HospitalInspections.org

Based on observation, document review and staff interview, the facility failed to provide sprinkler protection throughout the facility as required by by NFPA 101 Life Safety Code when door locking arrangements are installed. This deficient practice of using magnetic locking doors for exiting arrangement, when not providing sprinkler protection throughout the facility might prevent speedy exiting and endanger the lives of patients, staff, and visitors. The deficient practice affects approximately all patients in all smoke zones. The facility has a capacity of 99 and census of 12 at the time of the survey.

Findings include:

During the survey on September 13th it is observed that the facility is using magnetic locking devices and delayed egress locking devices while the basement level of the facility is not sprinkler protected.

Staff Member B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following:

(1) Locks complying with 19.2.2.2.5 shall be permitted.
(2) Delayed-egress locks complying with 7.2.1.6.1 shall be permitted.
(3) Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.
(4) Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted.
(5) Approved existing door-locking installations shall be permitted. 2012 NFPA 101, 19.2.2.2.4

Review of the following NFPA Standard revealed: Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:

(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3)The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with
19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the device.
(5) The locks release by independent activation of each of the following:
(a) Activation of the smoke detection system required by 19.2.2.2.5.2(2)
(b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)
Door-locking arrangements shall be permitted in accordance with either 19.2.2.2.5.1 or 19.2.2.2.5.2.
Door-locking arrangements shall be permitted where the clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3)*The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with
19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the device.
(5) The locks release by independent activation of each of the following:
(a) Activation of the smoke detection system required by19.2.2.2.5.2(2)
(b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)
2012 NFPA 101, 19.2.2.2.5.2

Sprinklers shall be permitted to be omitted from spaces underground floors, exterior docks, and platforms where all of the following conditions prevail:
(1) The space is not accessible for storage purposes and is protected against accumulation of wind-borne debris.
(2) The space contains no equipment such as conveyors or fuel-fired heating units.
(3) The floor over the space is of tight construction.
(4) No combustible or flammable liquids or materials that under fire conditions would convert into combustible or flammable liquids are processed, handled, or stored on the floor above the space.
Unless the requirements of 8.15.10.3 are met, sprinkler
protection shall be required in electrical equipment rooms. 2010 NFPA 13 8.15.6.2, 8.15.10.1


Review of the following NFPA Standard revealed: Health care occupancies that find it necessary to lock means of egress doors shall, at all times, maintain an adequate staff qualified to release locks and direct occupants from the immediate danger area to a place of safety in case of fire or other emergency. 2012 NFPA 101, 19.7.3.2

Based on observation and staff interview the facility does not assure that doors in a smoke barrier are equipped with a self-closing device. This deficient practice of not equipping smoke barrier doors with a self-closing device will allow smoke products to pass through these doors into the adjacent smoke zones, affecting one patient in 2 of 14 smoke zones. The facility has a capacity of 99 and census of 12 at the time of the survey.

Findings include:

During the survey on September 11th At 9:35 a.m. The South leaf of door number 1064 failed to latch upon drop test.

Staff member B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. 2012 NFPA 101, 19.2.2.2.7

Based on record review and staff interview, the facility failed to perform required maintenance on the kitchen range hood fire suppression system as required by NFPA 96. This deficient practice fails to provide a properly maintained fire suppression system as required in 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, affecting no patients in one of 14 smoke zones. The facility has a capacity of 99 with a census of 12 at the time of survey.

Findings include:

During record review on September 12th, 2018 it is observed that the facility is missing one of the semiannual inspections for 2017. 2/5/17 is the date for the only inspection report provided for 2017 year.

Staff B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed:

Maintenance of the fire-extinguishing systems and listed exhaust hoods containing a constant or fire-activated water system that is listed to extinguish a fire in the grease removal devices, hood exhaust plenums, and exhaust ducts shall be made by properly trained, qualified, and certified person( s) acceptable to the authority having jurisdiction at least every 6 months. 2011 NFPA 96 11.2.1*

Based on observation and record review, the facility failed to fix devices listed as failed on the report for the annual inspection and testing of the fire alarm system as required by NFPA 72. Failure to fix these devices fails to ensure reliability of the alarm system in the event of an emergency, affecting 8 patients in 7 of 14 smoke zones. The facility has a capacity of 99 and census of 12 at the time of the survey.

Findings include:

During record review on September 12th it is revealed that the fire alarm vendor inspection and testing report required by NFPA 72 and dated July 26, 2018 has devices that failed and have not been replaced or repaired. The following signaling devices failed to operate on alarm:

1. 2nd floor OB by nurse station,
2. 1st floor MRI by equipment Room,
3. 2nd floor by A and B elevators,
4. 2nd floor north nurses station,
5. First floor Main entrance by PBX

And the following air handlers did not shut down on alarm:

1. 2 South (North Mechanical Room)
2. 3 North.

The FACP is an addressable system and according to the FACP no devices were showing a trouble at the time of the inspection.

During record review on September 13th it is revealed that no documentation is available for review showing that the kitchen vent hood connections to the FACP are being tested to set off the fire alarm system.

Staff member B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6. 2012 NFPA 101, 19.3.4.1

Review of the following NFPA Standard revealed: Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 2012 NFPA 101, 4.6.12.4

Review of the following NFPA Standard revealed: To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code. 2012 NFPA 101, 9.6.1.5

Review of the following NFPA Standard revealed: 14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested
(8) Functional test of detectors
(9)Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Test of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

K372 Smoke Barrier Penetrations Existing
S/S F
14 of 14 SZ
All Residents

Based on observation and staff interview the facility fails to maintain smoke barriers to at least one-half hour fire resistance. This deficient practice would prevent containment of fire and smoke, affecting all residents in one of six smoke zones including the only dining area. The facility has a capacity of 99 with a census of 12 at the time of survey.

Findings include:

During the survey on September 11th, 2018 the following is observed:

1. At 8:15 a.m. There is a 3-inch by 1-inch hole above surgery storage.

2. At 8:30 a.m. There is a 6-inch by 4-inch hole and a 3-inch by 3-inch hole above surgery exit corridor near surgery room 3.

3. At 8:30 a.m. There is a 1/2-inch penetration through both sides of the barrier wall above fire door 1054. (x2)

4. At 8:55 a.m. There are multiple penetrations in the South barrier wall of surgery corridor around 6-inch pipe.

5. At 9:05 a.m. There is a 6-inch hole in the barrier wall above first floor men's staff bathroom.

6. At 9:10 a.m. There is a 1.5-inch penetration in the barrier wall above the corridor for dietitian and security offices. (x2)

7. At 9:30 a.m. There is an 8-inch by 3-feet pipe chase with penetrations going through a rated barrier wall above staff first floor entry/exit.

8. At. 9:40 a.m. There are penetrations above 1064. On the West side of the door there is a 2-inch x 4-inch penetration with pipes coming through the wall and the East side has un-taped sheetrock seams and 2-inch x 4-inch hole in 2-hour Fire rated wall above door.

9. At 11:05 a.m. The 1-hour Rated wall across from elevators does not continue up through the ceiling to the next floor. There is ductwork in the way approximately 40 feet long by 2 ft.

10. At. 11:30 a.m. There is a 2.5-inch hole in the rated wall above fire door 1050.

11. At 11:40 a.m. The continuation of 1-hour rated wall starting above pre/post operation room 124 and ending at the corner of the radiology managers office is not continued to ceiling. The rated wall area that is missing is approximately 4 ft. tall by 100 ft. wide.

12. At. 2:20 p.m. Above the second ceiling rated opening from the sliding exit doors in rated ceiling of women's health there is an 18-inch by 2-inch pipe chase that is not protected.

13. At. 2:30 p.m. There are 6 penetrations in rated wall above the ultrasound door.

14. At 2:35 p.m. Above the ceiling of the sonogram restroom there are two penetrations in the rated wall.

15. At 2:40 p.m. There are 4 penetrations in rated wall above sonogram ceiling.

16. At 2:20 p.m. The smoke barrier above the door labeled Fm1056 is not complete to the ceiling deck. There is a 3-feet by 8-feet opening in the rated wall.

17. At. 2:25 p.m. There are voids around 2 different 12-inch pipes in the rated wall of the corridor above the entrance to MRI.

13. At. 3:05 p.m. There is a 12-inch diameter hole cut in the rated wall above Northern corner of the lab.

14. At 3:05 p.m. There are 2 penetrations in ceiling above lab storage East wall.

15. At 3:10 p.m. There are 2 penetrations above the ceiling tile in lab restroom.

16. At 3:13 p.m. Above the ceiling tile of the South east corner of the lab breakroom there 2 penetrations one is ½-inch in diameter and the other is in the far Southeast upper corner and is approximately 8-inches by 8-inches.

Staff B and C were present and acknowledged these findings.

During the survey on September 12th, 2018 the following is observed:


17. At 9:55 a.m. There is an unprotected 2-inch gap that is in the rated wall due to an expansion joint in rated wall in respiratory apartment.

18. At 10:00 a.m. There are four 1-inch holes and one 6-inch x 12-inch void in the rated corridor to 2 South across from respiratory therapy apartment.

19. At 10:20 a.m. There are 6 holes above fire doors 1066 OB entrance.

20. At 10:20 a.m. There is a 3-inch hole in the rated wall across from the elevators on the 2nd floor.

21. At 10:30 a.m. There is a 6-inch by 8-inch hole in rated wall and three ½-inch holes in rated wall in ceiling above second floor corridor office.

22. At 10:40 a.m. Above the ceiling of the quality director's office the rated wall is not carried to the next floor. Approx. 3-feett x 15-feet.

23. At 10:45 a.m. In the 2nd floor private consultation room above the ceiling there is a 2-inch x 4-inch opening in the rated wall.

24. At 10:55 a.m. There is a 3-inch hole in the rated wall with a 1-inch pipe running through it above the ceiling in the bathroom of the second-floor locker room.

25. At 11:15 a.m. There is a 3-inch by 2-inch gap with three pipes going through it that is unprotected in a rated wall in the 2 North EVS closet.

26. At 11:40 a.m. There is a penetration rated wall above the ductwork in the equipment room on the third floor.

27. At 11:55 a.m. The 1 hour rated wall in a soiled utility on 3rd floor outside of room 312 has the wall missing between the ceiling and the next floor. The wall is between room 312 and soiled utility multiple penetrations noted above the ceiling as well.

28. At 12:00 a.m. There are five 12-innch pipe penetrations through the rated wall above ceiling in room 313.

Staff B and C were present and acknowledged these findings.

29. At 9:50 a.m. There are 8 2-inch pipe penetrations in the rated wall of kitchen storage.

30. At 9:55 a.m. There are 3 penetrations around 6-inch pipe and a void around the ductwork going through a rated wall above the ceiling tile in the kitchen dry goods storage

31. At 10:05 a.m. There is a void in rated wall next to duct work above walk-in refrigerator.

32. At 10:10 a.m. There is a 2-inch by 4-inch penetration in the rated wall above the Main Street conference room ceiling.

33. At 10:15 a.m. There is a ½ inch void (x3) above the entrance to cafeteria and pipe chase that is 1-inch x 3 ft with voids around all pipes.

34. At 10:20 a.m. There is a void around 2-inch sprinkler pipe above the condiments area in dining room rated wall.

35. At 10:25 a.m. There is a ½-inch penetration for conduit, a ½-inch penetration for yellow wire and 10-foot seam that is not sealed in rated wall above vending machine area.

36. At 10:30 a.m. There is a 1-inch pipe penetration above the exit from cafeteria to dining room.

37. 10:35 a.m. There is a 2-inch void around ductwork in cafeteria rated wall (x2) and void around ½ inch conduit (x2)

38. 10:45 a.m. There is a 1-inch by 2-inch penetration for conduit above the health information management office.

39. 10:50 a.m. there is a 2-foot by 2-foot void above the ceiling in surgery exit and 2 ½ -inch hole (x2) in the rated wall.

Staff C was present and acknowledged these findings.

During the survey on September 13th, 2016 the following is observed:

40. at 9:10 a.m. There are multiple penetrations and rated walls in the basement.

Staff B was present and acknowledged these findings

Review of the following NFPA Standard revealed: Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum ½ 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) (c).
(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. 2012 NFPA 101, 19.3.7.3

Review of the following NFPA Standard revealed: Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier, or by use of a combination thereof. Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces. 2012 NFPA 101, 8.5.2.1 and 8.5.2.2

Review of the following NFPA Standard revealed: The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers. 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. 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. Where sprinklers penetrate a single membrane of a fire resistance-rated assembly in buildings equipped throughout with an approved automatic fire sprinkler system, noncombustible escutcheon plates shall be permitted, provided that the space around each sprinkler penetration does not exceed 112 in. (13 mm), measured between the edge of the membrane and the sprinkler. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be securely set in the smoke barrier, and the space between the item and the sleeve shall be filled with a material capable of restricting the transfer of smoke. 2012 NFPA 101, 8.5.6.1 through 8.5.6.5

Based on observation and record review, the facility fails to maintain fire dampers in heating, ventilation and air conditioning assemblies as required. This deficient practice of not identifying, testing and maintaining fire dampers as required, increases the risk fire affecting 0 patients 1 of 14 smoke zones. The facility has a capacity of 99 with a census of 12 at the time of survey.

Findings include:

During record review on September 12th the fire damper 6-year inspection documentation revealed that 9 of the fire dampers failed and need to be replaced. The facility has failed to replace or repair the 9 failed fire dampers.

Staff member B was present during the survey and record review and acknowledged the findings.

Review of the following NFPA Standard revealed: Air-conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2012 NFPA 101, 9.2.1

Review of the following NFPA Standard revealed: Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. 2012 NFPA 90A, 5.4.8.1

Review of the following NFPA Standard revealed: The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.2010 NFPA 80, 19.4.1.1

Based on record review and staff interview, the facility is not conducting fire drills at different times as required and is not properly recording the results and facts relating to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency, affecting all patients in all seventeen smoke zones. The facility has a capacity of 99 with a census of 12 at the time of survey.

Findings include:

During record review on September 13th, the following is observed:

1. Review of fire drill records for the last 7 quarters revealed that in all of the quarters in 2017 and in the first two quarters of 2018, the facility was conducting fire drills based on a 2 shift cycle missing the 3rd shift employee on dietary employment roll.
2. Review of fire drill records for the last 7 quarters revealed that there are 5 drills between 2130 and 2230, 9 drills conducted in the 9:00 am hour, 4 in the 1300 hour, and 4 in the 0100 hour.

Staff Member B was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 2012 NFPA 101, 19.7.1.4

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 19.7.1.6

Based on observation and staff interview the facility is not ensuring that fire and smoke rated doors and assemblies are inspected and tested annually. This deficient practice of not ensuring fire and smoke rated doors and assemblies are inspected and tested annually, prevents the ability of the facility to properly confine fire and smoke products and to properly defend occupants in place, affecting all patients in all 14 smoke zones. The facility has a capacity of 99 with a census of 12 patients at the time of the survey.

Findings include:

During the survey on September 12th, 2018 it is revealed that there is no documentation that the fire and smoke rated doors and assemblies are inspected and tested annually.

Staff member B was present at the time of the observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 8O, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2012 NFPA 101, 7.2.1.15.2

Review of the following NFPA Standard revealed: Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 2010 NFPA 80, 5.2.1

Review of the following NFPA Standard revealed: Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting. 2010 NFPA 80, 5.2.3.1 and 5.2.3.2

Based on observation, record review and staff interview the facility failed to assure that portable space heaters being used within the facility are code compliant. This deficient practice could cause a fire due to excessive heat, affecting approximately 0 patients in 1 of 14 smoke zones. The facility has a capacity of 99 with a census of 12 at the time of survey.

Findings include:

During the survey on September 13th at 2:00 p.m. A portable heater is observed in shipping and receiving office (x2) and there is no documentation to indicate that the heating element does not exceed 212 degrees Fahrenheit.

Staff member B was present at the time of observation and acknowledged the findings.

Review of the following NFPA Standard revealed: Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:

(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (l00°C). 2012 NFPA 101, 19.7.8

Based on observation and staff interview, the facility fails to assure that all relocatable power taps meet the requirements NFPA 70 National Electrical Code and NFPA 99 Health Care Facilities Code. This deficient practice increases the risk of an electrical fire and affects all patients in all smoke zones. The facility has a capacity of 99 with a census of 12 patients at the time of the survey.

Findings include:

1. On September 13th at 12:25pm There are three appliances totaling approximately 21 Amps plugged into a power strip in the medical records 2 coffee makers and a toaster.

2. On September 12th during record review it is revealed that Power strips throughout the facility are not in compliance with UL listing requirements. The facility is in the process of switching out the deficient power strips with the correct ones and creating a policy and procedure for annual inspections of the power strips throughout the facility.

3.On September 12th it is noted that no documented maintenance and testing program is available for review for the hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered. No Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.


Maintenance Staff A was present during the survey and acknowledged the findings.

Review of the following NFPA Standard revealed: 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. 2012 NFPA 101, 9.1.2

Review of the following NFPA Standard revealed: Where used as permitted in 400.7(A)(3), (A)(6), and (A)(8), each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet or cord connector body.

Exception: As permitted in 368.56. 2011 NFPA 70, 400.7

Review of the following NFPA Standard revealed: Unless specifically permitted, flexible cords and cable shall not be used as a substitute for fixed wiring of a structure. 1999 NFPA 70, 400-8

Review of the following NFPA Standard revealed: In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in 210.23(A) through (D) and as summarized in 210.24 and Table 210.24. 2011 NFPA 70, 210.23

Review of the following NFPA Standard revealed: The flexible cord, including the grounding conductor, shall be of a type suitable for the particular application; shall be listed for use at a voltage equal to or greater than the rated power line voltage of the appliance; and shall have an ampacity, as given in Table 400.5(A) of NFPA 70, National Electrical Code, equal to or greater than the current rating of the device. 2012 NFPA 99, 10.2.3.1.1

Review of the following NFPA Standard revealed: 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.
(5) Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. . 2012 NFPA 99, 10.2.3.6

Review of the following NFPA Standard revealed: Nonpatient care-related electrical equipment, including facility- or patient-owned appliances that are used in the patient care vicinity and will, in normal use, contact patients, shall be visually inspected by the patient's care staff or other personnel. 2012 NFPA 99, 10.4.2.1

Review of the following NFPA Standard revealed: A record shall be maintained of the tests required by this chapter and associated repairs or modification. 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.
2012 NFPA 99, 6.3.4.2.1.1 and 6.3.4.2.1.2