HospitalInspections.org

Based on observation and interview, the facility failed to maintain corridor walls to resist the passage of smoke.

Findings:

On February 12, 2013 between 11:30 a.m. and 2:44 p.m., accompanied by the Director of Facilities Operation, the evaluator observed the following.

Main Hospital Bldg. 1; 2nd floor

1.) In the medical/surgical unit by room 206, there was an one square foot penetration through the corridor wall located obove the ceiling.

2.) At decontamination room (2123), there was an unsealed sleeve creating a 2 inch diameter penetration through the wall separating the decontamination room from the corridor. The sleeve was behind a wall mounted monitor and had cables running through it.

Based on observation and interview, the hospital failed to ensure that doors protecting corridor openings were provided and that there were no impediments to closing the doors. This was evidenced by one door that was obstructed from closing and one door that was removed for the convenience of the staff. This could result in the passage of smoke and flames in the event of a fire.

Finding:

Main Campus - On February 13, 2013, 10:30 a.m., the evaluator conducted an inspection of the hospital and observed that the Physical Medicine door (1105) was held open with a magnet. The door did not release upon activation of the fire alarm.

The evaluator conducted an inspection of the Emergency Room and observed that the facility staff had removed the door to room 5. The evaluator observed the remaining cut-out of the door's hinges on the doorframe. The other emergency patient room doors were in place.

In case of a fire emergency, the corridor doors shall protect the fire access corridor from the passage of smoke.



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Based on observation, the facility failed to ensure corridor doors were provided with a means to keep the doors closed and were not obstructed from closing.

Findings:

On February 12, 13, 15, 2013, accompanied by the Director of Facilities Operation and on February 14, 2013 accompanied by engineering, the evaluator observed the following.

Main Hospital Bldg. 1; 2nd floor

2.) On February 12, 3013 between 11:40 a.m. and 2:44 p.m., the 20 min. fire rated self-closing corridor door of Same Day Recovery and the 20 min. fire rated corridor door of room 200 were held open by magnets placed behind the doors.

3.) On February 12, 2013 between 2:44 p.m. and 4:40 p.m., the corridor door of room 204 failed to close remaining open 1 ft. Closer observation revealed the door protector at the spine of the door was bent and obstructed the door from closing.

4.) On February 12, 2013 between 2:44 p.m. and 4:40 p.m., the nurses lounge corridor door (2208) failed to self-close to latch.

5.) On February 12, 2013 between 2:44 p.m. and 4:40 p.m., the corridor door of room 215 failed to hold closed.

Main Hospital Bldg. 3; 1st floor, BHU West

6.) On February 15, 2013 at 2:00 p.m., the corridor door of the Activity/Dining room had a roller latch as the means for keeping the door closed. The roller latch failed to hold the door closed. Roller latches are prohibited by CMS regulations in all health care facilities.

Main Hospital Bldg. 3; 2nd floor OB Overflow/Med Unit

7.) On February 15, 2013 at 11:02 a.m., the corridor door of the NST (Neonatal Stress Test) room has held open by a kick down door holder in front of the door.

Main Hospital Bldg. 4, 1st floor

8.) On February 13, 2013 between 9:00 a.m. and 10:14 a.m., the corridor door of the laboratory was was held open by a magnet behind the door.

South Campus D/P APH

9.) On February 14, 2013 between 8:38 a.m. and 9:50 a.m., accompanied by engineering the evaluator observed the corridor doors of patient rooms 2, 11 and 14 failed to hold closed when shut.

Based on observation and interview, the facility failed to ensure that all patient care areas were provided with exit locations clearly identified at all times.

Finding:

Main Campus

1.) On February 12, 2013, at 11:58 a.m., the evaluator conducted an inspection of the Same Day Surgery Suite and eleven patient beds. The suite had two doors leading to the fire exit access corridor. The evaluator did not observe that any of the doors were marked and identified with an illuminated fire exit sign. The suite area in front of door 1 was used to stored patient care equipment.

The evaluator conducted an inspection of the Behavior Unit and observed that one of two smoke barrier doors did not have a fire exit sign. An interview was held with the staff member in charge and she stated that the sign was removed because the facility did not want the patients to exit out of the smoke barrier doors and into the next smoke compartment.

In case of fire or smoke emergency, all fire exits shall be clearly identified with an illuminated fire exit sign at all times. No changes shall be made without prior approval from the authority having jurisdiction that might impact patient safety in case of a fire or evacuation emergency.


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South Campus D/P APH

2.) On February 14, 2013 between 9:00 a.m. and 9:33 a.m., accompanied by engineering, the evaluator observed there was no illuminated exit sign at one of two dining/activity room exits. A sign on the door indicated "Alarmed Emergency Exit Only."

3.) Between 10:10 a.m. and 10:45 a.m., there were no exit signs at two exits from the kitchen to the parking lot. There was a manual fire alarm box located next to one of the exit doors.

Outpatient Services - Day Program

4.) On February 14, 2013 at 2:35 p.m., accompanied by the Director of Facilities Operation, the evaluator observed there was no exit sign marking the exit from Group Room 1. The posted evacuation plan identified the exit as part of the evacuation route.

Main Campus

Based on observation and interview, the hospital failed to maintain the exit access so that the fire exits were readily accessible and identifiable at all times. This was evidenced by two of two fire exit signs leading to the fire exit access corridors located in the Same Day Surgery Department and was the only Emergency Room exit access used as storage for patient equipment. This could result in a delay in exiting the hospital from the Same Day Surgery Department and Emergency Room in the event of a fire or other emergency affecting patients, and the staff.

Finding:

On February 13, 2013, the evaluator conducted an inspection of the hospital's Same Day Surgery Department and observed two doors leading to the exit access corridor. The evaluator observed one of two doors (1) was used to store the patient equipment.

An interview was held with two facility staff members and they stated that one staff would lead the patients out of door 1 and the other staff stated that she would lead the patients out of door 2. There were no fire exit signs posted anywhere within the Same Day Surgery Department at the time of the survey.

At 10:25 a.m., the evaluator inspected the Emergency Room and observed two patients' beds and a portable x-ray machine held in the corridor near the smoke barrier fire doors. The evaluator observed a sign posted on the wall that read "Do not block."

An interview was held with the Building Supervisor and he stated that he would have the equipment relocated as soon as possible.



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NFPA 101 Life Safety Code 2000 Edition

19.2.1 General.
Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.

7.2.1.9.1 General. Where means of egress doors are operated by power upon the approach of a person or doors with power-assisted manual operation, the design shall be such that, in the event of power failure, the door opens manually to allow egress travel or closes where necessary to safeguard the means of egress. The forces required to open such doors manually shall not exceed those required in 7.2.1.4.5, except that the force required to set the door in motion shall not exceed 50 lbf (222 N). The door shall be designed and installed so that when a force is applied to the door on the side from which egress is made, it shall be capable of swinging from any position to the full use of the required width of the opening in which it is installed (see 7.2.1.4). On the egress side of each door, there shall be a readily visible, durable sign that reads as follows:

IN EMERGENCY, PUSH TO OPEN

The sign shall be in letters not less than 1 in. (2.5 cm) high on a contrasting background.

These Standards were not met as evidenced by:

Based on observation and interview, the facility failed to ensure 4 of 4 power operated exit doors opened manually and failed to maintain a legible "IN EMERGENCY, PUSH TO OPEN" sign at 1 of 4 power operated exit doors.

Findings:

Main Hospital Bldg. 1; 1st floor

2.) On February 12, 2013, at approximately 10:30 a.m. and accompanied by the Director of Facilities Operation, the evaluator observed the power operated exit doors located at the employees entrance, ER and ER reception failed to open manually when the power to the doors was turned off.

During an interview between 11:15 a.m. and 4:00 p.m., the Director of Facilities Operation stated he tested the power operated exit door at the main entrance and it failed to open manually when the power to the doors was turned off.

At 4:00 p.m., the "IN EMERGENCY, PUSH TO OPEN" sign at the panic bar of the main entrance power door was noted to be worn and illegible.

Based on observation and interview, the facility failed to ensure that the corridors remained clear of patient care and staff equipment (e.g. computer on wheels/blood pressure machines).

Finding:

On February 12, 2013, the evaluator conducted an inspection of the facility's Main Campus and observed the following equipment held in the corridor between patient rooms 209 and 215: 3 blood pressure machines on wheels, 3 laptop computers on wheels, 2 chairs and one large weighing scale. At 3:45 p.m., the evaluator observed a portable x-ray machine plugged into a corridor outlet located near the radiology transcription room.

An interview was held with the Building Supervisor and he stated that he would have the equipment
relocated as soon as possible.

Based on observation and interview, the hospital failed to assure that Patient Transport equipment was made available in case of an evacuation or fire emergency.

Finding;

On February 12, 2013, at 3:00 p.m., the evaluator inspected the hospital and observed a door that was locked. An interview was held with the licensed nurse and she stated that only the EVS staff and the House Supervisor had the key to the room.

The licensed nurse summoned an EVS staff member and the evaluator observed an EVS cart and Patient Transport equipment hanging on the back wall. She also stated the equipment was available throughout the hospital for the staff to use in case of a fire or evacuation emergency.

The evaluator requested the House Supervisor to re-open the door and thirty minutes elapsed before the door was open. The House Supervisor stated that EVS does not have a key to open the door and they (EVS) will not remove the equipment. She stated that only the licensed staff will use the equipment in case of an emergency.

In case of a fire or evacuation emergency, there shall not be a delay in safely and expeditiously removing patients to a safe area.

NFPA 72 National Fire Alarm Code 1999 Edition

2-1.3.2 In all cases, initiating devices shall be supported independently of their attachment to the circuit conductors.

This standard was not met as evidenced by:

Based on observation, the facility failed to maintain a heat detector in accordance with NFPA 72.

Finding:

Main Hospital Bldg. 4; Basement

On February 15, 2013 at 3:20 p.m., accompanied by the Director of Facilities Operation, the evaluator observed 1 of 3 heat detectors at the ceiling of Equipment Room B-525 was supported only by its electrical wire connections.

2-3.6.1.3 Detectors shall not be installed until after the construction cleanup of all trade is complete and final.

Based on observation and interview, the facility failed to ensure that smoke detectors located in a suspended and unoccupied area were maintain in optimal and working condition at all times.

Finding:

Main Campus - On February 12, 2013, the evaluator conducted an inspection of a suspended Distinct Part Skill Nursing Unit. The evaluator observed six smoke detectors throughout the area and four of six smoke detectors were covered at the time of the inspection.

The evaluator observed combustibles such as furniture, wallboards, wood, desks and chairs, cans of roofing tar, construction blueprints and plans, plastic sheets, pressurized canisters and aerosol cans, cans of paint, bales of insulation material, roofing composition packets, and packing blankets. The evaluator observed a portable stationary saw and a drill press held on the floor; cut sections of metal bars, brackets, and beams with a pile of metal shaving lying on the floor next to the portable stationary saw.

An interview was held with the Building Supervisor and he stated that there was a patient care area located on the second floor directly above the suspended Distinct Part Skill Nursing Unit. He stated that the area was being used to "stage" construction for an ongoing seismic hospital construction project and the corridor located near the cafeteria was vacuumed approximately fourteen times a day.

On February 13, 2013, an interview was held with the authority having jurisdiction, Office of Statewide Health Planning and Development (OSPHD), and he stated that the suspended Distinct Part Skill Nursing Unit should not be used for storage or construction staging at any time.

In case of fire or smoke emergency, the smoke detectors shall be made immediately available and shall be maintained in optimal condition at all times.

Based on observation, the facility failed to ensure closing of the sprinkler shut off valve activated a local alarm.

Finding:

South Campus D/P APH

On February 14, 2013 between 1:17 p.m. and 2:35 p.m. accompanied by engineering the evaluator observed engineering shut the sprinkler shut off valve. The shutting of the valve activated the full fire alarm throughout the building instead of a local tamper alarm at a continuously manned location.

The fire alarm is representative of a fire or smoke emergency, while the local alarm is representative of tampering with the valve that controls the water supply to the sprinkler system.

1.) NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition

2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

This requirement was not met as evidenced by:

Based on observation and interview, the facility failed to ensure five pop down sprinklers were not painted.

Finding:

Main Hospital Bldg. 3

On February 12, 2013 at 10:05 a.m., accompanied by the Director of Facilities Operation, the evaluator observed five pop down sprinklers at an exterior canopy were painted.


2.) NFPA 13 Standard for the Installation of Sprinkler Systems 1999 edition

5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of
Water-Based Fire Protection Systems 1998 Edition

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

These requirements were not met as evidenced by:

Based on observation and interview, the facility failed to maintain sprinklers in accordance with NFPA 13 and 25 by having an obstruction less than 18 inches below a sprinkler deflector.

Finding:

South Campus D/P APH

On February 14, 2013 between 9:33 a.m. and 9:50 a.m., accompanied by engineering, the evaluator observed the clean linen room had pillows stored up against the sprinkler head.

NFPA 10, 1998 Edition, Standard for Portable Fire Extinguishers. 1-6.5 Cabinets housing fire extinguishers shall not be locked. Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

Based on observation, the hospital failed to maintain the portable fire extinguishers in the facility in accordance with NFPA 10. This was evidenced by portable fire extinguishers being stored in a locked cabinet and the key was kept at the nurse station. This could result in a delay in extinguishing a fire.

Finding:

On February 20, 2013, the evaluator conducted an inspection of the hospital's Behavioral Health Unit. The evaluator observed that the portable fire extinguishers were locked in the corridor cabinets. (near room 171).

An interview was held with the Charge Nurse and she was asked to open the portable fire extinguisher's cabinet and she stated that she did not have the key and she would have to go to the nurse's station to pick it up.

The evaluator asked another licensed staff member to open the cabinet and she stated that the key was kept at the nurse station. In case of fire emergency, access to the portable fire extinguishers shall not be delayed.

NFPA 96, 1998 Edition,

2-2 Hood Size. Hoods shall be sized and configured to provide for the capture and removal of grease-laden vapors.

5-2.2 Exhaust air volumes for hoods shall be of sufficient level to provide for capture and removal of grease-laden cooking vapors. Test data, performance acceptable to the authority having jurisdiction, or both, shall be provided, display, or both upon request.

11-3.1 Hoods shall be sized and located in a manner capable of capturing and containing all of the effluent discharging from the appliances. The hood and its exhaust system shall comply with Chapters 2 through 7.

Based on observation and interview, the facility failed to ensure that all grease-laden producing kitchen cooking equipment was situated under the kitchen exhaust and extinguishing system. The facility failed to ensure that the kitchen exhaust system continued to remove the cooking fumes and grease. The facility failed to ensure that cooking equipment that is replaced or serviced are placed back into service with a six-inch clearance under the cooking hood system.

Finding:

The evaluator conducted an inspection of the hospital kitchen exhaust system and observed that the facility had a canopy kitchen hood with cooking equipment on both sides. The evaluator observed the following; excessive grease damaged ceiling tiles throughout the kitchen and grease producing equipment located at the edge of the kitchen hood canopy and beyond its' grease removing capacity.

An interview was held with the kitchen supervisor and he stated that the kitchen ceiling tiles were due due to be cleaned.

Based on observation, the facility failed to ensure a means of egress was continuously maintained and was free of all obstructions or impediments.

Finding:

South Campus D/P APH

On February 14, 2013 between 9:33 a.m. and 9:50 a.m., accompanied by engineering, the evaluator observed three storage racks along 8 ft. of a kitchen exit corridor, thereby reducing the 6 ft. wide corridor to 4 ft.

(1 ) NFPA 70, NEC, 1999, 517-32. Life Safety Branch, No function other than those listed in (a) through (f) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.

Based on observation and interview, the facility failed to ensure that the emergency outlets were limited to essential equipment.

Finding:

Main Campus. On February 12, 2013, the evaluator conducted an inspection of the facility and observed that the emergency outlets were used for non-essential use. The evaluator observed the following equipment being stored in the corridor, located between patient room 209 - 215, and connected to the red emergency outlets: 3 blood pressure machines on wheels, 3 laptops on wheels and one large weighing scale.

An interview was held with the Building Supervisor and he stated that the equipment was getting charged and he would have the items relocated as soon as possible.

(2) NFPA 70, National Electrical Code, 1999 Edition, ARTICLE 517- HEALTH CARE FACILITIES (2) 517-33. Critical Branch(c) Receptacle Identification. The receptacles or the faceplates for receptacles supplied by the critical branch shall have a distinctive color or marking so as to be readily recognizable.

Based on observation and interview, the facility failed to ensure that the critical branch faceplates were all of a distinctive color as to be readily recognizable at all times.

Finding:

On February 12, 2013, at 11:27, the evaluator conducted a Life Safety Code inspection of the facility. The evaluator observed that the patient sleeping rooms had red and beige electrical outlet faceplates. The red and beige electrical outlet faceplates were connected and branched out on the wall: patient room 245 and 252.

An interview was held with the Building Supervisor and he stated that all the patients sleeping rooms' electrical outlets were connected to the critical branch. He also stated that he was not sure if the staff knew that they could use all the electrical outlets in the patients' rooms in case of an interruption of normal power.

In case of an interruption of normal power, the emergency electrical outlets that are connected to the critical power shall be of distinctive color at all time as to avoid delay.




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NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9-3.2 Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

9-3.3.1 All valves shall be inspected weekly.

9-3.3.2 The valve inspection shall verify that the valves are in the following condition:

(f) Provided with appropriate identification.

These standards were not met as evidenced by:

Based on observation, the facility failed to ensure there was a legible identification sign at the door of the room that housed the inspector test valve.

Finding:

South Campus D/P APH

4.) On February 14, 2013 at 2:00 p.m., accompanied by engineering, the evaluator observed the identification sign at the inspector test valve was faded and illegible.


Outpatient Services - OB & Family Health

5.) On February 15, 2013 at 10:10 a.m., accompanied by the Director of Facilities Operation, the evaluator observed the identification sign at the door that housed the inspector test valve was painted over making it illegible.


NFPA 80 Standard for Fire Doors and Fire Windows 1999 Edition

15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and made available to the authority having jurisdiction.

The Standard was not met as evidenced by:

Based on observation, the facility failed to ensure three vertical rolling fire doors were inspected and tested annually. Inspection and testing are essential to ensure vertical roll down fire doors perform as expected when called upon to do so.

Findings:

Main Hospital Campus

Building 3; 1st floor BHU

6.) On February 15, 2013 at 1:30 p.m., accompanied by The Director of Facilities Operation, the evaluator observed a vertical sliding fire door at the corridor pass through window of BHU 1 west medication room. Closer observation revealed the mechanism included three fusible links. Further observation revealed there was no tag or label at the door or its perimeter to indicate the door had been inspected and tested annually.

On February 15, 2013 at 2:05 p.m. accompanied by The Director of Facilities Operation the evaluator observed a vertical sliding fire door at the corridor pass through window of the BHU 1 south nurses station. Closer observation revealed there was no tag or label at the door or its perimeter to indicate the door had been inspected and tested annually.

Review of the annual fire door inspection and drop test log dated 4/26/12, from the door services company, revealed the sliding and rolling fire doors located at the OB & Family Health basement, BHU 1 west medication room and 1 south nurses station were not included in the annual inspection and drop test.


Outpatient Services - OB & Family Health

7.) On February 15, 2013 at 9:53 a.m., accompanied by the Director of Facilities Operation, the evaluator observed an opened vertical rolling fire door at a wall in the basement. Closer observation revealed the mechanism included two fusible links. Further observation revealed there was no tag or label at the door or its perimeter to indicate the door had been inspected and tested annually.


NFPA 99 Health Care Facilities 1999 edition

4-3.5.2.2(b)(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

4-5.5.2.2(b)(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

This requirement was not met as evidenced by:

Based on observation, the facility failed to ensure nonflammable gases were stored in accordance with NFPA 99 by not segregating empty cylinders from full cylinders and having penetrations through the room they were stored in.

Findings:

Main Hospital Bldg. 2; Generator Yard

8.) On February 12, 2013 at 10:25 a.m., at the generator yard, accompanied by the Director of Engineering, the evaluator observed full oxygen e-cylinders and empty oxygen e-cylinders being stored next to each other in an exterior cage. Closer observation revealed there was no signage or other markings to identify the empty cylinders from full cylinders.

(1.) National Electric Code 1999 Edition Article 400, Section 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.


These Requirements were not met as evidenced by:

Based on observation and interview, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70, National Electrical Code. NFPA 70 contains provisions necessary for safety and its purpose is the practical safeguarding of persons and property from hazards arising from the use of electricity. Hazards often occur because of overloading of wiring systems by methods or usage not in conformity with this code. To meet power supply needs, extension cords and/or power strips are often used and interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Extension cords are sometimes used to energize power strips in locations far from receptacles. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire, particularly when combustible materials are in contact with the wires.

Finding:

Main Campus - On February 12, 2013, at 2:00 p.m., the evaluator conducted an inspection of the Operating Room and observed that the four pieces of medical equipment (bed, bear hugger, computer, and emergency light) were connected to a surge protector. The evaluator inspected patient room 206 and observed a black extension cord and four pieces of patient care equipment were plugged into the surge protector at the time of the observation.

An interview was held with the Building Supervisor and he stated that the extension cords would be removed as soon as possible.

The evaluator conducted an inspection of the patient sleeping rooms and the Mammography room and observed surface electrical outlets installed in those areas.




16281

NFPA 70 National Electrical Code 1999 Edition

110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.

110.26 Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(a) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of (1), (2), and (3) or as required or permitted elsewhere in this Code.

(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(a). Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.

Table 110.26(a) Working Spaces

0-150 Nominal Voltage to Ground
Condition 1, 2 and 3 3 feet minimum clear distance

151-600 Nominal Voltage to Ground
Condition 1 3 feet minimum clear distance
Condition 2 3 1/2 feet minimum clear distance
Condition 3 4 feet minimum clear distance

Notes:
1. For SI units, 1 ft = 0.3048
2. Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(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.

(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(e). Within the height requirements of this section, other equipment associated with the electrical installation located above or below the electrical equipment shall be permitted to extend not more than 6 in. (153 mm) beyond the front of the electrical equipment.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

305-3.(d) Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

305-4.(h) Protection form Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where passing through doorways or other pinch points, protection shall be provided to avoid damage.

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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.

400-9. Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by section 400-7(a). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400-4) No. 14 and larger shall permitted if conductors are spliced in accordance with Section 110-14-(b) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

410-3. Live Parts. Fixtures, lampholders, lamps, and receptacles shall have no live parts normally exposed to contact. Exposed accessible terminals in lampholders, receptacles, and switches shall not be installed in metal fixture canopies or in open bases of portable table or floor lamps.

410-4. Fixtures in Specific Locations.

(c) In Ducts or Hoods. Fixtures shall be permitted to be installed in commercial cooking hoods where all of the following conditions are met.

(2.) The fixture shall be constructed so that all exhaust vapors, grease, oil, or cooking vapors are excluded from the lamp and wiring compartment. Diffusers shall be resistant to thermal shock.

(3) Parts of the fixture exposed within the hood shall be corrosion resistant or protected against corrosion, and the surface shall be smooth so as not to collect deposits and facilitate cleaning.

(4) Wiring methods and materials supplying the fixture(s) shall not be exposed within the cooking hood.

These requirements were not met as evidenced by:

Based on observation, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 National Electrical Code by daisy chaining power strips and extension cords, using extension cord as a substitute for fixed wiring, having loose receptacles, using an electrical panel room for storage and having an exposed electrical socket in a cooking hood.

Findings:

On February 12, 13, 15, 20, 21, 2013, accompanied by the Director of Facilities Operation and on February 14, 2013 by Engineering, the evaluator observed the following.

Main Hospital Bldg. 1; 1st floor

2.) On February 13, 2013 at 11:15 a.m., in the Emergency Room charting area, a computer was connected to a power strip that was connected to an extension cord connected to the wall receptacle.

Main Hospital Bldg. 1; 2nd floor

3.) On February 12, 2013 between 11:40 a.m. and 4:40 p.m., there were loose receptacles in rooms 203, 205, 208 and at the corridor outside the OR staff lounge.

4.) Between 11:40 a.m. and 12:00 p.m., in same day surgery, there was a missing light diffuser exposing the electrical wiring of a ceiling light fixture 8 ft. above the ground.

5.) Between 2:15 p.m. and 2:44 p.m., in the OR doctor's lounge, a computer system was connected to a power strip that was connected to an extension cord connected to the wall receptacle.

Main Hospital Bldg. 3; 1st floor BHU 1 South

6.) On 2/15/13 at 2:25 p.m., in BHU 1 south nurse's station, there was a fax machine connected to an extension cord that was connected to a power strip that was connected to a second power strip that in turn was connected to a surface mounted wall receptacle. There was also a three receptacle non-surge protected adapter connected to a wall receptacle.

Main Hospital Bldg. 3; 2nd floor

7.) On February 13, 2013 between 11:02 a.m. and 11:35 a.m., in room 244, there was a loose red emergency power receptacle.

Main Hospital Auditorium

8.) On February 15, 2013 between 3:20 p.m. and 4:30 p.m., in the auditorium, there was a household tap (zip cord) extension cord going from behind a presentation screen on the auditorium stage into the suspended ceiling above. The extension cord was connected to a second zip cord within the ceiling. Further observation revealed a third zip cord behind the wood wall of the auditorium.

South Campus D/P APH

9.) On February 14, 2013, at 8:58 a.m., service disconnect electrical panel (DP-B) room was used to store two charting boards, two bedside tables, a bed side table, a bent piece of metal and a bag of empty plastic bottles.

10.) Between 10:10 a.m. and 10:45 a.m., in the South Campus cafeteria, the lamp and light shield were missing from the hood of a ventless cooking system potentially exposing the electrical light socket to exhaust vapors, grease, oil, or cooking vapors.