HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations through the ceiling and walls. This affected three of four floors plus the basement in the Mineral King Wing and the Woodlake Rural Clinic, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a tour of the facility and interview with staff from 11/4/19 to 11/6/19, the integrity of the building construction was observed in the Mineral King and Acequia Wings, and the Woodlake Rural Clinic.

MINERAL KING

11/4/19

1. At 11:40 a.m., Room 2E-19 in the 2 East Wing was observed with an approximately 1 inch by 3 inch penetration through a ceiling tile. Upon interview, Staff 1 confirmed the finding and stated she was not sure how long the penetration had been there.

2. At 3:22 p.m., the corridor in the 3 Center Wing was observed with an approximately 3 inch by 2 inch penetration through a ceiling tile. Upon interview, Staff 1 confirmed the finding and stated the penetration was of a significant size.

11/5/19

3. At 8:29 a.m., Room 3W-13 in the 3 West Wing was observed with an circular penetration through a ceiling tile that was approximately 5 inches in diameter. Upon interview, Staff 1 confirmed the finding.


27994

11/4/19

MINERAL KING

4. At 10:32 a.m., there was an approximately 1/4 inch penetration in the wall near an electrical panel in the Fourth Floor Center Data Room.



29753

11/4/19

MINERAL KING

5. At 11:09 a.m., four penetrations were observed in the Basement Lab Storage Area. Two of the four penetrations measured approximately 1 inch by 3/4 inch, and the other two penetrations measured approximately 1 inch by 3/8 inch. The penetrations were located in the South Wall of the storage area. When interviewed, Staff 3 confirmed the presence of the four penetrations.

11/5/19

MINERAL KING

6. At 9:42 a.m., an approximately 12 inch by 24 inch penetration was observed in the ceiling of the Storage Room inside the Manager's Office. The penetration was caused by an approximately displaced 24 inch by 24 inch ceiling tile.

7. At 3:07 p.m., an approximately 4 inch circular penetration was observed in the ceiling of the Surgeons Lounge. The penetration was caused by a missing escutcheon ring. When interviewed, Staff 3 confirmed that the escutcheon ring was missing from the sprinkler assembly.

11/6/19

WOODLAKE RURAL CLINIC

At 9:34 a.m., a penetration in the Housekeeping Room was observed. The penetration measured approximately 1 1/2 inches by 2 inches, and surrounded an approximately 1 inch water line pipe. When interviewed, Staff 4 acknowledged the finding.

Based on observation and interview, the facility failed to maintain the cooking facilities. This was evidenced by filters that were not properly seated within the hood. This could result in the increased risk of a grease fire, and affected the kitchen area in the Mineral King Wing.

NFPA 101, Life Safety Code, 2012 Edition

19.3.2.5 Cooking Facilities.
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition

Chapter 6 Grease Removal Devices in Hoods
6.2 Installation.
6.2.3 Grease Filters.
6.2.3.3 Grease filters shall be arranged so that all exhaust air passes through the grease filters.

Findings:

During a tour of the facility and interview with staff on 11/5/19, the Kitchen in the Mineral King Wing was observed.

At 10:56 a.m., two of 19 filters were not seated or positioned within the hood in a manner that would allow all exhaust air to pass through each filter. An approximately 4 inch gap was created between Filter 1 and another filter to the left of it. An approximately 2 inch gap was created between Filter 2 and another filter to the right of it. Upon interview, Staff 3 acknowledged and confirmed that the two filters were not seated in the proper position within the hood.

Based on observation, record review, and interview, the facility failed to provide a functioning fire alarm system for the entire facility. This was evidenced by an inoperable fire alarm system for the Second Floor West Wing Intensive Care Unit (ICU) for more than one of four quarters of the year, and by trouble signals on the fire alarm control panel (FACP) in the Mineral King and Acequia Wing due to ongoing construction. This affected the main hospital, and could result in delayed notification of a fire emergency.

NFPA 101, Life Safety Code, 2012 Edition

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

NFPA 72 National Fire Alarm, 2010 edition

14.2.1.1 Performance Verification. To ensure operational integrity, the system shall have an inspection, testing, and maintenance program.

14.2.1.2.2 System defects and malfunctions shall be corrected.

Findings:

During a tour of the facility, record review, and interview with staff from 11/4/19 to 11/7/19, the fire alarm system records were reviewed, and the fire alarm control panels were observed.

MINERAL KING

1. On 11/5/19 at 2:45 p.m., the documents titled, 'Wet Pipe Fire Sprinkler System, Inspection, Testing, and Maintenance," indicated the Waterflow from the Second Floor West Wing failed to activate the fire alarm system during tests on 11/19/18 and 2/18/19. The fire sprinkler system was documented as functional on 5/13/19 and 8/8/19.

In an interview at 4:23 p.m., Staff 2 indicated the facility started a fire watch for the Second Floor West Wing on 11/20/18 when the fire alarm system was deemed inoperable. Staff 2 explained the facility was required to upgrade their fire alarm system, due to irreplaceable parts, and obtained permits through the authority having jurisdiction (AHJ).

2. On 11/6/19, in an interview at 12:29 p.m., Staff 2 confirmed the facility's fire alarm system was inoperable for approximately six months, but indicated the system is currently functional. Staff 2 acknowledged that while the system was functional, the system failed approval by the AHJ due to the vendor deviating from the original plans, so the facility has continued a fire watch. Staff 2 did not have the specific dates of when the upgrade was started or when the deviation from the plans occurred.

3. At 2:13 p.m., review of the documentation of the fire alarm system functional testing on 3/5/19 indicated the Second Floor West Wing devices, including three manual pull stations, twenty-three smoke detectors, and three duct detectors failed to activate the fire alarm system.

4. On 11/7/19, at 10:05 a.m., a timeline of events was requested from the facility that summarized the failure of the fire alarm system, the deviation of plans, when the facility became aware of the deviation, and where the facility was currently with the projects. The facility was allowed to email this summary in order to allow time to gather accurate dates.

5. In an email on 11/11/19 at 3:27 p.m., the Staff 2 sent an email that indicated after obtaining approvals and permits from the AHJ, the fire alarm system upgrade was initiated on 7/1/19 and completed on 8/3/19. The vendor immediately deviated from the plans, but the facility was unaware of the deviation until the Inspector of Record (IOR) inspected the project on 8/7/19. The facility is currently waiting for the architect to issue a change order to the original plans. No date was provided indicating when the revision was submitted to the facility's architect. It has been over three months since the IOR's inspection.

It is unclear how long the fire alarm system was inoperable, as documentation indicated it was first noted with failure of the water flow to activate the alarm on 11/19/18, but functional on 5/13/19. The facility indicated the project completion was not until 8/3/19, which conflicts with the functional test on 5/13/19. The failure of the fire alarm system initiating devices on 3/5/19 indicate the system was inoperable for at least four months, with the potential of up to nine months.


29753

11/4/19

ACEQUIA

6. At 2:31 p.m., a "trouble" signal was displayed on the FACP. Upon interview, Staff 3 stated the panel displayed the "trouble" signal because of a previous Code Blue alarm that was not cleared, and added that construction was ongoing on Floors 5 and 6 of the wing.

7. At 3:20 p.m., the remote Simplex system in the PBX Room displayed a "trouble" signal. Upon interview, Staff 3 stated the panel displayed a "trouble" signal because of the ongoing construction. Staff 3 further stated that despite the display, the fire alarm system still functions as intended, and that the construction contractor provides fire watch coverage.

11/5/19

MINERAL KING

8. At 10:28 a.m., a "trouble" signal was displayed on the FACP. Upon interview, Staff 3 stated the panel was in "trouble mode" because of the ongoing construction throughout the building.

Based on observation, interview, and record review, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the failure to perform weekly visual inspections of one of two fire pumps, by the failure to document monthly inspections of the fire sprinkler system riser tamper switches, and by missing escutcheon rings and a sprinkler that was loaded with debris. These deficient practices affected the Mineral King Wing, the Acequia Wing, and the Urgent Care facility, and could result in a delayed notification of a malfunctioning automatic fire sprinkler.

NFPA 101 Life Safety Code, 2012 Edition

19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.1.1 Each automatic sprinkler system required by another section of this code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler System

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

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.

4.3.1 Records shall be made for all inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

8.2 Inspection

8.2.1 The purpose of inspection shall be to verify that the pump assembly appears to be in operating condition and is free from physical damage.

8.2.2* The pertinent visual observations specified in the following checklists shall be performed weekly:
(1) Pump house conditions as follows:
(a) Heat is adequate, not less than 40°F (5°C) for pump room with diesel pumps without engine heaters.
(b) Ventilating louvers are free to operate.
(2) Pump system conditions as follows:
(a) Pump suction and discharge and bypass valves are fully open.
(b) Piping is free of leaks.
(c) Suction line pressure gauge reading is within acceptable range.
(d) System line pressure gauge reading is within acceptable range.
(e) Suction reservoir is full.
(f) Wet pit suction screens are unobstructed and in place.
(g) Waterflow test valves are in the closed position.
(3) Electrical system conditions as follows:
(a) Controller pilot light (power on) is illuminated.
(b) Transfer switch normal pilot light is illuminated.
(c) Isolating switch is closed - standby (emergency) source.
(d) Reverse phase alarm pilot light is off, or normal phase rotation pilot light is on.
(e) Oil level in vertical motor sight glass is within acceptable range.
(f) Power to pressure maintenance (jockey) pump is provided.
(4) Diesel engine system conditions as follows:
(a) Fuel tank is at least two-thirds full.
(b) Controller selector switch is in auto position.
(c) Batteries' (2) voltage readings are within acceptable range.
(d) Batteries' (2) charging current readings are within acceptable range.
(e) Batteries' (2) pilot lights are on or battery failure (2) pilot lights are off.
(f) All alarm pilot lights are off.
(g) Engine running time meter is reading.
(h) Oil level in right angle gear drive is within acceptable range.
(i) Crankcase oil level is within acceptable range.
(j) Cooling water level is within acceptable range.
(k) Electrolyte level in batteries is within acceptable range.
(l) Battery terminals are free from corrosion.
(m) Water-jacket heater is operating.
(5)*Steam system conditions: Steam pressure gauge reading is within acceptable range.

Table 13.1.1.2 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance

Inspection
Control Valves - Locked: Monthly
Tamper switches: Monthly

13.3.2.1 All valves shall be inspected weekly.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

NFPA 13, Standard for the Installation of Sprinkler Systems, 2010 Edition
6.2.7 Escutcheons and Cover Plates
6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.
6.2.7.2* Escutcheons used with recessed, flush-type, or concealed sprinklers shall be part of a listed sprinkler assembly.

Findings:

During the facility tour and record review with staff from 11/5/19 to 11/7/19 the automatic fire sprinkler system was observed and maintenance records were reviewed.

11/6/19

MINERAL KING

1. At 2:15 p.m., the fire pump records were reviewed for electric fire pump servicing the Mineral King Wing. The document titled, "Monthly Mineral King Wing Electric Fire Pump Test," indicated the pump was inspected and tested monthly. There were no other documents indicating the pump system and electrical system were visually inspected at least weekly.

In an interview at 3:27 p.m., Staff 2 indicated the electric fire pump was only inspected and tested monthly, and confirmed the electric fire pump was not inspected weekly.

11/7/19

MINERAL KING AND ACEQUIA

2. At 9:54 a.m., the monthly fire sprinkler system visual inspections were reviewed. The document titled, "Monthly Gauge/Control Valve/System Valve Check," indicated the fire sprinkler gauges and control valves were inspected monthly. There were no records that indicated the tamper switches were inspected monthly.

3. At 10:23 a.m., the diesel fire pump, located in the Fire Pump Room, in the basement of the Acequia Wing was observed with two outside, stem and yoke (OS&Y) control valves that were equipped with mechanical tamper switches.

In an interview at 10:24 a.m., Staff 2 indicated the control valves were inspected monthly for correct position and leaks. When probed about tamper switch inspections, Staff 2 confirmed the tamper switches were inspected monthly, but not documented.

4. At 10:30 a.m., the electric fire pump, located in the Northern Yard on the exterior of the Mineral King Wing, was observed with two locked OS&Y control valves with mechanical tamper switches.

In another interview at 10:31 a.m., Staff 2 confirmed there was no documentation of any tamper switch inspections.




29753

11/5/19

MINERAL KING

5. At 3:07 p.m. in the Surgeon's Lounge, an approximately 4 inch circular penetration in the ceiling surrounded a sprinkler without an escutcheon ring. The sprinkler was loaded with dark, dust-like debris. Upon interview, Staff 3 acknowledged the findings.




40596

11/6/19

URGENT CARE

6. At 9:12 a.m., the automatic fire sprinkler system components in the Radiology Restroom in the Urgent Care Building were observed. One sprinkler head was observed missing an escutcheon ring. Upon interview, Staff 5 confirmed the finding and stated the escutcheon ring fell because the ceiling tile was dropping and pushed the ring off.

Based on observation, the facility failed to maintain the fire extinguishers. This was evidenced by a fire extinguisher that was obstructed. This affected one of four floors in the Mineral King Wing, and could result in the delay in access in the event of a emergency.

NFPA 101 Life Safety Code, 2012 edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with
NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguisher, 2010 edition
6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility with staff on 11/4/19, the fire extinguishers were observed.

MINERAL KING

At 10:15 a.m., an enclosed ABC fire extinguisher cabinet labeled K6-4/6 on the 4th floor of Room W411 Case Management Manger office was obstructed from opening by empty water bottles. The date on the service tag was 6/17/19.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to latch, and by corridor doors that were obstructed from closing. This affected two of four floors in the Mineral King Wing and one of four floors in the Acequia Building, and could result in the spread of smoke and fire, in the event of a fire emergency.

NFPA 101 Life Safety Code, 2012 Edition
19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:

(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.

19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interview with staff from 11/4/19 to 11/7/19, the facility's corridor doors were observed in the Mineral King Wing and the Acequia Wing.

11/4/19

MINERAL KING

1. At 10:18 a.m., the corridor door to Room 3E-5 in the 3 East Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

2. At 10:32 a.m., the corridor door to the Anti Room next to Room 3E-9 in the 3 East Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

3. At 10:44 a.m., the corridor door to the Linen Storage in the 3 East Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

4. At 11:00 a.m., the corridor door to the Nutrition Broderick Room in the 3 East Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

5. At 11:14 a.m., the corridor door to the Pediatric Treatment Room in the 3 East Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

6. At 11:51 a.m., the corridor door to the Labor and Delivery Triage Unit in the 2 East Wing was observed. The door was equipped with a timed automatic self-closing device and failed to fully close and latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding and stated the air pressure was affecting the door's ability to latch.

7. At 2:46 p.m., the corridor door to the Work Room in the 3 South Wing was observed. The door was equipped with an automatic release device and was obstructed from closing by a trash can. Upon interview, Staff 1 confirmed the finding and stated the door would not close if the fire alarm system was activated.

8. At 2:53 p.m., the corridor door to the Supply Room in the 3 South Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

9. At 3:45 p.m., the corridor door to the Electrical Room in the 3 Center Wing was observed. The door was equipped with a self-closing device and failed to latch when allowed to self-close. Upon interview, Staff 1 confirmed the finding.

11/5/19

ACEQUIA

10. At 10:30 a.m., the corridor door to the Physician's Office on the third floor was observed. The door was equipped with a self-closing device and was obstructed from closing by a chair. Upon interview, Staff 4 confirmed the finding.


27994

11/4/19

ACEQUIA

11. At 11:02 a.m., the self-closing door to the Office Room 4152 on the 4th floor of Telemetry was obstructed by a chair that prevented the door from closing.





29753

11/4/19

MINERAL KING

12. At 11:40 a.m., the corridor door to the Office of the Laboratory Director (EB20) was observed and tested. The door was equipped with a self-closing device, and failed to latch when tested.

Based on record review, and interview, the facility failed to maintain the elevators with firefighter's service recall. This was evidenced by the failure to inspect, test, operate, and document monthly inspections and maintenance of the elevators. This affected the entire facility, and could result in delayed notification of malfunctioning components essential for firefighting purposes.


NFPA 101, Life Safety Code Unit, 2012 Edition

9.4.2.2 Except as modified herein, existing elevators, escalators, dumbwaiters, and moving walks shall be in accordance with the requirements of ASME A17.3, Safety Code for Existing Elevators and Escalators.

9.4.2.3 Elevators in accordance with ASMEA17.7/CSA B44.7, Performance-Based Safety Code for Elevators and Escalators, shall be deemed to comply with ASME A17.1/CSA B44, Safety Code for Elevators and Escalators, or ASME A17.3, Safety Code for Existing Elevators and Escalators.

9.4.6.1 Elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.

9.4.6.2 All elevators equipped with fire fighters' emergency operations in accordance with 9.4.3 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASMEA17.1/CSA B44, Safety Code for Elevators and Escalators.

9.4.6.3 The elevator inspections and tests required by 9.4.6.1 shall be performed at frequencies complying with one of the following:
(1) Inspection and test frequencies specified in Appendix N of ASME A17.1/CSA B44, Safety Code for Elevators and Escalators
(2) Inspection and test frequencies specified by the authority having jurisdiction

19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.


Findings:

During record review with staff on 11/6/19, the elevator maintenance records were requested.

MINERAL KING

1. At 2:42 p.m., the documents titled, "Elevator Fire Recall Test," indicated the elevator fire recall functions were supposed to be tested monthly. For elevators #6, 7, and 8, the documentation indicated tests were performed in May, July, and August of 2019. There were no other records that indicated the elevators were operated for the months of April, June, September, or October 2019, and November of 2018.

In an interview at 4:33 p.m., Staff 1 indicated a vendor performed the elevator testing for the facility, and confirmed there was no documentation of all monthly tests.

ACEQUIA

2. At 3:39 p.m., the documents titled, "Elevator Fire Recall Test Log," indicated the elevator fire recall functions were supposed to be tested monthly. For elevators #1-7, the documentation indicated tests were performed January to September 2019. There were no other records that indicated the elevators were operated for the months of October 2019, and November, December of 2018.

In an interview at 4:33 p.m., Staff 1 confirmed the monthly inspections were missing from the elevator tests documentation.

Based on observation and interview, the facility failed to provide training for all staff. This was evidenced by staff that could not identify proper procedures for responding to a fire. This could result in delayed response to a fire, and affected one of four floors in the Mineral King Wing.

NFPA 101, Life Safety Code, 2012 Edition

19.7* Operating Features.
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel,
written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for
their evacuation from the building when necessary.
19.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 19.7.1.1.
19.7.1.3 A copy of the plan required by 19.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.
19.7.1.4* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency
fire conditions.
19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Findings:

During a tour of the facility with staff on 11/5/19, hospital staff were interviewed regarding procedures for responding to a fire.

MINERAL KING - PHARMACY

At 11:21 a.m., Pharmacy Staff 1 was given a scenario and asked to provide information regarding the extinguishment of a fire within the Pharmacy area. Pharmacy Staff 1 was unable to provide the information requested. During the interview, Pharmacy Staff 1 stated they have been employed with the hospital for six years, and that they participated in one fire drill. Pharmacy Staff 1 went on to clarify that they had participated in more than one fire drill, but just showed up with a fire extinguisher, and was not instructed on how to use it.

Based on observation, the facility failed to maintain safe usage of the portable space heaters. This was evidenced by the noncompliant use of portable space heaters. This could result in the increased risk of a fire, and affected one of four floors in the Mineral King Wing.

Findings:

During a tour of the facility with staff on 11/5/19, the portable space heaters in non-patient areas were observed.

MINERAL KING

1. At 9:53 a.m., a portable space heater was in use in the Physician's Dictation Room, Office 2. The portable space heater was observed directly beneath the desk, and was connected to a power strip. A warning label affixed to the cord of the space heater indicated that the space heater should be plugged directly into a wall outlet, and should not be connected to an extension cord or power strip. A warning label affixed to the space heater advised of a 3 foot clearance between the space heater and combustible materials.

2. At 2:38 p.m., a portable space heater was in use in the Reception Area of the Surgery Center Waiting Room. The space heater was observed beneath the reception desk and was situated less then 3 feet from the receptionist, the surrounding furniture, and a plastic wastebasket with a plastic liner. The space heater measured 40 inches by 5 inches.

Based on observation and interview, the facility failed to maintain the electrical system receptacles. This was evidenced by the failure to provide tamper-resistant receptacles, or provide a listed cover for receptacles in the pediatric location. This affected one of four floors in the Mineral King Wing, and could result in an electrical shock, should pediatric patients tamper with the receptacles.

Findings:

During a tour of the facility and interview with staff on 11/5/19, the electrical system receptacles were observed.

MINERAL KING

At 8:14 a.m., the Pediatric Location on the Third Floor was observed. There were no tamper-resistant outlets or a listed cover for all receptacles in the patient rooms (Rooms 1 to 11). Upon interview, Staff 2 confirmed the finding.

Based on observation, record review, and interview, the facility failed to maintain the electrical systems-wet procedure locations. This was evidenced by the failure to provide the proper protection in the operating rooms. This affected one of four floors in the Acequia Wing, and could result in a delay in evaluating the risk factors to protect the patients.

Findings:

During a tour of the facility, record review, and interview with staff on 11/5/19, the operating rooms were observed and records were requested.

ACEQUIA

At 8:30 a.m., approximately nine operating rooms (ORs) on the Second Floor were observed without isolated power or ground-fault circuit interrupter outlets. Upon interview, Staff 2 confirmed the finding and acknowledged the facility did not have a documented risk assessment for the ORs.

Based on observation, the facility failed to maintain the emergency power supply (EPS). This was evidenced by the storage of unrelated items in the EPS enclosure room. This affected the generator location, and could result in a fire hazard.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities, Utilities shall comply with the provisions of section 9.1
19.5.1.1 Utilities shall comply with the provisions of section 9.1
9.1.3.1 Emergency Generators and standby power systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition.
7.11 Protection.
7.11.1 The room in which the EPS equipment is located shall not be used for other purposes that are not directly related to the EPS. Parts, tools, and manuals for routine maintenance and repair shall be permitted to be stored in the EPS room.

Findings:

During a tour of the facility with staff on 11/4/19, the EPS Enclosure Room was observed.

At 11:27 a.m., the generator location was observed with three diesel generators. Two pressure washers, leaf vacuum equipment, and a barbecue grill were stored inside the EPS Enclosure Room.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by electrical panels that were not labeled, by an obstructed electrical panel, and by a missing a cover plate. This affected two of four floors in the Mineral King Wing and one of four floors in the Acequia Wing, and could result in an increased risk of an electrical fire.

NFPA 101 Life Safety Code, 2012 edition
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations,
which shall be permitted to be continued in service.

NFPA 70 National Electrical Code, 2011 edition

ARTICLE 110 Requirements for Electrical Installations

110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner
(A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

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

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater.
In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
110.22 Identification of Disconnecting Means.
(A) General. Each disconnecting means shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

408.4 Field Identification Required.
(A) Circuit Directory or Circuit Identification. Every circuit and circuit modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions
of occupancy.

408.7 Unused Openings. Unused openings for circuit breakers and switches shall be closed using identified closures, or other approved means that provide protection substantially equivalent to the wall of the enclosure.

Findings:

During a tour of the facility with staff on 11/4/19 through 11/6/19, the electrical equipment was observed.

11/4/19

MINERAL KING

1. At 10:27 a.m., Electrical Panel 4EB2 on the South Fourth Floor Corridor was observed with Breakers 21 and 42 in the ON position. The breakers were not legibly identified as to their clear, evident, and specific purpose or use.

2. At 10:32 a.m., Electrical Panel 4C-Phone/Fed Rm 3EB on the Fourth Floor Center Data Room was observed with Breakers 3, 5, and 7 in the ON position. The breakers were not legibly identified as to their clear, evident, and specific purpose or use.

3. At 10:36 a.m., a junction box with blue wiring inside was observed in Hemodialysis, Room 408. The junction box did not have a cover plate.

4. At 10:38 a.m., Electrical Panel 4EA2 on the North Fourth Floor Corridor was observed. Inside the panel, Breaker 32 was in the ON position, and was not legibly identified as to its clear, evident, and specific purpose or use.

11/5/19

ACEQUIA

5. At 8:33 a.m., a storage cart was stationed within approximately 3 inches of an unlabeled electrical panel located on the Second Floor of CVOR 6.



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MINERAL KING

6. At 11:56 a.m., the electrical panels in the corridor in the 2 East Wing were observed. Electrical Panel 2EB was observed with circuit 42 in the ON position and was not labeled to its clear, evident, and specific purpose or use. Upon interview, Staff 1 stated she was not sure where the circuit led to.

7. At 12:05 p.m., the electrical panels in the corridor in the 2 East Wing were observed. Electrical Panel 2ECA#2 was observed with circuits 57, 69, 71, 73, 75, 77, 79, 81, and 83 in the ON position and were not labeled to their clear, evident, and specific purpose or use. Upon interview, Staff 1 stated she was not sure where the circuits led to.

11/5/19

MINERAL KING

8. At 8:25 a.m., the electrical equipment in Room 3W-18 in the 3 West Wing was observed. One electrical cover plate was observed hanging by a cord and was not flush to the ceiling tile. Upon interview, Staff 1 confirmed the finding.

9. At 8:44 a.m., the electrical panels in the corridor in the 3 West Wing were observed. Electrical Panel 3F was missing one cover plate on circuit 36. Upon interview, Staff 1 confirmed the finding.

10. At 8:46 a.m., the electrical panels in the corridor in the 3 West Wing were observed. Electrical Panel 3EM-1 was observed with circuits 76 and 78 in the ON position and were not labeled to their clear, evident, and specific purpose or use. Upon interview, Staff 1 confirmed the finding.




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ACEQUIA

11. At 8:40 a.m., electrical panel PNL E-ILH inside the First Floor East Electrical Room was observed. Access to the panel was blocked by an approximately 6 foot ladder.

Based on observation, the facility failed to maintain the electrical equipment. This was evidenced by power strips that were suspended off the floor, by power strips and other power sources that were connected to each other, and by the presence and use of a non-Underwriters Laboratories (UL) listed power strip. This affected one of four floors in the Mineral King Wing and one of four floors in the Acequia Wing, and could result in electrical shock or the ignition of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition

10.2.3.5.1 Cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections.

10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart-mounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

NFPA 101, Life Safety Code, 2012 Edition

19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of section 9.1

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition

400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.
Exception: Listed portable single-pole devices that are intended to accommodate such tension at their terminals shall be permitted to be used with single-conductor flexible cable.
Informational Note: Some methods of preventing pull on a cord from being transmitted to joints or terminals are knotting the cord, winding with tape, and fittings designed for the purpose.

Findings:

During a tour of the facility with staff on 11/4/19 to 11/7/19, the electrical equipment was observed.

11/4/19

MINERAL KING

1. At 10:20 a.m., a power strip with items connected to it was observed inside the South Fourth Floor Medication Room. The power strip was suspended off the floor.

2. At 10:32 a.m., a power strip with items connected to it was observed inside the Fourth Floor Center Data Room. The power strip was suspended off the floor.

3. At 10:33 a.m., a power strip with items connected to it was observed inside the Fourth Floor Center Data Room near one of three data processing towers. The power strip was suspended off the floor.





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11/4/19

MINERAL KING

4. At 10:40 a.m., two power strips inside Sleep Room 2 located in the 3 East Wing were connected together. A lamp and a cell phone charger were plugged into the power strips.



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MINERAL KING

5. At 11:34 a.m., six desks were observed inside the Lab Office, Room E107. An uninterruptible power source (UPS) and a power strip were observed beneath Desk 6, located directly to the right of the entrance into the room. Computer equipment was plugged into the power strip. Computer equipment and the power strip were connected to the UPS.

ACEQUIA

6. At 2:44 p.m., a power strip was observed inside the Environmental Services Office. A microwave oven and computer equipment were connected to the power strip. The amperage load on the power strip was calculated at 14 amperes.

7. At 3:40 p.m., a power strip was observed inside the Registration Office. A toaster, a small refrigerator, and a microwave oven was connected to the power strip. In addition, the power strip was suspended approximately 11 inches above the floor.

Upon interview, Staff 3 confirmed the findings.

11/5/19

ACEQUIA

8. At 8:34 a.m., a UPS and a power strip were observed inside the MRI Control Room. Computer equipment and a cell phone charger were plugged into the UPS. Two wireless intravenous controllers and the UPS were plugged into the power strip.

9. At 10:05 a.m., a power strip was observed near the "old darkroom" inside the X-Ray Control Area. A cell phone charger, computer equipment, and a 12-amp portable air conditioner were plugged into the power strip.

MINERAL KING

10. At 3:03 p.m., computer equipment was connected to a non UL-listed power strip observed inside the Surgeons Lounge.

Upon interview, Staff 3 confirmed the findings.

Based on observation and interview, the facility failed to maintain the gas equipment. This was evidenced by unsecured tanks and storage of combustible material near oxygen cylinders. This affected the Medical Gas Yard and one of four floors in the Acequia Wing, and could result in a fire hazard.

NFPA 99, Health Care Facilities, 2012 edition
11.3 Cylinder and Container Storage Requirements.
11.3.1* Storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3.
11.3.2* Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3.
11.3.2.3 Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or materials by one of the following:
(1) Minimum distance of 6.1 m (20 ft)
(2) Minimum distance of 1.5 m (5 ft) 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
(3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1.2 hour.
11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3.
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
5.1.3.3.2* Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall meet the following requirements:
(7) They shall be provided with racks, chains, or other fastenings to secure all cylinders from falling, whether connected, unconnected, full, or empty

Findings:

During a tour of the facility and interview with staff on 11/4/19, the Gas equipment was observed.

11/4/19

MEDICAL GAS YARD

1. At 11:34 a.m., one empty nitrogen tank and approximately 30 H tanks were unsecured and freestanding on the concrete floor in the Medical Gas yard.

2. At 11:35 a.m., there were wood pallets stored within inches of the unsecured tanks.





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ACEQUIA

3. At 2:55 p.m., 17 full E cylinders and six empty E cylinders were observed inside the Compressed Gas Cylinders Room. Plastic and other combustibles were stored less than five feet from the cylinders. Upon interview, Staff 3 acknowledged and confirmed the finding.