HospitalInspections.org

Based on document review and interview, the facility failed to provide an emergency plan (EP) at all locations. This was also evidenced by the absence of an EP at the outpatient location. This affected 33 patients at the Outpatient Rehabilitation Services and could result in staff's incorrect response during an emergency.

Findings:

During document review and interview with the ESC and the ECM, the EP plan was requested.

Outpatient Rehabilitation Services

1. During an interview on 5/7/19 at 1:50 p.m., the ESC was asked if there was an EP manual located at the Outpatient Rehabilitation Services? The ESC stated that there was not a copy of the EP at the Outpatient Rehabilitation Services location. The ESC also stated that they only have two copies of the EP. One was located in the ESC Office at the Main Hospital and the other was located on a mobile cart.

Based on document review and interview, the facility failed to review and approve the emergency plan (EP) on an annual basis. This was evidenced by an annual review sign off sheet that was lacking indication that all committees required to review and approve the EP had done so. This affected 85 patients at the Main Hospital and 33 patients at the Outpatient Rehabilitation Services and could result in staff's incorrect response during an emergency.

Findings:

During document review and interview with the ESC and the ECM, the EP plan was requested.

Main Hospital

1. On 5/7/19 at 12:43 p.m., a document titled, "Annual Review and Approval" was provided. The document indicated that the Quality Management Committee and the Medical Executive Committee were both required to review and approve the EP. The document also indicated that the Medical Executive Committee had not reviewed the EP. Upon interview the ESC confirmed this finding and stated that the EP had not been reviewed and approved by the Medical Executive Committee just yet.

Outpatient Rehabilitation Services

2. On 5/7/19 at 12:44 p.m., a document titled, "Annual Review and Approval" was provided. The document indicated that the Quality Management Committee and the Medical Executive Committee were both required to review and approve the EP. The document also indicated that the Medical Executive Committee had not reviewed the EP. Upon interview the ESC confirmed this finding and stated that the EP had not been reviewed and approved by the Medical Executive Committee just yet.

Based on document review and interview, the facility failed to complete the required disaster drills. This was evidenced by the absence of two of two disaster drills and the failure to provide documentation that indicated they had participate in a full-scale community-based exercise or demonstrate the efforts made to identify the availability of a full-scale community-based exercise. This affected 33 patients at the Outpatient Rehabilitation Services and could result in a delayed response to a full-scale community wide emergency.

Findings:

During document review and interview with the ESC and the ECM records of emergency preparedness training drills were requested.

Outpatient Rehabilitation Services

1. On 5/7/19 at 2:00 p.m., there were no records provided that indicated the facility had completed any facility based drills in the past 12 months. There were also no records provided that indicated there was a community-based drill or that community entities were contacted to attempt a full-scale community-based emergency exercise drill.

Upon interview, the ESC confirmed this finding and stated that the staff at the Outpatient Rehabilitation Services works at the Main Hospital as well and did participate in the drills completed at the Main Hospital. The ESC also stated that the Outpatient Rehabilitation Services was not incorporated into the drills.

Based on observation and interview, the facility failed to maintain the building construction. This was evidenced by unsealed penetrations in the walls and ceiling. This affected one of two floors at the Main Hospital and could result in the spread of fire and smoke in the event of a fire.

Findings:

During a tour of the facility and interview with the ECM and LE, the walls and ceilings were observed.

Main Hospital-Level 1

1. On 5/6/19 at 10:39 a.m., the Janitorial Closet with door labeled 833 in the Intensive Care Unit was observed. There was a penetration located on the east wall. The penetration was approximately 1/2 inch diameter in size. Upon interview, the ECM and the LE confirmed this finding.

2. On 5/6/19 at 1:08 p.m., the Storage Closet with door labeled 705B located within the OR Clean Supply Room was observed. There was a penetration located in the ceiling area near the back wall. The penetration was approximately 1/2 inch diameter in size. Upon interview, the ECM and the LE confirmed this finding.

Based on observation and interview, the facility failed to maintain the means of egress. This was evidenced by a designated exit door that was obstructed. This affected one of two floors at the Main Hospital and could result in a delayed evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

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

Findings:

During a tour of the facility and interview with the ECM and the LE, the egress doors were observed.

Main Hospital-Lower Level

1. On 5/6/19 at 2:16 p.m., the designated exit door next to the Rehabilitation Services Room 1002B was observed. The door led from the inside of the hospital to the exit discharge. There was a 55 gallon receptacle placed directly in front of the door on the egress side. Upon interview, the ECM and the LE confirmed this finding.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by a door to a hazardous area that was not equipped with a self-closing device. This affected one of two floors, and could result in the increased potential for the spread of fire and/or smoke to other areas.

Findings:

During a tour of the facility with ECM and LE on 5/6/19, the hazardous areas were observed.

1. At 10:24 a.m., the door to the Kitchen Dry Storage was not equipped with a self closure or automatic closing. The room was approximately 114 square feet in size. The room was housing dry goods, papers packing, and boxes.

Based on observation and interview, the facility failed to maintain the manual alarm boxes. This was evidenced by one the manual alarm box that was obstructed from access. This affected one of two floors at the Main Hospital and could result in the inability to locate and/or obtain the manual alarm box in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.2.2 Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses' control stations or other continuously attended staff location, provided that both of the following criteria are met:
(1) Such manual fire alarm boxes are visible and continuously accessible.


Findings:

During a tour of the facility and interview with the LE, the the manual alarm boxes were observed.

Main Hospital-Level 1

1. On 5/8/19 at 10:53 a.m., the manual alarm box located in the Security Office was observed. There was a refrigerator, a microwave, and a keurig coffee machine that were stationed in front of the manual alarm box. The manual alarm box was not accessible. Upon interview, the LE confirmed this finding.

Based on document review, observation, and interview, the facility failed to maintain the fire alarm system. This was evidence by the absence of an annual charger tests, an annual 30 minute discharge tests, and semi-annual load voltage tests for the sealed lead-acid back-up batteries on the on the fire alarm control units (FACUs). This was also evidenced by the absence of an annual fire alarm system inspection/test. This affected two of two floors at the Main Hospital and one of one smoke compartment at the Outpatient Rehabilitation Services and could result in system impairment during an emergency situation.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6
9.6.1.5* 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.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Table 14.4.2.2
5. Batteries
(b) Battery Replacement
Batteries shall be replaced in accordance with the recommendations of the alarm equipment manufacturer or when the recharged battery voltage or current falls below the manufacturer ' s recommendations.

Table 14.4.5 Testing Frequencies.
6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test: Initial/Reacceptance and Annually
(2) Discharge test (30 minutes): Initial/Reacceptance and Annually
(3) Load voltage test: Initial/Reacceptance and Semiannually

Findings:

During document review, observation, and interview with the ECM and the LE, the FACUs were observed and records were requested.

Main Hospital

On 5/6/19 the FACU was located on Level 1 (Door 931). The FACU was observed with three sealed lead acid back-up batteries that were dated 11/15.

1. On 5/7/19 at 3:35 p.m., there were no records provided that indicated three of three sealed lead-acid batteries used to back-up the FACU had an annual charger test and an annual 30 minute discharge test completed in the past 12 months. There were also no records provided that indicated the batteries had the two semi-annual load voltage tests completed in the past 12 months. Upon interview, the ECM and the LE confirmed this finding and stated that they confirmed with the fire alarm system vendor that the vendor did not complete the testing.

Outpatient Rehabilitation Services

On 5/8/19, the FACU was located in the Telephone/Communications Room on the first floor. The FACU was observed with four sealed lead acid back-up batteries that were dated 1/2/14.

2. On 5/8/19 at 9:18 a.m., there were no records provided that indicated four of four sealed lead-acid batteries used to back-up the FACU had an annual charger test and an annual 30 minute discharge test completed in the past 12 months. There were also no records provided that indicated that the batteries had the two semi-annual load voltage tests completed in the past 12 months. Upon interview, the EMC confirmed this finding and stated they would be contacting the leasing manager of the Outpatient Rehabilitation Services Building for the records on the battery testing.

The facility was given until 5:00 p.m. on 5/8/19 to provide a the battery annual and semi-annual testing records to the CDPH. No documents were received.

3. On 5/8/19 at 9:25 a.m., there was no documentation available that indicated the batteries had been replaced in the past 5 years. Upon interview, the ECM and the LE acknowledged this finding and stated that they would talk to the Leasing Manager for the Outpatient Rehabilitation Services Building. The facility was given until 5:00 p.m. on 5/8/19 to provide documentation indicating that the batteries had been replaced within the past 5 years to CDPH.

On 5/8/19 at 5:00 p.m., CDPH did not receive the annual and semi-annual battery testing records or documentation indicating the batteries had been replaced in the past 5 years from the facility.

Based on document review and interview, the facility failed to maintain the smoke detector devices. This was evidenced by three of three single station battery powered smoke alarms that were not tested on a weekly basis as required per the manufacturer. This affected one of of two floors at the Main Hospital and could result in the delayed notification in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.2.10.1.1 Where required by another section of this Code, single-station and multiple-station smoke alarms shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code, unless otherwise provided in 9.6.2.10.1.2, 9.6.2.10.1.3, or 9.6.2.10.1.4.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published
instructions and this Code.

14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the equipment manufacturer's published instructions.

Findings:

During document review, a tour of the facility, and interview with the ECM and the LE, the smoke detector device records were requested.

Main Hospital-Level 1

On 5/6/19 at 11:06 a.m., a single station battery powered smoke alarm was observed in the Physician Sleeping Room (Door 635). At the time, the ECM stated that there were a total of three battery powered smoke alarms in the building.

1. On 5/7/19 at 3:48 p.m., there were no records provided that indicated the battery powered smoke alarms throughout the building were tested on a weekly basis. Upon interview, the ECM and the LE confirmed this finding.

During an interview on 5/8/19 at 11:05 a.m., the LE confirmed that they had checked the battery powered smoke detectors and verified that they should be tested weekly per the manufacture requirements.

Based on observation, document review, and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by nine sprinkler heads that were covered in debris. This was also evidenced by the absence of a 5 year certification and an annual sprinkler system inspection/test. This affected two of two floors at the Main Hospital and one of one smoke compartment at the Outpatient Rehabilitation Services and could result in the malfunction of the automatic fire sprinkler system in the event of a fire.

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 Automatic Sprinklers and Other Extinguishing Equipment
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by the 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.
4.1.1.2 Inspection, testing, and maintenance shall be performed by personnel who have developed competence through training and experience.

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.

4.3.2 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.
5.2.1.1.6* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
5.2.1.1.7 Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.
5.2.1.3 Stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the installation standard shall be corrected.
5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6
5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.
5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.
5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
5.2.2.3* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
5.2.2.4 Pipe and fittings installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.
5.2.3.1 Hangers and seismic braces shall not be damaged or loose.
5.2.3.2 Hangers and seismic braces that are damaged or loose shall be replaced or refastened.
5.2.3.3* Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection.
5.2.3.4 Hangers and seismic bracing installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

5.3.4* Antifreeze Systems. The freezing point of solutions in antifreeze shall be tested annually by measuring the specific gravity with a hydrometer or refractometer and adjusting the solutions if necessary.
13.2.5* Main Drain Test. A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
13.3.3.1 Each control valve shall be operated annually through its full range and returned to its normal position.
13.3.3.2* Post indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve.

13.4.1.2 Alarm valves and their associated strainers, filters and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition.

13.6.2.1* All backflow preventers installed in fire protection system piping shall be tested annually by conducting a forward flow test of the system at the designed flow rate, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.

14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material.
14.2.1.1 Alternative nondestructive examination methods shall be permitted.
14.2.1.4 Non-metallic pipe shall not be required to be inspected internally.

Findings:

During a facility tour, document review, and interview with the ECM and the LE, the automatic fire sprinkler systems were observed and records were requested.

Main Hospital-Level 1

1. On 5/6/19 at 10:53 a.m., the sprinkler head located outside door labeled 2010 and door labeled 2011 in the Maternity Newborn Unit was covered in debris. The area/space between the deflector spokes was not visible. Upon interview, the ECM and the LE acknowledged this finding.

2. On 5/6/19 at 10:57 a.m., the sprinkler head located Soiled/Holding Room of the Maternity Newborn Unit was observed with white substance on the sprinkler deflector. Upon interview, the ECM and the LE acknowledged this finding.

3. On 5/6/19 at 11:00 a.m., the sprinkler head located in the corridor area next to fire door labeled 721A, adjacent to Room 548 was covered in debris. Upon interview, the ECM and the LE acknowledged this finding.

4. On 5/6/19 at 11:10 a.m., the sprinkler head located in the corridor area outside door labeled 629 was covered in debris. Upon interview, the ECM and the LE acknowledged this finding.

5. On 5/6/19 at 11:13 a.m., the sprinkler heads in Patient Room 2044 of Labor and Delivery were observed. The two sprinkler heads located near the windows were covered in debris. Both sprinkler heads had debris hanging from the deflectors. Upon interview, the ECM acknowledged this finding.

6. On 5/6/19 at 1:06 p.m., the sprinkler head located in the corridor area outside the C-Section OR was covered in debris. The area/space between the deflector spokes was not visible. Upon interview, the ECM and the LE confirmed this finding.

Main Hospital-Lower Level

7. On 5/6/19 at 1:28 p.m., the sprinkler heads in Patient Room 1135 (door 327) were observed. The sprinkler heads located above Bed A and Bed B were covered in debris. Upon interview the ECM and the LE confirmed this finding.

Outpatient Rehabilitation Services

On 5/8/19 at 8:15 a.m., the sprinkler system riser was located in the Telephone/Communications Room. The Riser had a tags that indicated the Sprinkler System Alarm Vendor 1 completed an annual sprinkler system inspection/test on October 2014 and a 5-year inspection/test on September 2011.

8. On 5/8/19 at 9:21 a.m., there was no annual sprinkler system report provided. Upon interview, the EMC confirmed this finding and stated that they would be contacting the leasing manager of the Outpatient Rehabilitation Services Building for the report. The facility was given until 5:00 p.m. on 5/8/19 to provide a current annual sprinkler system report to the California Department of Public Health (CDPH).

9. On 5/8/19 at 9:25 a.m., there was no 5-year sprinkler system report provided. Upon interview, the EMC confirmed this finding and stated that they would be contacting the leasing manager of the Outpatient Rehabilitation Services Building for the report. The facility was given until 5:00 p.m. on 5/8/19 to provide a current 5-year sprinkler system report to the CDPH.

On 5/8/19 at 5:00 p.m., CDPH did not receive a current annual or 5-year sprinkler system report for the Outpatient Rehabilitation Service Building from the facility.

Based on document review and interview, the facility failed to maintain the sprinkler system out of service policy. This was evidenced by the absence of a fire watch policy in the event the sprinkler system was impaired. This affected two of two floors at the Main Hospital and could result in delayed emergency assistance in the event of a fire during sprinkler system disruption.

Findings:

During document review and interview with the ECM and the LE, the fire watch policy was requested.

Main Hospital

1. On 5/8/19 at 10:53 a.m., there was no fire watch policy provided in the event that the automatic sprinkler system was impaired for more than 10 hours in a 24-hour period. Upon interview, the ECM confirmed this finding and stated that they only had a fire watch policy in the event that the fire alarm system was impaired.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by two corridor doors that were obstructed from closing and another door that failed to latch. This affected one of two floors at the Main Hospital and could result in the inability to contain smoke and/or fire to a room.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.6.3.10* Doors shall not be held open be devices other then those that release when the door is pushed or pulled.

Findings:

During a tour of the facility and interview with the ECM and the LE, the corridor doors were observed.

Main Hospital-Level 1

1. On 5/6/19 at 10:46 a.m., the door labeled 765 to the Physician Dictation Room was obstructed from closing by an office chair that was placed directly in front of the door. The door was equipped with a self-closing device and a magnetic hold that was interfaced with the fire alarm system. Upon interview, the ECM and the LE confirmed this finding.

2. On 5/6/19 at 11:46 a.m., the corridor door labeled 910B to the Quiet Room located in Radiology was obstructed from closing by a wooden table that was placed directly in front of the door. The door was equipped with a self-closing device and a magnetic hold that was interfaced with the fire alarm system. Upon interview, the ECM and the LE confirmed this finding.

3. On 5/6/19 at 1:11 p.m., the corridor door labeled 704 in the OR did not latch when tested. The door was equipped with a self-closing device. Upon interview, the ECM and the LE confirmed this finding.

Based on observation and interview, the facility failed to maintain the electrical system and its components. This was evidenced by two electrical panels that were obstructed. This affected one of two floors at the Main Hospital and could result in the inability to access the electrical panels during an emergency.

NFPA 101, Life Safety Code, 2012 edition
19.5.1 Utilities.191.5.1.1 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
110.26 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.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (A)(2), and (A)(3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
(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.

Findings:

During a tour of the facility and interview with the ECM and the LE, the electrical system was observed.

Main Hospital-Level 1

1. On 5/6/19 at 11:07 a.m., the electrical panels located in the Communication Room (Door 659) were observed. Electrical panel BLN-23 and electrical panel BLN-22 were obstructed from accessing by a rolling table that was placed directly in front of the panels.

2. On 5/6/19 at 1:13 p.m., the electrical panels located in the Room 693 in the OR were observed. Electrical panel BHC-21 and electrical panel BLC-21 were obstructed from accessing by a storage cart that was placed directly in front of the panels.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by two power strips that were used incorrectly and another five power strips that were suspended off the ground. This was also evidenced by an extension cord that was used for medical equipment. This affected two of two floors at the Main Hospital and one of one smoke compartment at the Outpatient Rehabilitation Services and could result in 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 Utilities
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 99, Health Care Facilities Code, 2012 Edition.
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 cartmounted, 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.

NFPA 70, National Electrical Code, 2011 Edition.
110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. Informational Note: Accepted industry practices are described in ANSI/NECA 1-2006, Standard Practices for Good Workmanship in Electrical Contracting, and other ANSI-approved installation standards.

240.5 Protection of Flexible Cords, Flexible Cables, and Fixture Wires. Flexible cord and flexible cable, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either 240.5(A) or (B).
(A) Ampacities. Flexible cord and flexible cable shall be protected by an overcurrent device in accordance with their ampacity as specified in Table 400.5(A)(1) and Table 400.5(A)(2). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402.5. Supplementary overcurrent protection, as covered in 240.10, shall be permitted to be an acceptable means for providing this protection.
(B) Branch-Circuit Overcurrent Device. Flexible cord shall be protected, where supplied by a branch circuit, in accordance with one of the methods described in 240.5(B)(1), (B)(3), or (B)(4). Fixture wire shall be protected, where supplied by a branch circuit, in accordance with 240.5(B)(2).

Findings:

During a tour of the facility and interview with the ECM, the LE, and the Rehabilitation Services Manager, the electrical equipment was observed.

Main Hospital-Level 1

1. On 5/6/19 at 11:02 a.m., the electrical equipment in Room with door labeled 612 was observed. There was a six outlet power strip plugged into a wall double outlet. The power strip had another power strip, two computers, and two monitors plugged into it. The second power strip had a computer and a monitor plugged into it. Upon interview, the ECM and the LE confirmed this finding.

2. On 5/6/19 at 11:30 a.m., the X-Ray Tech Core Room was observed. There was a six outlet power strip suspended off the ground. Upon interview, the ECM and the LE acknowledged this finding.

3. On 5/6/19 at 11:31 a.m., the X-Ray Tech Core Room was observed. There was a x-ray disc monitor plugged into an extension cord. Upon interview, the ECM and the LE acknowledged this finding.

Main Hospital-Lower Level

4. On 5/6/19 at 2:34 p.m., the Shipping and Receiving Room was observed. There was a 6 outlet power strip located below Desk 1 that was suspended off the ground. Upon interview, the ECM and the LE confirmed this finding and stated that the power strip needed to be remounted to the wall.

5. On 5/6/19 at 2:17 p.m., the Rehabilitation Services Room 1002B was observed. There was a 12.4 amperage (AMP) microwave plugged into a 15 AMP power strip. The usage exceeded 75 percent. Upon interview, the ECM acknowledged this finding.

Outpatient Rehabilitation Services

6. On 5/8/19 at 8:37 a.m., the Work Station Area was observed. Desk 1, Desk 2, and Desk 5 all had six outlet power strips suspended off the ground. The power strips had a desk computer and a monitor plugged into them. Upon interview, the ECM, the LE, and the Rehabilitation Services Manager confirmed this finding.