HospitalInspections.org

Building 2

7. At 10:11 a.m., there was an approximately eight inch by three inch unsealed penetration in the wall of Storage Room (CC-3072). The penetration was located in the wall behind the corridor door to that room.

Based on observation, the facility failed to maintain the integrity of the building corridor walls. This was evidenced by two unsealed penetrations in corridor walls. This affected two of four floors in the Main Hospital (Building 1) and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with engineering staff, the corridor walls and ceilings were observed.

1. On 7/17/12 at 1:16 p.m., there was one approximately two inch wide unsealed penetration in the corridor wall near Room (H3556).

2. On 7/17/12 at 1:50 p.m., there was one approximately six inch by two inch unsealed penetration in the corridor wall near Room (H2574). The penetration was located near the base of the wall.

Building 2

During a facility tour with engineering staff on 7/19/12, the doors in the facility were observed.

13. At 10:30 a.m., the corridor door to the Data Closet (CC-3012) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to air pressure differences.

14. At 11:05 a.m., the corridor roll down fire door to Surgery Control Room (CC-3218) was observed. The roll down path of the fire door was obstructed by a telephone, a box of gloves, and a paper tray. The items were located directly in the drop down path of the roll down fire door.

Building 1

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by 1 of 2 door leafs that failed to positively latch. This could lead to the penetration of smoke or fire into the next smoke compartment. This affected 1 of 4 floors.

Findings:

During a tour of the facility with Safety Officer 1, the smoke barrier doors were observed.

Main Hospital, West Pavilion, 2nd Floor, 7/20/12:

At 9:30 p.m., the right leaf of the fire doors on the C2 entrance failed to latch during fire alarm testing.

Based on observation, the facility failed to protect their corridors from the hazardous areas. This was evidenced by doors to hazardous areas that were obstructed from latching, a hazardous area that was not equipped with a self-closing door, and unsealed penetrations in the walls and ceilings of hazardous areas. This affected three of four floors in Building 1 (Main Hospital), one of three floors in the ASC (Building 2). This could result in smoke spreading to the corridors and delay evacuation in the event of a fire from the hazardous areas.

Findings:

Building 1

During a facility tour with engineering staff, the hazardous areas in the facility were observed.

1. On 7/17/12 at 11:31 a.m., the corridor door to the Soiled Utility Room (HD345) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 7/17/12 at 3:23 p.m., the corridor door to the Soiled Utility Room (H2312) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 7/17/12 at 3:25 p.m., the Storage Room (HH2311) was observed to be over fifty square feet in area. The room contained combustible items in storage. The corridor door to the room was equipped with a self-closing device. The arm of the self-closing device was detached from the door frame. The door was held open to the fullest extent and allowed to close. The door failed to close.

4. On 7/17/12 at 3:29 p.m., the Supply Room (H2308) was observed to be over fifty square feet in area. The room contained combustible items in storage. The corridor door to the room was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.



31203

5. At 1:56 p.m., on the second floor, Operating Room, in the Building Services room, there was a 2 by 4 inch square penetration between the conduits on the top right wall.

6. At 2:26 p.m., on the second floor, E Pod, the Housekeeping closet in Room HE212, there was a 5 inch long penetration on the right side of wall near the floor.

7. At 2:39 p.m. on the second floor, E Pod, the Communication room in Room HE240C, there was an approximately 3 by 3 inch penetration on the top left hand corner of the wall.

8. At 3:36 p.m., on the second floor, Nuclear Medicine, in the Oxygen Room H2223A, there were four pipes that needed sealing.

9. At 10:42 a.m., on the first floor, Room H1412 near the X-Ray department, in the Telecom closet, there was an approximately 2 by 3 inch circular penetration on the left side of the closet.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by two fire alarm chimes that failed to emit audible sounds and strobe light that failed. This affected two of four floors in building 1 (Main Hospital) and one of threee floors in building 3. This could result in a delayed notification of a fire to patients and staff.

NFPA 101, 2000 edition
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 the occupancy.

Findings:

Building 1

During a facility tour with engineering staff, the fire alarm system and components were observed.

1. On 7/20/12 at 10:08 a.m., the fire alarm system was activated. The fire alarm chime-strobe (51-001/2) near the second floor down escalator was observed. The chime portion of the device failed to emit an audible sound.



30514

2. At 10:53 a.m., on 7/21/12, the chime of the strobe/chime combo in Building 1 (Main Hospital) labeled 15-002/4 located next to Women's Restroom H0142, was not functioning.

Based on observation, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by sprinklers that had missing or dislodged escutcheon fittings, sprinklers that did not have eighteen inches of clearance, and sprinklers that had accumulation of debris. This affected four of four floors in building 1 (Main Hospital) and could result in a delayed response of the automatic fire sprinkler system.

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

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

Building 1

During a facility tour with engineering staff, the facility's automatic fire sprinkler system was observed.

1. On 7/17/12 at 11:06 a.m., one sprinkler in the Tub Room (HF354) was missing a escutcheon fitting. A penetration in the ceiling around the sprinkler pipe was observed.

2. On 7/17/12 at 3:42 p.m., one sprinkler in Room (H2251) was missing an escutcheon fitting. A penetration in the ceiling around the sprinkler pipe was observed.

3. On 7/18/12 at 9:37 a.m., one sprinkler in the Kitchen Walk-In #1 did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of food approximately six inches directly below the sprinkler head.

4. On 7/18/12 at 9:41 a.m., four sprinklers in the Kitchen Dish Wash Area were observed to have a thick accumulation of dark debris.

5. On 7/18/12 at 3:49 p.m., one sprinkler in the Office Room (H0344) Closet did not have eighteen inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of items approximately six inches directly below the sprinkler head.



30514

6. At 10:40 a.m., 7/18/12, East Pavilion, First Floor, Room HH143, a table was stacked up to approximately 10 inches from the sprinkler deflector.



31203

7. At 1:27 p.m., on the third floor, Building 1, Main Hospital, in Room H3577, there was a missing escutcheon ring and exposed 1/2 inch circular penetration.

8. At 1:29 p.m., on the third floor, Building 1, in Room H3590B, 1 of 2 sprinkler escutcheons was loose.

9. At 9:49 a.m., on the first floor, Building 1, in the Cafeteria, 1 of 2 sprinkler escutcheons was missing above the food service area.

10. At 11:24 a.m., on the first floor, Building 1, Cold room outside the Lab, in Room H1532, the escutcheon was loose and the deflector was filled with debris.

11. At 1:50 p.m., on the ground floor, Building 1, F Pod, in Room HF066, 1 of 2 sprinkler escutcheon was loose and had an approximately 2 inch penetration.

12. At 2:04 p.m., on the ground floor, Building 1, F Pod, Housekeeping closet, in Room HF012, there was a missing escutcheon and it had an approximately 2 inch circular penetration.

13. At 2:07 p.m., on the ground floor, Building 1, F Pod, in Room HF044, there was a missing escutcheon cover.

14. At 2:09 p.m., on the ground floor, Building 1, F Pod, in Room HF043, there was a missing escutcheon cover.

15. At 2:15 p.m., on the ground floor, Building 1, F Pod, in Room HF039, there was a missing escutcheon cover.

16. At 2:42 p.m., on the ground floor, Building 1, D Pod, in Room HD018, 2 of 2 sprinkler escutcheons were loose.

17. At 2:54 p.m., on the ground floor, Building 1, D Pod, in Room HD0A02, there was a missing escutcheon and had a 1 inch circular penetration..

18. At 3:09 p.m., on the ground floor, building 1, D Pod, in Room HD023, 1 of 2 sprinkler escutcheons was loose and had a 1 inch circular penetration.

19. At 3:11 p.m., on the ground floor, building 1, D Pod, in Restroom HD022, the escutcheon was loose and had an approximately 1 1/2 inch circular penetration.

Based on record review and interview, the facility failed to maintain their fire/smoke dampers. This was evidenced by two of the facility's fire/smoke dampers that had failed a 2009 inspection and have not yet been repaired. This affected one of four floors in building 1, (Main Hospital) and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

Building 1

During record review with engineering staff, the facility's fire/smoke dampers maintenance records were reviewed.

On 7/19/12 at 3:55 p.m., the facility's fire/smoke damper inspection records were reviewed. The facility had a fire/smoke damper inspection in 2009. The fire/smoke damper inspection report indicated that fire/smoke damper FSD0220 and FSD0221 were in need of repair. Engineer 1 was interviewed at that time. Engineer 1 indicated that the two fire/smoke dampers were missing a time delay relay. Engineer 1 indicated that without the time delay relay the dampers, if closed, would cause the air duct to emplode. Engineer 1 indicated that the facility has submitted plans to the Office of Statewide Health Planning and Development (OSHPD) for correcting the fire/smoke damper issue.

Based on observation and interview, the facility failed to maintain their means of egress free from obstructions. This was evidenced by items stored in the corridor. This affected two of four floors in building 1, (Main Hospital) and one of three floors in building 2. This could result in a delayed evacuation in the event of an emergency.

NFPA 101, 2000 edition
7.1.10 Means of Egress Reliability.
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.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

Building 1

During a facility tour with staff, the facility's corridors were observed.

1. On 7/17/12 at 2:08 p.m., the corridors outside the Operating Rooms were observed. Gurneys, beds, carts, and other items were positioned in the corridor. Surgery Staff 1 was interviewed at that time. Surgery Staff 1 indicated that the items are kept at this location when not in use. The clear width in the corridors at that location were reduced from eight feet to approximately five feet.

2. On 7/18/12 at 4:01 p.m., the corridors in the Phase One portion of the ground floor outside Rooms (H0338), (H0315G), and (H0225) were observed. Linen carts, medical supply pallets, and other items were positioned in the corridor. Safety Officer 2 was interviewed at that time. Safety Officer 2 indicated that due to construction work in the Central Processing Area, items have been placed in the corridor. The clear width in the corridors at that location were reduced from eight feet to approximately five feet.

Building 4

Based on observation and interview, the facility failed to ensure that decorations were flame-retardant. This was evidenced by untreated decoration in an examination room. This deficient practice could result in the increased risk of fire, and affected one of four floors.

NFPA 101, Life Safety Code, 2000 Edition
19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame retardant.
Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a tour of the facility with engineering staff on 7/19/12, the furnishings and decorations were observed.

1. 4th Floor, Dermatology Clinic, 7/19/12:

At 11:17 a.m., in Examination Room 27, a blue blanket approximately 5 feet by 10 feet was hanging on the wall. The blanket was being used as a background for patient pictures.

Based on observation, the facility failed to maintain their storage of oxygen compressed gas cylinders. This was evidenced by medical gas cylinder storage locations that had electrical fixtures mounted on the wall below five feet, medical gas cylinders that were free standing, medical gas cylinders that were not equipped with valve protection caps, and medical gas cylinders stored adjacent to combustible items. This affected two of four floors in the Main Hospital and could result in a medical gas cylinder initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)8 When cylinder valve protection caps are supplied, they shall be secured tightly in place unless the cylinder is connected for use.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
8-3.1.11.2(c) Oxidizing gases, such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During a facility tour with engineering staff, the facility's medical gas cylinder storage and manifold locations were observed.

1. On 7/17/12 at 1:43 p.m., the Medical Gas Storage Room (H2526) was observed. The room contained twenty-four E-size cylinders. The light switch in the room was fixed to the wall approximately four feet high from floor level.

2. On 7/17/12 at 2:09 p.m., one oxygen E-size cylinder was located in the corridor near Room (H2516). The cylinder was free standing, unsecured, and unattended.

3. On 7/18/12 at 2:13 p.m., the Medical Gas Manifold Room (H0325) was observed. A light switch in the room was fixed to the wall approximately four feet high from floor level. An electrical wall receptacle was fixed to the wall approximately one foot high from floor level.

4. On 7/18/12 at 2:25 p.m., the Medical Gas Storage Room (H0219) was observed. A light switch in the room was fixed to the wall approximately four feet high from floor level.

5. On 7/18/12 at 2:26 p.m., six medical gas cylinders in the Medical Gas Storage Room (H0219) were free standing, unsecured, and unattended.

6. On 7/18/12 at 2:33 p.m., the Medical Gas Empty Cylinder Storage Area near the Loading Dock was observed. Three medical gas cylinders were free standing, unsecured, and unattended. Eight medical gas cylinders were not equipped with valve protection caps. Three soiled linen carts filled with soiled linen were stored directly adjacent to five medical gas cylinders. The outdoor storage location was provided with automatic fire sprinkler coverage.


31203


7. At 2:50 p.m., on the ground floor, D Pod, the Oxygen cylinder room in Room HD045, there was 1 of 6 E-cylinder oxygen tank that was on the floor unsecured.

Based on observation, the facility failed to maintain their anesthetizing locations. This was evidenced by twenty-one Operating Rooms that were not equipped with emergency battery-powered lighting units and the facility's failure to maintain relative humidity levels in their anesthetizing locations at thirty-five percent or greater. This affected all patients and staff and could result in a loss of visibility during a surgical procedure or an operating room fire due to electrostatic charges in an oxygen rich environment.

NFPA 101, 2000 edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, 1999 edition
3-3.2.1.2(a)5 Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electric Code, Section 700-12(e).

NFPA 70, 1999 edition
700-12(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 87.5 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 1.5 hours. Storage batteries, whether of the acid or alkali type, shall be designed and constructed to meet the requirements of emergency service.
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.
Exception: In a separate and uninterrupted area supplied by a minimum of three normal lighting circuits, a separate branch circuit for unit equipment shall be permitted if it originates from the same panelboard as that of the normal lighting circuits and is provided with a lock-on feature.

Findings:

During record review and a facility tour with engineering staff, the facility's anesthetizing locations were observed.

1. On 7/17/12 at 2:05 p.m., the facility's Operating Rooms were observed. The facility has twenty-one Operating Rooms. Operating Room 17 was not observed to be equipped with an emergency battery-powered lighting unit. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the Operating Rooms are equipped with emergency generator back-up. Engineering Staff 2 indicated that the Operating Rooms are not equipped with emergency battery-powered lighting units. There were no lighting units in the Operating Rooms that would provide automatic emergency lighting in the event of a power failure in conjunction with an emergency generator transfer delay or malfunction.

2. On 7/19/12 at 3:55 p.m., the facility's humidity records for their anesthetizing locations were reviewed. The facility logs humidity levels in their twenty-one Operating Rooms once daily. At the end of each week, Safety Officer 2 creates a summary page of the humidity values. The summary page includes the minimum and maximum humidity levels reached in each Operating Room as well as the average humidity levels for each Operating Room for that week. The summary page is then sent to multiple department heads for review. The facility's policy for maintaining humidity levels in their anesthetizing locations was reviewed. The facility's policy indicated that they would maintain relative humidity in their anesthetizing locations between thirty and sixty percent. The humidity summary page indicated that twenty-one of twenty-one Operating Rooms had recorded minimum humidity levels below thirty-five percent. Safety Officer 2 was interviewed at that time. Safety Officer 2 indicated that he only records the humidity values and creates the summary page. Safety Officer 2 indicated that he does not routinely adjust relative humidity if the recorded humidity value for that day was outside the facility's desired thirty to sixty percent range. There were no records that indicated relative humidity levels in the twenty-one Operating Rooms were being maintained at thirty-five percent or greater.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by the use of extension cords as substitutes for permanent wiring, cover plates that were missing, and electrical panels that were obstructed. This affected four of four floors in building 1(Main Hospital), one of three floors in building 2, and one of three floors in building 3. This could result in an electrical fire to occur.


NFPA 70, 1999 edition
110-26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
110-26(a)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.
110-26(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
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
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

Building 1

During a facility tour with engineering staff, the facility's electrical equipment and wiring were observed.

1. On 7/17/12 at 11:39 a.m., a computer on wheels located in the corridor outside Room (HD342) was observed. The computer was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

2. On 7/17/12 at 3:45 p.m., one of two refrigerators in Room (H2256) was plugged into a surge protected multi-outlet extension cord.

3. On 7/18/12 at 9:43 a.m., ten electrical panels in the Kitchen were obstructed by the storage of six carts in that location. Signs on the electrical panels indicated to not place any carts or racks in front of the electrical panels. The carts were positioned directly in front of the electrical panels.

4. On 7/18/12 at 2:20 p.m., a light switch near Room (H0316A) was missing a cover plate. Electrical wiring was exposed.

5. On 7/18/12 at 3:02 p.m., an electrical panel near Room (H0541F) was obstructed by carts positioned directly in front of the panel. A sign on the panel indicated to keep clear and accessible at all times.

6. On 7/18/12 at 3:33 p.m., office equipment in Room (H0301D) was plugged into a surge protected multi-outlet extension cord that was plugged into a non-surge protected extension cord.

7. On 7/18/12 at 3:35 p.m., office equipment in Room (H0301F) was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

8. On 7/18/12 at 3:36 p.m., office equipment in Room (H0301H) was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

9. On 7/18/12 at 3:51 p.m., office equipment in Room (H0349) was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

10. On 7/18/12 at 3:52 p.m., office equipment in Room (H0348) was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.


30514


Main Hospital, East Pavilion, 2nd Floor, 7/17/12:

12. At 1:30 p.m., in Conference Room HG212, two power strips were mounted on the wall. The power strips were used for wheelchair chargers and Computer on Wheels (COWs). Safety Officer 1 acknowledged the mounted power strip.

13. At 1:50 p.m., in the Staff Lounge, a microwave and coffee machine was plugged into a power strip that was mounted to the table. Safety Officer 1 acknowledged the mounted power strip.

14. At 2:21 p.m., in alcove space C2A04, a surge protector was mounted to the wall.

15. At 2:24 p.m., by Office HC232, a power strip was mounted on the wall. Power strip was being used to recharge COWs. Safety Officer 1 acknowledged the mounted power strip.

Main Hospital, Boswell, 2nd Floor, 7/17/12:

16. At 2:50 p.m., in Conference Room A202 in the Cardiovascular Clinic, an IT data communication box was detached from the wall.

Main Hospital, Ground Floor, 7/18/12:

17. At 2:15 p.m., in the Respiratory Conference Room, three stacked chairs were blocking access to the electrical panel.

18. At 2:38 p.m., in Physical Therapy H0120, the cover to a junction box was missing. The junction box was next to desk 719.


31203


11. At 10:13 a.m., 7/18/12, on the first floor, Emergency Department, in the Staff Lounge Room H1258, there were two circuit breakers that were blocked by a lounge chair.

Based on observation, the facility failed to ensure that their installation of alcohol based hand rub dispensers was not adjacent to an ignition source. This was evidenced by the mounting of five alcohol based hand rub dispensers over or adjacent to ignition sources. This affected three of four floors in Building 1 (Main Hospital) and one of three floors in Building 2. This could result in ignition of fire from alcohol and the ignition source.

Findings:

During a facility tour with staff, the alcohol based hand rub dispensers in the facility were observed.

1. On 7/17/12 at 2:30 p.m., an alcohol based hand rub dispenser in Room (HD231) was mounted on the wall approximately two feet above an electrical wall receptacle. The hand rub was 62 percent ethyl alcohol by volume.

2. On 7/17/12 at 2:33 p.m., an alcohol based hand rub dispenser in Room (HD233) was mounted on the wall approximately two feet above an electrical wall receptacle. The hand rub was 62 percent ethyl alcohol by volume.

3. On 7/18/12 at 10:06 a.m., an alcohol based hand rub dispenser in Room (H1219) was mounted on the wall approximately two inches above a light switch. The hand rub was 62 percent ethyl alcohol by volume.

4. On 7/18/12 at 11:05 a.m., an alcohol based hand rub dispenser in Room (H1517C) was mounted on the wall approximately four inches above a light switch. The hand rub was 62 percent ethyl alcohol by volume.

5. On 7/18/12 at 3:58 p.m., an alcohol based hand rub dispenser in Room (H0338) was mounted on the wall approximately six inches above a light switch. The hand rub was 62 percent ethyl alcohol by volume.

Building 2

During a facility tour with engineering staff on 7/19/12, the facility's alcohol based hand rub dispensers were observed.

6. At 10:22 a.m., two alcohol based hand rub dispensers in the North Core Room (CC-3041) were mounted approximately six inches above two light switches. The alcohol based hand rub dispensers were located near the two corridor doors to the North Core Room (CC-3041). The alcohol based hand rub was sixty-two percent ethyl alcohol by volume.