:15 a.m., the corridor door 8W-6 failed to positive latch, in the Game Room.

2. At 10:45 a.m., the corridor door 8W8C-3C was blocked from completely opening.

3. At 10:55 a.m., there was a cover blank missing over the door knob creating an approximately two inch circular penetration on the door 8E-13.

4. At 11:05 a.m., there was a ¼ inch by 2 inch unsealed crescent penetration around the door knob on the door 8E-14.

5. At 11:15 a.m., the corridor door 8E-27 failed to fully close and positive latch in the Patient Exam Holter Hook-up Room.

6. At 11:27 a.m., the corridor double door 8E-29A failed to positive latch.

Fifth Floor -
7. At 2:10 p.m., the corridor double door failed to positive latch to the Linen Closet Room LC-506.

8. At 2:33 p.m., the corridor door failed to positive latch to the Patient Room 5E-12.

Based on observation, document review and interview, the facility failed to maintain their smoke barrier doors to prevent the passage of smoke. This was evidenced by doors that failed to positive latch, by doors that were obstructed from closing and by batteries for an automatic-closing WON door that exceeded their life span. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff, in the event of a fire. This affected four of eight floors and the basement in the Main Hospital.

Findings:

During the facility tour, with Facility Director 2, from January 9, 2012 through January 11, 2012, the smoke barrier doors were observed.

On January 9, 2012:

1. At 2:00 p.m., the smoke barrier cross-corridor door CC5-3 closed during alarm testing on the Fifth Floor of the Main Hospital. The south door failed to close and positive latch.

2. During record review on January 10, 2012, at 2:54 p.m., the inspection report from JAM Fire Protection was reviewed. The report indicated that the WON door batteries had exceeded their life span. The WON doors were located in the Basement, 1st Floor, and 2nd Floor in the Main Hospital Building. The 12-Volt batteries were dated June 2005, with a life span of 5 years. Facility Director-2 was interviewed and stated that he was not aware that the batteries had exceeded their life span.

3. During the facility tour on January 11, 2012, at 8:50 a.m., the smoke barrier door labeled CC-2-7 failed to release from its magnet and positive latch during fire alarm testing. One of two doors closed but failed to latch. Both doors were equipped with magnet release automatic-closing devices and latching mechanisms. The doors were located by the Pathology Department on the second floor in the Main Hospital Building.

4. At 8:53 a.m., the smoke barrier door labeled CC-2-8 had a detached self-closing device on one door. The self-closing device was hanging from the door frame, near the Chemistry Laboratory, on the 2nd Floor in the Main Hospital Building.

5. At 9:30 a.m., the north smoke barrier door, CC4-2, failed to positive latch after closing. The door was on the Fourth Floor of the Main Hospital.

6. At 10:20 a.m., the east smoke barrier door, CC1-3, failed to positive latch after closing, on the First floor of the Main Hospital.

7. At 10:25 a.m., the north smoke barrier door, CC1-12, failed to positive latch after closing. The door was on the First Floor of the Main Hospital.

Based on observation, the facility failed to protect hazardous areas as evidenced by a biohazard room without a self-closure and hazardous storage areas without clearance. This could allow the spread of smoke and fire from the hazardous areas to other areas in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected two of eight floors in the Main Hospital and Building N-24.

Findings:

During the facility tour with Facility Director 2 from January 9, 2012 through January 12, 2012 the hazardous areas were observed.

On January 9, 2012:

1. At 11:25 a.m., there was storage to the ceiling in Storeroom 8E1 on the Eighth Floor in the Main Hospital.

2. At 1:30 p.m., there was storage to the ceiling in Storeroom 5W11 on the Fifth Floor in the Main Hospital.

3. At 1:55 p.m., there was storage to the ceiling in Storeroom 5W39 on the Fifth Floor in the Main Hospital.

4. At 1:58 p.m., there was storage to the ceiling in Storeroom 5W41 on the Fifth Floor in the Main Hospital.

On January 12, 2012:

5. At 10:45 a.m., the door was propped open and failed to have a self-closing device to the Biohazard Room in Building N-24.

Based on observation, the facility failed to maintain signage of hazardous materials in accordance with NFPA 99. This was evidenced by laboratories containing significant quantities of flammable liquids with no signage posted on entry doors. This could result in personnel being unaware of the hazardous contents in the laboratory which could potentially cause injury in the event of a fire or other emergency. This affected one of eight floors in the Main Hospital.

NFPA 99, Health Care Facilities, 1999 Edition
10-8.2.1 All doors leading to laboratories in health-related facilities shall be marked with signage indicating the fire hazards of materials when significant quantities, as defined below, are intended to be used within the area. For signage ' ' significant quantities ' ' in an area shall include any of the following:
(a) Hazardous materials in glass containers that are 1 gal (4.4 L) in size or larger
(b) Compressed gases or cryogenic liquids in containers that are greater than 5 in. (12.7 cm) in diameter and 15 in. (48 cm) in length
(c) Dry hazardous chemicals in containers in excess of 5 lb (2.2.7 kg)
(d) Aggregate quantities of hazardous materials exceeding 200 lb (91 kg), or flammable liquids exceeding 10 gal (44.4 L)
10-8.2.2 All doors leading to laboratories, laboratory work areas, and laboratory storage areas, shall be identified with signs to warn emergency response personnel of unusual or severe hazards that are not directly related to the fire hazards of contents.
10-8.2.3 It shall be the responsibility of the laboratory safety officer to ensure periodically that the signage properly indicates the nature of the materials being used within the identified space.
10-8.2.4 It shall be the duty of the senior person responsible for activities in respective laboratory areas to inform the laboratory safety officer of changes in protocol and procedures that involve variations in the fire and associated hazards of materials used in individual spaces.

Findings:

During a tour of the facility with the Facility Manager and Lab Staff-1 on January 11, 2012, the laboratories were observed.

Between 9:13 a.m. and 9:43 a.m., the Laboratories were observed to contain flammable liquids, such as Methanol and Ethanol, in glass containers that were 1 gallon or larger on the second floor in the Main Hospital Building. The following doors leading into laboratory rooms containing these liquids did not have signage: 2S-6, 2S-8, 2S-10, 2S-18A, 2S-18C, 2S-38, and 2S-29.

Based on observation and interview, the facility failed to arrange patient doors such that patients can open the door from inside without using a key as evidenced by patient doors with locks and no available keys. This could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff. This affected one of eight floors in the Main Hospital.

Findings:

During the facility tour and interview with Facility Director 2 on January 9, 2012, the patient room doors were observed.

1. At 2:15 p.m., there was a key lock on PCU Patient Room 5E4 and no available key on the Fifth Floor.

2. At 2:20 p.m., there was a key lock on PCU Patient Room 5E5 and no available key on the Fifth Floor.

3. At 2:37 p.m., there was a key lock on Patient Room 5EGCRC15 and no available key on the Fifth Floor.

4. At 2:39 p.m., there was a key lock on Patient Room 5EGCRC14 and no available key on the Fifth Floor.

5. At 2:41 p.m., there was a key lock on Patient Room 5EGCRC13 and no available key.

6. At 2:43 p.m., there was a key lock on Patient Room 5EGCRC12 and no available key.

7. At 2:45 p.m., there was a key lock on Patient Room 5EGCRC11 and no available key. Facility Director 2 stated that staff did not have keys. Facility Director 2 was able to use a master key in the doors.

Based on observation, document review and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 101 and NFPA 72. This was evidenced by the fire alarm not being heard throughout occupied spaces, strobe lights that failed to operate and the failure to conduct inspection and testing of the fire alarm system. This had the potential to have a fire alarm system fail, increasing the risk of injury to patients, visitors and staff. This affected 4 of 8 floors in the Main Hospital and 3 of 3 outpatient clinics.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.

7-3.1 Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Findings:

On January 11, 2012 and January 12, 2012, the fire alarm systems were tested and observed, documents reviewed and staff interviewed.

On January 11, 2012:

1. At 9:02 a.m., in the Main Hospital 2 of 2 strobes in front of Room 8C-14 and 8C-18 did not flash during alarm system testing.

2. At 9:08 a.m., in the Main Hospital the strobe outside Room 7W-40 did not flash during alarm system testing.

3. At 9:15 a.m., in the Main Hospital the strobe outside Room 6W-22 did not flash during alarm system testing.

4. At 10:40 a.m., in the Main Hospital, the fire alarm could not be heard in the Employee Kitchen on the First Floor. There was no strobe or annunciator.

5. At 11:18 a.m., the fire alarm system was activated at the Family Health Center. When the water flow test for the sprinkler system was tested, the alarm was not heard on the B-side of the Clinic Area that was located on the 2nd Floor. A faint sound from the fire alarm system was heard on the A-side of the Clinic Area that was located on the 2nd Floor. No audible device was observed on the 2nd Floor.

On January 12, 2012:

6. At 10:35 a.m., the fire alarm system was activated at the Outpatient Occupational Therapy/Physical Therapy Center located in the N-31 Building. When the manual fire alarm pull station located by the exit was tested, no alarm was heard throughout the building. No audible device was observed to be installed. The pull station did send a signal to the monitoring station.

7. At 10:52 a.m., the fire alarm system was activated at the Outpatient Clinic located in the N-24 Building. When the manual fire alarm pull station #321 was tested in the A-side of the building, no alarm was heard throughout the building. No audible device was observed to be installed in the A-side of the building. The pull station did send a signal to the monitoring station.

8. At 5:00 p.m., there were no records provided for the testing and inspection of the fire alarm system for the Outpatient-Family Health Center. Facility Director 2 stated that Los Angeles County did not require the testing of the fire alarm system and the facility would test the fire alarm system in the future.

Based on observation, record review and interview, the facility failed to ensure the maintenance, inspection and testing of the battery operated smoke detectors. This was evidenced by no records for the weekly testing of the battery operated smoke detectors per manufacturer instructions. This could result in a smoke detector malfunction, and increase the risk of injury to patients, visitors and staff in the event of an emergency. This affected buildings N-31 and N-24.

Findings:

During the facility tour and fire alarm testing, document review and interview with the Facility Director 1, Facility Director 2, Facility Manager and Facility Staff 1 on January 12, 2012, the smoke detectors were observed, documents reviewed and staff interviewed.

On January 12, 2012:

1. At 10:35 a.m., battery-operated smoke detectors were observed and tested in Building N-31. Facility Director 2 stated that batteries were changed every six months but there were no logs for weekly testing per manufacturer instructions.

2. At 10:55 a.m., battery-operated smoke detectors were observed and tested in Building N-24. Facility Director 2 stated that batteries were changed every six months but there were no logs for weekly testing per manufacturer instructions.

3. At 2:00 p.m., there was no documentation provided for the weekly testing of the battery operated smoke detectors as specified in the manufacturer instructions for Building N-31 and N-24.

Based on document review and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by failing to perform quarterly testing of the sprinkler system, this affected the Outpatient-Family Health Center. This could result in the failure of the sprinkler system in the event of a fire. This affected one of three outpatient Clinics.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

3-3.3 Alarm Devices. Where provided, waterflow alarm and supervisory devices shall be tested on a quarterly basis.

9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During document review on January 11, 2012 and January 12, 2012, the records for the sprinkler system were requested and reviewed.

On January 11, 2012:

1. At 11:30 a.m., the records for the sprinkler system for the Outpatient-Family Health Center were requested.

On January 12, 2012:

2. At 5:00 p.m., no records were received for the quarterly inspection and testing for the automatic sprinkler system. Facility Director-2 stated that the facility's local fire authority does not require quarterly testing of the sprinkler system.

Based on observation, the facility failed to maintain the laundry chute in accordance with 9.5 as evidenced by penetrations in the laundry chute and the door to the laundry chute room failing to latch. This could result in a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected eight of eight floors and the basement in the Main Hospital.

SECTION 9.5 RUBBISH CHUTES, INCINERATORS, AND LAUNDRY CHUTES
9.5.1 Enclosure. Rubbish chutes and laundry chutes shall be separately enclosed by walls or partitions in accordance with the provisions of Section 8.2. Inlet openings serving chutes such chutes shall open only to a room that is designed and used exclusively for accessing the chute opening. The room shall be separated from other spaces in accordance with Section 8.4.
Exception No. 1: Existing installations having properly enclosed service
chutes and properly installed and maintained service openings shall be permitted to have inlets open to a corridor or normally occupied space.
Exception No. 2: Rubbish chutes and laundry chutes shall be permitted
to open into rooms not exceeding 400 ft2 (37 m2) in area used for storage, provided that the room is protected by automatic sprinklers.
9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Findings:

During the facility tour with Facility Director 2 on January 9, 2012, the laundry chute areas were observed.

1. At 1:40 p.m., there were three ¼ inch unsealed penetrations in the door to the laundry chute in Room 5W23 on the Fifth floor.

2. At 1:45 p.m., the self-closing corridor door failed to fully close and positive latch to the Laundry Chute Room 5W23 on the Fifth floor.

Based on observation and interview, the facility failed to ensure means of egress were free of all obstructions, as evidenced by gurneys, mobile carts and various hospital supplies in the egress path. This could result in delay of evacuation in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected one of eight floors of the Main Hospital.

Findings:

During the facility tour with Facility Director 2 on January 11, the egress paths were observed.

At 8:35 a.m., the cross-corridor between Operating Room 4 between Operating Room 5 contained storage on both sides of the corridor leaving a 36 inch clearance in in the middle on the Second Floor. The inside corridor marked in red for no storage, contained a C-Arm and a patient surgery table. The corridor posted a directional exit sign. Facility Director 2 stated that storage was an issue and that it was noted on the weekly rounds.

Based on observation, the facility failed to maintain the medical gas storage areas in accordance with NFPA 99. This was evidenced by unsecured oxygen cylinders. This could result in a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected one of eight floors in the Main Hospital.

NFPA 99 Health Care Facilities 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During the facility tour with Facility Director 2 on January 9, 2012 and January 10, 2012 the oxygen storage areas were observed.

On January 9, 2012:

1. At 1:50 p.m., there was an unsecured empty E cylinder of oxygen sideways on the floor in the Equipment Supply Room 5W20 on the Fifth Floor.

On January 10, 2012:

2. At 11:13 a.m., the caged outdoor medical gas storage area had an R-size (20 cubic feet) oxygen cylinder that was unsecured and standing upright in the outdoor medical gas storage area of the Main Hospital.

Based on observation, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by high wattage appliances plugged into surge protectors, electrical faceplates that were broken or missing, a GFI receptacle green indicator light that was not illuminated and a safety switch panel that was obstructed. This could result in an electrical fire and increase the risk of injury to patients, visitors and staff. This affected three of eight floors in the Main Hospital and one of three Clinics.

NFPA 70, National Electrical Code, 1999 Edition.
110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(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.

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.

During the facility tour with Facility Director 1, Facility Director 2, Facility Manager and Facility Staff 1 from January 9, 2012 through January 11, 2012, the electrical appliances and equipment were observed.

On January 9, 2012:

1. At 10:00 a.m., there was a four plug adapter box in use in Room 8W11 Office A on the Eighth Floor in the Main Hospital.

2. At 10:10 a.m., there was an electrical Outlet missing a faceplate on the left wall in Room 8W14 Office B on the Eighth Floor in the Main Hospital.

3. At 10:15 a.m., in Room 6W-1 the green indicator light on the GFI receptacle adjacent to the sink was not illuminated on the sixth floor in the Main Hospital.

4. At 10:50 a.m., there was an adapter box in use in Room 8L1 Main Office on the Eighth Floor in the Main Hospital.

5. At 11:20 a.m., there was a refrigerator plugged into a surge protector in Room 8E -21C on the Eighth Floor in the Main Hospital

On January10, 2012:

6. At 10:30 a.m., in Room B-303C a refrigerator and a microwave were plugged into a surge protector in the Main Hospital.

7.At 11:10 a.m., in the ITS staff area in the Main Hospital, there was a toaster and a microwave plugged into a surge protector.

8. At 11:15 a.m., in the Main Hospital in Room B 251 in the main computer room, A/C No. 1 safety switch panel clearance had one computer chair, and a mobile computer monitor stand blocking access.

9. At 1:45 p.m., in the Main Hospital, in the pharmacy staff area at cubicle number one, there was a refrigerator and a microwave plugged into a surge protector.

On January 11, 2012

10. At 10:53 a.m., the receptacle wall outlet at the Family Health Center had a broken faceplate. The outlet was located in Station I Clinic Area A.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by penetrations in the walls and ceilings. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff, in the event of a fire. This affected three of eight floors in the Main Hospital.

Findings:

During the facility tour with Facility Director 1, Facility Director 2, Facility Manager and Facility Staff 1 on January 9, 2012 and January 10, 2012, the facility walls and ceilings were observed.

On January 9, 2012: - 3rd Floor in the Main Hospital Building.

1. At 2:35 p.m., there were two approximately one inch penetrations behind a wall clock over the entry door in Room 3E-9.

On January 10, 2012 - 1st Floor in the Main Hospital Building.

1. At 9:50 a.m., in Room B-108, there was an approximately two inch penetration in the ceiling above the escutcheon ring in Room B-108.

2. At 9:55 a.m., there was no escutcheon ring around the sprinkler, exposing an approximately one inch penetration in the ceiling in Room B-158.

3. At 10:00 a.m., the wall in the CT Scan Room had a penetration that measured approximately 1 inch. The penetration was located adjacent to the door labeled 1-H-5. The penetration was at the height of the door knob.

Based on observation, the facility failed to maintain the facility doors, as evidenced by doors that failed to latch, by penetrations in the doors and by a door that was obstructed from opening completely. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected two of eight floors in the Main Hospital.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with Facility Director 2 on January 9, 2012, the facility doors were observed.

Eighth Floor -
1. At 10:15 a.m., the corridor door 8W-6 failed to positive latch, in the Game Room.

2. At 10:45 a.m., the corridor door 8W8C-3C was blocked from completely opening.

3. At 10:55 a.m., there was a cover blank missing over the door knob creating an approximately two inch circular penetration on the door 8E-13.

4. At 11:05 a.m., there was a ¼ inch by 2 inch unsealed crescent penetration around the door knob on the door 8E-14.

5. At 11:15 a.m., the corridor door 8E-27 failed to fully close and positive latch in the Patient Exam Holter Hook-up Room.

6. At 11:27 a.m., the corridor double door 8E-29A failed to positive latch.

Fifth Floor -
7. At 2:10 p.m., the corridor double door failed to positive latch to the Linen Closet Room LC-506.

8. At 2:33 p.m., the corridor door failed to positive latch to the Patient Room 5E-12.

Based on observation, document review and interview, the facility failed to maintain their smoke barrier doors to prevent the passage of smoke. This was evidenced by doors that failed to positive latch, by doors that were obstructed from closing and by batteries for an automatic-closing WON door that exceeded their life span. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff, in the event of a fire. This affected four of eight floors and the basement in the Main Hospital.

Findings:

During the facility tour, with Facility Director 2, from January 9, 2012 through January 11, 2012, the smoke barrier doors were observed.

On January 9, 2012:

1. At 2:00 p.m., the smoke barrier cross-corridor door CC5-3 closed during alarm testing on the Fifth Floor of the Main Hospital. The south door failed to close and positive latch.

2. During record review on January 10, 2012, at 2:54 p.m., the inspection report from JAM Fire Protection was reviewed. The report indicated that the WON door batteries had exceeded their life span. The WON doors were located in the Basement, 1st Floor, and 2nd Floor in the Main Hospital Building. The 12-Volt batteries were dated June 2005, with a life span of 5 years. Facility Director-2 was interviewed and stated that he was not aware that the batteries had exceeded their life span.

3. During the facility tour on January 11, 2012, at 8:50 a.m., the smoke barrier door labeled CC-2-7 failed to release from its magnet and positive latch during fire alarm testing. One of two doors closed but failed to latch. Both doors were equipped with magnet release automatic-closing devices and latching mechanisms. The doors were located by the Pathology Department on the second floor in the Main Hospital Building.

4. At 8:53 a.m., the smoke barrier door labeled CC-2-8 had a detached self-closing device on one door. The self-closing device was hanging from the door frame, near the Chemistry Laboratory, on the 2nd Floor in the Main Hospital Building.

5. At 9:30 a.m., the north smoke barrier door, CC4-2, failed to positive latch after closing. The door was on the Fourth Floor of the Main Hospital.

6. At 10:20 a.m., the east smoke barrier door, CC1-3, failed to positive latch after closing, on the First floor of the Main Hospital.

7. At 10:25 a.m., the north smoke barrier door, CC1-12, failed to positive latch after closing. The door was on the First Floor of the Main Hospital.

Based on observation, the facility failed to protect hazardous areas as evidenced by a biohazard room without a self-closure and hazardous storage areas without clearance. This could allow the spread of smoke and fire from the hazardous areas to other areas in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected two of eight floors in the Main Hospital and Building N-24.

Findings:

During the facility tour with Facility Director 2 from January 9, 2012 through January 12, 2012 the hazardous areas were observed.

On January 9, 2012:

1. At 11:25 a.m., there was storage to the ceiling in Storeroom 8E1 on the Eighth Floor in the Main Hospital.

2. At 1:30 p.m., there was storage to the ceiling in Storeroom 5W11 on the Fifth Floor in the Main Hospital.

3. At 1:55 p.m., there was storage to the ceiling in Storeroom 5W39 on the Fifth Floor in the Main Hospital.

4. At 1:58 p.m., there was storage to the ceiling in Storeroom 5W41 on the Fifth Floor in the Main Hospital.

On January 12, 2012:

5. At 10:45 a.m., the door was propped open and failed to have a self-closing device to the Biohazard Room in Building N-24.

Based on observation, the facility failed to maintain signage of hazardous materials in accordance with NFPA 99. This was evidenced by laboratories containing significant quantities of flammable liquids with no signage posted on entry doors. This could result in personnel being unaware of the hazardous contents in the laboratory which could potentially cause injury in the event of a fire or other emergency. This affected one of eight floors in the Main Hospital.

NFPA 99, Health Care Facilities, 1999 Edition
10-8.2.1 All doors leading to laboratories in health-related facilities shall be marked with signage indicating the fire hazards of materials when significant quantities, as defined below, are intended to be used within the area. For signage ' ' significant quantities ' ' in an area shall include any of the following:
(a) Hazardous materials in glass containers that are 1 gal (4.4 L) in size or larger
(b) Compressed gases or cryogenic liquids in containers that are greater than 5 in. (12.7 cm) in diameter and 15 in. (48 cm) in length
(c) Dry hazardous chemicals in containers in excess of 5 lb (2.2.7 kg)
(d) Aggregate quantities of hazardous materials exceeding 200 lb (91 kg), or flammable liquids exceeding 10 gal (44.4 L)
10-8.2.2 All doors leading to laboratories, laboratory work areas, and laboratory storage areas, shall be identified with signs to warn emergency response personnel of unusual or severe hazards that are not directly related to the fire hazards of contents.
10-8.2.3 It shall be the responsibility of the laboratory safety officer to ensure periodically that the signage properly indicates the nature of the materials being used within the identified space.
10-8.2.4 It shall be the duty of the senior person responsible for activities in respective laboratory areas to inform the laboratory safety officer of changes in protocol and procedures that involve variations in the fire and associated hazards of materials used in individual spaces.

Findings:

During a tour of the facility with the Facility Manager and Lab Staff-1 on January 11, 2012, the laboratories were observed.

Between 9:13 a.m. and 9:43 a.m., the Laboratories were observed to contain flammable liquids, such as Methanol and Ethanol, in glass containers that were 1 gallon or larger on the second floor in the Main Hospital Building. The following doors leading into laboratory rooms containing these liquids did not have signage: 2S-6, 2S-8, 2S-10, 2S-18A, 2S-18C, 2S-38, and 2S-29.

Based on observation and interview, the facility failed to arrange patient doors such that patients can open the door from inside without using a key as evidenced by patient doors with locks and no available keys. This could result in delayed response to a fire and increase the risk of injury to patients, visitors and staff. This affected one of eight floors in the Main Hospital.

Findings:

During the facility tour and interview with Facility Director 2 on January 9, 2012, the patient room doors were observed.

1. At 2:15 p.m., there was a key lock on PCU Patient Room 5E4 and no available key on the Fifth Floor.

2. At 2:20 p.m., there was a key lock on PCU Patient Room 5E5 and no available key on the Fifth Floor.

3. At 2:37 p.m., there was a key lock on Patient Room 5EGCRC15 and no available key on the Fifth Floor.

4. At 2:39 p.m., there was a key lock on Patient Room 5EGCRC14 and no available key on the Fifth Floor.

5. At 2:41 p.m., there was a key lock on Patient Room 5EGCRC13 and no available key.

6. At 2:43 p.m., there was a key lock on Patient Room 5EGCRC12 and no available key.

7. At 2:45 p.m., there was a key lock on Patient Room 5EGCRC11 and no available key. Facility Director 2 stated that staff did not have keys. Facility Director 2 was able to use a master key in the doors.

Based on observation, document review and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 101 and NFPA 72. This was evidenced by the fire alarm not being heard throughout occupied spaces, strobe lights that failed to operate and the failure to conduct inspection and testing of the fire alarm system. This had the potential to have a fire alarm system fail, increasing the risk of injury to patients, visitors and staff. This affected 4 of 8 floors in the Main Hospital and 3 of 3 outpatient clinics.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.

7-3.1 Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Findings:

On January 11, 2012 and January 12, 2012, the fire alarm systems were tested and observed, documents reviewed and staff interviewed.

On January 11, 2012:

1. At 9:02 a.m., in the Main Hospital 2 of 2 strobes in front of Room 8C-14 and 8C-18 did not flash during alarm system testing.

2. At 9:08 a.m., in the Main Hospital the strobe outside Room 7W-40 did not flash during alarm system testing.

3. At 9:15 a.m., in the Main Hospital the strobe outside Room 6W-22 did not flash during alarm system testing.

4. At 10:40 a.m., in the Main Hospital, the fire alarm could not be heard in the Employee Kitchen on the First Floor. There was no strobe or annunciator.

5. At 11:18 a.m., the fire alarm system was activated at the Family Health Center. When the water flow test for the sprinkler system was tested, the alarm was not heard on the B-side of the Clinic Area that was located on the 2nd Floor. A faint sound from the fire alarm system was heard on the A-side of the Clinic Area that was located on the 2nd Floor. No audible device was observed on the 2nd Floor.

On January 12, 2012:

6. At 10:35 a.m., the fire alarm system was activated at the Outpatient Occupational Therapy/Physical Therapy Center located in the N-31 Building. When the manual fire alarm pull station located by the exit was tested, no alarm was heard throughout the building. No audible device was observed to be installed. The pull station did send a signal to the monitoring station.

7. At 10:52 a.m., the fire alarm system was activated at the Outpatient Clinic located in the N-24 Building. When the manual fire alarm pull station #321 was tested in the A-side of the building, no alarm was heard throughout the building. No audible device was observed to be installed in the A-side of the building. The pull station did send a signal to the monitoring station.

8. At 5:00 p.m., there were no records provided for the testing and inspection of the fire alarm system for the Outpatient-Family Health Center. Facility Director 2 stated that Los Angeles County did not require the testing of the fire alarm system and the facility would test the fire alarm system in the future.

Based on observation, record review and interview, the facility failed to ensure the maintenance, inspection and testing of the battery operated smoke detectors. This was evidenced by no records for the weekly testing of the battery operated smoke detectors per manufacturer instructions. This could result in a smoke detector malfunction, and increase the risk of injury to patients, visitors and staff in the event of an emergency. This affected buildings N-31 and N-24.

Findings:

During the facility tour and fire alarm testing, document review and interview with the Facility Director 1, Facility Director 2, Facility Manager and Facility Staff 1 on January 12, 2012, the smoke detectors were observed, documents reviewed and staff interviewed.

On January 12, 2012:

1. At 10:35 a.m., battery-operated smoke detectors were observed and tested in Building N-31. Facility Director 2 stated that batteries were changed every six months but there were no logs for weekly testing per manufacturer instructions.

2. At 10:55 a.m., battery-operated smoke detectors were observed and tested in Building N-24. Facility Director 2 stated that batteries were changed every six months but there were no logs for weekly testing per manufacturer instructions.

3. At 2:00 p.m., there was no documentation provided for the weekly testing of the battery operated smoke detectors as specified in the manufacturer instructions for Building N-31 and N-24.

Based on document review and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by failing to perform quarterly testing of the sprinkler system, this affected the Outpatient-Family Health Center. This could result in the failure of the sprinkler system in the event of a fire. This affected one of three outpatient Clinics.

NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

3-3.3 Alarm Devices. Where provided, waterflow alarm and supervisory devices shall be tested on a quarterly basis.

9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During document review on January 11, 2012 and January 12, 2012, the records for the sprinkler system were requested and reviewed.

On January 11, 2012:

1. At 11:30 a.m., the records for the sprinkler system for the Outpatient-Family Health Center were requested.

On January 12, 2012:

2. At 5:00 p.m., no records were received for the quarterly inspection and testing for the automatic sprinkler system. Facility Director-2 stated that the facility's local fire authority does not require quarterly testing of the sprinkler system.

Based on observation, the facility failed to maintain the laundry chute in accordance with 9.5 as evidenced by penetrations in the laundry chute and the door to the laundry chute room failing to latch. This could result in a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected eight of eight floors and the basement in the Main Hospital.

SECTION 9.5 RUBBISH CHUTES, INCINERATORS, AND LAUNDRY CHUTES
9.5.1 Enclosure. Rubbish chutes and laundry chutes shall be separately enclosed by walls or partitions in accordance with the provisions of Section 8.2. Inlet openings serving chutes such chutes shall open only to a room that is designed and used exclusively for accessing the chute opening. The room shall be separated from other spaces in accordance with Section 8.4.
Exception No. 1: Existing installations having properly enclosed service
chutes and properly installed and maintained service openings shall be permitted to have inlets open to a corridor or normally occupied space.
Exception No. 2: Rubbish chutes and laundry chutes shall be permitted
to open into rooms not exceeding 400 ft2 (37 m2) in area used for storage, provided that the room is protected by automatic sprinklers.
9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

Findings:

During the facility tour with Facility Director 2 on January 9, 2012, the laundry chute areas were observed.

1. At 1:40 p.m., there were three ¼ inch unsealed penetrations in the door to the laundry chute in Room 5W23 on the Fifth floor.

2. At 1:45 p.m., the self-closing corridor door failed to fully close and positive latch to the Laundry Chute Room 5W23 on the Fifth floor.

Based on observation and interview, the facility failed to ensure means of egress were free of all obstructions, as evidenced by gurneys, mobile carts and various hospital supplies in the egress path. This could result in delay of evacuation in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected one of eight floors of the Main Hospital.

Findings:

During the facility tour with Facility Director 2 on January 11, the egress paths were observed.

At 8:35 a.m., the cross-corridor between Operating Room 4 between Operating Room 5 contained storage on both sides of the corridor leaving a 36 inch clearance in in the middle on the Second Floor. The inside corridor marked in red for no storage, contained a C-Arm and a patient surgery table. The corridor posted a directional exit sign. Facility Director 2 stated that storage was an issue and that it was noted on the weekly rounds.

Based on observation, the facility failed to maintain the medical gas storage areas in accordance with NFPA 99. This was evidenced by unsecured oxygen cylinders. This could result in a fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected one of eight floors in the Main Hospital.

NFPA 99 Health Care Facilities 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks of fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During the facility tour with Facility Director 2 on January 9, 2012 and January 10, 2012 the oxygen storage areas were observed.

On January 9, 2012:

1. At 1:50 p.m., there was an unsecured empty E cylinder of oxygen sideways on the floor in the Equipment Supply Room 5W20 on the Fifth Floor.

On January 10, 2012:

2. At 11:13 a.m., the caged outdoor medical gas storage area had an R-size (20 cubic feet) oxygen cylinder that was unsecured and standing upright in the outdoor medical gas storage area of the Main Hospital.

Based on observation, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by high wattage appliances plugged into surge protectors, electrical faceplates that were broken or missing, a GFI receptacle green indicator light that was not illuminated and a safety switch panel that was obstructed. This could result in an electrical fire and increase the risk of injury to patients, visitors and staff. This affected three of eight floors in the Main Hospital and one of three Clinics.

NFPA 70, National Electrical Code, 1999 Edition.
110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(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.

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.

During the facility tour with Facility Director 1, Facility Director 2, Facility Manager and Facility Staff 1 from January 9, 2012 through January 11, 2012, the electrical appliances and equipment were observed.

On January 9, 2012:

1. At 10:00 a.m., there was a four plug adapter box in use in Room 8W11 Office A on the Eighth Floor in the Main Hospital.

2. At 10:10 a.m., there was an electrical Outlet missing a faceplate on the left wall in Room 8W14 Office B on the Eighth Floor in the Main Hospital.

3. At 10:15 a.m., in Room 6W-1 the green indicator light on the GFI receptacle adjacent to the sink was not illuminated on the sixth floor in the Main Hospital.

4. At 10:50 a.m., there was an adapter box in use in Room 8L1 Main Office on the Eighth Floor in the Main Hospital.

5. At 11:20 a.m., there was a refrigerator plugged into a surge protector in Room 8E -21C on the Eighth Floor in the Main Hospital

On January10, 2012:

6. At 10:30 a.m., in Room B-303C a refrigerator and a microwave were plugged into a surge protector in the Main Hospital.

7.At 11:10 a.m., in the ITS staff area in the Main Hospital, there was a toaster and a microwave plugged into a surge protector.

8. At 11:15 a.m., in the Main Hospital in Room B 251 in the main computer room, A/C No. 1 safety switch panel clearance had one computer chair, and a mobile computer monitor stand blocking access.

9. At 1:45 p.m., in the Main Hospital, in the pharmacy staff area at cubicle number one, there was a refrigerator and a microwave plugged into a surge protector.

On January 11, 2012

10. At 10:53 a.m., the receptacle wall outlet at the Family Health Center had a broken faceplate. The outlet was located in Station I Clinic Area A.