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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by the failure to seal penetrations in the walls and ceilings. This affected two of six smoke compartments on two floors in the Kern Medical Center (KMC) main building, and one of four smoke compartments in the Sagebrush building. This could result in the spread of smoke from one compartment to another in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the ceilings and walls in the facility were observed.

May 26, 2010
Sagebrush:
1. At 12:28 p.m., there were 4 approximately 3/4 inch conduit wall penetrations with approximately 1/4 inch unsealed around the conduits, one approximately 4 inch wall penetration, and 2 approximately eight inch cast iron pipes with approximately one inch unsealed around the pipes, in the wall inside Room 45.
2. At 12:31 p.m., there were 2 approximately one inch by four inch penetrations, and 1 approximately one inch by three inch penetrations around approximately 3/4 inch conduits, inside x-ray Room 2407.

May 26, 2010
KMC Main Building:
First Floor:
1. At 3:19 p.m., there was an approximately one inch by three inch wall penetration with data wires exposed, in the left wall in Operating Room #7.
2. At 4:55 p.m., there were two approximately 1/2 inch wall penetrations inside the cafeteria.

Based on observation, the facility failed to ensure that doors protecting corridor openings shall be provided with a means suitable for keeping the doors closed, and that there are no impediments to closing the doors. This was evidenced by doors that were obstructed from closing, and by doors that were not provided with a means suitable for keeping the doors closed. This affected six of six smoke compartments on four floors in the main building, one of four smoke compartments in the Sagebrush building, and one of two smoke compartments in the F Ward Clinic. This could result in the passage of smoke and flames in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the corridor doors in the facility were observed.

May 25, 2010
KMC Main Building:
Fourth Floor:
1. At 3:17 p.m., the door to Room 4111 was obstructed by a pink floor sign and a stool inside the room.
2. At 3:30 p.m., the door to Room 4232 was obstructed by a yellow floor sign and a chair inside the room.

May 26, 2010
KMC Main Building:
First Floor:
1. At 9:47 a.m., the door to Room 1314 was held open by black rubber tubing which was tied to the door knob on the back side of the door.
2. At 10:11 a.m., the door to Basement stair #5 was held open with a round metal cylinder.
3. At 10:12 a.m., the door to the Medical Library was held open with a trashcan inside the room.

Third Floor:
4. At 2:36 p.m., the door to the Laundry room to the right of Room 3111 was held open with a trashcan inside the room.
5. At 2:52 p.m., the door to Room 3224 was held open with a trashcan inside the room.

Second Floor:
6. At 3:58 p.m., the door to Room 2117 was obstructed by a chair inside the room.
7. At 4:18 p.m., the door to Room 2020 was held open with a Sparkletts water bottle inside the room.
8. At 4:19 p.m., the door to Room 2057 was held open by a chair inside the room.
9. At 4:20 p.m., the door to Room 2011 was held open by a chair inside the room.

First Floor:
10. At 4:24 p.m., the door to the A Wing waiting room was held open by a chair inside the room.
11. At 4:28 p.m., the door to Room 1035 was held open by a rubber wedge.
12. At 4:38 p.m., the door to Ultrasound Room #3 was held open by a chair inside the room.
13. At 4:49 p.m., the door to Room 1158 had self-closing hardware that failed to latch the door. The strike hardware was stuck inside the door, and the door failed to latch.
14. At 4:53 p.m., the door to Room 1209 was held open by a wooden wedge.

May 26, 2010
F Ward Clinic:
At 10:31 a.m., the door to Room 138 was held open with a stool inside the room.

May 26, 2010
Sagebrush:
At 11:44 a.m., the door to Room 2408 was held open with a wooden wedge.


May 27, 2010
KMC Main Building:
First Floor:
1. At 8:27 a.m., the door to Room 1319 was held open with a 5 pound weight.
2. At 9:02 a.m., the door to Room 1546 was held open with a chair. The self-closing device failed to latch the door when tested.
3. At 9:03 a.m., the door to Room 1547 was held open with a chair.
4. At 9:08 a.m., the door to Room 1507 was held open by a rubber wedge.

Based on observation, the facility failed to maintain the integrity of doors that are permitted to be held open by devices that automatically close all such doors upon activation of the fire alarm system. This was evidenced by a door that failed to automatically release and close upon activation of the fire alarm system. This affected one of six smoke compartments on one floor of the KMC main building, and could result in the spread of smoke from one compartment to another in the event of a fire.

Findings:

On a facility tour with facility staff on May 26, 2010, the doors held open by magnetic devices were observed during testing of the fire alarm system.

Main Building:
Second Floor:
At 9:16 a.m., the pair of doors outside the entrance to the Intensive Care Unit (ICU) were observed during testing of the fire alarm. The right side door near ICU 2407 failed to automatically release from the magnetic hold-open device.

Based on observation, the facility failed to ensure that smoke barrier walls have a 1/2 hour fire resistance rating and are constructed in accordance with Section 8.3. This was evidenced by smoke barrier walls that had unsealed penetrations around pipes and cables. This affected two of six smoke compartments in the main building, and could result in the spread of smoke from one compartment to another in the event of a fire.

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 the facility tour with facility staff from May 25 to May 27, 2010, the smoke barrier walls were observed.

May 25, 2010
KMC Main Building:
Fourth Floor:
1. At 3:05 p.m., there was an approximately 1/2 inch penetration around a wire in the smoke barrier wall above door 4057.
2. At 3:10 p.m., there was an approximately one inch by three inch penetration above fire door 405 to the left of Room 4058.
3. At 3:14 p.m., there was an approximately three inch round penetration, and an approximately 2 1/2 inch white flexible cable penetration with approximately 1/2 inch unsealed around the penetration, above door 408 to the left of Room 4130.

May 26, 2010
KMC Main Building:
First Floor:
At 4:44 p.m., there was an approximately 2 inch conduit penetration with approximately 1/2 inch unsealed around the penetration, in the smoke barrier wall to the left of Room 1129.

Based on observation, the facility failed to ensure that smoke barrier doors are capable of resisting the passage of smoke, that the doors are self-closing, and that the doors are free from impediments. This was evidenced by smoke barrier doors that failed to close completely and latch upon testing of the fire alarm system devices. This affected two of six smoke compartments on two floors in the main building, and could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire.

Findings:

On a facility tour with facility staff on May 26, 2010, the doors protecting openings in smoke barriers in the facility were observed during testing of the fire alarm system.

May 26, 2010
Main Building:
Fourth Floor:
At 8:42 a.m., the left door of the pair of smoke barrier doors to the left of Room 4470 failed to self-close when the fire alarm was tested. The left door released but was obstructed from closing approximately 6 inches from the door frame by the coordinator arm at the top of the door frame.

Basement:
At 10:07 a.m., the left door of the pair of smoke barrier doors FD 118 outside the X-ray waiting room closed but failed to latch when the fire alarm was tested.

Based on observation, the facility failed to maintain the exit access in the facility so that exits are readily accessible at all times. This effected four exit corridors on three floors in the main building, and could result in a delay in exiting the facility in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the exit corridors in the facility were observed.

May 26, 2010
KMC Main Building:
Third Floor:
At 8:59 a.m., there was an approximately 5 feet high directional floor sign in the exit corridor opposite Room 3049. The sign read "Internal Medicine Applicants go to Room 3034".

Second Floor:
1. At 3:47 p.m., there was a garden hose coiled outside the exit door near Room 2352 which obstructed the door from opening into the exit path.
2. At 3:54 p.m., there was a chair obstructing one of two exit doors from Central Supply Room 2129.
3. At 4:11 p.m., there was a cabinet obstructing one of two exit doors from Room 2046.

May 27, 2010
KMC Main Building:
First Floor:
At 8:49 a.m., there was an approximately five foot high metal easel with an approximately three feet wide sign on it which read "Exit" and "Salida", in the exit corridor, outside Room 1438.

Based on observation and interview, the facility failed to maintain the integrity of the fire alarm system in accordance with NFPA 72. This was evidenced by a "trouble" light illuminated on the fire alarm control panel in the main building, and on the fire alarm control panel in one off-site building. This affected the entire main facility, and one off-site building, and could result in a delay in notification in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the fire alarm control panels were observed.

May 26, 2010
Main Building:
First Floor:
At 8:20 a.m., the main fire alarm control panel was observed. There was a "trouble" light illuminated on the panel. In an interview with staff, staff stated that there were four dirty smoke detectors that triggered the "trouble" signal on the panel. Staff stated that the smoke detectors would be serviced by a fire alarm technician.

Sagebrush:
At 11:16 a.m., the main fire alarm control panel was observed. There was "trouble" light illuminated on the panel. In an interview with staff, staff stated that there was a dirty smoke detector that triggered the "trouble" signal on the panel. Staff stated that the fire alarm monitoring company had been contacted on May 25, 2010 to report the "trouble" signal on the panel, and that the smoke detector would be serviced by a fire alarm technician.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by storage within 18 inches of a sprinkler head on two floors in the main building, and by missing escutcheon rings in the main building and one off-site building. This could result in the failure of the spray pattern to develop if the sprinkler system were activated, or in the spread of smoke or fire in the event of a fire. This affected two of six smoke compartments on two floors in the main building, one of four floors in the main building, and one of two smoke compartments in one off-site building.

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

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the automatic sprinkler system was observed.

May 26, 2010
Sagebrush:
At 12:55 p.m., there was an escutcheon ring missing from one of four sprinkler heads in Room 1234.

Main Building:
First Floor:
At 4:51 p.m., there was storage within approximately eight inches of the sprinkler head in Room 1202.


May 27, 2010
Main Building:
First Floor:
1. At 8:02 a.m., there was an escutcheon ring missing on one of two sprinkler heads in the women's restroom in the Lobby.
2. At 8:56 a.m., there was storage within approximately ten inches of the sprinkler head in the Gift Shop storage room.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in the facility in accordance with NFPA 10. This was evidenced by portable fire extinguishers that were stored unsecured, and by portable fire extinguishers that were obstructed. This affected three of four floors in the main building, and one of two smoke compartments in one offsite building. This could result in a delay in extinguishing a fire.

NFPA 10, Chapter 4 Inspection, Maintenance, and Recharging
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 10 (1998 edition) 1-6.7
Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the portable fire extinguishers were observed.

May 25, 2010
Main Building:
At 9:25 a.m., and 12:47 p.m., there were 24 portable fire extinguishers stored unsecured on the floor to the right entrance to the Engineering Department.

May 26, 2010
Sagebrush:
At 11:20 a.m., there were 3 portable fire extinguishers stored unsecured under the desk in the Security office.

Main Building:
Second Floor:
At 3:53 p.m., the fire extinguisher cabinet in Central Supply Room 2129 was obstructed by a metal cart on wheels.

First Floor:
1. At 4:30 p.m., the fire extinguisher cabinet to the right of Room 139 was obstructed by a metal cart on wheels.
2. At 4:41 p.m., the portable fire extinguisher cabinet in the Radiology registration area was obstructed by a recycling container.

May 27, 2010
Main Building:
First Floor:
1. At 8:06 a.m., there were 24 portable fire extinguishers stored unsecured on the floor to the right entrance to the Engineering Department. In an interview with staff, staff stated that the Security Department was responsible for the portable fire extinguishers.
2. At 8:36 a.m., the 24 portable fire extinguishers were removed from outside the Engineering Department.
3. At 11:57 a.m., there were 24 portable fire extinguishers stored unsecured on the ground inside a fenced area opposite the entrance to the Engineering Department.

Basement:
At 9:17 a.m., the portable fire extinguisher between Room 015 and 016 was obstructed by a scale.

Based on observation, the facility failed to provide ashtrays of noncombustible material and safe design, and failed to provide metal containers with self-closing cover devices, in all areas where smoking is permitted. This affected one of three designated smoking areas in the main building, one of one designated smoking area in one offsite buildings, and one non-designated smoking area in one offsite building. This could result in an increased risk of fire if embers from a cigarette were scattered from the designated smoking area.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the designated smoking areas were observed.

May 26, 2010

Main Building:
At 10:42 a.m., a man in a wheelchair was observed smoking outside the north entrance near the construction site. In an interview with staff, staff stated that this was not a designated smoking area. Staff asked the man to extinguish his cigarette, and explained that this was not a designated smoking area. There was a "no smoking" sign approximately 10 feet to the left of when the man was sitting. There were two extinguished cigarettes observed on the ground under the wheelchair.

Sagebrush:
1. At 11:49 a.m., there was a floor area approximately 15 inches by 24 inches with extinguished cigarette butts inside the locked exterior fire sprinkler room. There was no ashtray, and no metal container with a self-closing cover device provided. In an interview with staff, staff stated that this was not a designated smoking area.
2. At 12:12 p.m., there was no ashtray, and no metal container with a self-closing cover device, provided in the designated smoking area for Elderlife on the east side of the building.

Main Building:
At 4:04 p.m., the exterior secure third floor psychiatric unit designated smoking area was observed. Five patients were observed smoking, and two staff were present. One of five patients was observed using the metal container provided in the designated smoking area. The area around and underneath the picnic table with benches provided was covered with extinguished cigarette butts. One patient was observed smoking and dropping ashes on the ground.

May 27, 2010
F Ward Clinic
At 9:30 a.m., there was no ashtray, and no metal container with a self-closing cover device, provided in the designated smoking area. Ten extinguished cigarette butts were observed on the ground.

Based on observation, the facility failed to maintain the integrity of the building service equipment by the use of a portable space heating device. This was evidenced by one portable space heating device observed in a staff sleeping room. This affected one of six smoke compartments on one floor in the main building, and could result in an increased risk of fire.

Findings:

On a facility tour with facility staff on May 25, 2010, a portable space heating device was observed.

Main Building
Fourth Floor:
At 2:55 p.m., there was a portable space heating device observed in staff sleeping Room 4034.

Based on observation, record review and interview, the facility failed to maintain the integrity of the humidity levels in the anesthesia locations. This was evidenced by the facility failing to maintain the humidity levels in five of eight operating rooms and one central room, and two of two labor and delivery rooms, in accordance with NFPA 99. This affected two of five smoke compartments and two floors in the main building, and could result in an increased risk of fire.

NFPA 99
Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supporting anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

On a facility tour, record review and interview with facility staff from May 25 to May 27, 2010, the records for the humidity levels were reviewed, and the operating rooms (OR's) were observed.

May 25, 2010
Main Building:
At 11:03 a.m., the humidity level records "Surgery Room Temperature and Humidity Log" were reviewed. The record stated that "Temperature and Humidity in Surgery Rooms must be checked and recorded daily. Room temperatures are required to be between 64 to 70 degrees (at the physician's discretion). Humidity readings are required to be between 30% to 60% RH".

In an interview with staff at 11:15 a.m., staff stated that the humidity levels were taken in the early morning by the staff person who prepared the OR'S.

The records stated that the humidity levels were below 35% for five of eight OR's and central room, and two of two Labor and Delivery rooms, on the following dates:

2009:
October, 2009:
OR Room #2:
On 10/29/09, the humidity level was 34%.

OR Room #4:
On 10/27/09, the humidity level was 28%. Called engineering decrease humidity
On 10/29/09, the humidity level was 25%. Called engineering decrease humidity
OR Room #5:
On 10/29/09, the humidity level was 28%. Called engineering decrease humidity
On 10/27/09, the humidity level was 32%.

OR Room #6.5:
On 10/29/09, the humidity level was 34%.

OR Room #7:
On 10/27/09, the humidity level was 27%. Called engineering decrease humidity
On 10/29/09, the humidity level was 23%. Called engineering decrease humidity

OR Room #8:
On 10/27/09, the humidity level was 28%. Called engineering decrease humidity
On 10/29/09, the humidity level was 23%. Called engineering decrease humidity

Fourth Floor:
Labor and Delivery Room 4122:
On 10/10/09, the humidity level was 28%. Engineering called 915
On 10/13/09, the humidity level was 33%. Gage (sic) broken
engineer notified

Labor and Delivery Room 4116:
On 10/10/09, the humidity level was 30%. Broken glass on gauge engineering
On 10/11/09, the humidity level was 27%. Engineering called @ 0718 Came up @ 0738
On 10/12/09, the humidity level was 25%. Broken gauge. Engineering aware
On 10/13/09, the humidity level was 26%. Engineering called @ 0701 left message
November, 2009:
OR Room #4:
On 11/1/09, the humidity level was 33%.
On 11/17/09, the humidity level was 27%. Called engineering decrease humidity

OR Room #5:
On 11/1/09, the humidity level was 34%.
On 11/17/09, the humidity level was 31%.

OR Room #7:
On 11/1/09, the humidity level was 31%.
On 11/8/09, the humidity level was 34%.
On 11/9/09, the humidity level was 34%.
On 11/17/09, the humidity level was 27%. Called engineering decrease humidity
On 11/24/09, the humidity level was 32%.
On 11/25/09, the humidity level was 32%.
On 11/29/09, the humidity level was 30%.
On 11/30/09, the humidity level was 30%.

December, 2009:
OR Room #4:
On 12/1/09, the humidity level was 34%.
On 12/2/09, the humidity level was 33%.
On 12/3/09, the humidity level was 32%.
On 12/6/09, the humidity level was 27%. Called engineering decrease humidity
On 12/7/09, the humidity level was 28%. " "
On 12/22/09, the humidity level was 24%. Called engineering decrease humidity
On 12/23/09, the humidity level was 22%. " "
On 12/28/09, the humidity level was 32%.
On 12/29/09, the humidity level was 34%.

OR Room #5:
On 12/6/09, the humidity level was 32%.
On 12/7/09, the humidity level was 33%.
On 12/22/09, the humidity level was 31%.
On 12/23/09, the humidity level was 30%.

OR Room #7:
On 12/1/09, the humidity level was 30%.
On 12/2/09, the humidity level was 31%.
On 12/3/09, the humidity level was 30%.
On 12/6/09, the humidity level was 26%.
On 12/7/09, the humidity level was 27%.
On 12/16/09, the humidity level was 34%.
On 12/22/09, the humidity level was 25%. Called engineering decrease humidity
On 12/23/09,the humidity level was 24%. " "
On 12/28/09, the humidity level was 32%.
On 12/29/09, the humidity level was 32%.

OR Room #8:
On 12/1/09, the humidity level was 27%. Called engineering about decrease humidity
On 12/2/09, the humidity level was 28%. " "
On 12/3/09, the humidity level was 27%. " "
On 12/6/09, the humidity level was 23%. Called engineering decrease humidity
On 12/7/09, the humidity level was 24%. " "
On 12/10/09, the humidity level was 30%.
On 12/13/09, the humidity level was 34%.
On 12/14/09, the humidity level was 34%.
On 12/16/09, the humidity level was 30%.
On 12/17/09, the humidity level was 32%.
On 12/21/09, the humidity level was 34%.
On 12/22/09, the humidity level was 22%. Called engineering decrease humidity
On 12/23/09, the humidity level was 20%. " "
On 12/28/09, the humidity level was 28% Called engineering decrease humidity
On 12/29/09, the humidity level was 28%. " "
On 12/30/09, the humidity level was 32%.

2010:
January, 2010
OR Room #4:
On 1/5/10, the humidity level was 33%.
On 1/6/10, the humidity level was 33%.
On 1/7/10, the humidity level was 31%.

OR Room #5:
On 1/5/10, the humidity level was 34%.
On 1/6/10, the humidity level was 34%.
On 1/7/10, the humidity level was 33%.
On 1/24/10, the humidity level was 34%.

OR Room #7:
On 1/3/10, the humidity level was 33%.
On 1/4/10, the humidity level was 34%.
On 1/5/10, the humidity level was 31%.
On 1/6/10, the humidity level was 31%.
On 1/7/10, the humidity level was 30%.
On 1/18/10, the humidity level was 34%.
On 1/20/10, the humidity level was 31%.
On 1/24/10, the humidity level was 30%.


OR Room #8:
On 1/3/10, the humidity level was 30%.
On 1/4/10, the humidity level was 30%.
On 1/5/10, the humidity level was 28%. Called engineering decrease humidity
On 1/6/10, the humidity level was 27%. " "
On 1/7/10, the humidity level was 27%. " "
On 1/11/10, the humidity level was 34%. " "
On 1/12/10, the humidity level was 33%.
On 1/18/10, the humidity level was 31%.
On 1/20/10, the humidity level was 28%. Called engineering decrease humidity
On 1/21/10, the humidity level was 30%.
On 1/24/10, the humidity level was 26%. Called engineering decrease humidity
On 1/25/10, the humidity level was 30%.
On 1/26/10, the humidity level was 33%.
On 1/27/10, the humidity level was 34%.
On 1/28/10, the humidity level was 33%.
On 1/31/10, the humidity level was 32%.


February, 2010
OR Room #8:
On 2/4/10, the humidity level was 29%. Called engineering decrease humidity
On 2/8/10, the humidity level was 31%.
On 2/9/10, the humidity level was 32%.
On 2/10/10, the humidity level was 31%. On 2/11/10, the humidity level was 33%.


March, 2010:
OR Room #5:
On 3/9/10, the humidity level was 31%.
On 3/11/10, the humidity level was 31%.
On 3/14/10, the humidity level was 31%.
On 3/25/10, the humidity level was 34%.
On 3/29/10, the humidity level was 33%.
On 3/30/10, the humidity level was 34%
On 3/3/1/10, the humidity level was 30%.

OR Room #7:
On 3/4/10, the humidity level was 30%.
On 3/7/10, the humidity level was 34%.
On 3/9/10, the humidity level was 29%.
On 3/10/10, the humidity level was 28%.
On 3/11/10, the humidity level was 29%.
On 3/14/10, the humidity level was 28%. Called engineering decrease humidity
On 3/25/10, the humidity level was 31%.
On 3/29/10, the humidity level was 33%.
On 3/30/10, the humidity level was 30%.
On 3/31/10, the humidity level was 25%. Called engineering decrease humidity

OR Room #8:
On 3/4/10, the humidity level was 25%.
On 3/7/10, the humidity level was 29%. Called engineering decrease humidityOn 3/9/10, the humidity level was 29%. " "
On 3/10/10, the humidity level was 27%. " "
On 3/11/10, the humidity level was 29%.
On 3/14/10, the humidity level was 28%. Called engineering decrease humidity
On 3/23/10, the humidity level was 33%.
On 3/25/10, the humidity level was 32%.
On 3/29/10, the humidity level was 34%.
On 3/30/10, the humidity level was 30%.
On 3/31/10, the humidity level was 24%. Called engineering decrease humidity


April, 2010
OR Room #2:
On 4/6/10, the humidity level was 34%.

OR Room #5:
On 4/1/10, the humidity level was 34%. Called engineering decrease humidity
On 4/5/10, the humidity level was 33%.
On 4/6/10, the humidity level was 30%.
On 4/7/10, the humidity level was 34%.
On 4/8/10, the humidity level was 35%.
On 4/11/10, the humidity level was 34%.
On 4/29/10, the humidity level was 30%.

OR Room #7:
On 4/1/10, the humidity level was 25%. Called engineering decrease humidity
On 4/5/10, the humidity level was 27%. Called engineering decrease humidity
On 4/6/10, the humidity level was 25%.
On 4/7/10, the humidity level was 30%.
On 4/8/10, the humidity level was 31%.
On 4/11/10, the humidity level was 30%. Chiller down
On 4/21/10, the humidity level was 33%.
On 4/22/10, the humidity level was 34%.
On 4/29/10, the humidity level was 25%. Called engineering decrease humidity

OR Room #8:
On 4/1/10, the humidity level was 25%. Called engineering decrease humidity
On 4/5/10, the humidity level was 25%.
On 4/6/10, the humidity level was 24%.
On 4/7/10, the humidity level was 30%.
on 4/8/10, the humidity level was 31%.
On 4/11/10, the humidity level was 30%. Chiller down
On 4/21/10, the humidity level was 34%.
On 4/29/10, the humidity level was 25%. Called engineering decrease humidity


May, 2010
OR Room #5: Action Taken:
On 5/12/10, the humidity level was 34%.
On 5/23/10, the humidity level was 32%.
On 5/24/10, the humidity level was 29%. Called engineering decrease (sic) humidity

OR Room # 6.5:
On 5/24, the humidity level was 34%.

OR Room #7:
On 5/2/10, the humidity level was 31%.
On 5/5/10, the humidity level was 27%.
On 5/6/10, the humidity level was 27%.
On 5/12/10, the humidity level was 30%.
On 5/13/10, the humidity level was 33%.
On 5/16/10, the humidity level was 30%.
On 5/20/10, the humidity level was 34%.
On 5/23/10, the humidity level was 26%. Called engineering decrease humidity
On 5/24/10, the humidity level was 24%. " " "

OR Room #8:
On 5/2/10, the humidity level was 32%.
On 5/3/10, the humidity level was 31%.
On 5/5/10, the humidity level was 27%. Called engineering
decrease humidity
On 5/6/10, the humidity level was 27%. " " "
On 5/12/10, the humidity level was 30%.
On 5/13/10, the humidity level was 33%.
On 5/16/10, the humidity level was 30%.
On 5/23/10, the humidity level was 26%.
On 5/24/10, the humidity level was 23%.

Based on observation, the facility failed to ensure that electrical wiring and equipment are maintained in accordance with NFPA 70 and NFPA 99. This was evidenced by the facility failing to maintain clearance in front of electrical panels, and by the use of an extension cord in one off-site building. This affected one of six smoke compartments on one floor in the main building, and two off-site buildings. This could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition 110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m ) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-43(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

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

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

Section 400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the electrical wiring and connections were observed.

May 26, 2010:
Sagebrush:
At 12:18 p.m., there was an uncovered approximately four inch by four inch electrical junction box above the ceiling tiles in Room 2104.

Main Building:
At 3:45 p.m., there was an approximately 120 gallon trash container stored within approximately 3 inches of three of three electrical panels in Room 2125.

May 27, 2010
F Ward Clinic:
At 9:40 a.m., there was a refrigerator and a water dispenser plugged into a surge protector, which was plugged into a wall outlet, in the southwest wing.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by the failure to seal penetrations in the walls and ceilings. This affected two of six smoke compartments on two floors in the Kern Medical Center (KMC) main building, and one of four smoke compartments in the Sagebrush building. This could result in the spread of smoke from one compartment to another in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the ceilings and walls in the facility were observed.

May 26, 2010
Sagebrush:
1. At 12:28 p.m., there were 4 approximately 3/4 inch conduit wall penetrations with approximately 1/4 inch unsealed around the conduits, one approximately 4 inch wall penetration, and 2 approximately eight inch cast iron pipes with approximately one inch unsealed around the pipes, in the wall inside Room 45.
2. At 12:31 p.m., there were 2 approximately one inch by four inch penetrations, and 1 approximately one inch by three inch penetrations around approximately 3/4 inch conduits, inside x-ray Room 2407.

May 26, 2010
KMC Main Building:
First Floor:
1. At 3:19 p.m., there was an approximately one inch by three inch wall penetration with data wires exposed, in the left wall in Operating Room #7.
2. At 4:55 p.m., there were two approximately 1/2 inch wall penetrations inside the cafeteria.

Based on observation, the facility failed to ensure that doors protecting corridor openings shall be provided with a means suitable for keeping the doors closed, and that there are no impediments to closing the doors. This was evidenced by doors that were obstructed from closing, and by doors that were not provided with a means suitable for keeping the doors closed. This affected six of six smoke compartments on four floors in the main building, one of four smoke compartments in the Sagebrush building, and one of two smoke compartments in the F Ward Clinic. This could result in the passage of smoke and flames in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the corridor doors in the facility were observed.

May 25, 2010
KMC Main Building:
Fourth Floor:
1. At 3:17 p.m., the door to Room 4111 was obstructed by a pink floor sign and a stool inside the room.
2. At 3:30 p.m., the door to Room 4232 was obstructed by a yellow floor sign and a chair inside the room.

May 26, 2010
KMC Main Building:
First Floor:
1. At 9:47 a.m., the door to Room 1314 was held open by black rubber tubing which was tied to the door knob on the back side of the door.
2. At 10:11 a.m., the door to Basement stair #5 was held open with a round metal cylinder.
3. At 10:12 a.m., the door to the Medical Library was held open with a trashcan inside the room.

Third Floor:
4. At 2:36 p.m., the door to the Laundry room to the right of Room 3111 was held open with a trashcan inside the room.
5. At 2:52 p.m., the door to Room 3224 was held open with a trashcan inside the room.

Second Floor:
6. At 3:58 p.m., the door to Room 2117 was obstructed by a chair inside the room.
7. At 4:18 p.m., the door to Room 2020 was held open with a Sparkletts water bottle inside the room.
8. At 4:19 p.m., the door to Room 2057 was held open by a chair inside the room.
9. At 4:20 p.m., the door to Room 2011 was held open by a chair inside the room.

First Floor:
10. At 4:24 p.m., the door to the A Wing waiting room was held open by a chair inside the room.
11. At 4:28 p.m., the door to Room 1035 was held open by a rubber wedge.
12. At 4:38 p.m., the door to Ultrasound Room #3 was held open by a chair inside the room.
13. At 4:49 p.m., the door to Room 1158 had self-closing hardware that failed to latch the door. The strike hardware was stuck inside the door, and the door failed to latch.
14. At 4:53 p.m., the door to Room 1209 was held open by a wooden wedge.

May 26, 2010
F Ward Clinic:
At 10:31 a.m., the door to Room 138 was held open with a stool inside the room.

May 26, 2010
Sagebrush:
At 11:44 a.m., the door to Room 2408 was held open with a wooden wedge.


May 27, 2010
KMC Main Building:
First Floor:
1. At 8:27 a.m., the door to Room 1319 was held open with a 5 pound weight.
2. At 9:02 a.m., the door to Room 1546 was held open with a chair. The self-closing device failed to latch the door when tested.
3. At 9:03 a.m., the door to Room 1547 was held open with a chair.
4. At 9:08 a.m., the door to Room 1507 was held open by a rubber wedge.

Based on observation, the facility failed to maintain the integrity of doors that are permitted to be held open by devices that automatically close all such doors upon activation of the fire alarm system. This was evidenced by a door that failed to automatically release and close upon activation of the fire alarm system. This affected one of six smoke compartments on one floor of the KMC main building, and could result in the spread of smoke from one compartment to another in the event of a fire.

Findings:

On a facility tour with facility staff on May 26, 2010, the doors held open by magnetic devices were observed during testing of the fire alarm system.

Main Building:
Second Floor:
At 9:16 a.m., the pair of doors outside the entrance to the Intensive Care Unit (ICU) were observed during testing of the fire alarm. The right side door near ICU 2407 failed to automatically release from the magnetic hold-open device.

Based on observation, the facility failed to ensure that smoke barrier walls have a 1/2 hour fire resistance rating and are constructed in accordance with Section 8.3. This was evidenced by smoke barrier walls that had unsealed penetrations around pipes and cables. This affected two of six smoke compartments in the main building, and could result in the spread of smoke from one compartment to another in the event of a fire.

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 the facility tour with facility staff from May 25 to May 27, 2010, the smoke barrier walls were observed.

May 25, 2010
KMC Main Building:
Fourth Floor:
1. At 3:05 p.m., there was an approximately 1/2 inch penetration around a wire in the smoke barrier wall above door 4057.
2. At 3:10 p.m., there was an approximately one inch by three inch penetration above fire door 405 to the left of Room 4058.
3. At 3:14 p.m., there was an approximately three inch round penetration, and an approximately 2 1/2 inch white flexible cable penetration with approximately 1/2 inch unsealed around the penetration, above door 408 to the left of Room 4130.

May 26, 2010
KMC Main Building:
First Floor:
At 4:44 p.m., there was an approximately 2 inch conduit penetration with approximately 1/2 inch unsealed around the penetration, in the smoke barrier wall to the left of Room 1129.

Based on observation, the facility failed to ensure that smoke barrier doors are capable of resisting the passage of smoke, that the doors are self-closing, and that the doors are free from impediments. This was evidenced by smoke barrier doors that failed to close completely and latch upon testing of the fire alarm system devices. This affected two of six smoke compartments on two floors in the main building, and could result in the spread of smoke or fire from one smoke compartment to another in the event of a fire.

Findings:

On a facility tour with facility staff on May 26, 2010, the doors protecting openings in smoke barriers in the facility were observed during testing of the fire alarm system.

May 26, 2010
Main Building:
Fourth Floor:
At 8:42 a.m., the left door of the pair of smoke barrier doors to the left of Room 4470 failed to self-close when the fire alarm was tested. The left door released but was obstructed from closing approximately 6 inches from the door frame by the coordinator arm at the top of the door frame.

Basement:
At 10:07 a.m., the left door of the pair of smoke barrier doors FD 118 outside the X-ray waiting room closed but failed to latch when the fire alarm was tested.

Based on observation, the facility failed to maintain the exit access in the facility so that exits are readily accessible at all times. This effected four exit corridors on three floors in the main building, and could result in a delay in exiting the facility in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the exit corridors in the facility were observed.

May 26, 2010
KMC Main Building:
Third Floor:
At 8:59 a.m., there was an approximately 5 feet high directional floor sign in the exit corridor opposite Room 3049. The sign read "Internal Medicine Applicants go to Room 3034".

Second Floor:
1. At 3:47 p.m., there was a garden hose coiled outside the exit door near Room 2352 which obstructed the door from opening into the exit path.
2. At 3:54 p.m., there was a chair obstructing one of two exit doors from Central Supply Room 2129.
3. At 4:11 p.m., there was a cabinet obstructing one of two exit doors from Room 2046.

May 27, 2010
KMC Main Building:
First Floor:
At 8:49 a.m., there was an approximately five foot high metal easel with an approximately three feet wide sign on it which read "Exit" and "Salida", in the exit corridor, outside Room 1438.

Based on observation and interview, the facility failed to maintain the integrity of the fire alarm system in accordance with NFPA 72. This was evidenced by a "trouble" light illuminated on the fire alarm control panel in the main building, and on the fire alarm control panel in one off-site building. This affected the entire main facility, and one off-site building, and could result in a delay in notification in the event of a fire.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the fire alarm control panels were observed.

May 26, 2010
Main Building:
First Floor:
At 8:20 a.m., the main fire alarm control panel was observed. There was a "trouble" light illuminated on the panel. In an interview with staff, staff stated that there were four dirty smoke detectors that triggered the "trouble" signal on the panel. Staff stated that the smoke detectors would be serviced by a fire alarm technician.

Sagebrush:
At 11:16 a.m., the main fire alarm control panel was observed. There was "trouble" light illuminated on the panel. In an interview with staff, staff stated that there was a dirty smoke detector that triggered the "trouble" signal on the panel. Staff stated that the fire alarm monitoring company had been contacted on May 25, 2010 to report the "trouble" signal on the panel, and that the smoke detector would be serviced by a fire alarm technician.

Based on observation, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by storage within 18 inches of a sprinkler head on two floors in the main building, and by missing escutcheon rings in the main building and one off-site building. This could result in the failure of the spray pattern to develop if the sprinkler system were activated, or in the spread of smoke or fire in the event of a fire. This affected two of six smoke compartments on two floors in the main building, one of four floors in the main building, and one of two smoke compartments in one off-site building.

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

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the automatic sprinkler system was observed.

May 26, 2010
Sagebrush:
At 12:55 p.m., there was an escutcheon ring missing from one of four sprinkler heads in Room 1234.

Main Building:
First Floor:
At 4:51 p.m., there was storage within approximately eight inches of the sprinkler head in Room 1202.


May 27, 2010
Main Building:
First Floor:
1. At 8:02 a.m., there was an escutcheon ring missing on one of two sprinkler heads in the women's restroom in the Lobby.
2. At 8:56 a.m., there was storage within approximately ten inches of the sprinkler head in the Gift Shop storage room.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in the facility in accordance with NFPA 10. This was evidenced by portable fire extinguishers that were stored unsecured, and by portable fire extinguishers that were obstructed. This affected three of four floors in the main building, and one of two smoke compartments in one offsite building. This could result in a delay in extinguishing a fire.

NFPA 10, Chapter 4 Inspection, Maintenance, and Recharging
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

NFPA 10 (1998 edition) 1-6.7
Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the portable fire extinguishers were observed.

May 25, 2010
Main Building:
At 9:25 a.m., and 12:47 p.m., there were 24 portable fire extinguishers stored unsecured on the floor to the right entrance to the Engineering Department.

May 26, 2010
Sagebrush:
At 11:20 a.m., there were 3 portable fire extinguishers stored unsecured under the desk in the Security office.

Main Building:
Second Floor:
At 3:53 p.m., the fire extinguisher cabinet in Central Supply Room 2129 was obstructed by a metal cart on wheels.

First Floor:
1. At 4:30 p.m., the fire extinguisher cabinet to the right of Room 139 was obstructed by a metal cart on wheels.
2. At 4:41 p.m., the portable fire extinguisher cabinet in the Radiology registration area was obstructed by a recycling container.

May 27, 2010
Main Building:
First Floor:
1. At 8:06 a.m., there were 24 portable fire extinguishers stored unsecured on the floor to the right entrance to the Engineering Department. In an interview with staff, staff stated that the Security Department was responsible for the portable fire extinguishers.
2. At 8:36 a.m., the 24 portable fire extinguishers were removed from outside the Engineering Department.
3. At 11:57 a.m., there were 24 portable fire extinguishers stored unsecured on the ground inside a fenced area opposite the entrance to the Engineering Department.

Basement:
At 9:17 a.m., the portable fire extinguisher between Room 015 and 016 was obstructed by a scale.

Based on observation, the facility failed to provide ashtrays of noncombustible material and safe design, and failed to provide metal containers with self-closing cover devices, in all areas where smoking is permitted. This affected one of three designated smoking areas in the main building, one of one designated smoking area in one offsite buildings, and one non-designated smoking area in one offsite building. This could result in an increased risk of fire if embers from a cigarette were scattered from the designated smoking area.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the designated smoking areas were observed.

May 26, 2010

Main Building:
At 10:42 a.m., a man in a wheelchair was observed smoking outside the north entrance near the construction site. In an interview with staff, staff stated that this was not a designated smoking area. Staff asked the man to extinguish his cigarette, and explained that this was not a designated smoking area. There was a "no smoking" sign approximately 10 feet to the left of when the man was sitting. There were two extinguished cigarettes observed on the ground under the wheelchair.

Sagebrush:
1. At 11:49 a.m., there was a floor area approximately 15 inches by 24 inches with extinguished cigarette butts inside the locked exterior fire sprinkler room. There was no ashtray, and no metal container with a self-closing cover device provided. In an interview with staff, staff stated that this was not a designated smoking area.
2. At 12:12 p.m., there was no ashtray, and no metal container with a self-closing cover device, provided in the designated smoking area for Elderlife on the east side of the building.

Main Building:
At 4:04 p.m., the exterior secure third floor psychiatric unit designated smoking area was observed. Five patients were observed smoking, and two staff were present. One of five patients was observed using the metal container provided in the designated smoking area. The area around and underneath the picnic table with benches provided was covered with extinguished cigarette butts. One patient was observed smoking and dropping ashes on the ground.

May 27, 2010
F Ward Clinic
At 9:30 a.m., there was no ashtray, and no metal container with a self-closing cover device, provided in the designated smoking area. Ten extinguished cigarette butts were observed on the ground.

Based on observation, the facility failed to maintain the integrity of the building service equipment by the use of a portable space heating device. This was evidenced by one portable space heating device observed in a staff sleeping room. This affected one of six smoke compartments on one floor in the main building, and could result in an increased risk of fire.

Findings:

On a facility tour with facility staff on May 25, 2010, a portable space heating device was observed.

Main Building
Fourth Floor:
At 2:55 p.m., there was a portable space heating device observed in staff sleeping Room 4034.

Based on observation, record review and interview, the facility failed to maintain the integrity of the humidity levels in the anesthesia locations. This was evidenced by the facility failing to maintain the humidity levels in five of eight operating rooms and one central room, and two of two labor and delivery rooms, in accordance with NFPA 99. This affected two of five smoke compartments and two floors in the main building, and could result in an increased risk of fire.

NFPA 99
Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supporting anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

On a facility tour, record review and interview with facility staff from May 25 to May 27, 2010, the records for the humidity levels were reviewed, and the operating rooms (OR's) were observed.

May 25, 2010
Main Building:
At 11:03 a.m., the humidity level records "Surgery Room Temperature and Humidity Log" were reviewed. The record stated that "Temperature and Humidity in Surgery Rooms must be checked and recorded daily. Room temperatures are required to be between 64 to 70 degrees (at the physician's discretion). Humidity readings are required to be between 30% to 60% RH".

In an interview with staff at 11:15 a.m., staff stated that the humidity levels were taken in the early morning by the staff person who prepared the OR'S.

The records stated that the humidity levels were below 35% for five of eight OR's and central room, and two of two Labor and Delivery rooms, on the following dates:

2009:
October, 2009:
OR Room #2:
On 10/29/09, the humidity level was 34%.

OR Room #4:
On 10/27/09, the humidity level was 28%. Called engineering decrease humidity
On 10/29/09, the humidity level was 25%. Called engineering decrease humidity
OR Room #5:
On 10/29/09, the humidity level was 28%. Called engineering decrease humidity
On 10/27/09, the humidity level was 32%.

OR Room #6.5:
On 10/29/09, the humidity level was 34%.

OR Room #7:
On 10/27/09, the humidity level was 27%. Called engineering decrease humidity
On 10/29/09, the humidity level was 23%. Called engineering decrease humidity

OR Room #8:
On 10/27/09, the humidity level was 28%. Called engineering decrease humidity
On 10/29/09, the humidity level was 23%. Called engineering decrease humidity

Fourth Floor:
Labor and Delivery Room 4122:
On 10/10/09, the humidity level was 28%. Engineering called 915
On 10/13/09, the humidity level was 33%. Gage (sic) broken
engineer notified

Labor and Delivery Room 4116:
On 10/10/09, the humidity level was 30%. Broken glass on gauge engineering
On 10/11/09, the humidity level was 27%. Engineering called @ 0718 Came up @ 0738
On 10/12/09, the humidity level was 25%. Broken gauge. Engineering aware
On 10/13/09, the humidity level was 26%. Engineering called @ 0701 left message
November, 2009:
OR Room #4:
On 11/1/09, the humidity level was 33%.
On 11/17/09, the humidity level was 27%. Called engineering decrease humidity

OR Room #5:
On 11/1/09, the humidity level was 34%.
On 11/17/09, the humidity level was 31%.

OR Room #7:
On 11/1/09, the humidity level was 31%.
On 11/8/09, the humidity level was 34%.
On 11/9/09, the humidity level was 34%.
On 11/17/09, the humidity level was 27%. Called engineering decrease humidity
On 11/24/09, the humidity level was 32%.
On 11/25/09, the humidity level was 32%.
On 11/29/09, the humidity level was 30%.
On 11/30/09, the humidity level was 30%.

December, 2009:
OR Room #4:
On 12/1/09, the humidity level was 34%.
On 12/2/09, the humidity level was 33%.
On 12/3/09, the humidity level was 32%.
On 12/6/09, the humidity level was 27%. Called engineering decrease humidity
On 12/7/09, the humidity level was 28%. " "
On 12/22/09, the humidity level was 24%. Called engineering decrease humidity
On 12/23/09, the humidity level was 22%. " "
On 12/28/09, the humidity level was 32%.
On 12/29/09, the humidity level was 34%.

OR Room #5:
On 12/6/09, the humidity level was 32%.
On 12/7/09, the humidity level was 33%.
On 12/22/09, the humidity level was 31%.
On 12/23/09, the humidity level was 30%.

OR Room #7:
On 12/1/09, the humidity level was 30%.
On 12/2/09, the humidity level was 31%.
On 12/3/09, the humidity level was 30%.
On 12/6/09, the humidity level was 26%.
On 12/7/09, the humidity level was 27%.
On 12/16/09, the humidity level was 34%.
On 12/22/09, the humidity level was 25%. Called engineering decrease humidity
On 12/23/09,the humidity level was 24%. " "
On 12/28/09, the humidity level was 32%.
On 12/29/09, the humidity level was 32%.

OR Room #8:
On 12/1/09, the humidity level was 27%. Called engineering about decrease humidity
On 12/2/09, the humidity level was 28%. " "
On 12/3/09, the humidity level was 27%. " "
On 12/6/09, the humidity level was 23%. Called engineering decrease humidity
On 12/7/09, the humidity level was 24%. " "
On 12/10/09, the humidity level was 30%.
On 12/13/09, the humidity level was 34%.
On 12/14/09, the humidity level was 34%.
On 12/16/09, the humidity level was 30%.
On 12/17/09, the humidity level was 32%.
On 12/21/09, the humidity level was 34%.
On 12/22/09, the humidity level was 22%. Called engineering decrease humidity
On 12/23/09, the humidity level was 20%. " "
On 12/28/09, the humidity level was 28% Called engineering decrease humidity
On 12/29/09, the humidity level was 28%. " "
On 12/30/09, the humidity level was 32%.

2010:
January, 2010
OR Room #4:
On 1/5/10, the humidity level was 33%.
On 1/6/10, the humidity level was 33%.
On 1/7/10, the humidity level was 31%.

OR Room #5:
On 1/5/10, the humidity level was 34%.
On 1/6/10, the humidity level was 34%.
On 1/7/10, the humidity level was 33%.
On 1/24/10, the humidity level was 34%.

OR Room #7:
On 1/3/10, the humidity level was 33%.
On 1/4/10, the humidity level was 34%.
On 1/5/10, the humidity level was 31%.
On 1/6/10, the humidity level was 31%.
On 1/7/10, the humidity level was 30%.
On 1/18/10, the humidity level was 34%.
On 1/20/10, the humidity level was 31%.
On 1/24/10, the humidity level was 30%.


OR Room #8:
On 1/3/10, the humidity level was 30%.
On 1/4/10, the humidity level was 30%.
On 1/5/10, the humidity level was 28%. Called engineering decrease humidity
On 1/6/10, the humidity level was 27%. " "
On 1/7/10, the humidity level was 27%. " "
On 1/11/10, the humidity level was 34%. " "
On 1/12/10, the humidity level was 33%.
On 1/18/10, the humidity level was 31%.
On 1/20/10, the humidity level was 28%. Called engineering decrease humidity
On 1/21/10, the humidity level was 30%.
On 1/24/10, the humidity level was 26%. Called engineering decrease humidity
On 1/25/10, the humidity level was 30%.
On 1/26/10, the humidity level was 33%.
On 1/27/10, the humidity level was 34%.
On 1/28/10, the humidity level was 33%.
On 1/31/10, the humidity level was 32%.


February, 2010
OR Room #8:
On 2/4/10, the humidity level was 29%. Called engineering decrease humidity
On 2/8/10, the humidity level was 31%.
On 2/9/10, the humidity level was 32%.
On 2/10/10, the humidity level was 31%. On 2/11/10, the humidity level was 33%.


March, 2010:
OR Room #5:
On 3/9/10, the humidity level was 31%.
On 3/11/10, the humidity level was 31%.
On 3/14/10, the humidity level was 31%.
On 3/25/10, the humidity level was 34%.
On 3/29/10, the humidity level was 33%.
On 3/30/10, the humidity level was 34%
On 3/3/1/10, the humidity level was 30%.

OR Room #7:
On 3/4/10, the humidity level was 30%.
On 3/7/10, the humidity level was 34%.
On 3/9/10, the humidity level was 29%.
On 3/10/10, the humidity level was 28%.
On 3/11/10, the humidity level was 29%.
On 3/14/10, the humidity level was 28%. Called engineering decrease humidity
On 3/25/10, the humidity level was 31%.
On 3/29/10, the humidity level was 33%.
On 3/30/10, the humidity level was 30%.
On 3/31/10, the humidity level was 25%. Called engineering decrease humidity

OR Room #8:
On 3/4/10, the humidity level was 25%.
On 3/7/10, the humidity level was 29%. Called engineering decrease humidityOn 3/9/10, the humidity level was 29%. " "
On 3/10/10, the humidity level was 27%. " "
On 3/11/10, the humidity level was 29%.
On 3/14/10, the humidity level was 28%. Called engineering decrease humidity
On 3/23/10, the humidity level was 33%.
On 3/25/10, the humidity level was 32%.
On 3/29/10, the humidity level was 34%.
On 3/30/10, the humidity level was 30%.
On 3/31/10, the humidity level was 24%. Called engineering decrease humidity


April, 2010
OR Room #2:
On 4/6/10, the humidity level was 34%.

OR Room #5:
On 4/1/10, the humidity level was 34%. Called engineering decrease humidity
On 4/5/10, the humidity level was 33%.
On 4/6/10, the humidity level was 30%.
On 4/7/10, the humidity level was 34%.
On 4/8/10, the humidity level was 35%.
On 4/11/10, the humidity level was 34%.
On 4/29/10, the humidity level was 30%.

OR Room #7:
On 4/1/10, the humidity level was 25%. Called engineering decrease humidity
On 4/5/10, the humidity level was 27%. Called engineering decrease humidity
On 4/6/10, the humidity level was 25%.
On 4/7/10, the humidity level was 30%.
On 4/8/10, the humidity level was 31%.
On 4/11/10, the humidity level was 30%. Chiller down
On 4/21/10, the humidity level was 33%.
On 4/22/10, the humidity level was 34%.
On 4/29/10, the humidity level was 25%. Called engineering decrease humidity

OR Room #8:
On 4/1/10, the humidity level was 25%. Called engineering decrease humidity
On 4/5/10, the humidity level was 25%.
On 4/6/10, the humidity level was 24%.
On 4/7/10, the humidity level was 30%.
on 4/8/10, the humidity level was 31%.
On 4/11/10, the humidity level was 30%. Chiller down
On 4/21/10, the humidity level was 34%.
On 4/29/10, the humidity level was 25%. Called engineering decrease humidity


May, 2010
OR Room #5: Action Taken:
On 5/12/10, the humidity level was 34%.
On 5/23/10, the humidity level was 32%.
On 5/24/10, the humidity level was 29%. Called engineering decrease (sic) humidity

OR Room # 6.5:
On 5/24, the humidity level was 34%.

OR Room #7:
On 5/2/10, the humidity level was 31%.
On 5/5/10, the humidity level was 27%.
On 5/6/10, the humidity level was 27%.
On 5/12/10, the humidity level was 30%.
On 5/13/10, the humidity level was 33%.
On 5/16/10, the humidity level was 30%.
On 5/20/10, the humidity level was 34%.
On 5/23/10, the humidity level was 26%. Called engineering decrease humidity
On 5/24/10, the humidity level was 24%. " " "

OR Room #8:
On 5/2/10, the humidity level was 32%.
On 5/3/10, the humidity level was 31%.
On 5/5/10, the humidity level was 27%. Called engineering
decrease humidity
On 5/6/10, the humidity level was 27%. " " "
On 5/12/10, the humidity level was 30%.
On 5/13/10, the humidity level was 33%.
On 5/16/10, the humidity level was 30%.
On 5/23/10, the humidity level was 26%.
On 5/24/10, the humidity level was 23%.

Based on observation, the facility failed to ensure that electrical wiring and equipment are maintained in accordance with NFPA 70 and NFPA 99. This was evidenced by the facility failing to maintain clearance in front of electrical panels, and by the use of an extension cord in one off-site building. This affected one of six smoke compartments on one floor in the main building, and two off-site buildings. This could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition 110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m ) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-43(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

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

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

Section 400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On a facility tour with facility staff from May 25 to May 27, 2010, the electrical wiring and connections were observed.

May 26, 2010:
Sagebrush:
At 12:18 p.m., there was an uncovered approximately four inch by four inch electrical junction box above the ceiling tiles in Room 2104.

Main Building:
At 3:45 p.m., there was an approximately 120 gallon trash container stored within approximately 3 inches of three of three electrical panels in Room 2125.

May 27, 2010
F Ward Clinic:
At 9:40 a.m., there was a refrigerator and a water dispenser plugged into a surge protector, which was plugged into a wall outlet, in the southwest wing.