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Based on observation and interview, the facility failed to maintain the fire-rated building construction in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations observed in the fire-rated sheeting. This deficient practice affected staff and residents in two of seven smoke compartments within the facility and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

8.2.3.2.4 Penetrations and Miscellaneous Openings in Fire Barriers.
8.2.3.2.4.1* Openings in fire barriers for air-handling ductwork or air movement shall be protected in accordance with 9.2.1.
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:

(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is
designed for the specific purpose.

(3) *Insulation and coverings for pipes and ducts shall not
pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

(4) 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 fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

Outpatient Services at 1199 Bush Street
During a tour of the facility with the Outpatient Services Director, Environmental Care Manager, and Plant Engineer on 5/18/11 at 11:47 a.m., there was an unsealed pipe sleeve in the Utility/Electrical Room located at the end of the corridor outside of Suite 140. This sleeve penetrated through the two hour fire-rated floor/ceiling assemble separating the first floor from the lower level. Engineering Staff confirmed the penetration

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This deficient practice affected four of twelve floors and the basement at the main hospital campus.

Findings:

During a tour of the facility with Hospital Staff On May 17, 2011 through May 20, 2011, the facility walls and ceilings were observed.

On 5/17/11:
At 4:06 p.m., in Room 1018 on the 10th floor there was a 1 inch round penetration in the right wall by the sink.

On 5/18/11:
At 10:12 a.m., in the Dirty Utility room on the 6th floor across from Room 604, there was a 1/2 inch round penetration in the wall by the Sharps container.

At 11:58 a.m., in Room B of the Rally/Family Visitation area on the 3rd floor there were 7 penetrations approximately 1/4 inch round each in the wall.

At 12:11 p.m., in Room 302 on the 3rd floor there was a 1 inch round penetration in the wall under the white board.

At 12:15 p.m., in Room 301-B on the 3rd floor there was a 1/2 inch round penetration in the wall by the door.

At 2:35 p.m., in the Physical Therapy office on the 2nd floor there were 10 penetrations approximately 1/2 inch round each in the back wall.

At 4:01 p.m., in the Laundry Room there was a 2 inch x 1 inch penetration in the wall behind the door.

Based on observation, the facility failed to maintain all doors free from obstructions to closing as evidenced by a door that was impeded from closing. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and two patients in the Hyperbaric Medicine Department.


Findings:

During a tour of the facility with the Environmental Care Manager and Plant Engineer on 5/18/11, at 10:25 a.m., the office door in the Hyperbaric unit was held open by a chair. No staff were present in the room during the observation. This door was in an office area separated from the Hyperbaric Treatment Room by fire rated doors.

Based on observation, the facility failed to maintain its fire-rated barriers in all vertical openings in accordance with 2000 NFPA 101. This was evidenced by a door in a fire-rated vertical opening which had the fire-rating tag removed and penetrations in the wall of a vertical opening between floors. This deficient practice affected all staff and patients on one of 13 floors and could potentially result in the spread of smoke and/or fire.

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.

8.2.3.2.3* Opening Protectives.
8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings:

During a tour of the facility with the Safety Manager and Engineering Staff on 5/18/11, at 9:25 a.m., the door to the Seventh Floor East Stairwell did not have the fire-rating tag on the door. Engineering Staff confirmed that the tag was missing.
During a tour of the Seventh Floor at 9:55 a.m., the west wall of Tray-veyor chute had two unsealed penetrations that were one-half inch in size. Engineering staff confirmed the penetrations

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to release from the magnet and positive latch. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire. This deficient practice affected all staff and patients on one of twelve floors and basement at the main hospital campus.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through May 20, 2011, the facilities smoke barrier corridor doors were observed.

On May 19, 2011:
At 11:18 a.m., the smoke barrier doors in the corridor that lead to building 58 on the 8th floor failed to release from the magnet and positive latch on the left side after activation of a smoke detector.

Based on observation and interview, the facility failed to protect its hazardous area enclosure in accordance with 2000 NFPA 101. This was evidenced by an enclosure which contained a degree of hazard greater than that normal to the general occupancy of the building with doors which were not equipped with a self-closing mechanism and another door that did not positive latch when tested.
This deficient practice affected one of seven smoke compartments on the first floor of the Main Hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the Laboratory with the Plant Engineer and the Laboratory Director on 5/18/11, smoke barrier doors were observed in the following locations:

1. At 3:35 p.m., the fire-rated doors by the north Blood Draw Room did not positive latch when tested. Engineering Staff confirmed that the door did not latch.

2. At 3:42 p.m., both doors to the Blood Draw Rooms had the self closures removed. These doors were rated at 3/4 of an hour and were the only barrier between the Laboratory and the Patient Waiting Area and Registration. Engineering Staff confirmed that the doors were fire rated and the closures had been removed.

Based on observation and interview, the facility failed to store flammable or combustible liquids in accordance with 1999 NFPA 99. This was evidenced by flammable liquids which were stored in and near an exit passageway and exit in a laboratory. This deficient practice affected all staff and patients in one of seven smoke compartments on the first floor of the Main Hospital building and could potentially result in the exit in the laboratory being unusable or hazardous in the event of a fire.

10-7.2.2 No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit.

Findings:

Main Hospital Building

During a tour of the Laboratory with the Plant Engineer and the Laboratory Director on 5/18/11, at 3:35 p.m., the flammable liquids storage cabinet was located in the path of egress and exit access at the east exit from the Laboratory. When asked if the storage cabinet was normally stored in that location, the Director of the laboratory stated that it was.

Based on observation, the facility failed to ensure that exits are readily accessible at all times as evidenced by exit doors that were equipped with double-action latching devices and an exit that was locked during business hours. This deficient practice affected all staff and patients on two of six floors and could potentially result in a delayed egress in the event of an emergency.

38.2.2.2 Doors.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
38.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

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

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

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

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

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

38.2.2.2 Doors.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
38.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

Findings:

Outpatient Services at 1199 Bush Street
During a tour of the facility with the Outpatient Services Director, Engineering Staff, and the Environmental Care Manager on 5/18/11, exit doors were observed in the following locations:

1. At 11:47 a.m., the corridor door near Office 140-4 in Suite 140 had a deadbolt type locking device as well a door knob that operated independently of each other requiring two distinct motions to operate from the egress side when locked.

2. At 12:05 p.m., the rear exit door near the Administrator's Office in Suite 300 had a deadbolt type locking device as well as a door knob that operated independently of each other requiring two distinct motions to open from the egress side when locked. This door had a sign on it stating that it should remain locked. This door is required to remain unlocked during business hours.

Based on observation, document review, and interview, the facility failed to maintain and test its emergency illumination in accordance with 2000 NFPA 101. This was evidenced by a battery-powered emergency lighting unit that did not function when tested and a lack of documentation for monthly and annual testing. This deficient practice affected all staff and patients on three of three floors at the Outpatient Services building on Bush Street and could potentially result in injury or delayed evacuation during an an emergency if egress lighting failed to function.

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

Findings:

During Document Review, on 5/17/11, at 10:00 a.m., the facility failed to provide documentation for testing its emergency egress lighting for the Outpatient Services building at 1199 Bush Street.

During a tour of the facility with the Maintenance Staff on 5/18/11, at 12:39 p.m., the battery back-up light in the Outpatient Clinic Suite 140 did not function when tested. When asked, the Director of Outpatient Services stated that the testing was not being documented.

Based on observation, the facility failed to provide exit and directional signs in accordance with 2000 NFPA 101. This was evidenced by the lack of exit signs in an areas where the direction of egress was not obvious and exit signs that were not properly illuminated. This deficient practice affected all staff and patients in three of twelve floors and basement of the Main Hospital Campus and could potentially result in a delayed evacuation in the event of an emergency.

7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
3.3.62 Exit Access. That portion of a means of egress that leads to an exit.
3.3.63 Exit Discharge. That portion of a means of egress between the termination of an exit and a public way.

Findings:

During a tour of the facility with Environmental Care Manager and Plant Engineer on 5/18/11, at 4:40 p.m., there was no directional or exit sign located outside of the Emergency Fire Exit near the Emergency Room Administration area. The Emergency Exit was identified as an exit on the egress side. In the exit discharge area on the outside of the building there was a cement retaining wall with no directional sign. To the left was a locked door and to the right was the actual path to the public way. This pathway had scaffolding the length of the wall against the building and at the other end was another wall with no exit sign posted.


27961


Findings:

During a tour of the facility with Hospital Staff On May 17, 2011 through May 20, 2011, exits and exit signs were observed in the following locations.

On May 18, 2011:
At 2:21 p.m., the Exit sign over the door by Room 233-A on the 2nd floor had a left bulb that was burnt out.

At 2:52 p.m., the Exit sign over the door by the Employee Health/OP Dietitian office on the 2nd floor had a left bulb that was burnt out.

At 4:45 p.m., the Exit sign over the door in the West Hallway next to the Patient Dressing room in the Radiology/Oncology area in the Basement had a right bulb that was burnt out.

Based on observation, the facility failed to maintain all fire alarm system devices as evidenced by fire alarm devices that failed to function when tested and devices that were not addressed correctly. This deficient practice affected all staff and patients on one unit of one of twelve floors and basement at the Main Hospital Building and could potentially result in a delayed response by staff and first responders in the event of a fire.

Findings:

During fire alarm testing on 5/19/11, at 12:14 p.m., the strobe/chime number 8 EKG located near the Holter Lab Pulmonary did not produce a visual or audible alarm.


27961

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.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

NFPA 101, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through may 20, 2011, the pull stations, smoke detector, strobes and chimes were tested and observed.

On May 19, 2011,
At 9:47 a.m., pull station 2158 on the 2nd floor was tested and the descriptor stated "Stair 1". The stairwell was actually labeled "Stair D". When interviewed on May 19, 2011 at 9:47 a.m., Staff 3 stated that they must have labeled it incorrectly and would make the change immediately.

At 10:33 a.m., pull station 4-180 on the 8th floor was activated by hospital staff and failed to initiate the alarms.

At 10:50 a.m., strobe and chime #4130 on the 6th floor failed to activate after testing a smoke detector.

At 11:28 a.m., the chime by elevator 5 on the 3rd floor failed to alarm after testing a smoke detector.

Based on record review and interview, the facility failed to test its smoke detectors in accordance with 1999 NFPA 72 of The National Fire Alarm Code. This was evidenced by a lack of documentation for smoke-sensitivity testing. This deficient practice affected all staff and patients on 13 floors of the main hospital and three of six floors of the outpatient services building and could potentially result in false alarms or no alarms if detectors are not within their listed sensitivity range, in the event of a fire.

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 be 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.

Findings:

During document review on 5/17/11, at 10:00 a.m., the facility failed to provide documentation indicating that the smoke detectors had been tested for sensitivity. During an interview with the Director of Plant Operations on 5/20/11, between 9:00 and 9:30 a.m., when asked if smoke detector sensitivity testing had been done for the Outpatient Services Building at 1199 Bush Street or the Main Hospital, the director stated that it "had not, but was going to be scheduled to be done soon".

Based on record review, the facility failed to ensure their smoke detectors were maintained, inspected and tested as evidenced by the facility's failure to provide sensitivity testing for their system based smoke detection devices and, by smoke detectors failing to activate an alarm when tested. This could cause harm to patients and staff in the event of a fire. This affected the main hospital at 900 Hyde Street, San Francisco, CA.

NFPA 72 - 7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years there after.

Findings:

During document review and alarm testing with the Hospital Staff on May 17, 2011 through May 20, 2011, the facilities records were reviewed and smoke detectors were tested.

On May 17, 2011:
At 1:25 p.m., there was no record of sensitivity testing for the smoke detectors for the main hospital at 900 Hyde Street, San Francisco, CA.

On May 18, 2011:
At 4:26 p.m., the Mechanical Room in the Basement had a smoke detector #2-065 that was covered in blue masking tape.

On May 19, 2011:
At 11:08 a.m., smoke detector 1-86 on the 8th floor failed to activate the alarms.

At 11:12 a.m., smoke detector 1-056 on the 8th floor failed to activate the alarms.

Based on document review and interview, the facility failed to test its fire pumps, in accordance with 1998 NFPA 25, as evidenced by a lack of documentation provided for weekly fire pump testing of its fire pumps at the Outpatient Services on Bush Street. This deficient practice affected all staff and patients on three of three floors of the six floor building and could potentially result in the fire pumps failing to operate properly in the event of a fire.

Table 5-1.1 Summary of Fire Pump Inspection, Testing, and Maintenance Item Activity Frequency Reference
Pump house, heating ventilating louvers Inspection Weekly 5-2.2.1
Fire pump system Inspection Weekly 5-2.2.1
Pump operation No-flow condition Test Weekly 5-3.2.1, 5-3.2.2
Flow condition Test Annually 5-3.3.1
Hydraulic Maintenance Annually 5-5.1
Mechanical transmission Maintenance Annually 5-5.1
Electrical system Maintenance Varies 5-5.1
Controller, various components Maintenance Varies 5-5.1
Motor Maintenance Annually 5-5.1
Diesel engine system, various components Maintenance Varies 5-5.1

5-2 Inspection.
5-2.1 The purpose of inspection is to verify that the pump assembly appears to be in operating condition and is free from physical damage.
5-2.2* The pertinent visual observations specified in the following checklists shall be performed weekly.
5-2.2.2 Pump System Conditions.
(a) Pump suction and discharge and bypass valves are fully open.
(b) Piping is free of leaks.
(c) Suction line pressure gauge reading is normal.
(d) System line pressure gauge reading is normal.
(e) Suction reservoir is full.
5-2.2.3 Electrical System Conditions.
(a) Controller pilot light (power on) is illuminated.
(b) Transfer switch normal pilot light is illuminated.
(c) Isolating switch is closed - standby (emergency) source.
(d) Reverse phase alarm pilot light is off or normal phase rotation pilot light is on.
(e) Oil level in vertical motor sight glass is normal.
5-3 Testing.
5-3.1 Purpose. The purpose of testing the pump assembly is to ensure automatic or manual operation upon demand and continuous delivery of the required system output. An additional purpose is to detect deficiencies of the pump assembly not evident by inspection.
5-3.2 Weekly Tests. Qualified operating personnel shall be in attendance during the weekly pump operation.
5-3.2.1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as a safety feature shall be permitted to discharge water.

Findings:

Outpatient Services at 1199 Bush Street
During document review, on 5/20/11, at 10:00 a.m., the facility failed to provide documentation for weekly inspection and testing of its fire pumps. When the director of Plant Operations was asked if the testing had been done for the Bush Street facility, Administrative Staff stated that it had not been done.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by missing escutcheon rings and sprinklers that were not free of debris. These could result in the fire sprinkler system not functioning as designed and increased risk of injury to residents and staff. This affected the main hospital building.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through May 20, 2011, the sprinkler system was observed.

On May 18, 2011:
At 2:20 p.m., in the Scope Cleaning room across from Room 233A on the 2nd floor, there was 1 of 2 sprinklers covered in paint.

At 4:56 p.m., the Storage Closet in the Pulmonary area in the Basement had a sprinkler missing an escutcheon ring.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by a fire extinguisher that was obstructed from view and access. This deficient practice affected staff and patients in one of seven smoke compartments and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

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

During a tour of the facility with Environmental Care Manager and Plant Engineer on 5/18/11, at 4:45 p.m., access to the fire extinguisher located in the MRI Lounge was blocked by a free-standing coat rack and three hand- bags on the floor in front of it.

Based on document review and interview, the facility failed to monitor the humidity levels for 3 of 9 operating rooms (OR's). This failure could increase the risk of a fire hazard, resulting in potential harm to patients during surgery. This affected the main hospital at 900 Hyde Street, San Francisco, CA.

NFPA 101, Life Safety Code 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Health Care Facilities 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
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 records review and interview with Hospital Staff on May 17, 2011 through May 20, 2011, the humidity logs were reviewed and the Chief Engineer was interviewed.

On May 17, 2011:
At 1:25 p.m., the humidity logs were reviewed and the humidity logs for Operating Rooms 5, 7, and 8 were not provided. When interviewed on May 17, 2011 at 1:25 p.m., the Chief Engineer stated that they did not log the humidity for those OR's and that the system was still being worked on because they had gone from 14 OR's to 9 larger OR's and the construction numbers and the computer numbers did not correspond yet. The facility uses a cross reference sheet to monitor most of the OR's.

Based on observation, the facility failed to ensure that the oxygen cylinders were stored in rooms that were properly identified for oxygen storage.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through May 20, 2011, the facilities oxygen storage areas were observed.

On May 18, 2011:
At 11:10 a.m., in Room 413 on the 4th floor, there were 6 " E " oxygen tanks stored and the room had no signage indicating it was used for oxygen storage and, a "no smoking" sign was not posted.

At 2:10 p.m., in the Utility Room on the 2nd floor there were 9 " E " oxygen tanks stored and the room had no signage indicating it was used for oxygen storage and, a "no smoking" sign was not posted.

Based on document review and staff interview, the facility failed to provide complete documentation of generator testing and inspection, in accordance with 1999 NFPA 99, as evidenced by incomplete documentation for weekly generator inspections, monthly load tests, generator transfer times, and what the actual load was during each monthly load test. This finding affected all staff and residents on three out of three floors of the six floor Outpatient Services at 1191 Bush Street and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

NFPA 99
3-4.1.1.8 Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

3-4.1.1.8 Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

Outpatient Services at 1199 Bush Street
During a review of the facility's documentation on 5/17/11, at 10:00 a.m., the facility failed to provide documentation for four out of twelve monthly full load tests. Documentation was missing from May to October of 2010. The facility failed to provide documentation for weekly visual inspections of its generator for approximately 46 of 52 weeks in a twelve month period. During document review on 5/20/11 at between 10:00 and 10:30 a.m., The Director of the Outpatient Services at 1199 Bush Street confirmed that the load testing and visual inspections had not been done during those times. Documentation in the generator log for monthly load tests did not show what the transfer time was during the monthly load tests or what the generator was being loaded at to determine if 30 percent of the name plate rating was being met. Engineering Staff stated that the 30 percent was being met each month.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities, in accordance with 1999 NFPA 70 and 1999 NFPA 99, as evidenced by high-wattage appliances that were plugged into power strips instead of being plugged directly into fixed wall outlets, power strips that were suspended, the permanent use of extension cords, and a broken electrical outlet. This deficient practice affected staff and residents in seven out of twelve floors and basement at the Main Hospital Building and could potentially result in the ignition of fire.

NFPA 70
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

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

110-12 requires that electrical equipment be installed in a neat and workman like manner.

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

Findings:

During a tour of the facility on 5/17/11, electrical wiring and equipment were observed in the following locations:

Main Hospital Building
1. At 3:30 p.m., there were three power strips that were plugged into each other in a chain in the Twelfth Floor Foundation Fund southeast corner office.

During a tour of the facility on 5/18/11, electrical wiring and equipment were observed in the following locations:

2. At 9:36 p.m., there was a microwave oven sitting on a table plugged into an outlet with the cord pulled tightly producing tension on the plug terminals. This microwave oven was in the Seventh Floor Dining Room.

3. At 10:00 a.m., there were two power strips plugged into each other on top of the counter top at the Seventh Floor Nurses' Station.

4. At 10:24 a.m., there was a coffee pot plugged into a power strip that was suspended above the floor. The cord to the coffee pot had tension applied to the plug terminals. This coffee pot was in an office area separated from the Hyperbaric Treatment Room.




27961

Findings:

During a tour of the facility with Hospital Staff on May 17, 2011 through May 20, 2011, the electrical system was observed.

On May 18, 2011:
At 9:40 a.m., in the Clean Utility room across from Room 805 on the 8th floor there was an orange extension cord used to plug in the medicine refrigerator that connected to the Omnicell machine.

At 9:56 a.m., the electrical panel board W8A on the 8th floor by Room 821 failed to label the circuits on the electrical panel.

At 10:45 a.m., Room 401 Conference Room on the 4th floor had a microwave and refrigerator plugged into an extension cord and not directly into the wall.

At 11:00 a.m., CPE Education room on the 4th floor had a couch and chair blocking the FACP closet.

At 11:03 a.m., Room 408 on the 4th floor had a fan plugged into an orange extension cord.

At 11:05 a.m., Room 410 on the 4th floor had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 11:25 a.m., Room 422 "IV Resource RN"on the 4th floor had a microwave and refrigerator plugged into a 3 plug adapter and not directly into the wall outlet.

At 12:10 p.m., Room 302 on the 3rd floor had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 4:00 p.m., the Linen Room in the Basement had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 4:06 p.m., the Mail Room in the Basement had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 5:20 p.m., the Materials/Purchasing Breakroom in the Basement had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 5:30 p.m., the Computer Training Room in the Basement had a yellow extension cord connected to a multi-outlet adapter which was connected to computer equipment and not directly into the wall outlet.

At 5:31 p.m., the Computer Training Room in the Basement had a broken electrical outlet in the wall at the front of the room.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition, as evidenced by an ABHR dispenser located above electrical fixtures and equipment. This finding affected smoke compartments within the facility and could potentially result in the ignition of fire.

Findings:

During a tour of the facility with the Environmental Care Manager, and Plant Engineer on 5/18/11, ABHR dispensers were observed in the following locations:

Main Hospital Campus
1. At 9:26 a.m., there was an ABHR dispenser located above an electrical outlet near Resident Room 701. The rooms on the seventh floor were in suspense and were not being used for patient care.

2. At 9:36 a.m., there was an ABHR dispenser located above a microwave oven on a table that was placed against the wall.

3. At 4:36 p.m., there was an ABHR dispenser located above a light switch in Emergency Room 118.

Outpatient Services at 1199 Bush Street
4. At 11:43 a.m., there was an ABHR dispenser located above a light switch in Room 3 Suite 140.

Based on observation and interview, the facility failed to maintain the fire-rated building construction in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations observed in the fire-rated sheeting. This deficient practice affected staff and residents in two of seven smoke compartments within the facility and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

8.2.3.2.4 Penetrations and Miscellaneous Openings in Fire Barriers.
8.2.3.2.4.1* Openings in fire barriers for air-handling ductwork or air movement shall be protected in accordance with 9.2.1.
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:

(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire 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 fire barrier, the sleeve shall be solidly set in the fire 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 fire resistance of the fire barrier.
b. It shall be protected by an approved device that is
designed for the specific purpose.

(3) *Insulation and coverings for pipes and ducts shall not
pass through the fire barrier unless one of the following conditions is met:
a. The material shall be capable of maintaining the fire resistance of the fire barrier.
b. The material shall be protected by an approved device that is designed for the specific purpose.

(4) 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 fire barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

Outpatient Services at 1199 Bush Street
During a tour of the facility with the Outpatient Services Director, Environmental Care Manager, and Plant Engineer on 5/18/11 at 11:47 a.m., there was an unsealed pipe sleeve in the Utility/Electrical Room located at the end of the corridor outside of Suite 140. This sleeve penetrated through the two hour fire-rated floor/ceiling assemble separating the first floor from the lower level. Engineering Staff confirmed the penetration

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This deficient practice affected four of twelve floors and the basement at the main hospital campus.

Findings:

During a tour of the facility with Hospital Staff On May 17, 2011 through May 20, 2011, the facility walls and ceilings were observed.

On 5/17/11:
At 4:06 p.m., in Room 1018 on the 10th floor there was a 1 inch round penetration in the right wall by the sink.

On 5/18/11:
At 10:12 a.m., in the Dirty Utility room on the 6th floor across from Room 604, there was a 1/2 inch round penetration in the wall by the Sharps container.

At 11:58 a.m., in Room B of the Rally/Family Visitation area on the 3rd floor there were 7 penetrations approximately 1/4 inch round each in the wall.

At 12:11 p.m., in Room 302 on the 3rd floor there was a 1 inch round penetration in the wall under the white board.

At 12:15 p.m., in Room 301-B on the 3rd floor there was a 1/2 inch round penetration in the wall by the door.

At 2:35 p.m., in the Physical Therapy office on the 2nd floor there were 10 penetrations approximately 1/2 inch round each in the back wall.

At 4:01 p.m., in the Laundry Room there was a 2 inch x 1 inch penetration in the wall behind the door.

Based on observation, the facility failed to maintain all doors free from obstructions to closing as evidenced by a door that was impeded from closing. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and two patients in the Hyperbaric Medicine Department.


Findings:

During a tour of the facility with the Environmental Care Manager and Plant Engineer on 5/18/11, at 10:25 a.m., the office door in the Hyperbaric unit was held open by a chair. No staff were present in the room during the observation. This door was in an office area separated from the Hyperbaric Treatment Room by fire rated doors.

Based on observation, the facility failed to maintain its fire-rated barriers in all vertical openings in accordance with 2000 NFPA 101. This was evidenced by a door in a fire-rated vertical opening which had the fire-rating tag removed and penetrations in the wall of a vertical opening between floors. This deficient practice affected all staff and patients on one of 13 floors and could potentially result in the spread of smoke and/or fire.

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.

8.2.3.2.3* Opening Protectives.
8.2.3.2.3.1 Every opening in a fire barrier shall be protected to limit the spread of fire and restrict the movement of smoke from one side of the fire barrier to the other. The fire protection rating for opening protectives shall be as follows:
(1) 2-hour fire barrier - 11/2-hour fire protection rating
(2) 1-hour fire barrier - 1-hour fire protection rating where used for vertical openings or exit enclosures, or 3/4-hour fire protection rating where used for other than vertical openings or exit enclosures, unless a lesser fire protection rating is specified by Chapter 7 or Chapters 11 through 42

8.2.5.2* Openings through floors, such as stairways, hoistways for elevators, dumbwaiters, and inclined and vertical conveyors; shaftways used for light, ventilation, or building services; or expansion joints and seismic joints used to allow structural movements shall be enclosed with fire barrier walls. Such enclosures shall be continuous from floor to floor or floor to roof. Openings shall be protected as appropriate for the fire resistance rating of the barrier.

Findings:

During a tour of the facility with the Safety Manager and Engineering Staff on 5/18/11, at 9:25 a.m., the door to the Seventh Floor East Stairwell did not have the fire-rating tag on the door. Engineering Staff confirmed that the tag was missing.
During a tour of the Seventh Floor at 9:55 a.m., the west wall of Tray-veyor chute had two unsealed penetrations that were one-half inch in size. Engineering staff confirmed the penetrations

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to release from the magnet and positive latch. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire. This deficient practice affected all staff and patients on one of twelve floors and basement at the main hospital campus.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through May 20, 2011, the facilities smoke barrier corridor doors were observed.

On May 19, 2011:
At 11:18 a.m., the smoke barrier doors in the corridor that lead to building 58 on the 8th floor failed to release from the magnet and positive latch on the left side after activation of a smoke detector.

Based on observation and interview, the facility failed to protect its hazardous area enclosure in accordance with 2000 NFPA 101. This was evidenced by an enclosure which contained a degree of hazard greater than that normal to the general occupancy of the building with doors which were not equipped with a self-closing mechanism and another door that did not positive latch when tested.
This deficient practice affected one of seven smoke compartments on the first floor of the Main Hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the Laboratory with the Plant Engineer and the Laboratory Director on 5/18/11, smoke barrier doors were observed in the following locations:

1. At 3:35 p.m., the fire-rated doors by the north Blood Draw Room did not positive latch when tested. Engineering Staff confirmed that the door did not latch.

2. At 3:42 p.m., both doors to the Blood Draw Rooms had the self closures removed. These doors were rated at 3/4 of an hour and were the only barrier between the Laboratory and the Patient Waiting Area and Registration. Engineering Staff confirmed that the doors were fire rated and the closures had been removed.

Based on observation and interview, the facility failed to store flammable or combustible liquids in accordance with 1999 NFPA 99. This was evidenced by flammable liquids which were stored in and near an exit passageway and exit in a laboratory. This deficient practice affected all staff and patients in one of seven smoke compartments on the first floor of the Main Hospital building and could potentially result in the exit in the laboratory being unusable or hazardous in the event of a fire.

10-7.2.2 No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit.

Findings:

Main Hospital Building

During a tour of the Laboratory with the Plant Engineer and the Laboratory Director on 5/18/11, at 3:35 p.m., the flammable liquids storage cabinet was located in the path of egress and exit access at the east exit from the Laboratory. When asked if the storage cabinet was normally stored in that location, the Director of the laboratory stated that it was.

Based on observation, the facility failed to ensure that exits are readily accessible at all times as evidenced by exit doors that were equipped with double-action latching devices and an exit that was locked during business hours. This deficient practice affected all staff and patients on two of six floors and could potentially result in a delayed egress in the event of an emergency.

38.2.2.2 Doors.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
38.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

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

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

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

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

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

38.2.2.2 Doors.
38.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
38.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

Findings:

Outpatient Services at 1199 Bush Street
During a tour of the facility with the Outpatient Services Director, Engineering Staff, and the Environmental Care Manager on 5/18/11, exit doors were observed in the following locations:

1. At 11:47 a.m., the corridor door near Office 140-4 in Suite 140 had a deadbolt type locking device as well a door knob that operated independently of each other requiring two distinct motions to operate from the egress side when locked.

2. At 12:05 p.m., the rear exit door near the Administrator's Office in Suite 300 had a deadbolt type locking device as well as a door knob that operated independently of each other requiring two distinct motions to open from the egress side when locked. This door had a sign on it stating that it should remain locked. This door is required to remain unlocked during business hours.

Based on observation, document review, and interview, the facility failed to maintain and test its emergency illumination in accordance with 2000 NFPA 101. This was evidenced by a battery-powered emergency lighting unit that did not function when tested and a lack of documentation for monthly and annual testing. This deficient practice affected all staff and patients on three of three floors at the Outpatient Services building on Bush Street and could potentially result in injury or delayed evacuation during an an emergency if egress lighting failed to function.

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

Findings:

During Document Review, on 5/17/11, at 10:00 a.m., the facility failed to provide documentation for testing its emergency egress lighting for the Outpatient Services building at 1199 Bush Street.

During a tour of the facility with the Maintenance Staff on 5/18/11, at 12:39 p.m., the battery back-up light in the Outpatient Clinic Suite 140 did not function when tested. When asked, the Director of Outpatient Services stated that the testing was not being documented.

Based on observation, the facility failed to provide exit and directional signs in accordance with 2000 NFPA 101. This was evidenced by the lack of exit signs in an areas where the direction of egress was not obvious and exit signs that were not properly illuminated. This deficient practice affected all staff and patients in three of twelve floors and basement of the Main Hospital Campus and could potentially result in a delayed evacuation in the event of an emergency.

7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.
3.3.62 Exit Access. That portion of a means of egress that leads to an exit.
3.3.63 Exit Discharge. That portion of a means of egress between the termination of an exit and a public way.

Findings:

During a tour of the facility with Environmental Care Manager and Plant Engineer on 5/18/11, at 4:40 p.m., there was no directional or exit sign located outside of the Emergency Fire Exit near the Emergency Room Administration area. The Emergency Exit was identified as an exit on the egress side. In the exit discharge area on the outside of the building there was a cement retaining wall with no directional sign. To the left was a locked door and to the right was the actual path to the public way. This pathway had scaffolding the length of the wall against the building and at the other end was another wall with no exit sign posted.


27961


Findings:

During a tour of the facility with Hospital Staff On May 17, 2011 through May 20, 2011, exits and exit signs were observed in the following locations.

On May 18, 2011:
At 2:21 p.m., the Exit sign over the door by Room 233-A on the 2nd floor had a left bulb that was burnt out.

At 2:52 p.m., the Exit sign over the door by the Employee Health/OP Dietitian office on the 2nd floor had a left bulb that was burnt out.

At 4:45 p.m., the Exit sign over the door in the West Hallway next to the Patient Dressing room in the Radiology/Oncology area in the Basement had a right bulb that was burnt out.

Based on observation, the facility failed to maintain all fire alarm system devices as evidenced by fire alarm devices that failed to function when tested and devices that were not addressed correctly. This deficient practice affected all staff and patients on one unit of one of twelve floors and basement at the Main Hospital Building and could potentially result in a delayed response by staff and first responders in the event of a fire.

Findings:

During fire alarm testing on 5/19/11, at 12:14 p.m., the strobe/chime number 8 EKG located near the Holter Lab Pulmonary did not produce a visual or audible alarm.


27961

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.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

NFPA 101, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through may 20, 2011, the pull stations, smoke detector, strobes and chimes were tested and observed.

On May 19, 2011,
At 9:47 a.m., pull station 2158 on the 2nd floor was tested and the descriptor stated "Stair 1". The stairwell was actually labeled "Stair D". When interviewed on May 19, 2011 at 9:47 a.m., Staff 3 stated that they must have labeled it incorrectly and would make the change immediately.

At 10:33 a.m., pull station 4-180 on the 8th floor was activated by hospital staff and failed to initiate the alarms.

At 10:50 a.m., strobe and chime #4130 on the 6th floor failed to activate after testing a smoke detector.

At 11:28 a.m., the chime by elevator 5 on the 3rd floor failed to alarm after testing a smoke detector.

Based on record review and interview, the facility failed to test its smoke detectors in accordance with 1999 NFPA 72 of The National Fire Alarm Code. This was evidenced by a lack of documentation for smoke-sensitivity testing. This deficient practice affected all staff and patients on 13 floors of the main hospital and three of six floors of the outpatient services building and could potentially result in false alarms or no alarms if detectors are not within their listed sensitivity range, in the event of a fire.

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 be 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.

Findings:

During document review on 5/17/11, at 10:00 a.m., the facility failed to provide documentation indicating that the smoke detectors had been tested for sensitivity. During an interview with the Director of Plant Operations on 5/20/11, between 9:00 and 9:30 a.m., when asked if smoke detector sensitivity testing had been done for the Outpatient Services Building at 1199 Bush Street or the Main Hospital, the director stated that it "had not, but was going to be scheduled to be done soon".

Based on record review, the facility failed to ensure their smoke detectors were maintained, inspected and tested as evidenced by the facility's failure to provide sensitivity testing for their system based smoke detection devices and, by smoke detectors failing to activate an alarm when tested. This could cause harm to patients and staff in the event of a fire. This affected the main hospital at 900 Hyde Street, San Francisco, CA.

NFPA 72 - 7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years there after.

Findings:

During document review and alarm testing with the Hospital Staff on May 17, 2011 through May 20, 2011, the facilities records were reviewed and smoke detectors were tested.

On May 17, 2011:
At 1:25 p.m., there was no record of sensitivity testing for the smoke detectors for the main hospital at 900 Hyde Street, San Francisco, CA.

On May 18, 2011:
At 4:26 p.m., the Mechanical Room in the Basement had a smoke detector #2-065 that was covered in blue masking tape.

On May 19, 2011:
At 11:08 a.m., smoke detector 1-86 on the 8th floor failed to activate the alarms.

At 11:12 a.m., smoke detector 1-056 on the 8th floor failed to activate the alarms.

Based on document review and interview, the facility failed to test its fire pumps, in accordance with 1998 NFPA 25, as evidenced by a lack of documentation provided for weekly fire pump testing of its fire pumps at the Outpatient Services on Bush Street. This deficient practice affected all staff and patients on three of three floors of the six floor building and could potentially result in the fire pumps failing to operate properly in the event of a fire.

Table 5-1.1 Summary of Fire Pump Inspection, Testing, and Maintenance Item Activity Frequency Reference
Pump house, heating ventilating louvers Inspection Weekly 5-2.2.1
Fire pump system Inspection Weekly 5-2.2.1
Pump operation No-flow condition Test Weekly 5-3.2.1, 5-3.2.2
Flow condition Test Annually 5-3.3.1
Hydraulic Maintenance Annually 5-5.1
Mechanical transmission Maintenance Annually 5-5.1
Electrical system Maintenance Varies 5-5.1
Controller, various components Maintenance Varies 5-5.1
Motor Maintenance Annually 5-5.1
Diesel engine system, various components Maintenance Varies 5-5.1

5-2 Inspection.
5-2.1 The purpose of inspection is to verify that the pump assembly appears to be in operating condition and is free from physical damage.
5-2.2* The pertinent visual observations specified in the following checklists shall be performed weekly.
5-2.2.2 Pump System Conditions.
(a) Pump suction and discharge and bypass valves are fully open.
(b) Piping is free of leaks.
(c) Suction line pressure gauge reading is normal.
(d) System line pressure gauge reading is normal.
(e) Suction reservoir is full.
5-2.2.3 Electrical System Conditions.
(a) Controller pilot light (power on) is illuminated.
(b) Transfer switch normal pilot light is illuminated.
(c) Isolating switch is closed - standby (emergency) source.
(d) Reverse phase alarm pilot light is off or normal phase rotation pilot light is on.
(e) Oil level in vertical motor sight glass is normal.
5-3 Testing.
5-3.1 Purpose. The purpose of testing the pump assembly is to ensure automatic or manual operation upon demand and continuous delivery of the required system output. An additional purpose is to detect deficiencies of the pump assembly not evident by inspection.
5-3.2 Weekly Tests. Qualified operating personnel shall be in attendance during the weekly pump operation.
5-3.2.1 A weekly test of electric motor-driven pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes.
Exception: A valve installed to open as a safety feature shall be permitted to discharge water.

Findings:

Outpatient Services at 1199 Bush Street
During document review, on 5/20/11, at 10:00 a.m., the facility failed to provide documentation for weekly inspection and testing of its fire pumps. When the director of Plant Operations was asked if the testing had been done for the Bush Street facility, Administrative Staff stated that it had not been done.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by missing escutcheon rings and sprinklers that were not free of debris. These could result in the fire sprinkler system not functioning as designed and increased risk of injury to residents and staff. This affected the main hospital building.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through May 20, 2011, the sprinkler system was observed.

On May 18, 2011:
At 2:20 p.m., in the Scope Cleaning room across from Room 233A on the 2nd floor, there was 1 of 2 sprinklers covered in paint.

At 4:56 p.m., the Storage Closet in the Pulmonary area in the Basement had a sprinkler missing an escutcheon ring.

Based on observation, the facility failed to maintain its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by a fire extinguisher that was obstructed from view and access. This deficient practice affected staff and patients in one of seven smoke compartments and could potentially cause a delay in access to the fire extinguishers resulting in the spread of smoke and/or fire.

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

During a tour of the facility with Environmental Care Manager and Plant Engineer on 5/18/11, at 4:45 p.m., access to the fire extinguisher located in the MRI Lounge was blocked by a free-standing coat rack and three hand- bags on the floor in front of it.

Based on document review and interview, the facility failed to monitor the humidity levels for 3 of 9 operating rooms (OR's). This failure could increase the risk of a fire hazard, resulting in potential harm to patients during surgery. This affected the main hospital at 900 Hyde Street, San Francisco, CA.

NFPA 101, Life Safety Code 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Health Care Facilities 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
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 records review and interview with Hospital Staff on May 17, 2011 through May 20, 2011, the humidity logs were reviewed and the Chief Engineer was interviewed.

On May 17, 2011:
At 1:25 p.m., the humidity logs were reviewed and the humidity logs for Operating Rooms 5, 7, and 8 were not provided. When interviewed on May 17, 2011 at 1:25 p.m., the Chief Engineer stated that they did not log the humidity for those OR's and that the system was still being worked on because they had gone from 14 OR's to 9 larger OR's and the construction numbers and the computer numbers did not correspond yet. The facility uses a cross reference sheet to monitor most of the OR's.

Based on observation, the facility failed to ensure that the oxygen cylinders were stored in rooms that were properly identified for oxygen storage.

Findings:

During a tour of the facility with the Hospital Staff on May 17, 2011 through May 20, 2011, the facilities oxygen storage areas were observed.

On May 18, 2011:
At 11:10 a.m., in Room 413 on the 4th floor, there were 6 " E " oxygen tanks stored and the room had no signage indicating it was used for oxygen storage and, a "no smoking" sign was not posted.

At 2:10 p.m., in the Utility Room on the 2nd floor there were 9 " E " oxygen tanks stored and the room had no signage indicating it was used for oxygen storage and, a "no smoking" sign was not posted.

Based on document review and staff interview, the facility failed to provide complete documentation of generator testing and inspection, in accordance with 1999 NFPA 99, as evidenced by incomplete documentation for weekly generator inspections, monthly load tests, generator transfer times, and what the actual load was during each monthly load test. This finding affected all staff and residents on three out of three floors of the six floor Outpatient Services at 1191 Bush Street and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

NFPA 99
3-4.1.1.8 Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

3-4.1.1.8 Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

Outpatient Services at 1199 Bush Street
During a review of the facility's documentation on 5/17/11, at 10:00 a.m., the facility failed to provide documentation for four out of twelve monthly full load tests. Documentation was missing from May to October of 2010. The facility failed to provide documentation for weekly visual inspections of its generator for approximately 46 of 52 weeks in a twelve month period. During document review on 5/20/11 at between 10:00 and 10:30 a.m., The Director of the Outpatient Services at 1199 Bush Street confirmed that the load testing and visual inspections had not been done during those times. Documentation in the generator log for monthly load tests did not show what the transfer time was during the monthly load tests or what the generator was being loaded at to determine if 30 percent of the name plate rating was being met. Engineering Staff stated that the 30 percent was being met each month.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities, in accordance with 1999 NFPA 70 and 1999 NFPA 99, as evidenced by high-wattage appliances that were plugged into power strips instead of being plugged directly into fixed wall outlets, power strips that were suspended, the permanent use of extension cords, and a broken electrical outlet. This deficient practice affected staff and residents in seven out of twelve floors and basement at the Main Hospital Building and could potentially result in the ignition of fire.

NFPA 70
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

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

110-12 requires that electrical equipment be installed in a neat and workman like manner.

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

Findings:

During a tour of the facility on 5/17/11, electrical wiring and equipment were observed in the following locations:

Main Hospital Building
1. At 3:30 p.m., there were three power strips that were plugged into each other in a chain in the Twelfth Floor Foundation Fund southeast corner office.

During a tour of the facility on 5/18/11, electrical wiring and equipment were observed in the following locations:

2. At 9:36 p.m., there was a microwave oven sitting on a table plugged into an outlet with the cord pulled tightly producing tension on the plug terminals. This microwave oven was in the Seventh Floor Dining Room.

3. At 10:00 a.m., there were two power strips plugged into each other on top of the counter top at the Seventh Floor Nurses' Station.

4. At 10:24 a.m., there was a coffee pot plugged into a power strip that was suspended above the floor. The cord to the coffee pot had tension applied to the plug terminals. This coffee pot was in an office area separated from the Hyperbaric Treatment Room.




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Findings:

During a tour of the facility with Hospital Staff on May 17, 2011 through May 20, 2011, the electrical system was observed.

On May 18, 2011:
At 9:40 a.m., in the Clean Utility room across from Room 805 on the 8th floor there was an orange extension cord used to plug in the medicine refrigerator that connected to the Omnicell machine.

At 9:56 a.m., the electrical panel board W8A on the 8th floor by Room 821 failed to label the circuits on the electrical panel.

At 10:45 a.m., Room 401 Conference Room on the 4th floor had a microwave and refrigerator plugged into an extension cord and not directly into the wall.

At 11:00 a.m., CPE Education room on the 4th floor had a couch and chair blocking the FACP closet.

At 11:03 a.m., Room 408 on the 4th floor had a fan plugged into an orange extension cord.

At 11:05 a.m., Room 410 on the 4th floor had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 11:25 a.m., Room 422 "IV Resource RN"on the 4th floor had a microwave and refrigerator plugged into a 3 plug adapter and not directly into the wall outlet.

At 12:10 p.m., Room 302 on the 3rd floor had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 4:00 p.m., the Linen Room in the Basement had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 4:06 p.m., the Mail Room in the Basement had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 5:20 p.m., the Materials/Purchasing Breakroom in the Basement had a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall outlet.

At 5:30 p.m., the Computer Training Room in the Basement had a yellow extension cord connected to a multi-outlet adapter which was connected to computer equipment and not directly into the wall outlet.

At 5:31 p.m., the Computer Training Room in the Basement had a broken electrical outlet in the wall at the front of the room.