HospitalInspections.org

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire. This was evidenced by unsealed penetrations observed in the fire-rated sheeting. This deficient practice affected staff and residents in two of four smoke compartments at the Main Hospital and one of two outpatient buildings. This could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

Findings:

During a tour of the facility with the Maintenance Staff on 6/25/12, penetrations were observed in the gypsum wallboard which could potentially result in the spread of smoke and/or fire.

Fall River Campus
1. At 11:24 a.m., the Telephone Room had an approximately one and one-half by one inch unsealed penetration.
2. At 12:10 p.m., the Radiologist's Office had a one inch by two inch unsealed penetration in the wall behind the monitor

Phlebotomy in Burney
3. At 4:45 p.m., there were two one inch unsealed penetrations in the northeast corner of the Communications Room.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and residents in three of four smoke compartments at the main hospital and one of two outpatient buildings.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, doors were inspected throughout the facility.

Fall River Campus
1. At 11:03 a.m., the door to the Outpatient Surgery did not positive latch when tested.

2. At 11:06 a.m., the door to Medical Records did not positive latch when tested.


Phlebotomy and X-Ray in Burney
3. At 4:40 p.m., the exit door leading from the X-Ray Clinic into the Skilled Nursing portion of the building was being held open by a door wedge.

Based on observation and interview, the facility failed to mark all exits with readily visible signs where the exit was not apparent in accordance with 2000 NFPA 101. This was evidenced by exits that were not marked. This affected staff and patients in one of four smoke compartments at the main hospital and one of two outpatient buildings and could potentially result in injury or delay during an evacuation.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be the nearest exit is not apparent.
7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, exits were observed.

Fall River Campus
1. At 10:30 a.m., the path of egress from the corridor to the Lobby was not marked with an exit directional sign. This location was identified on the evacuation diagram as a potential path of egress to the public way.

2. At 12:10 p.m., there was no exit sign above the cross-corridor door near Nurses' Station 1. With the cross-corridor doors closed, the exit sign at the end of the corridor could not be seen.

X-Ray in Burney
3. At 4:35 p.m., the south exit door from the clinic did not have an exit sign above the door stating, "Emergency Exit Only". The evacuation diagram identified this as an exit.

4. At 4:36 p.m., the door leading from the X-Ray room to the Lobby of the Clinic did not have an exit directional sign guiding the building's occupants to the left into the Lobby.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations. This affected three of five smoke compartments at the main campus and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, smoke barriers were inspected throughout the facility.

Fall River Campus
1. At 3:53 p.m., there was an approximately one inch penetration around one side of the the main sprinkler pipe in the attic near Nurses' Station 1.

2. At 4:03 p.m., there were two approximately one inch by eight inch unsealed penetrations in the ceiling near Patient Room 402. These penetrations were around two medical gas pipes traveling through the wall. Staff 1 stated that the penetration dated back to the original construction of that part of the building.

Based on observation and interview, the facility failed to protect its hazardous area enclosures in accordance with 1999 NFPA 99. This was evidenced by rooms which contained combustible materials that posed a degree of hazard greater than that normal to the general occupancy of the building that were not equipped with self-closing mechanisms on the doors. This deficient practice affected one of four smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.

10.5.1
Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected in accordance with NFPA 99. (Laboratories that are not considered to be a severe hazard meet the provisions of K29.) Laboratories in health care occupancies and medical and dental offices are in accordance with NFPA 99, Standard for Health Care Facilities.


Findings:

During a tour of the facility with the Maintenance Staff on 6/25/12, hazardous area enclosures were observed.

Fall River Campus
1. At 10:32 a.m., the corridor doors to the Laboratory were open during the survey and were not equipped with a self-closing device on the doors

2. At 3:12 p.m., the walls of the Ambulance Office were covered with loosely attached papers on the walls. The east and north walls were covered approximately 50 percent with papers attached to the wall. The west wall was covered approximately 40 percent with papers on the walls. This office did not have a self-closing mechanism on the corridor door. The facility did not provide documentation that the papers had been flame treated or were inherently flame resistant.

Based on observation, the facility failed to ensure that exits are readily accessible at all times. This was evidenced by doors that were equipped with double-action latching and locking hardware and deadbolt locks. This affected all staff and patients in three of four smoke compartments at the Main Hospital and could potentially result in a delayed egress in the event of an emergency.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with the Maintenance Staff, on 6/25/12, exit access doors were observed.

Fall River Campus
1. At 11:06 a.m., the door to Nursing Administration was equipped with a double-action door latch and lock requiring two distinct motions to open the door when locked.

2. At 11:08 a.m., the door to Patient Room 408 was equipped with a double-action door latch and lock requiring two distinct motions to open the door when locked.

3. At 11:10 a.m., the exit door from the Copy Room was equipped with a double-action door latch and lock requiring two distinct motions to open the door when locked.

4. At 11:18 a.m., the door to the Pharmacy was equipped with a doorknob with a deadbolt lock below it. Pharmacy Staff stated that the deadbolt lock was required because of the medicines kept in the Pharmacy.

5. At 11:24 a.m., the Materials Management Office door was equipped with a key pad lock. On the egress side of the door, the approximately one and one-quarter inch diameter knob had to be turned counter clockwise to open the door.

6. At 11:29 a.m., the Director of Nursing Office was equipped with double-action door latch and lock requiring two distinct motions to open the door when locked.

7. At 11:40 a.m., the Recovery Room door had a push button combination lock with a deadbolt below it.

8. At 11:45 a.m., Operating Rooms 1 and 2 both had deadbolt locks on the doors.

9. At 12:04 p.m., the door to X-Ray 2 had a dead bolt lock that was 60 inches above the floor.

10. At 12:30 p.m., the door to the Business Compliance Office had a push button lock. On the egress side of the door the door could only be opened by turning the knob counter clockwise.

Based on observation and document review, the facility failed to provide, maintain and test its emergency illumination in accordance with 2000 NFPA 101.
This was evidenced by the following:
The failure to document the monthly and annual testing of its battery powered emergency lighting units.
Battery-powered emergency lighting units that did not function when tested.
Areas that did not have battery-powered emergency lighting units in locations that might be unlit during a loss of normal power. This affected all staff and patients in one of four smoke compartments at the Main Hospital and one of two outpatient buildings and could potentially result in injury or a delayed evacuation in the event of an emergency.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

Fall River Campus
1. During a tour of the facility with the Maintenance Staff on 6/25/12, at 10:57 a.m., the battery back-up light in the Out Patient Surgery did not function when tested.
During record review on 6/25/12, at 12:46 p.m., documentation for monthly and annual testing of the battery-powered emergency lighting was requested. Maintenance Staff stated that the lighting units are tested, but that it is not documented.

Phlebotomy and X-Ray in Burney
2. On 6/25/12, at 4:45 p.m., the corridor area outside of the X-Ray Room did not have a battery-powered emergency lighting unit to illuminate the means of egress. This room is located in a clinic that does not have a generator for emergency power. When asked, Maintenance Staff stated that during certain times of the year and times of the day, the area could be dark during a loss of power.

Based on record review and staff interview, the facility failed to periodically test its automatic sprinkler system in accordance with NFPA 101, 4.6.12 and NFPA 25. This was evidenced by a lack of documentation for the annual and quarterly sprinkler testing and inspection of its dry pipe sprinkler system and by a lack of documentation provided for the annual inspection and testing of its wet pipe systems. This affected all staff and patients in four of four smoke compartments at the Main Hospital and two of two outpatient buildings and could potentially result in the spread of smoke and/or fire.


NFPA101
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

1998 NFPA 25
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test at 20 years and every 10 years thereafter 2-3.1.1 Exception No. 2
Sprinklers Test at 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-3.3.2* Testing the waterflow alarm on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection.

Findings:

During record review on 6/25/12, sprinkler system testing and inspection records were reviewed.

Fall River Campus
1. At 12:46 p.m., the facility failed to provide documentation for the annual inspection and testing of it wet pipe system.

X-Ray in Burney
2. At 12:48 p.m., the facility failed to provide documentation for the annual and quarterly sprinkler inspection and testing of its dry pipe system. Maintenance Staff stated that they were not testing the flow alarm quarterly for the dry pipe system. Staff stated that they were not sure if the dry pipe system had a bypass connection and did not want to test the system using the Inspector's Test Connection which might trip and fill the dry system with water.

Phlebotomy in Burney
3. At 12:55 p.m. The facility failed to provide documentation for the annual inspection and testing of its wet pipe sprinkler system.

Maintenance Staff confirmed that the testing had not been done and stated that it would be scheduled to be done.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by a fire extinguisher that had items stored in front of it and was not readily accessible. This affected staff and patients in one of two outpatient buildings and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).


Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, fire extinguishers were observed

X-Ray Room
At 8:04 a.m., the fire extinguisher mounted to the wall located at the south exit door had items stored in front of it. There were a stool and tray stand stored along the wall in front of the extinguisher.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items stored in the exit corridor. This affected all staff and patients at one of two outpatient buildings and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility on 6/26/12, exit corridor were inspected.

X-Ray at Burney
At 8:04 a.m., the south exit from the Clinic was impeded by a table and trash can on one side of the corridor and a stool and tray on the other.

Based on observation, the facility failed to protect its medical compressed gas cylinders in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored free standing on the floor in a room. This affected one of four smoke compartments at the Main Hospital and could potentially result in injury or damage to the cylinders if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, compressed gas cylinders were observed.

Fall River Campus
At 10:32 a.m., there was an E-size carbon dioxide cylinder free standing on the floor in the Laboratory.

Based on record review and interview, the facility failed to maintain all parts of its piped medical gas system in accordance with 1999 NFPA 99. This was evidenced by noted discrepancies in the annual medical gas certification report that had not been repaired. This affected four of four smoke compartments at the Main Hospital and could potentially result in the acceleration of fire.

Findings:

During document review on 6/25/12, the medical gas report was reviewed.

Fall River Campus
At 12:45 p.m., the gas report dated 9/8/12 had the following discrepancies:

1. 400 Wing Exam B oxygen A missing front assembly
2. 400 Wing Outside Room 402 Oxygen valve leaks at valve stem. Valve is not repairable.
3. Surgery Hallway panel is subject of service bulletin for fire hazard and should be replaced.
4. 200 Wing Hallway outside of Room 220 panel is subject of service bulletin for fire hazard and should be replaced. Green light is out. There is no power to signal lamp. In need of service.
5. 400 Wing Hallway outside of Room 405 panel is subject of service bulletin for fire hazard and should be replaced.
6. Unable to locate main valve inside hospital. Also could not locate main line pressure switch. No source valve located.

Based on document review and interview, the facility failed to protect it anesthetizing locations in accordance with 1999 NFPA 99. This was evidenced by the failure to maintain the relative humidity in its operating room to insure that it is equal to or greater than 35 percent and by the failure to provide and maintain battery-powered emergency lighting units in anesthetizing locations. This affected one of four smoke compartments within the facility and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment. This could also potentially result in a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer, if the generator fails to start).

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

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

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

NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During record review with Maintenance Staff on 6/25/12, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
1. At 11:45 a.m., Operating Room Staff provided a log of Operating Room 1 relative humidity and temperature readings. Documentation indicated that over a six month period in 2012, 112 days out of 124 days the humidity levels were below 35 percent. Forty-eight day were documented as being 25 percent and lower. When asked, Operating Room Staff stated that the gauge that was previously used was not working and a new gauge had been purchased and was now documenting the humidity levels in Operating Room 1. Staff stated that Operating Room 2 was no longer used.

At 11:58 a.m., this surveyor observed that the humidity level in Operating Room 1 was at 68 percent at that time.

2. At 11:55 a.m., there were no battery-operated task lights in Operating Room 2 on the wall. OR Staff stated that the anesthesia machine, which has a battery back-up, has its own light. At 12:00 p.m., the battery powered task light in Operating Room 1 did not come on when tested by pushing the test button.

Based on document review and interview, the facility failed to provide continuing safety education in accordance with 1999 NFPA 99. This was evidenced by the facility's failure to provide documentation for periodic laboratory safety education for all laboratory personnel. This affected one of four smoke compartments at the Main Hospital and could potentially result in accidents occurring in the laboratory.

10-2.1.3.3* Emergency procedures shall be established for extinguishing clothing fires.

10-2.1.4 Orientation and Training.
New laboratory personnel shall be taught general safety practices for the laboratory and specific safety practices for the equipment and procedures they will use.

10-2.1.4.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

Findings:

During document review with Maintenance Staff on 6/25/12, at 12:45 p.m., the facility failed to provide documentation of laboratory-specific safety training. Laboratory Personnel stated that the documentation would be provided, if available.

Based on document review and staff interview, the facility failed to provide complete documentation of generator testing in accordance with 1999 NFPA 110. This was evidenced by incomplete documentation for weekly generator inspections. This finding affected all staff and patients in four of four smoke compartments at the Main Hospital and one of two outpatient buildings and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

Findings:

Fall River Campus
1. During a review of the facility's documentation on 6/25/12, at 12:45 p.m., documentation indicated that generator weekly visual inspections were missing for approximately 11 out of 52 weeks in a 12 month period.

Phlebotomy at Burney
During a review of the facility's documentation on 6/25/12, at 12:45 p.m., documentation indicated that generator weekly visual inspections were missing for approximately 11 out of 52 weeks in a 12 month period.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by use of power strips which were suspended above the floor, high wattage devices which were plugged into power strips, and the permanent use of extension cords. This affected all staff and residents in two of four smoke compartments at the Main Hospital and one of two outpatient buildings and could potentially result in the ignition of fire.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, electrical wiring and equipment were observed.

Fall River Campus
1. At 10:57 a.m., there was a 16 gauge multi-outlet extension cord with a toaster and a coffee pot plugged into it in the Break Room.
2. At 11:13 a.m., there was a power strip suspended above the floor with a microwave oven plugged into it.

3. At 11:18 a.m.,the Supply/Break Room had a power strip suspended above the floor with a microwave oven plugged into it.

Phlebotomy at Burney
4. At 4:45 p.m., the Blood Draw Room had a coffee pot and a microwave oven plugged into a power strip.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition. This was evidenced by ABHR dispensers located above light switches. This finding affected one of four smoke compartments within the facility and could potentially result in the ignition of fire.

Where Alcohol Based Hand Rub (ABHR) dispensers are installed:
The corridor is at least 6 feet wide
The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
The dispensers shall have a minimum spacing of 4 ft from each other
Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
Dispensers are not installed over or adjacent to an ignition source.
If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Findings:

Fall River Campus
During a tour of the facility with Maintenance Staff on 6/25/12, ABHR dispensers were observed.

Between 10:40 a.m., and 12:10 p.m., ABHR dispensers were observed above light switches in the following locations:
1. Patient Rooms 102, 108, 408
2. The Break Room
3. The Nursing Administration Office
4. Room 408
5. The Pharmacy

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire. This was evidenced by unsealed penetrations observed in the fire-rated sheeting. This deficient practice affected staff and residents in two of four smoke compartments at the Main Hospital and one of two outpatient buildings. This could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

Findings:

During a tour of the facility with the Maintenance Staff on 6/25/12, penetrations were observed in the gypsum wallboard which could potentially result in the spread of smoke and/or fire.

Fall River Campus
1. At 11:24 a.m., the Telephone Room had an approximately one and one-half by one inch unsealed penetration.
2. At 12:10 p.m., the Radiologist's Office had a one inch by two inch unsealed penetration in the wall behind the monitor

Phlebotomy in Burney
3. At 4:45 p.m., there were two one inch unsealed penetrations in the northeast corner of the Communications Room.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and residents in three of four smoke compartments at the main hospital and one of two outpatient buildings.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, doors were inspected throughout the facility.

Fall River Campus
1. At 11:03 a.m., the door to the Outpatient Surgery did not positive latch when tested.

2. At 11:06 a.m., the door to Medical Records did not positive latch when tested.


Phlebotomy and X-Ray in Burney
3. At 4:40 p.m., the exit door leading from the X-Ray Clinic into the Skilled Nursing portion of the building was being held open by a door wedge.

Based on observation and interview, the facility failed to mark all exits with readily visible signs where the exit was not apparent in accordance with 2000 NFPA 101. This was evidenced by exits that were not marked. This affected staff and patients in one of four smoke compartments at the main hospital and one of two outpatient buildings and could potentially result in injury or delay during an evacuation.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be
marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be the nearest exit is not apparent.
7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, exits were observed.

Fall River Campus
1. At 10:30 a.m., the path of egress from the corridor to the Lobby was not marked with an exit directional sign. This location was identified on the evacuation diagram as a potential path of egress to the public way.

2. At 12:10 p.m., there was no exit sign above the cross-corridor door near Nurses' Station 1. With the cross-corridor doors closed, the exit sign at the end of the corridor could not be seen.

X-Ray in Burney
3. At 4:35 p.m., the south exit door from the clinic did not have an exit sign above the door stating, "Emergency Exit Only". The evacuation diagram identified this as an exit.

4. At 4:36 p.m., the door leading from the X-Ray room to the Lobby of the Clinic did not have an exit directional sign guiding the building's occupants to the left into the Lobby.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations. This affected three of five smoke compartments at the main campus and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, smoke barriers were inspected throughout the facility.

Fall River Campus
1. At 3:53 p.m., there was an approximately one inch penetration around one side of the the main sprinkler pipe in the attic near Nurses' Station 1.

2. At 4:03 p.m., there were two approximately one inch by eight inch unsealed penetrations in the ceiling near Patient Room 402. These penetrations were around two medical gas pipes traveling through the wall. Staff 1 stated that the penetration dated back to the original construction of that part of the building.

Based on observation and interview, the facility failed to protect its hazardous area enclosures in accordance with 1999 NFPA 99. This was evidenced by rooms which contained combustible materials that posed a degree of hazard greater than that normal to the general occupancy of the building that were not equipped with self-closing mechanisms on the doors. This deficient practice affected one of four smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.

10.5.1
Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard are protected in accordance with NFPA 99. (Laboratories that are not considered to be a severe hazard meet the provisions of K29.) Laboratories in health care occupancies and medical and dental offices are in accordance with NFPA 99, Standard for Health Care Facilities.


Findings:

During a tour of the facility with the Maintenance Staff on 6/25/12, hazardous area enclosures were observed.

Fall River Campus
1. At 10:32 a.m., the corridor doors to the Laboratory were open during the survey and were not equipped with a self-closing device on the doors

2. At 3:12 p.m., the walls of the Ambulance Office were covered with loosely attached papers on the walls. The east and north walls were covered approximately 50 percent with papers attached to the wall. The west wall was covered approximately 40 percent with papers on the walls. This office did not have a self-closing mechanism on the corridor door. The facility did not provide documentation that the papers had been flame treated or were inherently flame resistant.

Based on observation, the facility failed to ensure that exits are readily accessible at all times. This was evidenced by doors that were equipped with double-action latching and locking hardware and deadbolt locks. This affected all staff and patients in three of four smoke compartments at the Main Hospital and could potentially result in a delayed egress in the event of an emergency.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.
Exception No. 1: This requirement shall not apply where otherwise provided in Chapters 18 through 23.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.
Exception No. 3: Where permitted in Chapters 12 through 42, key operation shall be permitted, provided that the key cannot be removed when the door is locked from the side from which egress is to be made.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with the Maintenance Staff, on 6/25/12, exit access doors were observed.

Fall River Campus
1. At 11:06 a.m., the door to Nursing Administration was equipped with a double-action door latch and lock requiring two distinct motions to open the door when locked.

2. At 11:08 a.m., the door to Patient Room 408 was equipped with a double-action door latch and lock requiring two distinct motions to open the door when locked.

3. At 11:10 a.m., the exit door from the Copy Room was equipped with a double-action door latch and lock requiring two distinct motions to open the door when locked.

4. At 11:18 a.m., the door to the Pharmacy was equipped with a doorknob with a deadbolt lock below it. Pharmacy Staff stated that the deadbolt lock was required because of the medicines kept in the Pharmacy.

5. At 11:24 a.m., the Materials Management Office door was equipped with a key pad lock. On the egress side of the door, the approximately one and one-quarter inch diameter knob had to be turned counter clockwise to open the door.

6. At 11:29 a.m., the Director of Nursing Office was equipped with double-action door latch and lock requiring two distinct motions to open the door when locked.

7. At 11:40 a.m., the Recovery Room door had a push button combination lock with a deadbolt below it.

8. At 11:45 a.m., Operating Rooms 1 and 2 both had deadbolt locks on the doors.

9. At 12:04 p.m., the door to X-Ray 2 had a dead bolt lock that was 60 inches above the floor.

10. At 12:30 p.m., the door to the Business Compliance Office had a push button lock. On the egress side of the door the door could only be opened by turning the knob counter clockwise.

Based on observation and document review, the facility failed to provide, maintain and test its emergency illumination in accordance with 2000 NFPA 101.
This was evidenced by the following:
The failure to document the monthly and annual testing of its battery powered emergency lighting units.
Battery-powered emergency lighting units that did not function when tested.
Areas that did not have battery-powered emergency lighting units in locations that might be unlit during a loss of normal power. This affected all staff and patients in one of four smoke compartments at the Main Hospital and one of two outpatient buildings and could potentially result in injury or a delayed evacuation in the event of an emergency.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

Fall River Campus
1. During a tour of the facility with the Maintenance Staff on 6/25/12, at 10:57 a.m., the battery back-up light in the Out Patient Surgery did not function when tested.
During record review on 6/25/12, at 12:46 p.m., documentation for monthly and annual testing of the battery-powered emergency lighting was requested. Maintenance Staff stated that the lighting units are tested, but that it is not documented.

Phlebotomy and X-Ray in Burney
2. On 6/25/12, at 4:45 p.m., the corridor area outside of the X-Ray Room did not have a battery-powered emergency lighting unit to illuminate the means of egress. This room is located in a clinic that does not have a generator for emergency power. When asked, Maintenance Staff stated that during certain times of the year and times of the day, the area could be dark during a loss of power.

Based on record review and staff interview, the facility failed to periodically test its automatic sprinkler system in accordance with NFPA 101, 4.6.12 and NFPA 25. This was evidenced by a lack of documentation for the annual and quarterly sprinkler testing and inspection of its dry pipe sprinkler system and by a lack of documentation provided for the annual inspection and testing of its wet pipe systems. This affected all staff and patients in four of four smoke compartments at the Main Hospital and two of two outpatient buildings and could potentially result in the spread of smoke and/or fire.


NFPA101
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

1998 NFPA 25
Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2
Sprinklers - extra-high temp. Test 5 years 2-3.1.1 Exception No. 3
Sprinklers - fast response Test at 20 years and every 10 years thereafter 2-3.1.1 Exception No. 2
Sprinklers Test at 50 years and every 10 years thereafter 2-3.1.1
Valves (all types) Maintenance Annually or as needed Table 9-1
Obstruction investigation Maintenance 5 years or as needed Chapter 10

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

2-3.3.2* Testing the waterflow alarm on dry pipe, preaction, or deluge systems shall be accomplished by using the bypass connection.

Findings:

During record review on 6/25/12, sprinkler system testing and inspection records were reviewed.

Fall River Campus
1. At 12:46 p.m., the facility failed to provide documentation for the annual inspection and testing of it wet pipe system.

X-Ray in Burney
2. At 12:48 p.m., the facility failed to provide documentation for the annual and quarterly sprinkler inspection and testing of its dry pipe system. Maintenance Staff stated that they were not testing the flow alarm quarterly for the dry pipe system. Staff stated that they were not sure if the dry pipe system had a bypass connection and did not want to test the system using the Inspector's Test Connection which might trip and fill the dry system with water.

Phlebotomy in Burney
3. At 12:55 p.m. The facility failed to provide documentation for the annual inspection and testing of its wet pipe sprinkler system.

Maintenance Staff confirmed that the testing had not been done and stated that it would be scheduled to be done.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by a fire extinguisher that had items stored in front of it and was not readily accessible. This affected staff and patients in one of two outpatient buildings and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).


Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, fire extinguishers were observed

X-Ray Room
At 8:04 a.m., the fire extinguisher mounted to the wall located at the south exit door had items stored in front of it. There were a stool and tray stand stored along the wall in front of the extinguisher.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items stored in the exit corridor. This affected all staff and patients at one of two outpatient buildings and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility on 6/26/12, exit corridor were inspected.

X-Ray at Burney
At 8:04 a.m., the south exit from the Clinic was impeded by a table and trash can on one side of the corridor and a stool and tray on the other.

Based on observation, the facility failed to protect its medical compressed gas cylinders in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored free standing on the floor in a room. This affected one of four smoke compartments at the Main Hospital and could potentially result in injury or damage to the cylinders if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, compressed gas cylinders were observed.

Fall River Campus
At 10:32 a.m., there was an E-size carbon dioxide cylinder free standing on the floor in the Laboratory.

Based on record review and interview, the facility failed to maintain all parts of its piped medical gas system in accordance with 1999 NFPA 99. This was evidenced by noted discrepancies in the annual medical gas certification report that had not been repaired. This affected four of four smoke compartments at the Main Hospital and could potentially result in the acceleration of fire.

Findings:

During document review on 6/25/12, the medical gas report was reviewed.

Fall River Campus
At 12:45 p.m., the gas report dated 9/8/12 had the following discrepancies:

1. 400 Wing Exam B oxygen A missing front assembly
2. 400 Wing Outside Room 402 Oxygen valve leaks at valve stem. Valve is not repairable.
3. Surgery Hallway panel is subject of service bulletin for fire hazard and should be replaced.
4. 200 Wing Hallway outside of Room 220 panel is subject of service bulletin for fire hazard and should be replaced. Green light is out. There is no power to signal lamp. In need of service.
5. 400 Wing Hallway outside of Room 405 panel is subject of service bulletin for fire hazard and should be replaced.
6. Unable to locate main valve inside hospital. Also could not locate main line pressure switch. No source valve located.

Based on document review and interview, the facility failed to protect it anesthetizing locations in accordance with 1999 NFPA 99. This was evidenced by the failure to maintain the relative humidity in its operating room to insure that it is equal to or greater than 35 percent and by the failure to provide and maintain battery-powered emergency lighting units in anesthetizing locations. This affected one of four smoke compartments within the facility and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment. This could also potentially result in a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer, if the generator fails to start).

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

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

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

NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During record review with Maintenance Staff on 6/25/12, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
1. At 11:45 a.m., Operating Room Staff provided a log of Operating Room 1 relative humidity and temperature readings. Documentation indicated that over a six month period in 2012, 112 days out of 124 days the humidity levels were below 35 percent. Forty-eight day were documented as being 25 percent and lower. When asked, Operating Room Staff stated that the gauge that was previously used was not working and a new gauge had been purchased and was now documenting the humidity levels in Operating Room 1. Staff stated that Operating Room 2 was no longer used.

At 11:58 a.m., this surveyor observed that the humidity level in Operating Room 1 was at 68 percent at that time.

2. At 11:55 a.m., there were no battery-operated task lights in Operating Room 2 on the wall. OR Staff stated that the anesthesia machine, which has a battery back-up, has its own light. At 12:00 p.m., the battery powered task light in Operating Room 1 did not come on when tested by pushing the test button.

Based on document review and staff interview, the facility failed to provide complete documentation of generator testing in accordance with 1999 NFPA 110. This was evidenced by incomplete documentation for weekly generator inspections. This finding affected all staff and patients in four of four smoke compartments at the Main Hospital and one of two outpatient buildings and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

Findings:

Fall River Campus
1. During a review of the facility's documentation on 6/25/12, at 12:45 p.m., documentation indicated that generator weekly visual inspections were missing for approximately 11 out of 52 weeks in a 12 month period.

Phlebotomy at Burney
During a review of the facility's documentation on 6/25/12, at 12:45 p.m., documentation indicated that generator weekly visual inspections were missing for approximately 11 out of 52 weeks in a 12 month period.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by use of power strips which were suspended above the floor, high wattage devices which were plugged into power strips, and the permanent use of extension cords. This affected all staff and residents in two of four smoke compartments at the Main Hospital and one of two outpatient buildings and could potentially result in the ignition of fire.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with Maintenance Staff on 6/25/12, electrical wiring and equipment were observed.

Fall River Campus
1. At 10:57 a.m., there was a 16 gauge multi-outlet extension cord with a toaster and a coffee pot plugged into it in the Break Room.
2. At 11:13 a.m., there was a power strip suspended above the floor with a microwave oven plugged into it.

3. At 11:18 a.m.,the Supply/Break Room had a power strip suspended above the floor with a microwave oven plugged into it.

Phlebotomy at Burney
4. At 4:45 p.m., the Blood Draw Room had a coffee pot and a microwave oven plugged into a power strip.