HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by an unsealed penetration in a wall. This could result in the spread of fire and smoke through compartments. This affected one of six buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Findings:

During a tour of the facility the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/5/16, the facility construction was observed.

Tulare
1. At 11:52 a.m., there was an approximately three inch by three inch unsealed penetration in the north wall, above the entrance door of the Material Management Receiving Room, with a 1/4 inch black wire going through. The Safety Officer acknowledged the finding.

Based on observation and interview, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to latch and corridor doors that were impeded from closing. This affected three of six buildings and could result in a delay to contain smoke or fire to a room.

NFPA 101 Life Safety Code, 2000 Edition
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

8.2.4.3.4* Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

19.3.6.3.3*. Hold-open devices that release when the door is pushed or pulled shall be permitted.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.4. All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/4/16 to 1/6/16, the doors in the facility were observed and staff were interviewed.

Tulare 1/4/16
1. At 12:35 p.m., the corridor door to Room 109 was impeded from closing with an unattended chair in the door path.

2. At 12:53 p.m., the latching mechanism to the corridor door to the Dialysis Room B2107 was completely covered with white tape and was not latching when tested.

At 12:54 p.m., the Safety Officer said that he was not aware of the tape being on the door and did not know how long that it was placed there.

3. At 1:16 p.m., the self-closing corridor door to the Surgery Waiting Room was impeded from closing with an alcohol based hand sanitizer on a stand that was placed in the door path.

4. At 1:45 p.m., the ICU self-closing door to the Oxygen Room was not latching when tested. There were 8 E-type cylinders in the room

1/5/16
5. At 9:29 a.m., the corridor door to Room 112 was hitting the door frame and was unable to close when tested.

6. At 9:32 a.m., the two self closing doors to the Ambulatory Care Unit were not latching when tested.

7. At 9:40 a.m., the self-closing door to Room 102 was not latching when tested.

8. At 9:48 a.m., the corridor door to Room 304 was not latching when tested.

Hillman 1/6/16
9. At 8:36 a.m., the self-closing corridor door to Room 7 was not latching when tested.

Lindsay 1/6/16
10. At 12:53 p.m., the office door near Room 2 was not latching when tested.

11. At 12:57 p.m., the latching mechanism and striker plate were completely covered with tape on the door to the Medical Records Office. The door was not latching when tested.

Based on observation, document review, and interview, the facility failed to maintain their automatic closing fire doors. This was evidenced by fire doors that failed to close and positive latch, and by fire doors that were impeded from closing. This failure affected two of six buildings and had the potential to allow the spread of smoke or flames in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/6/16 to 1/7/16, the fire doors were observed, testing documents were requested, and staff were interviewed.

Hillman 1/6/16
1. At 8:16 a.m., the fire door latching mechanism was completely covered with clear tape and was unable to latch when released from the magnetic hold open device. The fire door was located near the Nurse Station.

2. At 8:41 a.m., the closure arm to the fire door to the Nutrition Room was removed and unable to self close when released by the magnetic hold open device.

At 8:51 a.m., Maintenance Worker 1 said during an interview that he did not know how long the fire doors were not working.

1/7/16
3. At 11:51 a.m., there was no documented evidence of testing the fire doors within the facility. There was no documented evidence that the fire doors and associated components (magnetic hold open devices, self-closers, etc.) were tested on the annual test dated 11/12/15 by a licensed vendor. The facility had approximately 6 fire doors.

Evolutions (Physical Therapy) 1/6/16
4. At 1:55 p.m., there was a rubber wedge under the fire door near the fire alarm control panel. The door was impeded from closing as designed.

At 1:56 p.m., Facility Maintenance Staff 1 said during an interview that there is always a wedge under the fire door to keep it open.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by a smoke barrier doors that failed to close flush. This affected one of six buildings and could result in a delay in containing smoke or fire to a smoke compartment.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/5/16, the facility smoke barrier doors were observed.

Tulare
1. At 9:16 a.m., the north smoke barrier door near the vending machine Room was approximately 1 inch from closing flush with the opposite door.

2. At 9:19 a.m., the exit door near Room 101 was approximately 1 inch from being flush with the opposite door. The Lead Maintenance acknowledged the finding.

Based on observation and interview, the facility failed to main their stairways as evidenced by combustible items stored in the stairwell. This could fuel a fire, become a trip hazard, and cause potential harm to patients evacuating during a fire emergency. This affected two of six buildings.

NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8. (d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.
Exception No. 1: Openings in exit passageways in covered mall buildings as provided in Chapters 36 and 37 shall be permitted.
Exception No. 2: In buildings of Type I or Type II construction, existing fire-protection rated doors shall be permitted to interstitial spaces provided that such space meets the following criteria:
(a) The space is used solely for distribution of pipes, ducts, and conduits.
(b) The space contains no storage.
(c) The space is separated from the exit enclosure in accordance with 8.2.3.
(e) Penetrations into and openings through an exit enclosure assembly shall be prohibited except for the following:
(1) Electrical conduit serving the stairway
(2) Required exit doors
(3) Ductwork and equipment necessary for independent stair pressurization
(4) Water or steam piping necessary for the heating or cooling
of the exit enclosure
(5) Sprinkler piping
(6) Standpipes
Exception No. 1: Existing penetrations protected in accordance with 8.2.3.2.4 shall be permitted.
Exception No. 2: Penetrations for fire alarm circuits shall be permitted within enclosures where fire alarm circuits are installed in metal conduit and penetrations are protected in accordance with 8.2.3.2.4.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Safety Officer, and Facility Coordinator on 1/4/15 to 1/6/16, the facility exit components were examined.

Tulare, 1/5/16
1. At 12:40 p.m., there was a 32 gallon shredding container full of paper stored in the stairwell near Room 1191. The Director of Plant Operations acknowledged the finding.

Evolutions (PT) 1/6/16
2. At 2:26 p.m., there were 5 empty buckets in the stairwell E2120. The Safety Officer removed the buckets upon discovery.

At 2:27 p.m., the Maintenance Worker 2 said during an interview that the construction contractor may have placed them in the stairwell yesterday (1/5/16) evening.

Based on observation and interview, the facility failed to maintain their emergency lighting units. This was evidenced by emergency lights that failed to illuminate when tested and by the failure to test battery powered emergency lighting units monthly for 30 seconds and annually for 90 minutes. This affected two of six buildings and could result in limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 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.

Findings:

During a tour of the facility with the Lead Maintenance, Safety Officer, and Facility Coordinator on 1/6/16 and 1/7/16, the emergency lighting units were tested and staff were interviewed.

Hillman 1/6/16
1. At 8:39 a.m., the emergency light (0981) near the RN office was not illuminating when the test button was pressed.

At 8:51 a.m., the Maintenance said during an interview that he tested the emergency lights only when he gets a work order. He said that it could be quarterly. He was unsure without looking at a work order at the last time the emergency lights were tested.

2. At 9:10 a.m., the back south emergency light (0992) near the exit was not illuminating when the test button was pressed.

1/7/16
3. At 9:53 a.m., there was no documented evidence of testing the emergency lights in the Hillman building for 30 seconds monthly and 90 minutes annually.

Evolution (Physical Therapy) 1/6/16
4. At 2:56 p.m., the emergency light (1043) was not illuminating when the test button was pressed.

Based on observation and interview, the facility failed to maintain their exit signs. This was evidenced by not installing an exit sign in all directions of egress, by exit signs that failed to illuminate when tested, and by exit signs that were not tested monthly. This affected four of six buildings and could result in a delay in evacuation due to limited exit sign visibility.

NFPA 101 Life Safety Code, 2000 edition
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.
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.

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/4/16 to 1/6/16, the facility exit signs equipped with an internal emergency power supply source along their means of egress were tested, testing documents were reviewed, and staff were interviewed.

Tulare, 1/4/16
1. At 12:48 p.m., there was no exit sign displayed in the corridor north of Room 102. The Director of Plant Operations acknowledged the finding.

1/5/16
2. At 12:17 p.m., the exit sign in the basement of the old Medical Records Room was not illuminating when the test button was pressed.

Hillman 1/6/16
3. At 8:51 a.m., the Maintenance Worker 1 said during an interview that he tested the exit signs quarterly and not monthly.

1/7/16
At 9:53 a.m., there was no documented evidence that the facility was testing the exit signs on a monthly basis as required in the Hillman building.

Earlimart 1/6/16
4. At 10:53 a.m., the exit sign (1119) near Room 2 was not illuminating when the test button was pressed.

Evolutions (PT) 1/6/16
5. At 2:38 p.m., the exit sign (1062) above stairwell E2106 was not illuminating when the test button was pressed.

Based on document review and interview, the facility failed to prepare staff members to respond to emergency situations at unexpected times as evidenced by 3 of 4 fire drills for the PM shift conducted at around the same time, no fire drill for 1 of 4 quarters for the NOC shift, and staff that did not know the facilities emergency fire procedures. This affected one of six buildings and could result in facility staff not being prepared to respond to a fire emergency.

NFPA 101, Life Safety Code (2000) Edition
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
19.7 Operating Features
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During document review with Lead Maintenance, Safety Officer, and Facility Coordinator on 1/4/16 to 1/6/16, the fire drill records were reviewed and staff were interviewed.

All Buildings 1/4/16 to 1/6/16
1. At 8:00 a.m. to 5:00 p.m., 3 of 16 staff interviewed were unable to describe the facilities emergency fire procedures including the fire response protocol (R.A.C.E., Rescue, Alarm, Contain, and Extinguish), fire extinguisher protocol (P.A.S.S., Pull, Aim, Squeeze, and Sweep), and emergency code for fire (Code Red). Hospital Staff 1, Environmental Services Staff 1, and PBX staff 1 were unable to explain the facility's emergency fire procedures. The emergency fire procedure information was on their identification badges but the staff were not aware that it was with them.

Tulare
2. At 3:18 p.m., there was no documented evidence of a NOC shift fire drill conducted for the second quarter (April, May, June) of 2015.

3. At 3:19 p.m., three of four fire drills for the PM shift during the past twelve months were conducted between 8:14 p.m. and 8:30 p.m. and not at varying times and conditions.

The 12/5/15 fire drill was conducted at 8:30 p.m.
The 8/21/15 fire drill was conducted at 8:10 p.m.
The 5/25/15 fire drill was conducted at 8:14 p.m.

Based on observation and interview, the facility failed to ensure that fire alarm notification devices were installed in all areas of the facility. This was evidenced by no fire alarm notification devices in one portion of the basement on the main campus. This affected one of six buildings and could result in a delayed notification of a fire alarm system activation.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.
19.3.4.4 Emergency Control. Operation of any activating device in the required fire alarm system shall be arranged to accomplish automatically any control functions to be performed by that device. (See 9.6.5.)
9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/5/16, the fire alarm system was tested and alarm notification devices were observed.

Tulare
1. At 12:19 p.m., the fire alarm system was activated. The fire alarm could not be heard in the old medical records section of the basement. There were no audible or visual fire alarm notifications devices installed in that section of the basement.

At 12:20 p.m., the Safety Officer acknowledged that the fire alarm system could not be heard in that portion of the basement.

Based on observation, document review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by the fire alarm control panel that indicated the system was in trouble, items that failed during fire alarm system tests and inspections that were not corrected, by failing to notify the authority having jurisdiction of the extended impairment of the fire alarm system, and by impeded fire alarm pull stations. This affected one of six buildings and could result in a failure of the fire alarm system. Failure of the fire alarm system could result in injury to patients, visitors, and staff due to delays in notification, evacuation, and emergency response forces.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.6 Trouble Signals. Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 1-5.4.6.1 or 1-5.4.6.2. Trouble signals required to indicate at the protected premises shall be indicated by distinctive audible signals. These audible trouble signals shall be distinctive from alarm signals. If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1/2 second. An audible trouble signal shall be permitted to be common to several supervised circuits. The trouble signal(s) shall be located in an area where it is likely to be heard.

1-5.4.6.1 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Control unit (central equipment) for protected premises fire alarm systems
(2) Building fire command center for emergency voice/alarm communications service
(3) Central station or remote station location for systems installed in compliance with Chapter 5

1-5.4.6.2 Trouble signals and their restoration to normal shall be visibly and audibly indicated at the proprietary supervising station for systems installed in compliance with Chapter 5.

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

5-2.6.1.4 Upon receipt of trouble signals or other signals pertaining solely to matters of equipment maintenance of the fire alarm systems, the central station shall perform the following actions:
(1) *Communicate immediately with persons designated by the subscriber
(2) Dispatch personnel to arrive within 4 hours to initiate maintenance, if necessary
(3) Provide notice, if required, to the subscriber or the authority having jurisdiction, or both, as to the nature of the interruption, the time of occurrence, and the restoration of service, when the interruption is more than 8 hours.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/4/16 to 1/7/16, the fire alarm system was observed, testing documents were reviewed, and staff were interviewed.

Tulare 1/4/16
1. At 11:43 a.m., the fire alarm control panel indicated 2 trouble signals. Trouble signals indicate that the fire alarm system is not fully working as designed.

At 11:45 a.m., the Director of Plant Operations said during an interview that he believed one trouble was due to a possible electrical short somewhere. He did not know what the second trouble signal was for. He indicated that the panel trouble signals started approximately 8 months ago (June 2015). He indicated that the facility started a fire watch on 12/16/15.

On 1/5/16 at 9:11 a.m., PBX Staff 1 said during an interview that the two trouble signals on the fire alarm control panel were there for at least 6 months, maybe longer.

1/4/16
2. At 12:44 p.m., the fire alarm pull station, in the ACU Waiting Room, was impeded from access by a chair that was positioned in front of the device.

3. At 1:36 p.m., the fire alarm pull station, at the ICU Nursing Station, was impeded from access by a copy machine that was positioned in front of the device.

1/4/16 to 1/5/16
4. On 1/4/16 at 4:10 p.m., fire alarm system test and inspection records were reviewed. The fire alarm system test and inspection record, completed by a licensed vendor on 3/31/15, identified several deficiencies with the fire alarm system. There was no documentation that indicated actions were completed to correct the deficiencies. The following items were identified on the report as deficient:

a. Battery load test
b. Operational test
c. CPADR Addressable (list 2) one failed
d. Remote charger failed
e. SGPW Signal/Aux power failed
f. Waterflow in the kitchen
g. Tamper
h. Door holder
i. 4 smoke detectors failed

5. On 1/4/16 at 4:14 p.m., the fire alarm system test and inspection record, completed on 6/26/15 by a licensed vendor, was reviewed. The record identified several deficiencies with the fire alarm system. There was no documentation that indicated actions were completed to correct the deficiencies. The following items were identified on the report as deficient:

a. CPADR Addressable
b. SGPWR Signal Aux power
c. Dialer
d. Tamper switch
e. Waterflow in the kitchen
f. (Basement) battery load test failed
g. 6 of 67 smoke detectors failed

6. On 1/4/16 at 4:16 p.m., there was no documentation that indicated the authority having jurisdiction was notified of an unusual occurrence when the fire alarm system was not working as designed for greater than eight hours.

Based on observation, document review, and interview, the facility failed to maintain smoke detectors. This was evidenced by the facility's failure to correct 27 of 67 smoke detectors that failed smoke sensitivity testing, by no smoke detectors in two fire alarm control panel rooms, and by no weekly testing of battery powered smoke detectors. This affected four of six buildings and could result in failure of the smoke detectors in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

19.3.4 Detection, Alarm, and Communications Systems.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

7-1.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.
Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the information regarding tests and all the applicable information requested in figure 7-5.2.2.
(1) Date
(2) Test Frequency
(3) Name of Property
(4) Address
(5) Name of person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section_____ ."
(8) Functional Test of Detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem, corrected/success-fully retested, device abandoned in place)

8-1.1.2* The performance of fire warning equipment for dwelling units discussed in Chapter 8 shall depend on such equipment being properly selected, installed, operated, tested, and maintained in accordance with the provisions of this code and with the manufacturer's instructions provided with the equipment.

Findings:

During document review with the Director of Plant Operations, Safety Officer, Facility Coordinator, and Lead Maintenance on 1/4/16 to 1/7/16, the smoke detectors maintenance records were reviewed and staff were interviewed.

Tulare 1/4/16 to 1/5/16
1. On 1/4/16 at 4:10 p.m., the fire alarm system test and inspection record, dated 6/26/15, indicated that 31 of 67 smoke detectors failed smoke sensitivity testing on 3/31/15. Four of the 31 failed smoke detectors were repaired on 6/26/15. The locations of the four repaired smoke detectors were not identified. There was no documentation that indicated the remaining 27 failed smoke detectors were repaired or replaced.

The following 31 smoke detectors were listed as failed: Rooms 102, 103, 104, 105, 106, 107, 109, 110, 111, 112, 113, 114, 115, 116, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, 215, 216, and in the Birthplace.

At 4:12 p.m., the Director of Plant Operations said during an interview that he has been searching for the smoke detector replacement components and has been having trouble finding them. He said that the smoke detectors are old and hard to find.

Hillman 1/6/15
2. At 8:22 a.m., there were eight battery powered smoke detectors within the facility. The manufacturer label inside the smoke detector read in part, "weekly testing required."

At 8:51 a.m., during an interview, Maintenance Worker 1 indicated that he believed he tested the battery powered smoke detectors quarterly or annually. He indicated he tested the smoke detectors when he gets a work order to do so.

On 1/7/16 at 9:53 a.m., there was no documentation that indicated the facility was testing the eight battery powered smoke detectors on a weekly basis. There was no documentation that a battery replacement policy or procedure was in place for the smoke detectors.

1/6/15
3. At 9:19 a.m., there was no smoke detector in the fire alarm control panel room. The fire alarm control panel was located in a utility closet. The room was unoccupied and kept closed.

Lindsay 1/6/15
4. At 1:20 p.m., there was no smoke detector in the fire alarm control panel room. The fire alarm control panel was located in a storage/equipment room. The room was unoccupied and kept closed.

Clinical Lab 1/6/15
5. At 3:12 p.m., the battery powered smoke detector in the staff break room was not sounding an alarm when tested. There were no lights emitting from the battery powered smoke detector.

Based on observation, document review, and interview, the facility failed to maintain the automatic sprinkler system. This was evidence by one of 13 automatic sprinkler system waterflow alarm valves that failed to activate the fire alarm system when tested, by one of 13 automatic sprinkler system waterflow alarm valves that was identified as deficient and had no record of repair, by sprinkler piping with external loads, and by one waterflow alarm valve that was not equipped with an identification sign. This affected one of six buildings and could result in a delayed response of the automatic sprinkler system or a delayed notifcation of a sprinkler activation, in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation

9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

9.7.1 Automatic Sprinklers.
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this 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.

19.3.4 Detection, Alarm, and Communications Systems.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

19.3.4.2* Initiation. Initiation of the required fire alarm systems shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.
Exception No. 1: 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 such manual fire alarm boxes are visible and continuously accessible and that travel distances required by 9.6.2.4 are not exceeded.
Exception No. 2: Fixed extinguishing systems protecting commercial cooking equipment in kitchens that are protected by a complete automatic sprinkler system shall not be required to initiate the fire alarm system.
Exception No. 3: Detectors required by the exceptions to 19.7.5.2 and 19.7.5.3.

19.3.4.3 Notification.
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1:* In lieu of audible alarm signals, visible alarmindicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.

19.3.5 Extinguishment Requirements.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

NFPA 13, Standard for the installation of sprinkler systems, 1999 edition
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.
Exception: Where an occupant, management firm, or managing individual has received the authority for inspection, testing, and maintenance in accordance with the Exception to 1-4.2, the occupant, management firm, or managing individual shall comply with 1-4.4.

2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

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.

NFPA 72, National Fire Alarm and Signaling Code, 1999 Edition
2-6 Sprinkler Waterflow Alarm-Initiating Devices.
2-6.1 The provisions of Section 2-6 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.

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.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During fire alarm testing with the Lead Maintenance, Facility Coordinator, and Safety Officer on 1/4/16 to 1/5/16, the automatic sprinkler system was tested, testing documents were reviewed, and staff and vendors were interviewed.

Tulare 1/4/16 to 1/5/16
1. On 1/4/16 at 4:10 p.m., the fire alarm system test and inspection records, dated 3/31/15 and 6/26/15, were reviewed. The tests completed on 3/31/15 and on 6/26/15 indicated that the automatic sprinkler system waterflow alarm valve for the kitchen failed. There was no documentation that indicated the failed waterflow alarm valve for the kitchen had been repaired.

2. On 1/5/16 at 12:09 p.m., there was no identifaction sign for the waterflow alarm valve located in the old Medical Records Room.

3. On 1/5/16 at 12:12 p.m., there were 12 blue wires strapped to the sprinkler piping in the old Medical Records Room. The wires were an external load on the sprinkler piping.

4. On 1/5/16 at 12:15 p.m., the waterflow alarm valve in the old Medical Records Room failed to activate the fire alarm system when tested. The water flowed for more than 2 minutes (127 seconds) without activating the fire alarm system.

At 1:45 p.m., the fire alarm vendor indicated during an interview that sometimes the waterflow valves fail then work during a retest. He said that he was not sure why.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by fire extinguishers that were not inspected monthly and by fire extinguishers that were not serviced annually. This affected two of six buildings and could result in a malfunctioning fire extinguisher.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition)
4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

4-4* Maintenance.
4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Facility Coordinator, and Safety Officer, on 1/4/16 to 1/6/16, the fire extinguishers were observed and staff were interviewed.

Tulare 1/4/16
1. At 11:59 a.m., the fire extinguisher in the Emergency Department 1, near Room 2, was not inspected during the month of September 2015. The fire extinguisher was last annually serviced on 5/18/15.

At 12:00 p.m., the Director of Plant Operations said during an interview that the fire extinguisher missed the visual inspection. He said that staff needed to sign the card and place the information on a log.

Hillman 1/6/16
2. At 8:19 a.m., two of six fire extinguishers in the building were last annually serviced on 5/20/14. The two fire extinguishers were approximately eight months overdue for an annual service and inspection. The Lead Maintenance person acknowledged the finding.

3. At 8:32 a.m., three of six fire extinguishers did not have monthly visual inspections during the months of April and May 2015. The Facility Coordinator acknowledged the finding and the location of each fire extinguisher.

Based on observation and interview, the facility failed to maintain a means of egress. This was evidenced by doors in a means of egress that did not swing in the direction of egress. This affected one of six buildings and could result in a delayed evacuation during a fire or disaster emergency.

NFPA 101, Life Safety Code, 2000 Edition
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.

7.2.1.4.3 A door shall swing in the direction of egress travel where used in an exit enclosure or where serving a high hazard contents area, unless it is a door from an individual living unit that opens directly into an exit enclosure.

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Lead Maintenance, and Facility Coordinator on 1/5/16, the egress doors were observed and staff were interviewed.

Tulare 1/5/16
1. At 9:44 a.m., both smoke barrier doors near Room 321 were swinging against the direction of egress.

At 9:47 a.m., the Lead Maintenance said during an interview that the facility is working on getting the doors replaced to swing with the direction of egress.

Based on observation, the facility failed to safely maintain the oxygen storage areas and secure their cylinders as evidenced by two E cylinders that were unsecured and a door to an oxygen storage area that was not self closing. This affected two of six buildings and could result in the potential for damage to the cylinders and harm to patients.

NFPA 101. Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with the Lead Maintenance, Facility Coordinator, and Safety Officer on 1/4/16 to 1/6/16, the facility oxygen storage areas were observed.

Tulare 1/4/16
1. 11:47 a.m., there was a free standing and unsecured E-sized oxygen cylinder in ED2 (Fast track).

2. At 1:41 p.m., there was a free standing and unsecured E-sized oxygen cylinder in Room 285 (ICU).

1/6/15
3. At 3:38 p.m., the self closing arm on the door to the oxygen tank farm was broken off. The door failed to self close. The facility Coordinator acknowledged the finding.

Based on observation and interview, the facility failed to maintain the anesthetizing locations. This was evidenced by the failure to provide battery powered emergency lighting units in four of four operating rooms. This affected one of six buildings and could result in a loss of emergency lighting in the event of a power failure in conjunction with a generator delay.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas (See Chapter 2 for definition of patient care area)
(a) Wiring, Regular Voltage.
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).

Findings:

During a tour of the facility with the Director of Plant Operations, Safety Officer, Lead Maintenance, and Facility Coordinator on 1/5/16, the operating rooms were observed.

Tulare 1/5/16
1. At 10:23 a.m., the facility was observed to not have any battery powered emergency lighting units in four of four operating rooms.

At 10:25 a.m., the Operating Room Manager said during an interview that they would use a flashlight if the power failed.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by an unsealed pipe penetrating a smoke barrier wall. This affected one of six buildings and could result in the faster spread of smoke or fire to other smoke compartments.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes 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 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.
(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 conditions:
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 the Lead Maintenance, Director of Plant Operations, Safety Officer, Facility Coordinator on 1/4/16, the facility's smoke barrier walls were observed.

Tulare 1/4/16
1. At 10:08 a.m., there was an approximately 3/4 inch unsealed pipe through the smoke barrier wall near Rooms 2150 and 2151. The Lead Maintenance acknowledged the finding.

Based on observation, the facility failed to maintain their electrical equipment and wiring connections. This was evidenced by the use of extension cords, power strips, and adapters as a substititute for fixed wiring. This was also evidenced by impeded electrical panels and damaged electrical outlet coverplates. This affected three of six buildings and could result in an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 edition
110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

Findings:

During a tour of the facility with the Director of Plant Operations, Lead Maintenance, Safety Officer, and Facility Coordinator on 1/4/16 to 1/6/16, the facility's electrical equipment and wiring connections were observed.

Tulare 1/4/16
1. At 11:31 a.m., electrical decorations on a holiday tree in the lobby was plugged into a white extension cord.

2. At 11:54 a.m., electrical panels C1 and C2 in Room EDI were impeded from access with an unattended bed in front of the electrical panels.

3. At 12:59 p.m., a black extension cord in use was plugged into a multi-outlet power strip in Room B2107 (Dialysis), in the Basement.

4. At 1:23 p.m., a brown extension cord in use at the Med Surg 2 Nursing Station.

1/5/16
5. At 9:03 a.m., there was an unattended food cart impeding the electrical panel near Room 103.

6. At 9:26 a.m., a black extension cord in use was plugged into a multi-outlet power strip under the desk of Med Surg 1 Nursing Station.

7. At 9:51 a.m., the electrical panel E2B, in the ICU lunch room, was impeded from access by an unattended recycling container.

8. At 11:30 a.m., there was a ladder against the electrical panel L on the Medical Records Room.

9. At 2:24 p.m., there was a three plug adapter in use in the Air Compressor/Housekeeping Supply Room, in the basement.

Hillman 1/6/16
10. At 8:28 a.m., there was a refrigerator in the General Practice Med Room plugged into a six plug adapter.

11. At 8:46 a.m., there was a multi-outlet power strip plugged into another multi-outlet power strip in the Billing Office, near the second cubicle to the north.

12. At 8:57 a.m., the electrical outlet in the office, identified as CPSP Office, was missing a cover plate. There was also a refridgerator plugged into a multi-outlet power strip in that same office.

Evolutions (PT) 1/6/16
13. At 2:45 p.m., the electrical outlet in Room E2118 was missing the bottom 1/3 of the cover plate. The Lead Maintenance acknowledged the finding.