HospitalInspections.org

Based on observation, the facility failed to maintain the building construction. This was evidenced by penetrations in their walls and ceilings. These penetrations affected 3 of 7 buildings and could potentially result in the spread of smoke or fire to other locations of the facility.

Findings:

During a facility tour with staff, the walls and ceilings were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 2:20 p.m., there was an approximately 2 inch by 2 inch penetration in the ceiling of the clean utility room in the respiratory therapy department located on the 2nd floor. The penetration was surrounding a sprinkler in that room.

2. On 4/8/10 at 3:09 p.m., there was an approximately 1 inch wide penetration in the ceiling of the general surgery room near room 2625 located on the 2nd floor. The penetration was surrounding a sprinkler in that room.

3. On 4/9/10 at 9:06 a.m., there was 1 approximately 1 inch wide penetration and 1 approximately 1/4 inch wide penetration in the ceiling of a closet in the orthopedics department located on the 1st floor. Cables were running through the penetrations.

4. On 4/9/10 at 11:41 a.m., there was an approximately 8 inch by 8 inch penetration in the ceiling of the 2nd level information technology room located in the Flats wing.


25385



Sacramento Ambulatory Surgery Clinic

5. During a tour of the facility, on 4/9/10, at 12:20 p.m., the Equipment Mechanical Room had three unsealed penetrations in the south wall approximately 12 feet up from the finished floor. These penetrations were the result of rigid electrical conduits which traveled through the wall and had a ? inch unsealed space around the conduit and the wallboard.

6. Between 12:30 and 12:45 p.m., the room identified as the I.T. Room had a ? unsealed penetration in the southwest corner of the wall caused by a rigid electrical conduit traveling through the wall.

Sacramento Camelia Building

7. During a tour of the facility with staff on 4/9/10, at 1:42 p.m., the Medications Room had a one inch unsealed penetration around a pipe in the ceiling in the north area of the room where the wall meets the ceiling.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors equipped with self closing devices that failed to latch or were impeded from shutting. This affected 4 of 7 buildings and could result in a delay to contain smoke or fire to an area.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 1:55 p.m., the door leading from the operating room department to the post anesthesia care unit, located on the 1st floor, was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

2. On 4/9/10 at 9:16 a.m., the cross-corridor door between the orthopedics department and the clinical laboratory department, located on the 1st floor, was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

3. On 4/9/10 at 10:42 a.m., the door to electrical room E24, located on the 1st floor, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch.


25385


Roseville Main Hospital

During a tour of the facility on 4/6/10, corridor doors were observed.

1. At 10:07 a.m., the door to the 1st Floor Gift Shop did not positive latch when released from an open position.
2. At 11:10 a.m., the 2nd floor corridor door to Patient Room 2014 was impeded from closing by a tall waste basket placed in the travel area of the door.
3. At 11:11 a.m., the 2nd floor corridor door to Patient Room 2004 was impeded from closing by a computer table.
4. At 1:35 p.m., the 2nd floor corridor door to the 2B Food Preparation Room had a cart which impeded the door from closing.
5. At 3:30 p.m., the WON door to the Emergency Room Admitting Office had two telephones and an approximately 1 inch thick stack of paper stored on the counter top which were impeding the fire door from closing.

Sacramento Camelia Building

6. During a tour of the facility with staff on 4/9/10, at 1:37 p.m., the door to the Office identified as E104 did not positive latch when released from an open position.

Rancho Cordova Eye Ambulatory Surgery Center

7. During a tour of the facility with staff on 4/8/10, at 3:00 p.m., the corridor door to the Charge Nurses Office would not positive latch when released from an open position.

8. At 3:15 p.m., the door to the sterilization room had a kick type door stop attached to the bottom of the door.

Based on observation, the facility failed to maintain their doors in exit passageways. This was evidenced by doors which were held open by magnetic devices, that did not release upon activation of the fire alarm system. This affected 3 of 7 buildings and could result in a delay to contain smoke or fire to a location.

Findings:

During a facility tour with staff, the doors in exit passageways were observed.

Sacramento Main Hospital:

1. On 4/9/10 at 3:37 p.m., 2 of 2 sets of cross corridor double doors, located on the 3rd floor, were equipped with self closing devices. The doors were held in the open position by magnetic devices. The doors failed to release from their magnetic holding devices when a manual pull station and a smoke detector on that floor were activated.


25385


Roseville Main Hospital

During fire alarm testing with staff on 4/8/10, at 6:30 a.m., the two sets of cross corridor doors separating smoke compartment 2G and the Women and Children Facility did not close during alarm testing. These doors were held open by devices designed to release upon activation of the fire alarm system. They failed to close when smoke detectors 97-12, 97-17, and 97-25 were tested with artificial smoke.

Roseville Women and Children's Center

During testing of the facility's automatic sprinkler system with staff on 4/8/10, at 9:30 a.m., the inspectors test valve was opened to simulate sprinkler system activation. During this time, five of five smoke barrier doors on the Third Floor failed to release from their magnetic hold open devices.

Rancho Cordova Ambulatory Surgery Center

4. During a tour of the facility on 4/8/10, at 3:15 p.m., the room identified as Storage Room 2197 did not have a self-closing mechanism on the door. This room contained 18 boxes of records and 17 individual stacks of forms on shelves. This room measured approximately 8 by 16 feet in size.






27893

Based on observation, the facility failed to maintain their hazardous areas enclosures. This was evidenced by doors to hazardous areas that were obstructed from latching, were not self closing, and a penetration in the wall of a hazardous area. This affected 2 of 7 buildings and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff, the facility's hazardous areas were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 9:41 a.m., the door to the 5th floor mechanical room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to air pressure. Compressed gas tanks and service equipment were located inside the room. The room was greater than 50 square feet.

2. On 4/9/10 at 10:40 a.m., the door to trash room E22, located on the 1st floor, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 4/9/10 at 11:21 a.m., there was an approximately 12 inch by 8 inch penetration in the wall of dirty utility room C102, located on the 1st floor. The penetration was in the wall below the sink in that room. A pipe was running through the penetration.

Based on document review, interview, and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the facility's failure to conduct 2 of 4 quarterly inspections on their automatic sprinkler system, the facility's failure to monitor the inspector's test valve alarm initiation times, the sprinkler system failing to alarm during flow testing, 1 sprinkler that was missing an escutcheon ring, and 2 sprinklers that did not have 18 inches of clearance around its deflector plate. These findings affected 7 of 7 buildings and could result in a delayed notification of a malfunctioning automatic sprinkler system and a delay to extinguish a fire due to sprinkler impairments or obstructions.

NFPA 13, 1999 edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, 1998 edition
2-2.2 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.
2-3.3 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, 1999 edition
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During document review on 4/5/10 and 4/7/10, the facility's automatic sprinkler system was observed. All buildings and locations were equipped with automatic sprinkler protection. According to staff and their sprinkler system inspection and testing policy, the facility's sprinkler systems were tested on a semi-annual basis. Staff indicated that they did not time the inspector's test valve alarm initiation time. They did not verify the alarm initiation time did not exceed 90 seconds.

During a facility tour with staff, the automatic sprinkler systems were observed.

Sacramento Main Hospital:

1. On 4/9/10 at 9:01 a.m., the sprinkler in room 1990, located on the 1st floor, was missing an escutcheon ring. The interior ceiling space was visible.

2. On 4/9/10 at 11:56 a.m., 1 sprinkler in the 1st floor pharmacy prescription storage room did not have 18 inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of boxes approximately 5 inches directly below the sprinkler deflector plate.


25385


Roseville Main Hospital

3. During a tour of the facility on 4/6/10, at 11:22 a.m., the 2nd Floor Conference Room Storage Closet had bags of fabric stored within eight inch of the bottom of the sprinkler head.


Rancho Cordova Ambulatory Surgery Center

4. During fire alarm testing on 4/8/10, at 4:07 p.m., the automatic sprinkler system inspectors test valve was fully opened to simulate the water flow from one sprinkler head. The automatic sprinkler system flow did not activate the fire alarm within the required 90 seconds. Testing was discontinued after 180 seconds with no alarm activation occurring at that time.

Sacramento Main Hospital

5. On 4/9/10 at 2:20 p.m., the sprinkler in the Basement Room 0488 was missing an escutcheon ring in the fire rated ceiling.

Based on observation and interview, the facility failed to monitor the use of portable space heaters. This was evidenced by a portable space heater in a staff office that did not have documentation verifying it did not exceed 212 degrees Fahrenheit. This affected 2 of 7 buildings and could result in a fire to ignite due to a portable space heater.

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

Sacramento Main Hospital:

1. On 4/9/10 at 9:36 a.m., there was a portable space heater in a 1st floor office room 1148. The office was adjacent to the clinical laboratory department. The portable space heater was not plugged in at the time. A staff member in that office indicated that the portable space heater, when used, would be plugged into a surge protected multi-outlet extension cord. The portable space heater was located below the desk in that office. There was no documentation that confirmed the portable space heater did not exceed 212 degrees Fahrenheit.


25385


Roseville Main Hospital

1. During a tour of the facility on 4/6/10, at 3:30 p.m., the first Emergency Room Admitting Cubical had a portable electric heater under the desk. This heater had no documentation indicating that it was an approved portable heater. When asked, staff stated that portable heaters were not allowed in the facility.

Based on observation, the facility failed to maintain a path of egress. This was evidenced by the storage of items outside 1 patient room that reduced the clear width to 25 inches. This affected 1 of 7 buildings and could result in a delayed evacuation due to an impeded egress path in the event of a emergency.

Findings:

During a facility tour with staff, the egress paths were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 10:24 a.m., the area outside room 4528, located on the 4th floor, was observed. Wheelchair devices and other items were stored in the space just outside the door. A small locker unit was stored on a wall opposite the stored items located outside the door. The clear width at the narrowest point was measured to be approximately 25 inches from the lockers to the storage items. An area of the floor was marked with yellow tape that staff said was approved by local authorities for the storage of items. The items stored in that area crossed over the yellow designated area by approximately 4 inches.

Based on observation, the facility failed to regulate the placement of excessive combustible furnishings and/or decorations as evidenced by papers which were loosely pinned to walls. This finding affected one of two smoke compartments on the third floor and could potentially result in the spread of smoke and/or fire.

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings,
in such limited quantities that a hazard of fire development or
spread is not present.

Roseville Main Hospital

During a tour of the facility on 4/6/10, at 10:52 p.m., the 3 North Nurse Station had three approximately 3 by 4 foot bulletin boards which were covered with loosely hanging 8.5 by 11 inch papers. On the opposite wall were two 2 by 3 foot posters near the ceiling and door, a bulletin board with papers pinned to it, and a paper organizer with four 8.5 by 11 inch compartments partially filled with papers.

Based on observation, the facility failed to maintain their storage of medical gas. This was evidenced by medical gas cylinders that were not individually secured and electrical receptacles that were below 5 feet in an oxygen storage location. This affected 3 of 7 buildings and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)4 The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Findings:

During a facility tour with staff, the facility's oxygen storage locations were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 9:37 a.m., 3 of 6 H tank sized compressed air cylinders in the 5th floor mechanical room. The cylinders were hooked up to a manifold and not secured. There was no chain or rack in place to prevent the cylinders from being knocked over. A sign in the room said, "Cylinders must be chained at all times."

2. On 4/8/10 at 1:51 p.m., the oxygen storage room located on the 2nd floor near the operating room department was observed. The room contained 6 H tank sized medical gas cylinders. The light switch in that room was measured to be approximately 54 inches from the switch to the floor. An electrical wall receptacle in that room was measured to be approximately 10 inches from the middle of the receptacle to the floor.

3. On 4/8/10 at 3:40 p.m., 30 nitrous oxide H tanks, in the facility's outside nitrous oxide manifold location, were chained to the wall in groups of 10. The tanks were not individually secured.

4. On 4/8/10 at 3:45 p.m., the facility's outside medical gas storage location was observed. Groups of 24 compressed gas H tanks, 18 oxygen H tanks, and 10 nitrous oxide H tanks were secured by 2 chains secured to the wall in 3 locations in that storage area. The cylinders were not individually secured.

5. On 4/9/10 at 12:55 p.m., there were 28 medical gas H tanks in the basement loading dock area that were secured by 2 chains affixed to a wall. The tanks were not individually secured.


25385


Roseville Main Hospital

During a tour of the outside of the Main Hospital on 4/5/10, between 2:00 and 2:20 p.m., the Mechanical Room located near the Boiler Room had five yellow compressed gas cylinders which were fastened together instead of individually secured.

Sacramento Ambulatory Surgery Clinic

During a tour of the facility on 4/9/10, at 12:30 p.m., the room identified as the I.T. Room had an H size compressed gas cylinder standing unsecured on the floor.

Based on document review, interview, and observation, the facility failed to maintain their anesthetizing locations. This was evidenced by the facility's failure to ensure the relative humidity levels were maintained equal to or greater than 35% and the facility's failure to have battery powered emergency lighting units in their anesthetizing locations. This affected 3 of 7 buildings and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment or a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer if the generator fails to start).
.

NFPA 99, 1999 edition
3-3.2.1.2(a)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 Electric Code, Section 700-12(e).
5.4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review, on 4/5/10 and 4/7/10, the facility's humidity logs and monitoring policy were observed. The facility's humidity monitoring policy indicated that the relative humidity in anesthetizing locations would be maintained between a range of 30% to 60%. Review of the facility's relative humidity logs for the past month were reviewed. 8 of 8 operating rooms at the Roseville Main Hospital had instances where the relative humidity dropped below 35% with the low being approximately 25%. 5 of 10 operating rooms at the Sacramento Main Hospital had instances where the relative humidity dropped below 35% with the low being approximately 30%.

During a facility tour with staff, the facility's anesthetizing locations were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 1:27 p.m., one of the facility's operating rooms was observed to be without a battery powered emergency lighting unit. A staff member indicated that the lights in the operating rooms were connected to the emergency generators and that none of the operating rooms were equipped with battery powered emergency lighting units.


25385



Sacramento Ambulatory Surgery Center

2. During a tour of the facility on 4/9/10, at 12:05 p.m., inspection of the facility's three operating rooms did not indicate battery-powered emergency task lighting. When Administrative Staff was asked if there was any type of battery powered lighting in the Operating Rooms, Staff stated that there were flashlights, but no permanent battery back-up lighting units in the Operating Rooms.

Rancho Cordova Ambulatory Surgery Center

3. During a tour of the facility on 4/8/10, at 3:30 p.m., a visual inspection of the facility's two operating rooms did not indicated the presence of battery-powered emergency task lighting. When asked about the back up lighting, Staff stated that they were not sure if there was battery powered back-up lighting units in the operating rooms.
During a later interview during the exit conference, Administrative Staff stated that the Operating Room lights did not have a battery power source for illumination.

Based on observation and document review, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords, 1 extension cord that was plugged into another extension cord, power strips that were connected to each other, and electrical receptacles that were missing faceplates. This affected 3 of 7 buildings and could increase the risk of an electrical fire to occur.

NFPA 70, 1999 edition
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.
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
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 10:05 a.m., an ice machine on the 5th floor was plugged into a surge protected multi-outlet extension cord.

2. On 4/8/10 at 10:58 a.m., a lamp on the 4th floor near room 4508 was plugged into an extension cord that was plugged into hospital grade surge protected multi-outlet extension cord.

3. On 4/8/10 at 11:44 a.m., a microwave oven and a miniature refrigerator in the 3rd floor staff lounge were plugged into 1 surge protected multi-outlet extension cord.

4. On 4/8/10 at 2:20 p.m., an electrical receptacle in the 2nd floor respiratory therapy clean utility room was missing a faceplate. Electrical wiring was exposed.

5. On 4/9/10 at 9:00 a.m., an electrical receptacle in the 1st floor orthopedics department room 1985 was missing a faceplate. The electrical receptacle was located near the desk in that room. Electrical wiring was exposed.

6. On 4/9/10 at 9:04 a.m., a miniature refrigerator in the 1st floor orthopedics department room 1965 was plugged into a surge protected multi-outlet extension cord.


25385


Roseville Main Hospital

7. During a tour of the facility on 4/6/10, at 9:46 a.m., the 1st floor Mail Room had a power strip under a desk which was suspended above the floor.
8. At 10:10 a.m., the 1st floor admitting office had an electrical plate cover missing on a red emergency plug outlet.

Sacramento Camelia Building

9. During a tour of the facility on 4/9/10, at 1:25 p.m., the room identified as E 122 Office had a power strip which was plugged into another power strip under a desk.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub (ABHR) dispensers. This was evidenced by the mounting of alcohol based hand rub dispensers over or adjacent to ignition sources. This affected 2 of 7 buildings and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the facility's alcohol based hand rub dispensers were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 4:11 p.m., an alcohol based hand rub dispenser in the 1st floor emergency room 2 soiled utility room was mounted approximately 2 inches to the right of the light switch in that room. The hand rub was 62.5% ethyl alcohol by volume.

2. On 4/9/10 at 8:43 a.m. to 8:47 p.m., the alcohol based hand rub dispensers in the 1st floor emergency department were observed. Alcohol based hand rub dispensers were mounted on the wall of treatment rooms 5, 8, and 16 within 5 inches of the light switches for those rooms. The hand rub was 62.5% ethyl alcohol by volume.

3. On 4/9/10 at 9:58 a.m., an alcohol based hand rub dispenser on the 1st floor ultrasound room R004 was mounted on the wall approximately 2 inches to the right of the light switch in that room. The hand rub was 62.5% ethyl alcohol by volume.

4. On 4/9/10 at 10:46 a.m., an alcohol based hand rub dispenser in the 1 North B station medication room was mounted on the wall approximately 2 inches to the right of the light switch in that room. The hand rub was 62.5% ethyl alcohol by volume.

5. On 4/9/10 at 12:04 p.m., 2 of 2 alcohol based hand rub dispensers in the 1 East A/B station medication room were mounted on the wall within 2 inches of the light switches in that room. The hand rub was 62.5% ethyl alcohol by volume.


25385


Sacramento Camelia Building

6. During a tour of the facility with staff on 4/9/10, at 1:35 p.m., the 1 West Nurses Station
had an ABHR dispenser which was located above the light switch.

7. During a tour of the facility with staff on 4/9/10, at 1:40 p.m., the corridor near Patient Room H6 had an ABHR dispenser which was located above the light switch.

Based on observation, the facility failed to maintain the building construction. This was evidenced by penetrations in their walls and ceilings. These penetrations affected 3 of 7 buildings and could potentially result in the spread of smoke or fire to other locations of the facility.

Findings:

During a facility tour with staff, the walls and ceilings were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 2:20 p.m., there was an approximately 2 inch by 2 inch penetration in the ceiling of the clean utility room in the respiratory therapy department located on the 2nd floor. The penetration was surrounding a sprinkler in that room.

2. On 4/8/10 at 3:09 p.m., there was an approximately 1 inch wide penetration in the ceiling of the general surgery room near room 2625 located on the 2nd floor. The penetration was surrounding a sprinkler in that room.

3. On 4/9/10 at 9:06 a.m., there was 1 approximately 1 inch wide penetration and 1 approximately 1/4 inch wide penetration in the ceiling of a closet in the orthopedics department located on the 1st floor. Cables were running through the penetrations.

4. On 4/9/10 at 11:41 a.m., there was an approximately 8 inch by 8 inch penetration in the ceiling of the 2nd level information technology room located in the Flats wing.


25385



Sacramento Ambulatory Surgery Clinic

5. During a tour of the facility, on 4/9/10, at 12:20 p.m., the Equipment Mechanical Room had three unsealed penetrations in the south wall approximately 12 feet up from the finished floor. These penetrations were the result of rigid electrical conduits which traveled through the wall and had a ? inch unsealed space around the conduit and the wallboard.

6. Between 12:30 and 12:45 p.m., the room identified as the I.T. Room had a ? unsealed penetration in the southwest corner of the wall caused by a rigid electrical conduit traveling through the wall.

Sacramento Camelia Building

7. During a tour of the facility with staff on 4/9/10, at 1:42 p.m., the Medications Room had a one inch unsealed penetration around a pipe in the ceiling in the north area of the room where the wall meets the ceiling.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors equipped with self closing devices that failed to latch or were impeded from shutting. This affected 4 of 7 buildings and could result in a delay to contain smoke or fire to an area.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 1:55 p.m., the door leading from the operating room department to the post anesthesia care unit, located on the 1st floor, was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

2. On 4/9/10 at 9:16 a.m., the cross-corridor door between the orthopedics department and the clinical laboratory department, located on the 1st floor, was equipped with a self closing device. The door was released from its magnetic holding device and allowed to close. The door failed to latch.

3. On 4/9/10 at 10:42 a.m., the door to electrical room E24, located on the 1st floor, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch.


25385


Roseville Main Hospital

During a tour of the facility on 4/6/10, corridor doors were observed.

1. At 10:07 a.m., the door to the 1st Floor Gift Shop did not positive latch when released from an open position.
2. At 11:10 a.m., the 2nd floor corridor door to Patient Room 2014 was impeded from closing by a tall waste basket placed in the travel area of the door.
3. At 11:11 a.m., the 2nd floor corridor door to Patient Room 2004 was impeded from closing by a computer table.
4. At 1:35 p.m., the 2nd floor corridor door to the 2B Food Preparation Room had a cart which impeded the door from closing.
5. At 3:30 p.m., the WON door to the Emergency Room Admitting Office had two telephones and an approximately 1 inch thick stack of paper stored on the counter top which were impeding the fire door from closing.

Sacramento Camelia Building

6. During a tour of the facility with staff on 4/9/10, at 1:37 p.m., the door to the Office identified as E104 did not positive latch when released from an open position.

Rancho Cordova Eye Ambulatory Surgery Center

7. During a tour of the facility with staff on 4/8/10, at 3:00 p.m., the corridor door to the Charge Nurses Office would not positive latch when released from an open position.

8. At 3:15 p.m., the door to the sterilization room had a kick type door stop attached to the bottom of the door.

Based on observation, the facility failed to maintain their doors in exit passageways. This was evidenced by doors which were held open by magnetic devices, that did not release upon activation of the fire alarm system. This affected 3 of 7 buildings and could result in a delay to contain smoke or fire to a location.

Findings:

During a facility tour with staff, the doors in exit passageways were observed.

Sacramento Main Hospital:

1. On 4/9/10 at 3:37 p.m., 2 of 2 sets of cross corridor double doors, located on the 3rd floor, were equipped with self closing devices. The doors were held in the open position by magnetic devices. The doors failed to release from their magnetic holding devices when a manual pull station and a smoke detector on that floor were activated.


25385


Roseville Main Hospital

During fire alarm testing with staff on 4/8/10, at 6:30 a.m., the two sets of cross corridor doors separating smoke compartment 2G and the Women and Children Facility did not close during alarm testing. These doors were held open by devices designed to release upon activation of the fire alarm system. They failed to close when smoke detectors 97-12, 97-17, and 97-25 were tested with artificial smoke.

Roseville Women and Children's Center

During testing of the facility's automatic sprinkler system with staff on 4/8/10, at 9:30 a.m., the inspectors test valve was opened to simulate sprinkler system activation. During this time, five of five smoke barrier doors on the Third Floor failed to release from their magnetic hold open devices.

Rancho Cordova Ambulatory Surgery Center

4. During a tour of the facility on 4/8/10, at 3:15 p.m., the room identified as Storage Room 2197 did not have a self-closing mechanism on the door. This room contained 18 boxes of records and 17 individual stacks of forms on shelves. This room measured approximately 8 by 16 feet in size.






27893

Based on observation, the facility failed to maintain their hazardous areas enclosures. This was evidenced by doors to hazardous areas that were obstructed from latching, were not self closing, and a penetration in the wall of a hazardous area. This affected 2 of 7 buildings and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff, the facility's hazardous areas were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 9:41 a.m., the door to the 5th floor mechanical room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to air pressure. Compressed gas tanks and service equipment were located inside the room. The room was greater than 50 square feet.

2. On 4/9/10 at 10:40 a.m., the door to trash room E22, located on the 1st floor, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 4/9/10 at 11:21 a.m., there was an approximately 12 inch by 8 inch penetration in the wall of dirty utility room C102, located on the 1st floor. The penetration was in the wall below the sink in that room. A pipe was running through the penetration.

Based on document review, interview, and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by the facility's failure to conduct 2 of 4 quarterly inspections on their automatic sprinkler system, the facility's failure to monitor the inspector's test valve alarm initiation times, the sprinkler system failing to alarm during flow testing, 1 sprinkler that was missing an escutcheon ring, and 2 sprinklers that did not have 18 inches of clearance around its deflector plate. These findings affected 7 of 7 buildings and could result in a delayed notification of a malfunctioning automatic sprinkler system and a delay to extinguish a fire due to sprinkler impairments or obstructions.

NFPA 13, 1999 edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, 1998 edition
2-2.2 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.
2-3.3 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, 1999 edition
2-6.2 Initiation of the alarm signal shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system. Movement of water due to waste, surges, or variable pressure shall not be indicated.

Findings:

During document review on 4/5/10 and 4/7/10, the facility's automatic sprinkler system was observed. All buildings and locations were equipped with automatic sprinkler protection. According to staff and their sprinkler system inspection and testing policy, the facility's sprinkler systems were tested on a semi-annual basis. Staff indicated that they did not time the inspector's test valve alarm initiation time. They did not verify the alarm initiation time did not exceed 90 seconds.

During a facility tour with staff, the automatic sprinkler systems were observed.

Sacramento Main Hospital:

1. On 4/9/10 at 9:01 a.m., the sprinkler in room 1990, located on the 1st floor, was missing an escutcheon ring. The interior ceiling space was visible.

2. On 4/9/10 at 11:56 a.m., 1 sprinkler in the 1st floor pharmacy prescription storage room did not have 18 inches of clearance around its deflector plate. The sprinkler was obstructed by the storage of boxes approximately 5 inches directly below the sprinkler deflector plate.


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Roseville Main Hospital

3. During a tour of the facility on 4/6/10, at 11:22 a.m., the 2nd Floor Conference Room Storage Closet had bags of fabric stored within eight inch of the bottom of the sprinkler head.


Rancho Cordova Ambulatory Surgery Center

4. During fire alarm testing on 4/8/10, at 4:07 p.m., the automatic sprinkler system inspectors test valve was fully opened to simulate the water flow from one sprinkler head. The automatic sprinkler system flow did not activate the fire alarm within the required 90 seconds. Testing was discontinued after 180 seconds with no alarm activation occurring at that time.

Sacramento Main Hospital

5. On 4/9/10 at 2:20 p.m., the sprinkler in the Basement Room 0488 was missing an escutcheon ring in the fire rated ceiling.

Based on observation and interview, the facility failed to monitor the use of portable space heaters. This was evidenced by a portable space heater in a staff office that did not have documentation verifying it did not exceed 212 degrees Fahrenheit. This affected 2 of 7 buildings and could result in a fire to ignite due to a portable space heater.

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

Sacramento Main Hospital:

1. On 4/9/10 at 9:36 a.m., there was a portable space heater in a 1st floor office room 1148. The office was adjacent to the clinical laboratory department. The portable space heater was not plugged in at the time. A staff member in that office indicated that the portable space heater, when used, would be plugged into a surge protected multi-outlet extension cord. The portable space heater was located below the desk in that office. There was no documentation that confirmed the portable space heater did not exceed 212 degrees Fahrenheit.


25385


Roseville Main Hospital

1. During a tour of the facility on 4/6/10, at 3:30 p.m., the first Emergency Room Admitting Cubical had a portable electric heater under the desk. This heater had no documentation indicating that it was an approved portable heater. When asked, staff stated that portable heaters were not allowed in the facility.

Based on observation, the facility failed to maintain a path of egress. This was evidenced by the storage of items outside 1 patient room that reduced the clear width to 25 inches. This affected 1 of 7 buildings and could result in a delayed evacuation due to an impeded egress path in the event of a emergency.

Findings:

During a facility tour with staff, the egress paths were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 10:24 a.m., the area outside room 4528, located on the 4th floor, was observed. Wheelchair devices and other items were stored in the space just outside the door. A small locker unit was stored on a wall opposite the stored items located outside the door. The clear width at the narrowest point was measured to be approximately 25 inches from the lockers to the storage items. An area of the floor was marked with yellow tape that staff said was approved by local authorities for the storage of items. The items stored in that area crossed over the yellow designated area by approximately 4 inches.

Based on observation, the facility failed to regulate the placement of excessive combustible furnishings and/or decorations as evidenced by papers which were loosely pinned to walls. This finding affected one of two smoke compartments on the third floor and could potentially result in the spread of smoke and/or fire.

19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings,
in such limited quantities that a hazard of fire development or
spread is not present.

Roseville Main Hospital

During a tour of the facility on 4/6/10, at 10:52 p.m., the 3 North Nurse Station had three approximately 3 by 4 foot bulletin boards which were covered with loosely hanging 8.5 by 11 inch papers. On the opposite wall were two 2 by 3 foot posters near the ceiling and door, a bulletin board with papers pinned to it, and a paper organizer with four 8.5 by 11 inch compartments partially filled with papers.

Based on observation, the facility failed to maintain their storage of medical gas. This was evidenced by medical gas cylinders that were not individually secured and electrical receptacles that were below 5 feet in an oxygen storage location. This affected 3 of 7 buildings and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4-3.1.1.2(a)4 The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Findings:

During a facility tour with staff, the facility's oxygen storage locations were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 9:37 a.m., 3 of 6 H tank sized compressed air cylinders in the 5th floor mechanical room. The cylinders were hooked up to a manifold and not secured. There was no chain or rack in place to prevent the cylinders from being knocked over. A sign in the room said, "Cylinders must be chained at all times."

2. On 4/8/10 at 1:51 p.m., the oxygen storage room located on the 2nd floor near the operating room department was observed. The room contained 6 H tank sized medical gas cylinders. The light switch in that room was measured to be approximately 54 inches from the switch to the floor. An electrical wall receptacle in that room was measured to be approximately 10 inches from the middle of the receptacle to the floor.

3. On 4/8/10 at 3:40 p.m., 30 nitrous oxide H tanks, in the facility's outside nitrous oxide manifold location, were chained to the wall in groups of 10. The tanks were not individually secured.

4. On 4/8/10 at 3:45 p.m., the facility's outside medical gas storage location was observed. Groups of 24 compressed gas H tanks, 18 oxygen H tanks, and 10 nitrous oxide H tanks were secured by 2 chains secured to the wall in 3 locations in that storage area. The cylinders were not individually secured.

5. On 4/9/10 at 12:55 p.m., there were 28 medical gas H tanks in the basement loading dock area that were secured by 2 chains affixed to a wall. The tanks were not individually secured.


25385


Roseville Main Hospital

During a tour of the outside of the Main Hospital on 4/5/10, between 2:00 and 2:20 p.m., the Mechanical Room located near the Boiler Room had five yellow compressed gas cylinders which were fastened together instead of individually secured.

Sacramento Ambulatory Surgery Clinic

During a tour of the facility on 4/9/10, at 12:30 p.m., the room identified as the I.T. Room had an H size compressed gas cylinder standing unsecured on the floor.

Based on document review, interview, and observation, the facility failed to maintain their anesthetizing locations. This was evidenced by the facility's failure to ensure the relative humidity levels were maintained equal to or greater than 35% and the facility's failure to have battery powered emergency lighting units in their anesthetizing locations. This affected 3 of 7 buildings and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment or a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer if the generator fails to start).
.

NFPA 99, 1999 edition
3-3.2.1.2(a)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 Electric Code, Section 700-12(e).
5.4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review, on 4/5/10 and 4/7/10, the facility's humidity logs and monitoring policy were observed. The facility's humidity monitoring policy indicated that the relative humidity in anesthetizing locations would be maintained between a range of 30% to 60%. Review of the facility's relative humidity logs for the past month were reviewed. 8 of 8 operating rooms at the Roseville Main Hospital had instances where the relative humidity dropped below 35% with the low being approximately 25%. 5 of 10 operating rooms at the Sacramento Main Hospital had instances where the relative humidity dropped below 35% with the low being approximately 30%.

During a facility tour with staff, the facility's anesthetizing locations were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 1:27 p.m., one of the facility's operating rooms was observed to be without a battery powered emergency lighting unit. A staff member indicated that the lights in the operating rooms were connected to the emergency generators and that none of the operating rooms were equipped with battery powered emergency lighting units.


25385



Sacramento Ambulatory Surgery Center

2. During a tour of the facility on 4/9/10, at 12:05 p.m., inspection of the facility's three operating rooms did not indicate battery-powered emergency task lighting. When Administrative Staff was asked if there was any type of battery powered lighting in the Operating Rooms, Staff stated that there were flashlights, but no permanent battery back-up lighting units in the Operating Rooms.

Rancho Cordova Ambulatory Surgery Center

3. During a tour of the facility on 4/8/10, at 3:30 p.m., a visual inspection of the facility's two operating rooms did not indicated the presence of battery-powered emergency task lighting. When asked about the back up lighting, Staff stated that they were not sure if there was battery powered back-up lighting units in the operating rooms.
During a later interview during the exit conference, Administrative Staff stated that the Operating Room lights did not have a battery power source for illumination.

Based on observation and document review, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords, 1 extension cord that was plugged into another extension cord, power strips that were connected to each other, and electrical receptacles that were missing faceplates. This affected 3 of 7 buildings and could increase the risk of an electrical fire to occur.

NFPA 70, 1999 edition
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.
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
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Sacramento Main Hospital:

1. On 4/8/10 at 10:05 a.m., an ice machine on the 5th floor was plugged into a surge protected multi-outlet extension cord.

2. On 4/8/10 at 10:58 a.m., a lamp on the 4th floor near room 4508 was plugged into an extension cord that was plugged into hospital grade surge protected multi-outlet extension cord.

3. On 4/8/10 at 11:44 a.m., a microwave oven and a miniature refrigerator in the 3rd floor staff lounge were plugged into 1 surge protected multi-outlet extension cord.

4. On 4/8/10 at 2:20 p.m., an electrical receptacle in the 2nd floor respiratory therapy clean utility room was missing a faceplate. Electrical wiring was exposed.

5. On 4/9/10 at 9:00 a.m., an electrical receptacle in the 1st floor orthopedics department room 1985 was missing a faceplate. The electrical receptacle was located near the desk in that room. Electrical wiring was exposed.

6. On 4/9/10 at 9:04 a.m., a miniature refrigerator in the 1st floor orthopedics department room 1965 was plugged into a surge protected multi-outlet extension cord.


25385


Roseville Main Hospital

7. During a tour of the facility on 4/6/10, at 9:46 a.m., the 1st floor Mail Room had a power strip under a desk which was suspended above the floor.
8. At 10:10 a.m., the 1st floor admitting office had an electrical plate cover missing on a red emergency plug outlet.

Sacramento Camelia Building

9. During a tour of the facility on 4/9/10, at 1:25 p.m., the room identified as E 122 Office had a power strip which was plugged into another power strip under a desk.