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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 1 of 9 smoke compartments and could result in potential harm to patients, staff and visitors, in the event of a fire.

Findings:

During a tour of the facility with the Plant Operations Supervisor on January 9, 2012, the facility walls and ceilings were observed.

Med-Surge:
1. At 9:23 a.m., there were two approximately 2 inch by 3 inch penetrations around cables, under the desk, in the back of the Nurse Station.

2. At 10:00 a.m., there was an approximately 1/2 inch penetration in the ceiling next to the sprinkler escutcheon ring, above bed "B" in Patient Room 102.

Based on observation, the facility failed to maintain corridor doors to latch and resist the passage of smoke. This was evidenced by failing to provide doors with devices suitable for keeping the doors closed and by failing to keep impediments from obstructing the doors from closing. This failure had the potential to allow the transfer of smoke and fire, in the event of a fire. This affected patients, staff and visitors in 6 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations and the Plant Operations Supervisor, on January 9 and January 10, 2012, the facility doors were observed.

Med-Surge - 1/9/12

1. At 9:20 a.m., the door to Patient Room 120, failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

2. At 9:24 a.m., the door to Patient Room 123, failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

3. At 9:27 a.m., the door to Patient Room 124 failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

4. At 9:43 a.m., the door to Patient Room 132 failed to close and latch.

5. At 10:05 a.m., the door to Patient Room 105 failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

6. At 10:14 a.m., the door to Patient Room 110 failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

7. At 9:43 a.m., the door to Patient Room 111 failed to close and latch.

Surgery Suite -

1. At 11:13 a.m., the door to the Recovery room was held open by a rubber wedge. The door was equipped with a self-closure.

2. At 11:15 a.m., the Surgery Utility room corridor door was impeded from closure by equipment. The door was equipped with a self-closure.


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Labor and Delivery -

1. At 9:41 a.m., the door to Room 201 failed to close and positive latch, in the Birthplace/Nursery area.

2. At 9:43 a.m., the door to Room 202 failed to close and positive latch.

3. At 10:20 a.m., the office in the kitchen had a door with a kick stand hold open device. The kick stand obstructed the door from closing.

4. At 11:06 a.m., the door to the Security Room was equipped with a self closing device. The door was held open with a door wedge. When the wedge was removed the door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

1/10/12 -

1. At 9:51 a.m., the convenience doors to the Nursery area, by Room 206, had a kick stand on each door.

2. At 10:43 a.m., the convenience doors by Room 127 were connected to the fire alarm system and released from the magnet during alarm testing. The doors closed but failed to positive latch on the left side.

Based on observation, the facility failed to maintain its smoke barrier doors on magnetic devices to close and latch. This was evidenced by doors that failed to latch shut upon activation of the fire alarm system. This failure affected 4 of 9 smoke compartments and could result in the potential spread of smoke in the event of a fire, causing harm to patients, staff and visitors.

NFPA 101, Life Safety Code 2000 Edition
19.2.2.2 Doors.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During fire alarm system testing, with the Director of Plant Operations and the Plant Operations Supervisor, on January 10, 2012, the smoke barrier doors were observed.

1. At 9:50 a.m., the double door leaf, next to Room 213, released from its magnetic device but failed to latch, when the fire alarm system was tested. This was acknowledged by the Plant Operations Supervisor.

2. At 10:25 a.m., the double door leaf next to the laboratory released from its magnetic device but failed to latch, when the fire alarm system was tested. This was acknowledged by the Plant Operations Supervisor.

Based on observation, the facility failed to maintain one hazardous area, as evidenced by a hazardous area that was not equipped with a self-closing door. This could result in the spread of smoke and fire, and affected patients, staff and visitors in 1 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations, on January 9, 2012, the hazardous storage areas were observed. Combustible storage areas greater than 50 square feet are considered hazardous and are required to have a self closing door.


At 10:23 a.m., the kitchen supply storage room contained supplies and combustible storage. The door was not equipped with a self-closing device and was left open for easy access to supplies.

Based on observation, the facility failed to maintain their automatic sprinkler system, as evidenced by a sprinkler missing an escutcheon ring. The escutcheon ring is used to cover the penetration around the sprinkler head and pipe. This could result in a delay in extinguishing a fire or the spread of smoke, in the event of a fire. This affected 1 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations, on January 9, 2012, the sprinkler system was observed.

At 9:55 a.m., one of two sprinklers were missing an escutcheon ring, in the Director of Labor and Delivery office.

Based on observation and interview, the facility failed to ensure that their portable fire extinguishers were easily accessible in accordance with NFPA 10. This was evidenced by a fire extinguisher that was impeded from access. This could result in a delay to extinguish a fire and increase the risk of injury to patients, visitors and staff. This affected 1 of 9 smoke compartments.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with Director of Plant Operations, on January 9, 2012, the fire extinguishers were observed.

At 10:23 a.m., the fire extinguisher in the kitchen was blocked from view and access, by the door to the storage room.

During an interview on 1/9/12 at 10:23 a.m., Staff 2 stated that the door was kept open in order to easily access the kitchen supplies.

Based on observation and interview, the facility failed to ensure a portable space heater was not used in a patient care area. This was evidenced by a personal space heater in the corridor of the Birthplace/Nursery area. This could potentially cause harm or death to residents, visitors and staff in the event the portable space heater ignited material around it causing a fire. This affected 1 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations on January 9, 2012, a space heater was observed in the corridor.

1. At 9:15 a.m., there was a personal space heater in the corridor across from the FCC Nursing Station in the Birthplace/Nursery area. The heater was a Dayton Model# 1VNX9, 120 volts, 1500 Watts, and was sitting on the ground next to a crash cart and an IV pole (see attached photo).

During an interview at 9:15 a.m., Staff 4 stated that the heater was used in a patient room about 2 weeks ago. The heater was used when the weather outside changed from warm to cold.

Based on observation, document review and interview, the facility failed to maintain humidity levels at 35% or greater in accordance with NFPA 99. This was evidenced by documentation of humidity levels less than 35% in 3 of 3 operating rooms and in 1 of 1 Labor Delivery room, and by the failure to document the corrective action when humidity levels were low. This failure could increase the risk of a fire hazard resulting from low humidity levels in the operating rooms causing harm to patients and staff in 3 Operating rooms and 1 Labor Delivery room.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1 Ventilation--Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During a tour of the facility with the Plant Operations Supervisor, on January 9, 2012, the humidity levels were observed and staff was interviewed.

Surgery Suite -

1. At 11:15 a.m., during an interview, the Surgery Orderly stated that he documents the Humidity and Temperatures for three Operating rooms. He stated that he calls engineering when the Humidity levels are below the facility policy which is 30%.

At 11:18 a.m., in Operating Room 3, the hydrometer noted the humidity to be at 22%.
At 11:21 a.m., in Operating Room 2, the hydrometer noted the humidity to be at 22%.
At 11:24 a.m., in Operating Room 1, the hydrometer noted the humidity to be at 20%.

2. At 11:28 a.m., during an interview, the Plant Operations Supervisor stated that when engineering staff receive a call from surgery, they go to the Operating rooms and reset the humidistat control. The Plant Operations Supervisor was asked if the calls from surgery were provided on a log or if a work order was created for the corrective action taken by engineering. He stated engineering did not keep a log or record any corrective actions for the humidity levels, and there was "no paper trail."

3. During document review and interview with the Director of Plant Operations and the Plant Operations Supervisor, on January 10, 2012, the facility provided Department Policy and Procedures for Engineering and for Perioperative Surgery for Humidity. The reports for daily humidity checks for the operating rooms and the Labor and Delivery room were reviewed.

At 8:30 a.m., the Perioperative Department Policy and Procedures noted the relative humidity should be maintained between 30% and 60%. The policy stated humidity shall be monitored and recorded daily and if out of range shall be reported and corrective action taken by Engineering department shall be documented on a log sheet.

At 8:45 a.m., the daily humidity log sheets were reviewed. The humidity levels documented for Operating Rooms 1 - 3 and for the Labor and Delivery room, were recorded between 19% and 26% on 1/3/12, 1/4/12, 1/05/12, 1/9/12, and 1/10/12. The daily humidity log sheet had a section for date, problems and corrective action. This section was blank on all the humidity log sheets, including the log sheets that documented low humidity levels.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of extension cords, by a damaged electrical receptacle, by patient care equipment plugged into surge protectors, and by the use of surge protectors to provide additional outlets in place of providing fixed wiring. This failure had the potential to increase the risk of an electrical fire, and affected patient, staff and visitors in 5 of 9 smoke compartments.


NFPA 70, National Electrical Code, 1999 Edition,

Article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)


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

Findings:

During a tour of the facility with the Director of Plant Operations and the Plant Operations Supervisor, on January 9, 2012, the electrical wiring and equipment were observed.


1. At 10:10 a.m., a 3 outlet adapter was plugged into a power strip in the Med-Surge Monitoring Room. This was acknowledged by the Plant Operations Supervisor.

2. At 10:21 a.m., a white extension cord was in use behind the Medical Records printer desk. This was acknowledged by the Plant Operations Supervisor.

3. At 11:10 a.m., the wall receptacle was damaged, on the right side of the wall, in the surgery suite recovery area backroom. This was acknowledged by the Plant Operations Supervisor.


27961

4. At 9:58 a.m., there was a surge protector used to extend power to the microwave in the "Staff Lounge Women Only" room.

5. At 9:59 a.m., there were 4 Radical -7 monitors, battery back up packs and 4 Isolette baby warmer beds plugged into three surge protectors. The "7 Plug Surge-Arrest Performance APC Network, 7 outlet, phone line protection" surge protectors were mounted to the walls between the Isolette baby warmers. The patient equipment was plugged in the surge protectors, instead of directly into a fixed wired electrical receptacle. The surge protectors were used as a substitute for fixed wiring and used to extend power to the baby warmers, monitors and battery back up packs.

6. At 10:12 a.m., there was a surge protector used to extend power to a refrigerator in the Case Management/Social Services office.

7. At 10:55 a.m., there was a surge protector used to extend power to a microwave in the Male Employee Lounge.

8. At 11:05 a.m., there was a surge protector used to extend power to a microwave and refrigerator in the Security Room.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 1 of 9 smoke compartments and could result in potential harm to patients, staff and visitors, in the event of a fire.

Findings:

During a tour of the facility with the Plant Operations Supervisor on January 9, 2012, the facility walls and ceilings were observed.

Med-Surge:
1. At 9:23 a.m., there were two approximately 2 inch by 3 inch penetrations around cables, under the desk, in the back of the Nurse Station.

2. At 10:00 a.m., there was an approximately 1/2 inch penetration in the ceiling next to the sprinkler escutcheon ring, above bed "B" in Patient Room 102.

Based on observation, the facility failed to maintain corridor doors to latch and resist the passage of smoke. This was evidenced by failing to provide doors with devices suitable for keeping the doors closed and by failing to keep impediments from obstructing the doors from closing. This failure had the potential to allow the transfer of smoke and fire, in the event of a fire. This affected patients, staff and visitors in 6 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations and the Plant Operations Supervisor, on January 9 and January 10, 2012, the facility doors were observed.

Med-Surge - 1/9/12

1. At 9:20 a.m., the door to Patient Room 120, failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

2. At 9:24 a.m., the door to Patient Room 123, failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

3. At 9:27 a.m., the door to Patient Room 124 failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

4. At 9:43 a.m., the door to Patient Room 132 failed to close and latch.

5. At 10:05 a.m., the door to Patient Room 105 failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

6. At 10:14 a.m., the door to Patient Room 110 failed to close and latch. The door latch hit the strike plate, which obstructed the door from latching.

7. At 9:43 a.m., the door to Patient Room 111 failed to close and latch.

Surgery Suite -

1. At 11:13 a.m., the door to the Recovery room was held open by a rubber wedge. The door was equipped with a self-closure.

2. At 11:15 a.m., the Surgery Utility room corridor door was impeded from closure by equipment. The door was equipped with a self-closure.


27961

Labor and Delivery -

1. At 9:41 a.m., the door to Room 201 failed to close and positive latch, in the Birthplace/Nursery area.

2. At 9:43 a.m., the door to Room 202 failed to close and positive latch.

3. At 10:20 a.m., the office in the kitchen had a door with a kick stand hold open device. The kick stand obstructed the door from closing.

4. At 11:06 a.m., the door to the Security Room was equipped with a self closing device. The door was held open with a door wedge. When the wedge was removed the door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

1/10/12 -

1. At 9:51 a.m., the convenience doors to the Nursery area, by Room 206, had a kick stand on each door.

2. At 10:43 a.m., the convenience doors by Room 127 were connected to the fire alarm system and released from the magnet during alarm testing. The doors closed but failed to positive latch on the left side.

Based on observation, the facility failed to maintain its smoke barrier doors on magnetic devices to close and latch. This was evidenced by doors that failed to latch shut upon activation of the fire alarm system. This failure affected 4 of 9 smoke compartments and could result in the potential spread of smoke in the event of a fire, causing harm to patients, staff and visitors.

NFPA 101, Life Safety Code 2000 Edition
19.2.2.2 Doors.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During fire alarm system testing, with the Director of Plant Operations and the Plant Operations Supervisor, on January 10, 2012, the smoke barrier doors were observed.

1. At 9:50 a.m., the double door leaf, next to Room 213, released from its magnetic device but failed to latch, when the fire alarm system was tested. This was acknowledged by the Plant Operations Supervisor.

2. At 10:25 a.m., the double door leaf next to the laboratory released from its magnetic device but failed to latch, when the fire alarm system was tested. This was acknowledged by the Plant Operations Supervisor.

Based on observation, the facility failed to maintain one hazardous area, as evidenced by a hazardous area that was not equipped with a self-closing door. This could result in the spread of smoke and fire, and affected patients, staff and visitors in 1 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations, on January 9, 2012, the hazardous storage areas were observed. Combustible storage areas greater than 50 square feet are considered hazardous and are required to have a self closing door.


At 10:23 a.m., the kitchen supply storage room contained supplies and combustible storage. The door was not equipped with a self-closing device and was left open for easy access to supplies.

Based on observation, the facility failed to maintain their automatic sprinkler system, as evidenced by a sprinkler missing an escutcheon ring. The escutcheon ring is used to cover the penetration around the sprinkler head and pipe. This could result in a delay in extinguishing a fire or the spread of smoke, in the event of a fire. This affected 1 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations, on January 9, 2012, the sprinkler system was observed.

At 9:55 a.m., one of two sprinklers were missing an escutcheon ring, in the Director of Labor and Delivery office.

Based on observation and interview, the facility failed to ensure that their portable fire extinguishers were easily accessible in accordance with NFPA 10. This was evidenced by a fire extinguisher that was impeded from access. This could result in a delay to extinguish a fire and increase the risk of injury to patients, visitors and staff. This affected 1 of 9 smoke compartments.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.

Findings:

During a tour of the facility with Director of Plant Operations, on January 9, 2012, the fire extinguishers were observed.

At 10:23 a.m., the fire extinguisher in the kitchen was blocked from view and access, by the door to the storage room.

During an interview on 1/9/12 at 10:23 a.m., Staff 2 stated that the door was kept open in order to easily access the kitchen supplies.

Based on observation and interview, the facility failed to ensure a portable space heater was not used in a patient care area. This was evidenced by a personal space heater in the corridor of the Birthplace/Nursery area. This could potentially cause harm or death to residents, visitors and staff in the event the portable space heater ignited material around it causing a fire. This affected 1 of 9 smoke compartments.

Findings:

During a tour of the facility with the Director of Plant Operations on January 9, 2012, a space heater was observed in the corridor.

1. At 9:15 a.m., there was a personal space heater in the corridor across from the FCC Nursing Station in the Birthplace/Nursery area. The heater was a Dayton Model# 1VNX9, 120 volts, 1500 Watts, and was sitting on the ground next to a crash cart and an IV pole (see attached photo).

During an interview at 9:15 a.m., Staff 4 stated that the heater was used in a patient room about 2 weeks ago. The heater was used when the weather outside changed from warm to cold.

Based on observation, document review and interview, the facility failed to maintain humidity levels at 35% or greater in accordance with NFPA 99. This was evidenced by documentation of humidity levels less than 35% in 3 of 3 operating rooms and in 1 of 1 Labor Delivery room, and by the failure to document the corrective action when humidity levels were low. This failure could increase the risk of a fire hazard resulting from low humidity levels in the operating rooms causing harm to patients and staff in 3 Operating rooms and 1 Labor Delivery room.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1 Ventilation--Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During a tour of the facility with the Plant Operations Supervisor, on January 9, 2012, the humidity levels were observed and staff was interviewed.

Surgery Suite -

1. At 11:15 a.m., during an interview, the Surgery Orderly stated that he documents the Humidity and Temperatures for three Operating rooms. He stated that he calls engineering when the Humidity levels are below the facility policy which is 30%.

At 11:18 a.m., in Operating Room 3, the hydrometer noted the humidity to be at 22%.
At 11:21 a.m., in Operating Room 2, the hydrometer noted the humidity to be at 22%.
At 11:24 a.m., in Operating Room 1, the hydrometer noted the humidity to be at 20%.

2. At 11:28 a.m., during an interview, the Plant Operations Supervisor stated that when engineering staff receive a call from surgery, they go to the Operating rooms and reset the humidistat control. The Plant Operations Supervisor was asked if the calls from surgery were provided on a log or if a work order was created for the corrective action taken by engineering. He stated engineering did not keep a log or record any corrective actions for the humidity levels, and there was "no paper trail."

3. During document review and interview with the Director of Plant Operations and the Plant Operations Supervisor, on January 10, 2012, the facility provided Department Policy and Procedures for Engineering and for Perioperative Surgery for Humidity. The reports for daily humidity checks for the operating rooms and the Labor and Delivery room were reviewed.

At 8:30 a.m., the Perioperative Department Policy and Procedures noted the relative humidity should be maintained between 30% and 60%. The policy stated humidity shall be monitored and recorded daily and if out of range shall be reported and corrective action taken by Engineering department shall be documented on a log sheet.

At 8:45 a.m., the daily humidity log sheets were reviewed. The humidity levels documented for Operating Rooms 1 - 3 and for the Labor and Delivery room, were recorded between 19% and 26% on 1/3/12, 1/4/12, 1/05/12, 1/9/12, and 1/10/12. The daily humidity log sheet had a section for date, problems and corrective action. This section was blank on all the humidity log sheets, including the log sheets that documented low humidity levels.

Based on observation, the facility failed to maintain the electrical wiring and equipment, as evidenced by the use of extension cords, by a damaged electrical receptacle, by patient care equipment plugged into surge protectors, and by the use of surge protectors to provide additional outlets in place of providing fixed wiring. This failure had the potential to increase the risk of an electrical fire, and affected patient, staff and visitors in 5 of 9 smoke compartments.


NFPA 70, National Electrical Code, 1999 Edition,

Article 110-12(C) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)


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

Findings:

During a tour of the facility with the Director of Plant Operations and the Plant Operations Supervisor, on January 9, 2012, the electrical wiring and equipment were observed.


1. At 10:10 a.m., a 3 outlet adapter was plugged into a power strip in the Med-Surge Monitoring Room. This was acknowledged by the Plant Operations Supervisor.

2. At 10:21 a.m., a white extension cord was in use behind the Medical Records printer desk. This was acknowledged by the Plant Operations Supervisor.

3. At 11:10 a.m., the wall receptacle was damaged, on the right side of the wall, in the surgery suite recovery area backroom. This was acknowledged by the Plant Operations Supervisor.


27961

4. At 9:58 a.m., there was a surge protector used to extend power to the microwave in the "Staff Lounge Women Only" room.

5. At 9:59 a.m., there were 4 Radical -7 monitors, battery back up packs and 4 Isolette baby warmer beds plugged into three surge protectors. The "7 Plug Surge-Arrest Performance APC Network, 7 outlet, phone line protection" surge protectors were mounted to the walls between the Isolette baby warmers. The patient equipment was plugged in the surge protectors, instead of directly into a fixed wired electrical receptacle. The surge protectors were used as a substitute for fixed wiring and used to extend power to the baby warmers, monitors and battery back up packs.

6. At 10:12 a.m., there was a surge protector used to extend power to a refrigerator in the Case Management/Social Services office.

7. At 10:55 a.m., there was a surge protector used to extend power to a microwave in the Male Employee Lounge.

8. At 11:05 a.m., there was a surge protector used to extend power to a microwave and refrigerator in the Security Room.