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Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetration in the ceiling. This affected one of seven floors in the California building. This could result in the expedited spread of smoke or fire to other areas of the facility.

Findings:

During a tour of the facility and interview with the Hospital Staff, the ceiling was observed.

California Building
1. On 3/21/19 at 8:57 a.m., there was an approximately 3 inch by 4 inch penetration observed in the ceiling located in the office near the Nurse Station. The penetration was in the office closet. The penetration was at the side of the sprinkler escutcheon. When interviewed, the ACE3 and SM confirmed the finding.

Based on observation, interview, and document review, the facility failed to maintain the delayed-egress doors. This was evidenced by one delayed-egress doors that failed to function as required and failed to activate an alarm as required when opened. This could result in a malfunction and delayed evacuation in the event of a fire and or emergency. This affected one of thirteen floors in the Van Ness Campus.

Findings:

During a tour of the facility with the Hospital Staff, the delayed-egress doors were observed.

Van Ness Campus:
1. On 3/21/19 at 11:21 a.m., the 15 second delayed-egress door located on the sixth floor was unlocked upon arrival. The Stationary Engineer initiated the release and the delayed-egress door opened immediately and there was no audible alarm signal. The delayed-egress door failed to function as required and activate an alarm as required. The were no lights displayed on the turn key. The ICU Nurse Manager stated that last week that the door was not working properly. The Chief Engineer provided a Work Request dated 3/8/19 that indicated the following under Remarks: "Door alert for forced entry has been disabled and needs to be turned back on patients/visitors are walking onto the unit and the staff are not receiving alerts".

Based on observation, document review, and interview, the facility failed to maintain the exit signs. This was evidenced by the failure to provide complete documentation of the required monthly visual inspections of the exit signs. This affected one of seven floors in the California Building, and could result in a delay in evacuation.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.


Findings:

During a tour of the facility, document review, and interview with the Hospital Staff, the exit signs were observed and documents were reviewed.

California Building
1. On 3/21/19 at 12:13 p.m., the facility failed to provide complete documentation of the monthly visual inspection for the illumination sources for exit signs. There were no monthly documentation provided for review from April through December 2018. When interviewed, the ACE3 stated that they were unable to locate the missing records at time of survey.

Based on document review and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to maintain the humidity level according to their policy for temperature and humidity in the operating rooms. This affected one of ten floors in the Buchanan Building, and could result in the ignition of fire in the operating rooms.

Findings:

During document review and interview with the Hospital Staff, the operating rooms humidity level logs were reviewed.

Buchanan Building
1. On 3/20/19 at 2:35 p.m., the humidity log for the nine operating rooms were reviewed. The readings of the humidity level for nine operating rooms were below 30 percent. The reading of the humidity level for the past twelve months were reviewed and the humidity level fell below 30% majority of the days. The policy for humidity level indicated between 30-60% range requirement. When interviewed, the ACE2 stated that they have no way to control humidity level in the operating rooms.

Based on observation and interview, the facility failed to maintain the location of the alcohol based hand rub dispenser (ABHR). This was evidenced by the ABHR that was installed over an ignition source. This affected one of ten floors in the Buchanan Building and could result in the increased risk of fire.

Findings:

During a tour of the facility and interview with the Hospital Staff, the ABHR was observed.

Buchanan Building
1. On 3/19/19 at 11:17 a.m., the ABHR in the Waterhouse Operating Room was observed. The ABHR was installed directly over the red receptacle outlet. The Ethyl Alcohol content of the ABHR was 62 percent. When interviewed, the CE2, ACE2, and SM confirmed the finding.

Van Ness Building
5. On 3/21/19, at 3:31 9.m., the Inspector's Test Valve (ITV) located at the stairwells, had no identification sign. The ITV was not provided with a permanently marked weatherproof metal or rigid plastic identification sign. The finding was confirmed by the CE.

Based on documentation and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to provide documentation for the monthly visual inspection of the valves and gauges. This was also evidenced by Inspector Test Valves (ITV) that had no identification signs. This could result in a malfunction of the automatic sprinkler system and a delay to locate and distinguish the control valves for the automatic sprinkler system in the event of a fire. This affected one of ten floors in the Buchanan Building, one of seven floors in the California Building, two of two floors in the Sacramento Building, one of nine floors in the Clay Building, and the Van Ness Campus.

Findings:

During a tour of the facility, document review, and interview, the sprinkler system were observed, record were requested, and staff were interviewed.

Sacramento Building:
1. On 3/20/19, at 11:26 a.m., the facility failed to provide records for the monthly inspection of the sprinkler valves and gauge at time of survey. When interviewed, ACE2 stated that they have no records for the monthly inspection.
Clay Building:

2. On 3/20/19, at 12:07 p.m., the facility failed to provide records for the monthly inspection of the sprinkler valves and gauge at time of survey. When interviewed, CE2 confirmed the finding.

Buchanan Building:
3. On 3/20/19, at 1:41 p.m., the facility failed to provide records for the monthly inspection of the sprinkler valves and gauge at time of survey. When interviewed, CE2 confirmed the finding.

California Building:
4. On 3/21/19, at 12:26 p.m., the facility failed to provide records for the monthly inspection of the sprinkler valves and gauge at time of survey. When interviewed, ACE3 confirmed the finding.

Van Ness Campus, Second Floor:
3. On 3/21/19, at 11:31 a.m., there were 75 portable fire extinguishers and a Class K fire extinguisher in the Work Room 2322 that were unsecured on the floor. When interviewed, the SE confirmed the finding and stated that the fire extinguishers were extra.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by the failure to inspect a fire extinguisher monthly, by a fire extinguisher that was obstructed from immediate access, and unsecured fire extinguishers. This could result in the device to malfunction in the event of a fire. This affected one of thirteen floors in the Van Ness Campus, one of ten floors in the Buchanan Building and one of two floors in the Sacramento Building.

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 Extinguishers, 2010 Edition
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

7.2.2 Procedures. Periodic inspection or electronic monitoring of fire extinguishers shall include a check of at least the following items:
(1) Location in designated place
(2) No obstruction to access or visibility
(3) Pressure gauge reading or indicator in the operable range or position
(4) Fullness determined by weighing or hefting for self-expelling-type extinguishers, cartridge-operated extinguishers, and pump tanks
(5) Condition of tires, wheels, carriage, hose, and nozzle for wheeled extinguishers
(6) Indicator for nonrechargeable extinguishers using push-to-test pressure indicators

7.2.4 Inspection Record Keeping.
7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed the initials of the person performing the inspection shall be recorded.
7.2.4.4 Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Finding:

During a tour of the facility and interview with the Hospital Staff, the facility's fire extinguishers were observed.

Buchanan Building:
1. On 3/19/19, at 11:05 a.m., the fire extinguisher in Jewett Operating Room was obstructed by a prep table. The table was placed against the fire extinguisher. The table had to be moved to inspect the fire extinguisher inspection tag. The Jewett Operating Room was located on third floor. When interviewed, the CE2, ACE2, and SM confirmed the finding.

Sacramento Building:
2. On 3/19/19, at 12:03 p.m., the fire extinguisher in the Soiled Utility room was placed on top of a counter freestanding and unsecured. The Soiled Utility room was located on the first floor. When interviewed, the Manager of the unit stated that the fire extinguisher needs to be picked up.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by doors that failed to self-close and latch and by doors that were impeded from closing. This affected one of thirteen floors in the Van Ness Campus and could result in the passage of smoke and flames in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
18.2 Means of Egress Requirements.
18.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 18.2.2 through 18.2.11.
7.1.10.1* General. 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.

Findings:

During a tour of the facility with the Hospital Staff, the facility's self-closing doors were observed.

Van Ness Campus, Fourth Floor:
1. On 3/20/19, at 11:18 a.m., the double door to the Imaging Equipment A, Room 4368 was observed. The double door was equipped with a self-closing device. The right door failed to latch when tested.

2. On 3/20/19, at 11:50 a.m., the door to the Ante Room 4302A located on the Post-Anesthesia Care Unit was equipped with a self-closing device that failed to latch when fully opened and closed. The door was tested three times and failed. This finding was confirmed by SE.

3. On 3/20/19, at 11:59 a.m., the door to Room 4238 located in the Ambulatory Care Unit B was equipped with a self-closing device that failed to latch when fully opened and closed. This finding was confirmed by SE.

Based on observation and interview, the facility failed to maintain the smoke integrity of the smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This could result in the spread of smoke and fire and increase the risk of injury to patients and staff in the event of a fire. This affected one of nine floors in the Clay Building and one of ten floors in the Buchanan Building.


NAPA 101, Life Safety Code, 2012 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(ac).
(B) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.


Findings:

During a tour of the facility and interview with the Hospital Staff, the smoke barrier walls were observed.

Clay Building:
1. On 3/19/19 at 1:35 p.m., there was an approximately 1/2 inch unsealed penetration around an electrical conduit in the smoke barrier wall. The smoke barrier wall was located near the elevator on the sixth floor. The elevator was near the ACU and IES units. When interviewed, the CE2 confirmed the finding.

2. On 3/19/19 at 1:56 p.m., there was an approximately 1/2 inch unsealed penetration around an electrical conduit in the smoke barrier wall. The smoke barrier wall was near Room 639 along the ACU corridor on the sixth floor. When interviewed, the CE2 confirmed the finding.

Buchanan Building:
3. On 3/19/19 at 2:08 p.m., there was an approximately 1/2 inch unsealed penetration near the beam in the smoke barrier wall. The smoke barrier wall was outside the main entrance to the operating rooms on the third floor. The penetration was confirmed the CE2.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by circuit breakers that were not legibly identified to specific purpose or use. This affected one of seven floors in the California building and could result in staff inability to identify the circuit breaker in the event of an emergency.


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

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. 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.


Findings:

During a tour of the facility and interview with the Hospital Staff, the electrical equipment was observed.

California Building
1. On 3/21/19 at 9:20 a.m., the electrical panel 34PA had Circuit Breakers 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15/17, 19, 21, 22, 23, and 24, that were not identified on the directory list provided. The circuit breakers were in the "ON" position. When interviewed, the CE3 stated that he does not know what the breakers are for.

Based on document review and interview, the facility failed to maintain fire drills. This was evidenced by the failure to provide fire drill record for all shifts once per quarter. This could result in staff to ineffectively protect patients in the event of an actual fire and could result in injury. This affected one of ten floors in the Buchanan Building and one of nine floors in the Clay Building.

Findings:

During document review and interview with the Hospital Staff, the fire drill records were reviewed.

Clay Building:
1. On 3/20/19 at 10:15 a.m., the facility failed to provide documentation for three of eight fire drills at least quarterly on each shift. The facility failed to provide the PM shift fire drill during the first quarter (January/February/March 2018), second quarter (April/May/June 2018), and fourth quarter (October/November/December 2018). The ACU and IES units on the sixth floor has two shifts, AM and PM shifts. When interviewed, the CE2, ACE2, and SM confirmed the finding.

Buchanan Building:
2. On 3/20/19 at 10:18 a.m., the facility failed to provide documentation for four of eight fire drills at least quarterly on each shift. The facility failed to provide the PM shift fire drill during the first quarter (January/February/March 2018), second quarter (April/May/June 2018), third quarter (July/August/September 2018), and fourth quarter (October/November/December 2018). The operating rooms located on the third floor and has two shifts, AM and PM shifts. When interviewed, the CE2, ACE2, and SM confirmed the finding.

Based on document review and interview, the facility failed to maintain fire doors. This was evidenced by the failure to provide an annual inspection and testing documentation for door openings and assemblies. This affected one of seven floors in the California Building, and could result in the malfunction of doors during an emergency.

Findings:

During document review and interview with the Hospital Staff, the document for door testing and inspections were requested.

California Building
1. On 3/21/19 at 12:50 p.m., the facility was not able to provide documentation for doors inspection and testing at the time of survey. When interviewed, the ACE3 confirmed the finding.

Based on observation and interview, the facility failed to maintain the use of portable space heating devices. This was evidenced by a portable space heater that was in a patient care room. This could result in ignition of fire and affected one of seven floors in the California building.

Findings:

During a tour of the facility and interview with the Hospital Staff, the portable space heater was observed.

California Building
1. On 3/21/19 at 9:12 a.m., a portable space heater was observed in patient care Room 385. The heater was plugged into the receptacle outlet. The heater was placed approximately 1 inch from a wood constructed drawers and 2 inch from a power strip. The precaution sign on the heater read "Caution, high temperature. Keep electrical cords, drapery, and other furnishings at least 3 feet from the front of the heater and away from the sides and rear." The wood drawer was placed in the rear and the power strip was in front of the heater. When interviewed, the ACE3 stated that the heater should not be in the room because the building has a heating system.

Based on observation, document review, and interview, the facility failed to maintain the electrical system and its components. This was evidenced by the failure to provide the electrical receptacle testing records. This affected one of ten floors in the Buchanan Building and one of seven floors in the California Building, and could result in an electrical fire.


NFPA 99, Health Care Facilities Code, 2012 Edition
6.3.2.2.8.1* Wet procedure locations shall be provided with special protection against electric shock.

6.3.2.2.8.5 In existing construction, the requirements of 6.3.2.2.8.1 shall not be required when a written inspection procedure, acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital to indicate that equipment grounding conductors for 120-V, singlephase, 15-A and 20-A receptacles; equipment connected by cord and plug; and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and the applicable performance requirements of this chapter.

(B) Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested as follows:
(1) When first installed
(2) Where there is evidence of damage
(3) After any repairs
(4) At intervals not exceeding 6 months


6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.
6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.


Findings:

During a tour of the facility, document review, and interview with the Hospital Staff, the records were requested.

Buchanan Building:
1. On 3/20/19, at 1:51 p.m., there were no records provided for review for the testing of the electrical outlets in the Operating Rooms located on the third floor. There were nine operating rooms on the third floor. When interviewed, the CE2 stated that he did not know of the every 6 months testing of the outlets.

California Building:
2. On 3/21/19, at 12:45 p.m., the facility failed to provide records for the annual electrical receptacle testing at time of survey. There were no previous records provided to indicate when the receptacles were last tested. When interviewed, the ACE3 confirmed the finding.

Van Ness Campus
5. On 3/19/19, at 4:07 p.m., the facility failed to provide documentation upon request for an annual fuel quality test of the six tanks of stored diesel fuel supply for the three 3000 kilowatt diesel generator's located at the Van Ness Campus. Upon interview at 4:20 p.m., the Chief Engineer stated that no one from the project team can provide information on the fuel quality test so it's scheduled for next week.

Based on document review and interview, the facility failed to maintain the emergency power supply (EPS). This was evidenced by the failure correct the discrepancy on the annual maintenance report, the failure to perform monthly conductance test of the generator battery, the failure to provide complete records of the weekly visual inspections, and the failure to conduct a fuel quality test at least annually. This affected thirteen of thirteen floors in the Van Ness Campus, one of seven floors in the California Building, and two of two floors in the Sacramento Building. This could result in the ineffective operation of the generator in the event of an emergency.


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

8.3.4.1 The permanent record shall include the following:
(1) The date of the maintenance report
(2) Identification of the servicing personnel
(3) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(4) Testing of any repair for the time as recommended by the manufacturer

8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.

8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kWrating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

8.4.2.4 Spark-ignited generator sets shall be exercised at least once a month with the available EPSS load for 30 minutes or until the water temperature and the oil pressure have stabilized.
8.4.2.4.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.4.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.3 The EPS test shall be initiated by simulating a power outage using the test switch(es) on the ATSs or by opening a normal breaker. Opening a normal breaker shall not be required.
8.4.4 Load tests of generator sets shall include complete cold starts.
8.4.5 Time delays shall be set as follows:
(1) Time delay on start:
(a) 1 second minimum
(b) 0.5 second minimum for gas turbine units
(2) Time delay on transfer to emergency: no minimum required
(3) Time delay on restoration to normal: 5 minutes minimum
(4) Time delay on shutdown: 5 minutes minimum
8.4.6 Transfer switches shall be operated monthly.
8.4.6.1 The monthly test of a transfer switch shall consist of electrically operating the transfer switch from the standard position to the alternate position and then a return to the standard position.



Findings:

During document review and interview with the Hospital Staff, the document were requested and reviewed.

Sacramento Building:
1. On 3/20/19, at 10:53 a.m., the facility did not provide records for 46 of 52 weekly visual inspections for the 10 kilowatt (KW) natural gas with propane back-up powered generator at time of survey. When interviewed, the CE2 stated that they have already identified that weekly visuals was not conducted and started to conduct weekly visuals in January 2019.

2. On 3/20/19, at 11:02 a.m., the annual service report dated 7/31/18 was reviewed. The comments in the report indicated "found minor oil weeps on the engine block". There were no documentation provided that it has been repaired. When interviewed, the CE2 stated that it has not been repaired because it's a small weep.

3. On 3/20/19, at 12:10 p.m., the facility failed to perform the monthly conductance test for the battery in the generator. When interviewed, the CE2 stated that they are not testing for conductance because it was a sealed battery.


California Building.
4. On 3/21/19, at 11:53 a.m., the facility did not provide records for 3 of 52 weekly visual inspections for the 300 kW diesel powered generator at time of survey. When interviewed, the ACE3 confirmed the finding.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by a power strip that was suspended off the floor. This could potentially result electrical shock or the ignition of an electrical fire. This affected one of nine floors in the Clay Building.


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.

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
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings.
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage 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.


Findings:

During a tour of the facility and interview with the Hospital Staff, the electrical wiring were observed.

Clay Building:
1. On 3/19/91 at 11:43 a.m., a Tripp-Lite power strip in Procedure Room 2 was observed suspended off the floor approximately 4 feet. The power strip was used to power a wireless phone and speaker. The Procedure Room 2 was located in the IES unit. This finding was confirmed by the CE2, ACE3, and SM.

Based on observation and interview, the facility failed to maintain the storage of gas cylinders. This was evidenced by cylinders that were not supported in a proper cylinder stand or cart. This could result in damage to the carbon dioxide gas cylinders and argon compressed cylinder. This affected one of nine floors in the Clay Building.

NFPA 99, Health Care Facilities Code, 2012 Edition

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.


Findings:

During a tour of the facility and interview with the Hospital Staff, the carbon dioxide gas cylinders and argon compressed cylinder were observed.

Clay Building
1. On 3/19/19 at 11:43 a.m., there were two carbon dioxide cylinders and one argon compressed cylinder that were laying flat on the floor and unsecured. The cylinders were not properly chained or supported in a proper cylinder stand or cart. The cylinders were observed in Room 610 located in the IES unit on the sixth floor. This finding was confirmed by ACE2, CE2, and SM.