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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetration in a wall. This affected 1 of 8 smoke compartments and had the potential to allow the spread of smoke during a fire and cause injury to patients, staff and visitors.

Findings:

During a tour of the facility with Staff 1 on October 24, 2012, the facility walls and ceilings were observed.

October 24, 2012

At 9:40 a.m., in the Staff Lounge near Room 116 was an approximately 3 inch diameter circular unsealed penetration in the wall, which copuld allow spread of fire or smoke. Staff 1 confirmed the unsealed penetration.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke during fire. This was evidenced by corridor doors that were impeded from closing, a roller latch on a corridor door, a double action lock, and corridor doors that failed to positive latch. This affected 6 of 8 smoke compartments which had the potential to allow the migration of smoke and fire into the corridors, their main path of escape. This could cause potential harm to the 44 patients, staff and visitors from smoke inhalation and burns.

Findings:

During a tour of the facility with Staff 1 on October 23, 2012 through October 25, 2012, the corridor doors were observed and a staff person was interviewed.

October 23, 2012

1. At 9:41 a.m., the self-closing corridor door to the Laboratory Staff Lounge was impeded from closing with a chair in front of the door. At 9:42 a.m., Staff 1 said during an interview that "he is always removing the chair from the front of the Laboratory Staff Lounge door."

2. At 9:50 a.m., the self-closing corridor door to Room 411 was impeded from closing with a trash can in front of the door. Staff 1 removed the item upon discovery.

3. At 9:52 a.m., the self-closing corridor door to Room 414 was impeded from closing with a trash can in front of the door. Staff 1 removed the item upon discovery.

4. At 9:56 a.m., the self-closing corridor door to Room 406 was impeded from closing with a chair in front of the door. Staff 1 removed the item upon discovery.

5. At 10:05 a.m., the self-closing corridor door to the Health Information Management Office was impeded from closing with a rubber wedge under the door.

October 24, 2012
6. At 8:36 a.m., the self-closing corridor door to the Admitting Office was impeded from closing with a Lion Statue in front of the door. Staff 1 removed the item upon discovery.

7. At 9:00 a.m., the self-closing corridor door to Room 405 failed to release from the magnetic hold open device connected to the fire alarm system and close during fire alarm testing.

8. At 9:01 a.m., the self-closing corridor door to Room 412 failed to release from the magnetic hold open device connected to the fire alarm system and close during fire alarm testing.

9. At 9:09 a.m., the self-closing corridor door to Room 416 was not latching when tested. The latching mechanism was stuck in the door.

10. At 9:10 a.m., the self-closing corridor door to Room 411 was not latching when tested. The latching mechanism was stuck in the door.

11. At 9:15 a.m., the self-closing corridor door to Room 115 was not latching when tested. The latching mechanism was stuck in the door.

12. At 9:17 a.m., the self-closing corridor door to Room 109 was not latching when tested. The latching mechanism was stuck in the door.

13. At 9:18 a.m., the self-closing corridor door to Room 108 was not latching when tested. The latching mechanism was stuck in the door.

14. At 9:19 a.m., the self-closing corridor door to Room 107 was not latching when tested. The latching mechanism was stuck in the door.

15. At 9:20 a.m., the self-closing corridor door to Room 106 was not latching when tested. The latching mechanism was stuck in the door.

16. At 9:21 a.m., the self-closing corridor door to Room 424 was not latching when tested. The latching mechanism was stuck in the door.

17. At 9:24 a.m., the self-closing corridor door to Room 103 was not latching when tested. The latching mechanism was stuck in the door. At 9:25 a.m., Staff 1 said during an interview that the doors were checked on a weekly basis but the latches were not inspected.

18. At 9:32 a.m., the self-closing corridor door to Room 217 was not latching when tested. The latching mechanism was stuck in the door.

19. At 9:34 a.m., the self-closing corridor door to Room 214 was not latching when tested. The latching mechanism was stuck in the door.

20. At 9:36 a.m., the self-closing corridor door to Room 213 was not latching when tested. The latching mechanism was stuck in the door.

21. At 9:41 a.m., the self-closing corridor door to the Staff Lounge was not latching when tested. The door would not self-close completely.

22. At 9:42 a.m., the self-closing corridor door to the Traction Room/Janitor Storage was not latching when tested. The door would not self-close completely.

October 24, 2012
23. At 12:50 p.m., the self-closing corridor door to the Employee Lockers on the third floor was not latching when tested. The latching mechanism was stuck in the door.

24. At 1:42 p.m., the self-closing corridor door to the Soiled Utility Room was not latching when tested. The door was not closing completely. The room was less than 50 square feet.

25. At 3:25 p.m., the corridor door to Center Nursing Station was not latching when tested. There was a roller latch on the door, which would not allow the door to positive latch, and no other latching mechanism. There was a double action lock (a lock that requires two actions to open) on the door. The dead bolt lock uses a key to open. At 3:26 p.m., Staff 1 said during an interview that he did not know that roller latches are prohibited.

October 25, 2012
26. At 9:20 a.m., the self-closing corridor door to Utility Room in the Operating Room was not latching when tested. The door was not self-closing completely. Staff 1 confirmed the door was not fully closing and latching.

27. At 10:02 a.m., the self-closing corridor door to the South entrance of the MDS(Minimum Data Set) Office was not latching when tested. Staff 1 confirmed the deficiency.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls in accordance with NFPA 101. This was evidenced by unsealed penetrations in the smoke barrier walls. The penetrations could result in the reduction in the facility's ability to protect in place and increase the risk of injury to the the patients due to smoke and fire. This affected 3 of 8 smoke compartments.
NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 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 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 Staff 1 on October 24, 2012, the smoke barrier walls were observed.

October 24, 2012

1. At 1:53 p.m., in the smoke barrier wall near the ICU (Intensive Care Unit) entrance, there was an approximately 3/4 inch unseal conduit pipe. Staff 1 confirmed the finding.

2. At 2:14 p.m., in the smoke barrier wall near the Operating Room main entrance, there was an approximately 1/2 inch unsealed conduit pipe. Staff 1 confirmed the finding.

3. At 2:21 p.m., in the West smoke barrier wall near the Laboratory, there was an approximately 2 inch by 3 inch unsealed penetration in the wall. Staff 1 confirmed the finding.

Based on observation and interview, the facility failed to maintain their exit signs to ensure egress paths were identified. This was evidenced by 6 of 67 exit signs that failed to illuminate with an internal emergency power supply source, exit signs that were missing in egress paths, and 3 of 6 exit signs that failed to illuminate without an internal power source. This affected 3 of 8 smoke compartments, and could result in a delay in evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
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 1.5 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.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a tour of the facility with Staff 1 on October 23, 2012, through October 25, 2012, the exit signs were observed, maintenance records were reviewed, and a staff person was interviewed.

October 23, 2012
1. At 9:46 a.m., the Exit signs B-20 and B-23 in the basement was not illuminating when the test button (battery test) was pressed. Staff 1 confirmed the finding.

October 24, 2012
At 9:48 a.m., Staff 3 said during an interview that "she tested the exit signs last week and the signs worked ok. She stated that if she found a problem then she would report it to her supervisor."

2. At 10:11 a.m., there was no exit sign in the south exit path from the Operating Room. Staff 1 confirmed that there was no exit sign in their egress path.

3. At 2:06 p.m., the CO6 exit sign near the Physician Lounge was not illuminating when tested. Staff 1 confirmed the exit sign was not illuminated.

October 25, 2012
4. At 9:54 a.m., Staff 2 inspected the three wall mounted exit signs near the floor (one each in the three units and without an internal power source "battery back up system") and said that the three exit signs are not working.

5. At 10:10 a.m., the east exit sign in the warehouse was not illuminating when inspected. When the test button (battery test) was pressed, the exit sign did not illuminate.

Based on staff interview, and document review, the facility failed to ensure staff were trained on their procedures to protect their patients from fire. This was evidenced by staff members who were not familiar with their fire emergency procedures. This could create panic and delay and cause potential for harm to patients if staff become confused and fail to follow or understand the emergency plan. This affected 1 of 8 smoke compartments.
NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The Administration of every health care occupancy shall have, in effect and available to all personnel, written copies of a plan for protection of all persons in the event of fire, for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with their duties under the plan. A copy of the plan shall be readily available at all times.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm.

Findings:

During fire alarm testing with Staff 1 on October 24, 2012, staff were interviewed and training documents were reviewed.

October 24, 2012

At 9:38 a.m., there were four staff members interviewed and 1 of 4 staff (Staff 4 through Staff 7) with greater than 5 years of experience (Staff 6) said they would yell "fire" instead of using the code word "Code Red" during a fire emergency to request for help.

At 12:35 p.m., under the facilities Fire and Life Safety Management Plan in the section titled objectives and under line number 2 revealed the following: Educate staff to the department specific Code Red Policies and Procedures.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with the NFPA 72, as evidenced by failing to keep impediments from obstructing manual fire alarm pull station devices from view and access. This would delay activating the fire alarm system and cause harm to patients in the event of a fire emergency. This affected 2 of 8 smoke compartments.
NFPA 72 National Fire Alarm Code (1999 Edition) section 2-8.2.1
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with Staff 1 on October 23, 2012, the manual fire alarm devices (pull stations) were observed and a staff person was interviewed.

October 23, 2012

1. At 10:03 a.m. the manual fire alarm pull station device in the Main Lobby was impeded from view. The manual fire alarm pull station was behind a 6 1/2 foot artifical tree.

At 10:04 a.m., Staff 1 said during an interview that he has moved that tree several times in order not to obstruct the pull station.

2. At 4:30 p.m., the East Pull Station fire alarm device in the Rehabilitation Room was impeded from access with 5 wheelchairs and 4 e-cylinders (oxygen tanks) in front of the device.

Based on observation and interview, the facility failed to ensure that smoke detectors were maintained in accordance with NFPA 72, 1999 edition. This was evidenced by 4 of 167 smoke detectors that failed to activate the fire alarm when tested with canned smoke. This could result in delayed notification of fire in the facility to the fire department, patients, staff and visitors causing potential injury from smoke inhalation and burns. This affected 3 of 8 smoke compartments.

Findings:

During fire alarm testing with Staff 1 on October 24, 2012, the smoke detectors were tested with canned smoke and a staff person was interviewed.

October 24, 2012

1. At 9:07 a.m., the smoke detector near Room 409 (labeled L1D084) was not activating the fire alarm when tested with canned smoke. Four attempts were made without activating the fire alarm system.

At 9:08 a.m., Staff 1 said during an interview that "the smoke detector (L1D084) had a lot of dust in it and maybe that is why it did work".

2. At 9:28 a.m., the smoke detector near the Physician lounge (labeled L1D008) was not activating the fire alarm when tested with canned smoke. Three attempts were made without activating the fire alarm system.

3. At 9:30 a.m., the smoke detector near the Nurse Manager Office (labeled L1D018) was not activating the fire alarm when tested with canned smoke. Four attempts were made without activating the fire alarm system.

4. At 9:53 a.m., the smoke detector in the Operating Room (no label on it) and between the Recovery and Central Process Rooms was not activating the fire alarm when tested with canned smoke. Three attempts were made without activating the fire alarm system.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by 1 of 2 inspector test valves that failed to activate the fire alarm system when tested and the fire department water connectors were impeded from view and access with ply wood on top of them. This could result in delayed notification of fire to the patients, staff, visitors and the Fire Department in the event of a fire and could result in injury to 44 patients, staff and visitors from smoke inhalation and burns. The blocked fire department connections could result in failure of the Fire Department to use the fire department connectors during fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-6.2* Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

NFPA 25, Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 1998 Edition
9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly

Findings:

During a tour of the facility with Staff 1 on October 24, 2012, through October 25, 2012, the sprinklers system and components were observed , maintenance documents were reviewed, and a staff person was interviewed.

October 24, 2012

At 11:00 a.m., the Inspector Test Valve (a valve that simulates water flowing from a sprinkler) in Respiratory Therapy failed to activate the fire alarm system when tested. The water valve was opened for over 2 minutes and 20 seconds and the fire alarm system did not activate. At 11:05 a.m., Staff 1 said during an interview that he is going to call the fire alarm company to get the valve replaced.

At 11:10 a.m., the information of the inspector test valve failing to activate the fire alarm system was provided to the Chief Executive Officer and she decided to initiate a fire watch until the valve is replaced.

At 11:41 a.m., A review of the last Inspector Test Valve report from (sprinkler company) dated October 18, 2012, revealed that the Inspector Test Valves (North and South) failed to activate the fire alarm system when tested. The report indicated that an adjustment was made to the inspector test valve and it worked when retested by (sprinkler company).

At 11:48 a.m., a Report date October 23, 2012, from (spinkler company) was provided from the facility with a bid for the sprinkler test valve to be replaced to correct the problem permanently.

At 1:09 p.m., the Fire Department Water Connectors and sign located outside and near the warehouse was covered from view and access with two 4 foot by 8 foot sheets of plywood in front of the sign and connectors.

October 25, 2012
At 6:48 a.m., the facility Fire watch (a person that is assigned to walk around the facility looking for fire and smoke) procedure was abated.

At 8:00 a.m., a report dated October 25, 2012, from Tri-Signal Integration indicated that the inspector test valve was replaced and re-tested.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system as evidenced by a sprinkler head that was covered with foreign materials and sprinklers that were not flush to the ceiling. The failure to maintain the sprinkler heads could result in a malfunction during a fire. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. The sprinkler heads could malfunction and cause potential harm to patients in the event of a fire emergency. This affected 2 of 8 smoke compartments.
NFPA 25 Inspection, Testing, and Maintenance of Water Base Fire Protection (1998 Edition)
2-2.1 Sprinklers.
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with Staff 1 on October 24, 2012, through October 25, 2012, the sprinkler system components were observed and a staff person was interviewed.

October 24, 2012

1. At 9:13 a.m., there was paint on the sprinkler head near smoke detector L1D095 in the Case Management Office. Staff 1 acknowledged the finding.

2. At 9:22 a.m., there was paint on the sprinkler head outside of Room 403. Staff 1 acknowledged the finding.

October 25, 2012

3. At 9:24 a.m., the escutcheon ring in the Doctor Lounge Shower Room was not flush to the ceiling. The escutcheon ring revealed an approximate 1/2 inch gap between the ceiling and ring. Staff 1 confirmed the finding.

4. At 9:32 a.m., 1 of 4 sprinklers escutcheon rings in Operating 4 was not flush to the ceiling. One sprinkler was covered with brown rusty looking mater and the escutcheon was approximately 1/4 from the ceiling. Staff 1 acknowledged the finding.

5. At 9:50 a.m., the two sprinklers near the main entrance was covered with brown looking matter. Staff 1 confirmed the finding.

6. At 9:51 a.m., Staff 1 said during an interview that the brown material that looks like rust and he said that he will have simplex look at the sprinklers.

Based on observation, the facility failed to ensure that fire safety was maintained in their oxygen cylinder storage areas. This was evidenced by a light switch installed less than 5 feet from the floor in their oxygen cylinder storage area, the failure to provide a precautionary sign on the gate to the storage area and failure to secure oxygen compressed cylinders. This affected 2 of 8 smoke compartments and could result in a fire and potential injury to patients, staff and visitors.

NFPA 99, Standard For Health Care Facilities 1999 edition
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

NFPA 99 Standard for Health Care Facilities (1999 Edition) 8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION

OXIDIZING GAS(ES) STORED WITHIN

NO SMOKING
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

NFPA 99, Standard For Health Care Facilities 1999 edition
4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder
storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not
communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be
stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches,
and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]. 1999 Edition

Findings:

During the facility tour with Staff 1 on October 23, 2012, through October 25, 2012, the facility oxygen storage areas were observed.

October 23, 2012

1. At 10:14 a.m., the light switch in the Room identified as the Oxygen Cylinder Storage Room, near Admitting, was mounted 48 inches from the floor.

October 24, 2012

2. At 1:05 p.m., there was no sign on the gate or near the fence to the main Oxygen Storage area located outside to indicate that Oxygen cylinders are stored within.

October 26, 2012
C-T SCAN Trailer

3. At 10:26 a.m., there was an oxygen tank (D Cylinder) that was laying on the floor unsecured in the C-T Scan trailer.

Based on document review, the facility failed to ensure that 35 % and above humidity is maintained in their Operating Rooms in accordance with NFPA 99, 1999 edition. This was evidenced by written documentation of humidity in the OR below 35 %. This could increase the occurence of fire and result in potential harm to patients. This affected 2 of 8 smoke compartments.

Findings:

During document review with Staff 1 on October 23, 20012, the humidity logs were reviewed.

October 23, 2012

At 1:38 p.m., the humidity log revealed that the humidity was below 35 % on the following dates in the Operating Room (OR):
March 5, 2012, the humidity was 30 % in OR 1 and 24 % in OR 3, March 7, 2012, the Humidity for OR 1 was 33 % and OR 3 was 18 %, March 8, 2012, the humidity was 24 % in OR 3, March 9, 2012, the humidity was 20 % in OR 3, January 30, 2012, the humidity in OR 1 was 30 %, and OR 3 was 21 %, and November 2, 2011, the humidity was 34 %, and November 10, 2011, the humidity was 32 %.

At 1:40 p.m., the facilities humidity log titled (name of hospital) Hospital San Diego, Environmental Check Log (Surgery Dept) indicated that the humidity acceptable range is 30 % to 60 %.

At 1:42 Staff 9 was interviewed and she stated that she will call maintenance to adjust the humidity when it is out of range.

At 1:43 p.m., there was no documentation that further test were performed to re-check the humidity when it was out of range.

Based on document review, and interview, the facility failed to maintain their emergency back-up power supply in accordance with NFPA 99, 1999 edtion. This was evidenced by the facility's failure to conduct annual supplemental test on their emergency generator within the past twelve months. This could result in failure of their back up power supply and could cause failure to provide power to the life safety systems and emergency equipment during power outage.

NFPA 110 Standard for Emergency and Standby Power Systems, 1999 Edition
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During record review conducted with Staff 1 on October 23, 2012, the generator test records were reviewed and a staff person was interviewed.

October 23, 2012

At 3:20 p.m., the facilities last annual supplemental test (Load Bank Test) was performed by (name of company) on August 14, 2011.

At 3:21 p.m., Staff 1 stated during an interview that the (name of company) test performed on August 14, 2011, was the last load bank test that was done.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70. This was evidenced by the use of flexible power cords, appliances plugged to multi-outlet extension cords, and unidentified circuits in their panelboards. This affected 3 of 8 smoke compartments. This could potentially increase the risk of an electrical fire causing harm to the patients.
NFPA 70, National Electrical Code (1999 Edition)
400.8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.
NFPA 70, National Electrical Code (1999 Edition) 384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer ' s name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or board.

Findings:

During a tour of the facility with Staff 1 on October 23, 2012, through October 25, 2012, the electrical equipment was observed.

October 23, 2012

1. At 9:40 a.m., there was a refrigerator and a microwave in the Lab Staff Lounge that was plugged into a multi-outlet power strip and not directly in to a wall outlet.

October 24, 2012

2. At 10:35 a.m., there was an orange extension cord plugged into a multi-outlet power strip in the Basement Infection Control Office. Staff 1 acknowledged the finding.

3. At 1:16 p.m., there was an orange extension cord in use in the Business Office and near the Marketing Desk. Staff 1 acknowledged the finding.

4. At 3:12 p.m., in Nutrition Room near Room 109 was an Electrical Panel (C1A) with 16 of 36 circuits that were unidentified. Circuits 5, 12, 14, 20, 22, 25, 27 through 36 were unmarked to their purpose. At 3:13 p.m., Staff 1 said during an interview that he did not know where the circuits are connected to.