HospitalInspections.org

Shiley Eye Center
4. On 5/27/11, at 6:50 a.m., there was an approximately 3/4 inch diameter hole in the wall behind the refrigerator in Clean Storage Room 321.

Child & Adolescent Psychiatric Services (CAPS).
5.On 5/31/11, at 11:02 a.m., Janitors Room 156 had a 3/4 inch penetration in the left wall.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the facility's ceilings and walls, affecting 2 of 11 floors in the Main Hospital Building, Child and Adolescent psychiatric Services Building and Moores Cancer Center and Shiley Eye Center. This could result in the spread of fire and smoke and potentially harm patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the walls and ceilings were observed.

Main Hospital - Hillcrest (2nd Floor)

1. On 05/25/2011, at 11:11 a.m., the wall to the Environmental Services Closet, located at 2-237, had four penetrations. Each penetration measured approximately 1-inch.

2. On 05/26/2011, at 10:47 a.m., the ceiling to Operating Room 4 had a penetration measuring approximately 1/2-inch. The penetration had a cable running through it.


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Main Hospital - Hillcrest (9th Floor)

3. On 5/25/2011, at 9:08 a.m., in the left side of the wall of consultation Room 9-307, there was a 1/2 inch diameter penetration.

Moores Cancer Center
6. On 05/27/2011, at 7:39 a.m., the wall to Room 1314 had two unsealed pipes that penetrated the wall to an adjacent room. Each pipe measured approximately 4-inches and had cables running through them.

7. On 05/27/2011, at 7:43 a.m., the ceiling and walls to the Communication Room, Room 1318, had multiple penetrations. More than 23 penetrations were counted: four penetrations measuring approximately 4-inches, eighteen penetrations measuring approximately 1-inch, and one penetration measuring approximately 6-inches by 15-inches.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor walls. This was evidenced by unsealed penetrations in the facility's corridor walls, affecting 3 of 11 floors in the Main Hospital Building. This had the potential for fire and smoke to spread quickly, resulting in harm to patients and staff with burns and/or smoke inhalation.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the corridor walls were observed.

Main Hospital - Hillcrest (4th Floor)
1. On 05/25/2011, at 10:45 a.m., there were two penetrations on the corridor wall on the 4th Floor. The first penetration was located above the drop down ceiling on the left side of the wall by 4-304, measuring approximately 1/2 inch in diameter. The second penetration was located above the drop down ceiling on the right side of the wall by 4-303E, measuring approximately 1/2 inch in diameter.

Main Hospital - Hillcrest (6th Floor)
2. On 05/25/2011, at 1:58 p.m., there was a penetration on the corridor wall on the 6th Floor. The penetration was located above the drop down ceiling on the left side of a black sprinkler pipe by 6-303B, measuring approximately 1/4 inch in diameter.


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Main Hospital - Hillcrest (5th Floor)
3. On 5/25/2011, at 3:09 p.m., in the Burn Center Corridor located across from Room 5-302, there were 2 penetrations approximately 1/2 inch each in diameter.

Based on observation, the facility failed to maintain the integrity of the corridor doors as evidenced by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke. This failure affected 1 of 11 floors and basement in the Main Hospital Building and 2 of 6 smoke compartments in the Child and Adolescent Psychiatric Services building. This could result in the spread of fire and or smoke, causing potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the closing of the corridor doors were observed.

Main Hospital - Hillcrest (11th Floor)
1. On 5/25/2011, at 10:11 a.m., the door to Room 1127 failed to latch when the door was closed.


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Main Hospital - Hillcrest (Basement Floor)
2. On 05/24/2011, at 2:36 p.m., the roll down WON-Door in the basement by the reception area in Suite L-203 was blocked from closing. The items found blocking the WON-Door from closing included a telephone, can with pens, a satisfaction survey box, and a bell.

Child & Adolescent Psychiatric Services (CAPS).
3. On 5/31/11, at 10:55 a.m., the door to Room 164 failed to latch when the door was closed.

4. On 5/31/11, at 10:59 a.m., the door to Room 153 failed to latch when the door was closed.

Based on observation, the facility failed to ensure that releasing mechanisms for the smoke barrier doors be maintained in working conditions. This affected 1 of 11 floors in the Main Hospital Building. This was evidenced by smoke barrier doors that failed to release from the magnet upon the activation of the fire alarm system. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients and the staff in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the smoke barrier doors were observed when the fire alarm system was tested.

Main Hospital - Hillcrest (1st Floor)
On 05/26/2011, at 1:27 p.m., 1 of 2 leaf doors in the Gift Shop failed to release from the magnet when the fire alarm system was activated.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations around wires and conduits in the smoke barrier walls. This failure affected 5 of 11 floors in the Main Hospital and could allow the spread of smoke during a fire from one compartment to the next compartment resulting in potential harm to patients, staff and visitors.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the facility smoke barrier walls were observed.

Main Hospital - Hillcrest (1st Floor)
1. On 5/24/2011, at 1:30 p.m., the smoke barrier wall next to Room 1-153 had an approximately 1/2 inch in diameter penetration in the center of the wall around white cable wires.

2. On 5/24/2011, at 2:13 p.m., the smoke barrier wall next to Room 1-317 had a 1 inch in diameter penetration around a conduit on the left side of the wall.

Main Hospital - Hillcrest (3rd Floor)
3. On 5/24/11, at 3:20 p.m., the smoke barrier wall next to the Heart Station West had a 1/4 inch diameter penetration next to a conduit in the center of the wall.


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Main Hospital - Hillcrest (Basement Floor)
4. On 05/24/2011, at 1:42 p.m., there was a penetration in the smoke barrier wall on the Basement Floor. The penetration was above the drop down ceiling by L-227, measuring approximately 1/2 inch in diameter.

Main Hospital - Hillcrest (2nd Floor)
5. On 05/24/2011, at 3:31 p.m., there was a penetration on the smoke barrier wall on the 2nd Floor. The penetration was above the drop down ceiling by 2-304, measuring approximately 1-inch by 1-inch and located on the edge of a pipe that measured approximately 4-inches.

6. On 05/24/2011, at 4:00 p.m., there was a penetration on the smoke barrier wall on the 2nd Floor. The penetration was above the drop down ceiling by 2-115, measuring approximately 1-foot by 4-inches and located by conduits that ran through the wall.

7. On 05/25/2011, at 8:51 a.m., there was a penetration on the smoke barrier wall on the 2nd Floor. The penetration was above the drop down ceiling by the Blood Bank, measuring approximately 1-inch.

Main Hospital - Hillcrest (6th Floor)
8. On 05/25/2011, at 1:51 p.m., there was a penetration on the smoke barrier wall on the 6th Floor. The penetration was above the drop down ceiling by 6-301, measuring approximately 1-inch in diameter and located by electrical conduits.

Based on observation, the facility failed to maintain the integrity of smoke barrier doors to prevent the passage of smoke. This was evidenced by a door that failed to positively latch upon closure and a gap between two leaf doors. This affected 3 of 11 floors in the Main Hospital Building. This had the potential of rapidly spreading smoke and fire from one smoke compartment to the next, resulting in injury to patients and staff from smoke inhalation and burns.

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the smoke barrier doors were observed.

Main Hospital - Hillcrest (2nd Floor)
1. On 05/26/2011, at 11:27 a.m., the smoke barrier doors on the 2nd Floor by the Blood Bank, 2-103, failed to positively latch 1 of 2 leaf doors. Both doors were equipped with latching mechanisms.

Main Hospital - Hillcrest (1st Floor-West Wing)
2. On 05/26/2011, at 2:30 p.m., the smoke barrier doors on the 1st Floor, in the West Wing, had a gap between the two leaf glass doors that measured approximately 1/2-inch in width and extended throughout the length of the door.


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Main Hospital - Hillcrest (8th Floor)
3. On 5/26/11, at 9:00 a.m., the North East side of the smoke barrier door failed to latch. The door was dragging heavily at the bottom and did not fully close.

Main Hospital - Hillcrest (2nd Floor)
4. On 5/26/11, at 11:30 a.m., the smoke barrier door leaf next to Room 2-111 failed to latch and the door would not stay in the hold open position.

Based on observation, the facility failed to maintain stairways cleared throughout its usable space. This was evidenced by carts being stored in the stairwell at the Shiley Eye Center. This had the potential of interfering with egress during a fire emergency, rendering the stairway unsafe or non-usable for patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose
that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the stairwell's egress was observed.

Shiley Eye Center
On 05/27/2011, at 6:56 a.m., the stairwell had three carts, identified by staff to belong to Environmental Services, that were being stored at the landing.

Based on observation, the facility failed to ensure that all exit discharges to the public way be maintained clear and unobstructed. This was evidenced by 1 of 6 exit discharges at the Child & Adolescent Psychiatric Services (CAPS) that had an obstructed pathway to the public way. This had the potential of delaying egress in the event of a fire or other emergency and could result in injury to patients and staff.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the exit discharge egress paths were observed.

Child and Adolescent Psychiatric Services.
On 05/31/2011, at 11:27 a.m., the exit discharge by the Cafeteria had obstructions in the pathway leading to the public way. Obstructions included overgrown vegetation that restricted the pathway to less than 28-inches and an unleveled surface throughout the pathway.

MRI Outpatient Services
7. On 5/26/11, at 7:26 a.m., the emergency light next to the scheduling office failed to illuminate during the push button test.

8. On 5/26/11, at 7:33 a.m., the emergency light in the waiting room failed to illuminate during the push button test.

9. On 5/26/11, at 7:35 a.m., the emergency light in the dressing room waiting area failed to illuminate during the push button test.

Based on observation, the facility failed to ensure that their emergency lighting were maintained in operational condition. This was evidenced by emergency lighting units that failed to illuminate when tested. This affected affecting 2 of 11 floors in the Main Hospital Building, MRI outpatient services and 1 of 3 floors at the Thornton Hospital. This had the potential for delay and confusion during emergency evacuation and causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the emergency lighting devices were observed and tested.

Main Hospital - Hillcrest (2nd Floor)
1.On 05/24/2011, at 3:40 p.m., the emergency lighting unit on the 2nd Floor by the Nursing Station in the Trauma/Surgical Intensive Care Unit failed to illuminate 2 of 2 light bulbs.

2. On 05/25/2011, at 8:43 a.m., the emergency lighting unit on the 2nd Floor by the Blood Bank Laboratory failed to illuminate 2 of 2 light bulbs.

3. On 05/25/2011, at 9:12 a.m., the emergency lighting unit on the 2nd Floor by the Laboratory 2-136 failed to illuminate 2 of 2 light bulbs.

4. On 05/25/2011, at 9:36 a.m., the emergency lighting unit on the 2nd Floor by the Laboratory 2-104 failed to illuminate 2 of 2 light bulbs.

5. On 05/26/2011, at 10:44 a.m., the emergency lighting units in Operating Room 1 failed to illuminate 1 of 2 lighting units.

Main Hospital - Hillcrest (1st Floor-West Wing)
6. On 05/25/2011, at 3:07 p.m., the emergency lighting unit by the Nursing Station in the West Wing failed to illuminate 2 of 2 light bulbs.

Thornton Hospital (Stairwell between 1st & 2nd Floor)
10. On 05/27/2011, at 12:55 p.m., the emergency lighting unit in Stairwell 3, between the 2nd Floor and the 3rd Floor, failed to illuminate 2 of 2 light bulbs.




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Thornton Hospital (2nd Floor)
11. On 5/27/11, at 10:00 a.m., the emergency light in the second floor East stairwell had 1 of 2 bulbs that was not working.

Based on staff interviews, the facility failed to ensure that staff members were aware of their duties to protect residents in the event of a fire. This was evidenced by a staff member who did not know where to activate the fire alarm system and could not explain procedures for a fire emergency at the Radiation Oncology & PET/CT Outpatient Center. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to residents and staff.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, staff members were interviewed.

Radiation Oncology & PET/CT Outpatient Center
On 05/27/2011, at 7:15 a.m., the staff member working at the front desk was interviewed to determine her knowledge of fire emergency procedures. The staff was asked to explain how to activate the fire alarm system and to explain what she would do in the event of a fire emergency. The staff member could not locate the closest fire alarm manual pull station and could not explain her responsibility in accordance with the facility's fire emergency plan.

Hyperbaric Medicine & Wound Healing Center

5. On 05/31/2011, at 9:37 a.m., the fire alarm was activated by a manual pull station located at the chamber console. The alarm sound was below the ambient sound level in the room housing the hyperbaric chamber. The hospital staff ackowledged that the fire alarm could not be heard. There was no chime or strobe light installed in the room.

Based on observation, interview, and document review, the facility failed to maintain their fire alarm system in accordance with NFPA 101 and 72. This was evidenced by staff members with no keys to activate locked fire alarm manual pull stations, chimes and audible devices that failed to operate, fire alarm not audible in the Hyperbaric Chamber and fire alarm annunciator panel not zoned correctly. This affected patients, staff and visitors in the Child and Adolescent Psychiatric Services and the Hyperbaric and Wound Care Center. This had the potential for delaying the notification of fire and summoning emergency personnel, resulting in injury to patients, visitors, and staff from fire.

NFPA 101 Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
4-3.2.2 To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupied area.


Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the fire alarm system was observed and tested.

Child and Adolescent Psychiatric Services building.
1. On 05/31/2011, at 11:42 a.m., the gymnasium had 2 of 2 fire alarm manual pull stations that required a key to operate. No facility staff had a key readily available to activate the fire alarm pull station, including administration staff, clinical staff, and maintenance staff. The Plant Operations Supervisor contracted to maintain the building stated that the pull stations had been replaced recently and he did not have a key for 2 of 2 fire alarm pull stations. The fire alarm inspection report dated 4/26/2011 showed that the pull stations had last been tested on January 20, 2011. During an interview on 06/01/2011, at 12:50 a.m., the facility staff stated the fire alarm inspection report dated 4/26/11 was the most recent test available for review.

2. On 05/31/2011, at 11:45 a.m., the fire alarm was activated and two sets of chime with strobe devices in the gymnasium failed to activate.

3. On 05/31/2011, at 11:51 a.m., the fire alarm was activated in the Main Building and all the audibles for the sets of chime with strobe devices installed throughout the facility failed to sound an alarm. The strobes did illuminate and flashed during testing. The fire drill document showed that the audible alarm were last checked on April 4, 2011. During an interview on 06/01/2011, at 1:00 p.m., the facility staff stated the fire drill record was the most recent test available for review.

4. On 06/01/2011, at 11:55 p.m., the fire alarm annunciator panel light indicator showed that the devices that were activated did not display the correct zone location of the devices.

Based on observation, the facility failed to ensure that their manual fire alarm pull stations were easily accessible to allow for quick activation of fire alarm. This was evidenced by a manual fire alarm pull station that was obstructed from view at the Radiation Oncology & PET/CT Outpatient Center. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the the fire alarm system was observed.

Radiation Oncology & PET/CT Outpatient Center
On 05/27/2011, at 7:13 a.m., there was a manual fire alarm pull station by the main lobby entrance that was obstructed by an Alcohol Based Hand Rub (ABHR) dispenser. The staff member working at the front desk could not identify the location of the fire alarm pull station.

Based on document review and interview, the facility failed to conduct smoke detector sensitivity test. This was evidenced by the facility's failure to provide records of sensitivity tests done for 34 of 34 smoke detectors in the Child and Adolescent Psychiatrict Services building from the time they were installed. This could result in failure to timely notify patients and staff of a fire in the facility and could result in serious injury from smoke and fire.

FIndings:

Child and adolescent Psychiatrict Services building.

On 05/24/2011, at 9:53 a.m., the sensitivity testing for all smoke detectors was requested. The facility staff stated on 06/01/2011, at 11:45 a.m., there was no record provided for the sensitivity testing of the smoke detectors.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 72. This was evidenced by a tamper switch that failed to sound a local alarm upon closing the Post Indicator Valve (PIV), affecting all patients, staff and visitors in all smoke compartments. This had the potential for someone to tamper with the sprinkler system's water supply and staff members to not be able to respond immediately, resulting in the failure of the sprinkler system in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the sprinkler system was observed.

Child and Adolescent Psychiatric Services.
On 06/01/2011, at 12:20 a.m., the PIV tamper switch failed to activate 2 of 3 local alarms at the annunciator panels after closing the valve supplying water to the sprinkler system.

Based on observation, the facility failed to ensure that the automatic sprinkler system be maintained and inspected periodically. This was evidenced by sprinklers that were missing escutcheon rings, missing quarterly inspection and testing and escutcheon rings not flush to the ceiling. This failure affected 1 of 11 floors in the Main Hospital Building, 6 smoke compartments at the Child and Adolescent Psychiatric services building and 2 of 3 floors of the Medical Office North (MON) building.. This could result in the fire sprinkler system to not function as designed in the event of a fire, causing potential harm to patients, staff and visitors.

NFPA 25, Standard for the Inspection, Testing, and
Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2 Inspection. 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.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the sprinkler system was observed.

Main Hospital - Hillcrest (11th floor)
1.On 5/25/11, at 10:14 a.m., the sprinkler escutcheon ring was missing in Room 1128.

Child & Adolescent Psychiatric Services (CAPS).

8. On 5/31/11, at 10:57 a.m., in Room 161, 1 of 2 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

9. On 5/31/11, at 11:05 a.m., in Conference Room 145, 1 of 2 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

10. On 5/31/11, at 11:07 a.m., in Laundry Room 135, the sprinkler cover (cap) was missing and revealed a penetration in the ceiling.

11. On 5/31/11, at 11:20 a.m., in Occupational Therapy Room 105, 1 of 4 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

12. On 5/31/11, at 11:30 a.m., in the CIS Day Room 115, 1 of 4 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

13. On 5/31/11, at 11:34 a.m., Physical Therapy Room 126 was missing a sprinkler cover (cap) and revealed a penetration in the ceiling.


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On May 23, 2011 through June 1, 2011, the quarterly sprinkler testing and inspection reports were reviewed.

14. On 5/31/11, at 12:00 a.m., the facility failed to provide documentation for 2 of 4 required quarterly test and inspection reports for the automatic sprinkler system between 07/07/2010 and 04/26/2011. During an interview on 06/01/2011, at 12:49 a.m., the facility staff stated there were no additional records for review.

Medical Office North (MON) 1st Floor
2. On 5/25/11, at 2:44 p.m., the sprinkler escutcheon next to Dressing Room 1-306, had a gap and was not flush with the ceiling.

3. On 5/25/11, at 2:50 p.m., in the Out Patient Registration corridor the sprinkler escutcheon ring was missing, revealing a penetration in the hard ceiling.

4. On 5/25/11, at 2:52 p.m., in the corridor across from Out Patient Registration there were two sprinkler escutcheon rings missing, revealing a penetration in the hard ceiling next to the Mens and Women's Restroom.

MON (2nd Floor)
5. On 5/25/11, at 3:18 p.m., in the Cath Lab next to Exam Room 1 the sprinkler escutcheon ring had a gap and was not flush with the ceiling.

6. On 5/25/11, at 3:36 p.m., 2 of 4 sprinkler escutcheon ring had gaps and were not flush with the ceiling in Procedure Room 2-402.

7. On 5/25/11, at 3:48 p.m., in the corridor outside of Room 323, the sprinkler escutcheon ring was missing revealing a penetration in the ceiling.

Based on observation, the facility failed to ensure that their portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by fire extinguishers that were obstructed from view. This affected 2 of 11 floors in the Main Hospital Building. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire.

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.

1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011,the fire extinguishers were observed.

Main Hospital - Hillcrest (2nd Floor)
1. On 05/25/2011, at 8:38 a.m., there was a fire extinguisher in the Blood Bank Laboratory on the 2nd Floor that was obstructed by a chair.

Main Hospital - Hillcrest (7th Floor)
2. On 05/26/2011, at 9:00 a.m., there was a fire extinguisher on the 7th Floor by Elevator 8 that was obstructed by a gurney, soiled linen cart, and a wheelchair.

Based on observation, the facility failed to ensure that smoking was allowed in their designated smoking areas to prevent accidental fire from lighted cigarette butts. This was evidenced by cigarette butts found on the ground in the facility, affecting 1 of 3 floors in the Medical Office North (MON) Building . This could result in accidental fire from cigarette butts.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the stairwells were observed.

MON (3rd Floor)
On 05/25/2011, at 8:38 a.m., at 11:29 a.m., there were approximately 12 cigarette butts on the ground in Stairwell 2 on the 3rd Floor that was not a designated smoking area. The facility (with the exception of Clinical Research studies that are conducted in designated areas) had prohibited smoking in all areas.

Based on observation, the facility failed to maintain their oxygen cylinder storage area in accordance with NFPA 99. This was evidenced by an electrical light switch and a red button that were installed less than 152 cm (5 ft) above the floor in the oxygen cylinder storage area at Thornton Hospital. This had the potential for an H-size cylinder to break the electrical fixtures and could result in fire and explosion.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the oxygen cylinder storage area was observed.

Thornton Hospital (Basement Floor)
On 05/27/2011, at 9:25 a.m., the oxygen cylinder storage room, located in the Basement Floor by the dock in L21, had two electrical fixtures that were installed below the 5-foot requirement from the floor. The electrical fixtures included a light switch and a red button.

Based on document review and interview, the facility failed to ensure that the humidity level at their anesthetizing locations be maintained above 35 percent in accordance with NFPA 99. This was evidenced by the facilities written policy requiring all anesthetizing locations be maintained between 20% and 60% and humidity logs with a reading of below 35 percent in anesthetizing locations. This affected 14 operating rooms on the second floor in the Main Hospital and 4 operating rooms in the South Wing same day surgery and 7 operating rooms in Thornton hospital. This failure could result in low humidity levels that can potentially lead to an increased risk of fire in the operating rooms.

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

Findings:

During document review and interview with Hospital Staff I (Facility Safety Director) on May 24, 2011, the relative humidity level reports and the facility policy for humidity levels were reviewed.

Main Hospital - Hillcrest
1. On 5/24/11, at 11:20 a.m., the facility provided records for the humidity levels for 11 operating rooms and for 3 Labor Delivery operating rooms. The reports noted Daily Checklist (rooms within Range 20% - 60% Rh). The facility failed to maintain a written Policy and Procedure to ensure the relative humidity is maintained at 35 percent or greater. During interview, the Facility Safety Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Shiley Eye Center
3. On 5/27/11, at 12:10 p.m., the facility provided records for the humidity levels for 4 operating rooms. The reports noted Daily Checklist (rooms within Range 20% - 60% Rh). The facility failed to maintain a written Policy and Procedure to ensure the relative humidity is maintained at 35 percent or greater. During interview, the Facility Safety Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Thornton Hospital
2. On 5/27/11, at 11:55 a.m., the facility provided records for the humidity levels for the operating rooms. The reports noted Daily Checklist (rooms within Range 20% - 60% Rh). The facility written Policy and Procedure for relative humidity in to ensure the relative humidity is maintained at 35 percent or greater. During interview, the Facility Safety Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Based on observation, the facility failed to ensure that flammable liquids were properly stored. This was evidenced by 7-8 Gallons of flammable liquids stored outside an approved storage cabinet. This could result in the rapid spread of fire and potentially cause injury to patients and staff in the event of a fire.

NFPA 99, Health Care Facilities, 1999 Edition
10-7.2.2* Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory.
Exception: Very small laboratory work areas acceptable to the authorities

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the flammable liquids in the laboratories were observed.

Main Hospital - Hillcrest (2nd Floor)
On 05/25/2011, at 1:15 p.m., the Surgical Pathology Laboratory in 2-100 had eight 5-Gallon and twelve 1-Gallon waste containers outside of a storage cabinet and within 100 square feet ratios. Upon further investigation, it was determined that these waste containers had approximately 7-8 Gallons of flammable liquids . Three of the 5-Gallon waste containers were tagged to contain Pen-Fix. The Material Safety Data Sheet (MSDS) categories Pen-Fix to have a Fire Hazard Flash Point of 4 (Below 73 degrees Fahrenheit); thus, Class I, as defined in NFPA 30 (Flammable and Combustible Liquids Code, 1996 Edition).

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by the use of power strips, power stirps interconnected to each other and the use of extension cords without overcurrent protection. This affected 7 of 11 floors in the Main Hospital, 2 of 3 floors and a basement in the Medical Office North (MON) Building, 1 of 3 floors in the Medical Office South (MOS) Building and 2 of 3 floors of the Thornton Hospital. This failure could result in the increase risk of an electrical fire resulting in potential harm to patients, staff and visitors.

NFPA 70, National Electrical Code, 1999 Edition
Article 400-Flexible Cords and Cables
Section 400-8.
Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable 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 ceiling, dropped ceiling, 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 buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Article 240-4, and HFCA Transmittal Notice 22-99, prohibits the use of extension cords without overcurrent protection.

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the facility electrical equipment and wiring were observed.

Main Hospital - Hillcrest (1st Floor)
1. On 5/24/11, at 1:09 p.m., in Administration office 1-121 there was a power strip plugged into an power strip next to the desk.

2. On 5/24/11, at 1:23 p.m., in Lasser Conference Room 1-153 there was a power strip plugged into a power strip next to the desk.

Main Hospital - Hillcrest (5th Floor)
3. On 5/24/11, at 3:30 p.m., in Room 514 the electrical cover plate was missing behind bed "A" television.

Main Hospital - Hillcrest (9th Floor)
4. On 5/25/11, at 9:14 a.m., in Room 9-310, there was a power strip plugged into a power strip and a refrigerator and microwave plugged into one of the power strips.

5. On 5/25/11, at 9:40 a.m., in Hemodialysis Room 928 there was a power strip plugged into a power strip.

Main Hospital - Hillcrest (11th Floor)
6. On 5/25/11, at 9:52 a.m., in the Social Work Room 11-310, there was a power strip plugged into a power strip.

Main Hospital - Hillcrest (10th Floor)
7. On 5/25/11, at 10:34 a.m., in Nursing Manager Office 10-307, there were two desk and both had power strips plugged into a power strip.

Main Hospital - Hillcrest (8th Floor)
8. On 5/25/11, at 11:24 a.m., in Room 804 and in Room 804 B, there were power strips plugged into power strips.


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Main Hospital - Hillcrest (2nd Floor)
9. On 05/25/2011, at 8:48 a.m., there was a 7-plug multi-outlet adapter that was sequentially plugged into a second 6-plug multi-outlet adapter that was then plugged into a receptacle wall outlet designed for 2-plugs. This was found in the Rheumatology Laboratory Office by 2-140.

10. On 05/25/2011, at 11:05 a.m., the receptacle outlet faceplate cover was not completely covering energized parts by 2-229.

Medical Office North(MON) (Basement Floor)
11. On 5/25/11, at 1:08 p.m., in Medical Records Room L-700, there was a power strip plugged into a power strip next to the desk.

MON (1st Floor)
12. On 5/25/11, at 2:35 p.m., in the Wound Clinic Room 1-402, there were two power strips plugged into a power strip next to the desk.

MON (2nd Floor)
13. On 5/25/11, at 3:34 p.m., in Cath Lab Procedure Room 2-402, there was a power strip plugged into a power strip and an extension cord plugged into one of the power strips.

MON (3rd Floor)
14. On 5/26/11, at 2:48 p.m., there was a power strip plugged into a power strip at the third floor Receptionist desk.

Thornton Hospital (2nd Floor)
15. On 5/27/11, at 9:42 a.m., there were two grey extension cords in use in Room 2-464.

16. On 5/27/11, at 10:11 a.m., in the ICU Room 2-305, there was a power strip plugged into a power strip.

17. On 5/27/11, at 10:18 a.m., in the ICU Room 2-028, there was a power strip plugged into a power strip.

Thornton Hospital (1st Floor)
18. On 5/27/11, at 10:24 a.m., in Room 1-246, there was a power strip plugged into a power strip.

19. On 5/27/11, at 10:27 a.m., in Room 1-253, an extension cord was plugged into a power strip.

20. On 5/27/11, at 10:48 a.m., in ED Room 1-101, there was a power strip plugged into a power strip.

Medical Offcie South (MOS), 2nd Floor
4. On 5/26/11, at 3:20 p.m., the ABHR dispenser in Room 2-264 was installed above the light switch.

5. On 5/26/11, at 12:50 p.m., the ABHR dispenser in Room 2-258 was installed above the light switch.

Moores Cancer Center
6. On 5/27/11, at 7:45 a.m., the ABHR dispenser in Room 1179 was installed above an electrical outlet.

Based on observation, the facility failed to install their Alcohol Based Hand Rub (ABHR) dispensers away from an ignition sources. This was evidenced by ABHR dispensers installed over or adjacent to electrical ignition sources. This affected 2 of 11 floors in the Main Hospital Building, 1 of 3 floors in the Medical Offices South (MOS) building, and 1 floor at the Moores Cancer Center. This had the potential for causing fire and harming patients and staff.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the ABHR dispensers were observed.

Main Hospital - Hillcrest (Basement Floor)
1. On 05/24/2011, at 2:11 p.m., the ABHR dispenser in the Linen Room on the Basement Floor was installed adjacent and within 6-inches from an electrical light switch.

Main Hospital - Hillcrest (2nd Floor)
2. On 05/25/2011, at 9:17 a.m., the ABHR dispenser in the Special Chemistry Laboratory, 2-135, on the 2nd Floor was installed adjacent and within 6-inches from an electrical light switch.

3. On 05/25/2011, at 9:39 a.m., the ABHR dispenser in the Cytology Laboratory, 2-113, on the 2nd Floor was installed above an electrical receptacle wall outlet.

Shiley Eye Center
4. On 5/27/11, at 6:50 a.m., there was an approximately 3/4 inch diameter hole in the wall behind the refrigerator in Clean Storage Room 321.

Child & Adolescent Psychiatric Services (CAPS).
5.On 5/31/11, at 11:02 a.m., Janitors Room 156 had a 3/4 inch penetration in the left wall.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the facility's ceilings and walls, affecting 2 of 11 floors in the Main Hospital Building, Child and Adolescent psychiatric Services Building and Moores Cancer Center and Shiley Eye Center. This could result in the spread of fire and smoke and potentially harm patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the walls and ceilings were observed.

Main Hospital - Hillcrest (2nd Floor)

1. On 05/25/2011, at 11:11 a.m., the wall to the Environmental Services Closet, located at 2-237, had four penetrations. Each penetration measured approximately 1-inch.

2. On 05/26/2011, at 10:47 a.m., the ceiling to Operating Room 4 had a penetration measuring approximately 1/2-inch. The penetration had a cable running through it.


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Main Hospital - Hillcrest (9th Floor)

3. On 5/25/2011, at 9:08 a.m., in the left side of the wall of consultation Room 9-307, there was a 1/2 inch diameter penetration.

Moores Cancer Center
6. On 05/27/2011, at 7:39 a.m., the wall to Room 1314 had two unsealed pipes that penetrated the wall to an adjacent room. Each pipe measured approximately 4-inches and had cables running through them.

7. On 05/27/2011, at 7:43 a.m., the ceiling and walls to the Communication Room, Room 1318, had multiple penetrations. More than 23 penetrations were counted: four penetrations measuring approximately 4-inches, eighteen penetrations measuring approximately 1-inch, and one penetration measuring approximately 6-inches by 15-inches.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor walls. This was evidenced by unsealed penetrations in the facility's corridor walls, affecting 3 of 11 floors in the Main Hospital Building. This had the potential for fire and smoke to spread quickly, resulting in harm to patients and staff with burns and/or smoke inhalation.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the corridor walls were observed.

Main Hospital - Hillcrest (4th Floor)
1. On 05/25/2011, at 10:45 a.m., there were two penetrations on the corridor wall on the 4th Floor. The first penetration was located above the drop down ceiling on the left side of the wall by 4-304, measuring approximately 1/2 inch in diameter. The second penetration was located above the drop down ceiling on the right side of the wall by 4-303E, measuring approximately 1/2 inch in diameter.

Main Hospital - Hillcrest (6th Floor)
2. On 05/25/2011, at 1:58 p.m., there was a penetration on the corridor wall on the 6th Floor. The penetration was located above the drop down ceiling on the left side of a black sprinkler pipe by 6-303B, measuring approximately 1/4 inch in diameter.


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Main Hospital - Hillcrest (5th Floor)
3. On 5/25/2011, at 3:09 p.m., in the Burn Center Corridor located across from Room 5-302, there were 2 penetrations approximately 1/2 inch each in diameter.

Based on observation, the facility failed to maintain the integrity of the corridor doors as evidenced by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke. This failure affected 1 of 11 floors and basement in the Main Hospital Building and 2 of 6 smoke compartments in the Child and Adolescent Psychiatric Services building. This could result in the spread of fire and or smoke, causing potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the closing of the corridor doors were observed.

Main Hospital - Hillcrest (11th Floor)
1. On 5/25/2011, at 10:11 a.m., the door to Room 1127 failed to latch when the door was closed.


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Main Hospital - Hillcrest (Basement Floor)
2. On 05/24/2011, at 2:36 p.m., the roll down WON-Door in the basement by the reception area in Suite L-203 was blocked from closing. The items found blocking the WON-Door from closing included a telephone, can with pens, a satisfaction survey box, and a bell.

Child & Adolescent Psychiatric Services (CAPS).
3. On 5/31/11, at 10:55 a.m., the door to Room 164 failed to latch when the door was closed.

4. On 5/31/11, at 10:59 a.m., the door to Room 153 failed to latch when the door was closed.

Based on observation, the facility failed to ensure that releasing mechanisms for the smoke barrier doors be maintained in working conditions. This affected 1 of 11 floors in the Main Hospital Building. This was evidenced by smoke barrier doors that failed to release from the magnet upon the activation of the fire alarm system. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients and the staff in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the smoke barrier doors were observed when the fire alarm system was tested.

Main Hospital - Hillcrest (1st Floor)
On 05/26/2011, at 1:27 p.m., 1 of 2 leaf doors in the Gift Shop failed to release from the magnet when the fire alarm system was activated.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations around wires and conduits in the smoke barrier walls. This failure affected 5 of 11 floors in the Main Hospital and could allow the spread of smoke during a fire from one compartment to the next compartment resulting in potential harm to patients, staff and visitors.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the facility smoke barrier walls were observed.

Main Hospital - Hillcrest (1st Floor)
1. On 5/24/2011, at 1:30 p.m., the smoke barrier wall next to Room 1-153 had an approximately 1/2 inch in diameter penetration in the center of the wall around white cable wires.

2. On 5/24/2011, at 2:13 p.m., the smoke barrier wall next to Room 1-317 had a 1 inch in diameter penetration around a conduit on the left side of the wall.

Main Hospital - Hillcrest (3rd Floor)
3. On 5/24/11, at 3:20 p.m., the smoke barrier wall next to the Heart Station West had a 1/4 inch diameter penetration next to a conduit in the center of the wall.


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Main Hospital - Hillcrest (Basement Floor)
4. On 05/24/2011, at 1:42 p.m., there was a penetration in the smoke barrier wall on the Basement Floor. The penetration was above the drop down ceiling by L-227, measuring approximately 1/2 inch in diameter.

Main Hospital - Hillcrest (2nd Floor)
5. On 05/24/2011, at 3:31 p.m., there was a penetration on the smoke barrier wall on the 2nd Floor. The penetration was above the drop down ceiling by 2-304, measuring approximately 1-inch by 1-inch and located on the edge of a pipe that measured approximately 4-inches.

6. On 05/24/2011, at 4:00 p.m., there was a penetration on the smoke barrier wall on the 2nd Floor. The penetration was above the drop down ceiling by 2-115, measuring approximately 1-foot by 4-inches and located by conduits that ran through the wall.

7. On 05/25/2011, at 8:51 a.m., there was a penetration on the smoke barrier wall on the 2nd Floor. The penetration was above the drop down ceiling by the Blood Bank, measuring approximately 1-inch.

Main Hospital - Hillcrest (6th Floor)
8. On 05/25/2011, at 1:51 p.m., there was a penetration on the smoke barrier wall on the 6th Floor. The penetration was above the drop down ceiling by 6-301, measuring approximately 1-inch in diameter and located by electrical conduits.

Based on observation, the facility failed to maintain the integrity of smoke barrier doors to prevent the passage of smoke. This was evidenced by a door that failed to positively latch upon closure and a gap between two leaf doors. This affected 3 of 11 floors in the Main Hospital Building. This had the potential of rapidly spreading smoke and fire from one smoke compartment to the next, resulting in injury to patients and staff from smoke inhalation and burns.

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the smoke barrier doors were observed.

Main Hospital - Hillcrest (2nd Floor)
1. On 05/26/2011, at 11:27 a.m., the smoke barrier doors on the 2nd Floor by the Blood Bank, 2-103, failed to positively latch 1 of 2 leaf doors. Both doors were equipped with latching mechanisms.

Main Hospital - Hillcrest (1st Floor-West Wing)
2. On 05/26/2011, at 2:30 p.m., the smoke barrier doors on the 1st Floor, in the West Wing, had a gap between the two leaf glass doors that measured approximately 1/2-inch in width and extended throughout the length of the door.


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Main Hospital - Hillcrest (8th Floor)
3. On 5/26/11, at 9:00 a.m., the North East side of the smoke barrier door failed to latch. The door was dragging heavily at the bottom and did not fully close.

Main Hospital - Hillcrest (2nd Floor)
4. On 5/26/11, at 11:30 a.m., the smoke barrier door leaf next to Room 2-111 failed to latch and the door would not stay in the hold open position.

Based on observation, the facility failed to maintain stairways cleared throughout its usable space. This was evidenced by carts being stored in the stairwell at the Shiley Eye Center. This had the potential of interfering with egress during a fire emergency, rendering the stairway unsafe or non-usable for patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose
that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the stairwell's egress was observed.

Shiley Eye Center
On 05/27/2011, at 6:56 a.m., the stairwell had three carts, identified by staff to belong to Environmental Services, that were being stored at the landing.

Based on observation, the facility failed to ensure that all exit discharges to the public way be maintained clear and unobstructed. This was evidenced by 1 of 6 exit discharges at the Child & Adolescent Psychiatric Services (CAPS) that had an obstructed pathway to the public way. This had the potential of delaying egress in the event of a fire or other emergency and could result in injury to patients and staff.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the exit discharge egress paths were observed.

Child and Adolescent Psychiatric Services.
On 05/31/2011, at 11:27 a.m., the exit discharge by the Cafeteria had obstructions in the pathway leading to the public way. Obstructions included overgrown vegetation that restricted the pathway to less than 28-inches and an unleveled surface throughout the pathway.

MRI Outpatient Services
7. On 5/26/11, at 7:26 a.m., the emergency light next to the scheduling office failed to illuminate during the push button test.

8. On 5/26/11, at 7:33 a.m., the emergency light in the waiting room failed to illuminate during the push button test.

9. On 5/26/11, at 7:35 a.m., the emergency light in the dressing room waiting area failed to illuminate during the push button test.

Based on observation, the facility failed to ensure that their emergency lighting were maintained in operational condition. This was evidenced by emergency lighting units that failed to illuminate when tested. This affected affecting 2 of 11 floors in the Main Hospital Building, MRI outpatient services and 1 of 3 floors at the Thornton Hospital. This had the potential for delay and confusion during emergency evacuation and causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the emergency lighting devices were observed and tested.

Main Hospital - Hillcrest (2nd Floor)
1.On 05/24/2011, at 3:40 p.m., the emergency lighting unit on the 2nd Floor by the Nursing Station in the Trauma/Surgical Intensive Care Unit failed to illuminate 2 of 2 light bulbs.

2. On 05/25/2011, at 8:43 a.m., the emergency lighting unit on the 2nd Floor by the Blood Bank Laboratory failed to illuminate 2 of 2 light bulbs.

3. On 05/25/2011, at 9:12 a.m., the emergency lighting unit on the 2nd Floor by the Laboratory 2-136 failed to illuminate 2 of 2 light bulbs.

4. On 05/25/2011, at 9:36 a.m., the emergency lighting unit on the 2nd Floor by the Laboratory 2-104 failed to illuminate 2 of 2 light bulbs.

5. On 05/26/2011, at 10:44 a.m., the emergency lighting units in Operating Room 1 failed to illuminate 1 of 2 lighting units.

Main Hospital - Hillcrest (1st Floor-West Wing)
6. On 05/25/2011, at 3:07 p.m., the emergency lighting unit by the Nursing Station in the West Wing failed to illuminate 2 of 2 light bulbs.

Thornton Hospital (Stairwell between 1st & 2nd Floor)
10. On 05/27/2011, at 12:55 p.m., the emergency lighting unit in Stairwell 3, between the 2nd Floor and the 3rd Floor, failed to illuminate 2 of 2 light bulbs.




21101

Thornton Hospital (2nd Floor)
11. On 5/27/11, at 10:00 a.m., the emergency light in the second floor East stairwell had 1 of 2 bulbs that was not working.

Based on staff interviews, the facility failed to ensure that staff members were aware of their duties to protect residents in the event of a fire. This was evidenced by a staff member who did not know where to activate the fire alarm system and could not explain procedures for a fire emergency at the Radiation Oncology & PET/CT Outpatient Center. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to residents and staff.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, staff members were interviewed.

Radiation Oncology & PET/CT Outpatient Center
On 05/27/2011, at 7:15 a.m., the staff member working at the front desk was interviewed to determine her knowledge of fire emergency procedures. The staff was asked to explain how to activate the fire alarm system and to explain what she would do in the event of a fire emergency. The staff member could not locate the closest fire alarm manual pull station and could not explain her responsibility in accordance with the facility's fire emergency plan.

Hyperbaric Medicine & Wound Healing Center

5. On 05/31/2011, at 9:37 a.m., the fire alarm was activated by a manual pull station located at the chamber console. The alarm sound was below the ambient sound level in the room housing the hyperbaric chamber. The hospital staff ackowledged that the fire alarm could not be heard. There was no chime or strobe light installed in the room.

Based on observation, interview, and document review, the facility failed to maintain their fire alarm system in accordance with NFPA 101 and 72. This was evidenced by staff members with no keys to activate locked fire alarm manual pull stations, chimes and audible devices that failed to operate, fire alarm not audible in the Hyperbaric Chamber and fire alarm annunciator panel not zoned correctly. This affected patients, staff and visitors in the Child and Adolescent Psychiatric Services and the Hyperbaric and Wound Care Center. This had the potential for delaying the notification of fire and summoning emergency personnel, resulting in injury to patients, visitors, and staff from fire.

NFPA 101 Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
4-3.2.2 To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupied area.


Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the fire alarm system was observed and tested.

Child and Adolescent Psychiatric Services building.
1. On 05/31/2011, at 11:42 a.m., the gymnasium had 2 of 2 fire alarm manual pull stations that required a key to operate. No facility staff had a key readily available to activate the fire alarm pull station, including administration staff, clinical staff, and maintenance staff. The Plant Operations Supervisor contracted to maintain the building stated that the pull stations had been replaced recently and he did not have a key for 2 of 2 fire alarm pull stations. The fire alarm inspection report dated 4/26/2011 showed that the pull stations had last been tested on January 20, 2011. During an interview on 06/01/2011, at 12:50 a.m., the facility staff stated the fire alarm inspection report dated 4/26/11 was the most recent test available for review.

2. On 05/31/2011, at 11:45 a.m., the fire alarm was activated and two sets of chime with strobe devices in the gymnasium failed to activate.

3. On 05/31/2011, at 11:51 a.m., the fire alarm was activated in the Main Building and all the audibles for the sets of chime with strobe devices installed throughout the facility failed to sound an alarm. The strobes did illuminate and flashed during testing. The fire drill document showed that the audible alarm were last checked on April 4, 2011. During an interview on 06/01/2011, at 1:00 p.m., the facility staff stated the fire drill record was the most recent test available for review.

4. On 06/01/2011, at 11:55 p.m., the fire alarm annunciator panel light indicator showed that the devices that were activated did not display the correct zone location of the devices.

Based on observation, the facility failed to ensure that their manual fire alarm pull stations were easily accessible to allow for quick activation of fire alarm. This was evidenced by a manual fire alarm pull station that was obstructed from view at the Radiation Oncology & PET/CT Outpatient Center. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the the fire alarm system was observed.

Radiation Oncology & PET/CT Outpatient Center
On 05/27/2011, at 7:13 a.m., there was a manual fire alarm pull station by the main lobby entrance that was obstructed by an Alcohol Based Hand Rub (ABHR) dispenser. The staff member working at the front desk could not identify the location of the fire alarm pull station.

Based on document review and interview, the facility failed to conduct smoke detector sensitivity test. This was evidenced by the facility's failure to provide records of sensitivity tests done for 34 of 34 smoke detectors in the Child and Adolescent Psychiatrict Services building from the time they were installed. This could result in failure to timely notify patients and staff of a fire in the facility and could result in serious injury from smoke and fire.

FIndings:

Child and adolescent Psychiatrict Services building.

On 05/24/2011, at 9:53 a.m., the sensitivity testing for all smoke detectors was requested. The facility staff stated on 06/01/2011, at 11:45 a.m., there was no record provided for the sensitivity testing of the smoke detectors.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 72. This was evidenced by a tamper switch that failed to sound a local alarm upon closing the Post Indicator Valve (PIV), affecting all patients, staff and visitors in all smoke compartments. This had the potential for someone to tamper with the sprinkler system's water supply and staff members to not be able to respond immediately, resulting in the failure of the sprinkler system in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the sprinkler system was observed.

Child and Adolescent Psychiatric Services.
On 06/01/2011, at 12:20 a.m., the PIV tamper switch failed to activate 2 of 3 local alarms at the annunciator panels after closing the valve supplying water to the sprinkler system.

Based on observation, the facility failed to ensure that the automatic sprinkler system be maintained and inspected periodically. This was evidenced by sprinklers that were missing escutcheon rings, missing quarterly inspection and testing and escutcheon rings not flush to the ceiling. This failure affected 1 of 11 floors in the Main Hospital Building, 6 smoke compartments at the Child and Adolescent Psychiatric services building and 2 of 3 floors of the Medical Office North (MON) building.. This could result in the fire sprinkler system to not function as designed in the event of a fire, causing potential harm to patients, staff and visitors.

NFPA 25, Standard for the Inspection, Testing, and
Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-2 Inspection. 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.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the sprinkler system was observed.

Main Hospital - Hillcrest (11th floor)
1.On 5/25/11, at 10:14 a.m., the sprinkler escutcheon ring was missing in Room 1128.

Child & Adolescent Psychiatric Services (CAPS).

8. On 5/31/11, at 10:57 a.m., in Room 161, 1 of 2 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

9. On 5/31/11, at 11:05 a.m., in Conference Room 145, 1 of 2 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

10. On 5/31/11, at 11:07 a.m., in Laundry Room 135, the sprinkler cover (cap) was missing and revealed a penetration in the ceiling.

11. On 5/31/11, at 11:20 a.m., in Occupational Therapy Room 105, 1 of 4 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

12. On 5/31/11, at 11:30 a.m., in the CIS Day Room 115, 1 of 4 sprinkler escutcheon rings had a gap and was not flush with the ceiling.

13. On 5/31/11, at 11:34 a.m., Physical Therapy Room 126 was missing a sprinkler cover (cap) and revealed a penetration in the ceiling.


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On May 23, 2011 through June 1, 2011, the quarterly sprinkler testing and inspection reports were reviewed.

14. On 5/31/11, at 12:00 a.m., the facility failed to provide documentation for 2 of 4 required quarterly test and inspection reports for the automatic sprinkler system between 07/07/2010 and 04/26/2011. During an interview on 06/01/2011, at 12:49 a.m., the facility staff stated there were no additional records for review.

Medical Office North (MON) 1st Floor
2. On 5/25/11, at 2:44 p.m., the sprinkler escutcheon next to Dressing Room 1-306, had a gap and was not flush with the ceiling.

3. On 5/25/11, at 2:50 p.m., in the Out Patient Registration corridor the sprinkler escutcheon ring was missing, revealing a penetration in the hard ceiling.

4. On 5/25/11, at 2:52 p.m., in the corridor across from Out Patient Registration there were two sprinkler escutcheon rings missing, revealing a penetration in the hard ceiling next to the Mens and Women's Restroom.

MON (2nd Floor)
5. On 5/25/11, at 3:18 p.m., in the Cath Lab next to Exam Room 1 the sprinkler escutcheon ring had a gap and was not flush with the ceiling.

6. On 5/25/11, at 3:36 p.m., 2 of 4 sprinkler escutcheon ring had gaps and were not flush with the ceiling in Procedure Room 2-402.

7. On 5/25/11, at 3:48 p.m., in the corridor outside of Room 323, the sprinkler escutcheon ring was missing revealing a penetration in the ceiling.

Based on observation, the facility failed to ensure that their portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by fire extinguishers that were obstructed from view. This affected 2 of 11 floors in the Main Hospital Building. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire.

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.

1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011,the fire extinguishers were observed.

Main Hospital - Hillcrest (2nd Floor)
1. On 05/25/2011, at 8:38 a.m., there was a fire extinguisher in the Blood Bank Laboratory on the 2nd Floor that was obstructed by a chair.

Main Hospital - Hillcrest (7th Floor)
2. On 05/26/2011, at 9:00 a.m., there was a fire extinguisher on the 7th Floor by Elevator 8 that was obstructed by a gurney, soiled linen cart, and a wheelchair.

Based on observation, the facility failed to ensure that smoking was allowed in their designated smoking areas to prevent accidental fire from lighted cigarette butts. This was evidenced by cigarette butts found on the ground in the facility, affecting 1 of 3 floors in the Medical Office North (MON) Building . This could result in accidental fire from cigarette butts.

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the stairwells were observed.

MON (3rd Floor)
On 05/25/2011, at 8:38 a.m., at 11:29 a.m., there were approximately 12 cigarette butts on the ground in Stairwell 2 on the 3rd Floor that was not a designated smoking area. The facility (with the exception of Clinical Research studies that are conducted in designated areas) had prohibited smoking in all areas.

Based on observation, the facility failed to maintain their oxygen cylinder storage area in accordance with NFPA 99. This was evidenced by an electrical light switch and a red button that were installed less than 152 cm (5 ft) above the floor in the oxygen cylinder storage area at Thornton Hospital. This had the potential for an H-size cylinder to break the electrical fixtures and could result in fire and explosion.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the oxygen cylinder storage area was observed.

Thornton Hospital (Basement Floor)
On 05/27/2011, at 9:25 a.m., the oxygen cylinder storage room, located in the Basement Floor by the dock in L21, had two electrical fixtures that were installed below the 5-foot requirement from the floor. The electrical fixtures included a light switch and a red button.

Based on document review and interview, the facility failed to ensure that the humidity level at their anesthetizing locations be maintained above 35 percent in accordance with NFPA 99. This was evidenced by the facilities written policy requiring all anesthetizing locations be maintained between 20% and 60% and humidity logs with a reading of below 35 percent in anesthetizing locations. This affected 14 operating rooms on the second floor in the Main Hospital and 4 operating rooms in the South Wing same day surgery and 7 operating rooms in Thornton hospital. This failure could result in low humidity levels that can potentially lead to an increased risk of fire in the operating rooms.

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

Findings:

During document review and interview with Hospital Staff I (Facility Safety Director) on May 24, 2011, the relative humidity level reports and the facility policy for humidity levels were reviewed.

Main Hospital - Hillcrest
1. On 5/24/11, at 11:20 a.m., the facility provided records for the humidity levels for 11 operating rooms and for 3 Labor Delivery operating rooms. The reports noted Daily Checklist (rooms within Range 20% - 60% Rh). The facility failed to maintain a written Policy and Procedure to ensure the relative humidity is maintained at 35 percent or greater. During interview, the Facility Safety Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Shiley Eye Center
3. On 5/27/11, at 12:10 p.m., the facility provided records for the humidity levels for 4 operating rooms. The reports noted Daily Checklist (rooms within Range 20% - 60% Rh). The facility failed to maintain a written Policy and Procedure to ensure the relative humidity is maintained at 35 percent or greater. During interview, the Facility Safety Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Thornton Hospital
2. On 5/27/11, at 11:55 a.m., the facility provided records for the humidity levels for the operating rooms. The reports noted Daily Checklist (rooms within Range 20% - 60% Rh). The facility written Policy and Procedure for relative humidity in to ensure the relative humidity is maintained at 35 percent or greater. During interview, the Facility Safety Director stated the humidity range has always been 20 percent and was not aware that it should be 35 percent or greater.

Based on observation, the facility failed to ensure that flammable liquids were properly stored. This was evidenced by 7-8 Gallons of flammable liquids stored outside an approved storage cabinet. This could result in the rapid spread of fire and potentially cause injury to patients and staff in the event of a fire.

NFPA 99, Health Care Facilities, 1999 Edition
10-7.2.2* Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gal (3.78 L) per 100 ft2 (9.23 m2). The total volume of Class I, II, and IIIA liquids, including those contained in approved storage cabinets and safety cans, shall not exceed 2 gal (7.57 L) per 100 ft2 (9.23 m2). No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit. At least one approved flammable or combustible liquid storage room shall be available within any health care facility regularly maintaining a reserve storage capacity in excess of 300 gal (1135.5 L). Quantities of flammable and combustible liquids for disposal shall be included in the total inventory.
Exception: Very small laboratory work areas acceptable to the authorities

Findings:

During a tour of the facility with Hospital Staff on May 23, 2011 through June 1, 2011, the flammable liquids in the laboratories were observed.

Main Hospital - Hillcrest (2nd Floor)
On 05/25/2011, at 1:15 p.m., the Surgical Pathology Laboratory in 2-100 had eight 5-Gallon and twelve 1-Gallon waste containers outside of a storage cabinet and within 100 square feet ratios. Upon further investigation, it was determined that these waste containers had approximately 7-8 Gallons of flammable liquids . Three of the 5-Gallon waste containers were tagged to contain Pen-Fix. The Material Safety Data Sheet (MSDS) categories Pen-Fix to have a Fire Hazard Flash Point of 4 (Below 73 degrees Fahrenheit); thus, Class I, as defined in NFPA 30 (Flammable and Combustible Liquids Code, 1996 Edition).

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by the use of power strips, power stirps interconnected to each other and the use of extension cords without overcurrent protection. This affected 7 of 11 floors in the Main Hospital, 2 of 3 floors and a basement in the Medical Office North (MON) Building, 1 of 3 floors in the Medical Office South (MOS) Building and 2 of 3 floors of the Thornton Hospital. This failure could result in the increase risk of an electrical fire resulting in potential harm to patients, staff and visitors.

NFPA 70, National Electrical Code, 1999 Edition
Article 400-Flexible Cords and Cables
Section 400-8.
Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cable 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 ceiling, dropped ceiling, 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 buildings walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Article 240-4, and HFCA Transmittal Notice 22-99, prohibits the use of extension cords without overcurrent protection.

Findings:

During a tour of the facility with the Hospital Staff on May 23, 2011 through June 1, 2011, the facility electrical equipment and wiring were observed.

Main Hospital - Hillcrest (1st Floor)
1. On 5/24/11, at 1:09 p.m., in Administration office 1-121 there was a power strip plugged into an power strip next to the desk.

2. On 5/24/11, at 1:23 p.m., in Lasser Conference Room 1-153 there was a power strip plugged into a power strip next to the desk.

Main Hospital - Hillcrest (5th Floor)
3. On 5/24/11, at 3:30 p.m., in Room 514 the electrical cover plate was missing behind bed "A" television.

Main Hospital - Hillcrest (9th Floor)
4. On 5/25/11, at 9:14 a.m., in Room 9-310, there was a power strip plugged into a power strip and a refrigerator and microwave plugged into one of the power strips.

5. On 5/25/11, at 9:40 a.m., in Hemodialysis Room 928 there was a power strip plugged into a power strip.

Main Hospital - Hillcrest (11th Floor)
6. On 5/25/11, at 9:52 a.m., in the Social Work Room 11-310, there was a power strip plugged into a power strip.

Main Hospital - Hillcrest (10th Floor)
7. On 5/25/11, at 10:34 a.m., in Nursing Manager Office 10-307, there were two desk and both had power strips plugged into a power strip.

Main Hospital - Hillcrest (8th Floor)
8. On 5/25/11, at 11:24 a.m., in Room 804 and in Room 804 B, there were power strips plugged into power strips.


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Main Hospital - Hillcrest (2nd Floor)
9. On 05/25/2011, at 8:48 a.m., there was a 7-plug multi-outlet adapter that was sequentially plugged into a second 6-plug multi-outlet adapter that was then plugged into a receptacle wall outlet designed for 2-plugs. This was found in the Rheumatology Laboratory Office by 2-140.

10. On 05/25/2011, at 11:05 a.m., the receptacle outlet faceplate cover was not completely covering energized parts by 2-229.

Medical Office North(MON) (Basement Floor)
11. On 5/25/11, at 1:08 p.m., in Medical Records Room L-700, there was a power strip plugged into a power strip next to the desk.

MON (1st Floor)
12. On 5/25/11, at 2:35 p.m., in the Wound Clinic Room 1-402, there were two power strips plugged into a power strip next to the desk.

MON (2nd Floor)
13. On 5/25/11, at 3:34 p.m., in Cath Lab Procedure Room 2-402, there was a power strip plugged into a power strip and an extension cord plugged into one of the power strips.

MON (3rd Floor)
14. On 5/26/11, at 2:48 p.m., there was a power strip plugged into a power strip at the third floor Receptionist desk.

Thornton Hospital (2nd Floor)
15. On 5/27/11, at 9:42 a.m., there were two grey extension cords in use in Room 2-464.

16. On 5/27/11, at 10:11 a.m., in the ICU Room 2-305, there was a power strip plugged into a power strip.

17. On 5/27/11, at 10:18 a.m., in the ICU Room 2-028, there was a power strip plugged into a power strip.

Thornton Hospital (1st Floor)
18. On 5/27/11, at 10:24 a.m., in Room 1-246, there was a power strip plugged into a power strip.

19. On 5/27/11, at 10:27 a.m., in Room 1-253, an extension cord was plugged into a power strip.

20. On 5/27/11, at 10:48 a.m., in ED Room 1-101, there was a power strip plugged into a power strip.