HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls. This has the potential to cause the spread of smoke and flames in the event of a fire. This affected 1 of 2 smoke compartments in Unit B.

Findings:

On March 9, 2010, during a tour of the facility with staff from 8:30 a.m. to 2:00 p.m. the walls and ceilings were observed.

1. Unit B at 12:07 p.m. in room 215 there was an unsealed penetration approximately 2 inches in the left wall with orange wire running through it.

Based on observation, the facility failed to maintain their corridor doors as evidenced by doors that failed to shut and latch upon self closure. This could cause the passage of smoke and flames in the event of a fire to other parts of the building and increase risk of injury to patients. This affected 1 of 1 smoke compartments in unit W-1 and 1 of 2 smoke compartments in unit B.

Findings:

On March 9, 2010, during a tour of the facility with staff from 8:30 a.m. to 2:00 p.m. the corridor doors were observed.

Unit W-1
1. At 11:38 a.m. room 1152 the door failed to shut and latch upon self closure.
2. At 11:44 a.m. room 1154 the door failed to shut and latch upon self closure.
3. At 11:46 a.m. room 1155 A the door failed to latch upon self closure.
4. At 11:47 a.m. room 1155 the door failed to latch.
5. At 11:56 a.m. room 1164 the door failed to latch.

Unit B
1. At 12:06 p.m. room 214 the door failed to latch upon self closure.

Based on document review and interview, the facility failed to conduct 1 of 2 required disaster drills in accordance with NFPA 99, Health Care Facilities, (1999 edition). This may cause staff to be unfamiliar with duties assigned in the event of a disaster. This affected 1 of 1 smoke compartments in W-1 and Unit B.

NFPA 99
11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

On March 9, 2010 at 8:54 a.m. during records review the disaster drill records and the Facility Bulletin No., 58 Disaster Plan were reviewed.

1. The Inter-office Memo dated June 1, 2009 was reviewed and indicated that a Disaster Drill Training / Table Top Exercise was conducted on May 21, 2009. This was a table top exercise that was conducted with the Porterville Developmental Center (PDC), Disaster Council Members and not involving the entire staff. The facility held a mass casualty disaster drill on December 4, 2009. The facility bulletin 58 page 5 section VIII Evaluation of Disaster Plan states the Disaster Plan is tested twice a year, and that the disaster drills will involve the entire facility.

Based on document review and interview, the facility failed to include the transmission of fire alarm signal during fire drills. This could cause staff to be unfamiliar with the sounds of the alarms and simulate actual fire condition. This affected 1 of 1 smoke compartments on unit W-1 and 2 of 2 smoke compartments on Unit B

19.7.1.2* Fire Drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When the drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

On March 9, 2010, the Fire/Disaster Evacuation Drill Reports were reviewed from April 2009 through January 2010.

1. The facility fire drill records indicated that the fire alarm was activated on 3 occasions during the past year. April 22, 2009 at 1320, August 8, 2009, at 1315 and October 3, 2009 at 1030. No alarms were activated on drills conducted after 1:20 p.m. At 11:33 a.m. during an interview with staff 4 , staff stated that the fire alarms were not activated during fire drills because staff were not trained to reset the fire alarm system. At 1:00 p.m. during an interview with staff 3, it was stated that the level of care staff work 12 hour shifts, from 0630 to 1930 and 1830 to 0700. During the drills held for the 1830 to 0700 shift no fire alarms were activated.

Based on observation and document review, the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, ( 1999 edition). This was evidenced by fire alarm system components that failed during testing and failure to provide documentation for the annual testing, inspection and maintenance of the fire alarm system. This could result in failure of the fire alarm system and cause injury to patients in the event of a fire.

Findings:

On March 9, 2010 from 8:30 a.m. to 2:00 p.m. the fire alarm maintenance records were reviewed . At 12:20 p.m. staff 4 stated that there was no current annual certification of the fire alarm system. When asked when the last certification was staff 4 had not been able to locate that information.
During testing of the fire alarm system with staff 4 from 12:39 p.m. and 12:54 p.m., the following devices failed when tested.

1. At 12:48 p.m. the chime by room 205 failed to emit a signal upon activation of the fire alarm system.
2. At 12: 50 p.m. the chime across from 201 failed to emit a signal upon activation of the fire alarm system.
3. At 12:52 p.m. the chime by door 237 failed to emit a signal upon activation of the fire alarm system.
4. At 12:5 4 p.m. the chime by room 224 failed to emit a signal upon activation of the fire alarm system.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code (1999 edition), a evidenced by surge protectors attached to building surfaces and surge protectors plugged into surge protectors. This could cause a fire from overloaded circuits.

NFPA 70, National Electrical Code 1999 Edition
400-8. USES NOT PERMITTED. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On March 9, 2010 during a tour of the facility from 8:30 a.m. to 2:00 p.m. the electrical wiring and equipment was observed.

1. At 11:52 a.m. on Unit W-1 in room 1156 there were 2 surge protectors attached to the building surface above the head of the bed.
2. At 12:17 p.m. on Unit B in office 246 there was a surge protector plugged into a surge protector.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls. This has the potential to cause the spread of smoke and flames in the event of a fire. This affected 1 of 2 smoke compartments in Unit B.

Findings:

On March 9, 2010, during a tour of the facility with staff from 8:30 a.m. to 2:00 p.m. the walls and ceilings were observed.

1. Unit B at 12:07 p.m. in room 215 there was an unsealed penetration approximately 2 inches in the left wall with orange wire running through it.

Based on observation, the facility failed to maintain their corridor doors as evidenced by doors that failed to shut and latch upon self closure. This could cause the passage of smoke and flames in the event of a fire to other parts of the building and increase risk of injury to patients. This affected 1 of 1 smoke compartments in unit W-1 and 1 of 2 smoke compartments in unit B.

Findings:

On March 9, 2010, during a tour of the facility with staff from 8:30 a.m. to 2:00 p.m. the corridor doors were observed.

Unit W-1
1. At 11:38 a.m. room 1152 the door failed to shut and latch upon self closure.
2. At 11:44 a.m. room 1154 the door failed to shut and latch upon self closure.
3. At 11:46 a.m. room 1155 A the door failed to latch upon self closure.
4. At 11:47 a.m. room 1155 the door failed to latch.
5. At 11:56 a.m. room 1164 the door failed to latch.

Unit B
1. At 12:06 p.m. room 214 the door failed to latch upon self closure.

Based on document review and interview, the facility failed to conduct 1 of 2 required disaster drills in accordance with NFPA 99, Health Care Facilities, (1999 edition). This may cause staff to be unfamiliar with duties assigned in the event of a disaster. This affected 1 of 1 smoke compartments in W-1 and Unit B.

NFPA 99
11-5.3.9* Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

On March 9, 2010 at 8:54 a.m. during records review the disaster drill records and the Facility Bulletin No., 58 Disaster Plan were reviewed.

1. The Inter-office Memo dated June 1, 2009 was reviewed and indicated that a Disaster Drill Training / Table Top Exercise was conducted on May 21, 2009. This was a table top exercise that was conducted with the Porterville Developmental Center (PDC), Disaster Council Members and not involving the entire staff. The facility held a mass casualty disaster drill on December 4, 2009. The facility bulletin 58 page 5 section VIII Evaluation of Disaster Plan states the Disaster Plan is tested twice a year, and that the disaster drills will involve the entire facility.

Based on document review and interview, the facility failed to include the transmission of fire alarm signal during fire drills. This could cause staff to be unfamiliar with the sounds of the alarms and simulate actual fire condition. This affected 1 of 1 smoke compartments on unit W-1 and 2 of 2 smoke compartments on Unit B

19.7.1.2* Fire Drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When the drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

On March 9, 2010, the Fire/Disaster Evacuation Drill Reports were reviewed from April 2009 through January 2010.

1. The facility fire drill records indicated that the fire alarm was activated on 3 occasions during the past year. April 22, 2009 at 1320, August 8, 2009, at 1315 and October 3, 2009 at 1030. No alarms were activated on drills conducted after 1:20 p.m. At 11:33 a.m. during an interview with staff 4 , staff stated that the fire alarms were not activated during fire drills because staff were not trained to reset the fire alarm system. At 1:00 p.m. during an interview with staff 3, it was stated that the level of care staff work 12 hour shifts, from 0630 to 1930 and 1830 to 0700. During the drills held for the 1830 to 0700 shift no fire alarms were activated.

Based on observation and document review, the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, ( 1999 edition). This was evidenced by fire alarm system components that failed during testing and failure to provide documentation for the annual testing, inspection and maintenance of the fire alarm system. This could result in failure of the fire alarm system and cause injury to patients in the event of a fire.

Findings:

On March 9, 2010 from 8:30 a.m. to 2:00 p.m. the fire alarm maintenance records were reviewed . At 12:20 p.m. staff 4 stated that there was no current annual certification of the fire alarm system. When asked when the last certification was staff 4 had not been able to locate that information.
During testing of the fire alarm system with staff 4 from 12:39 p.m. and 12:54 p.m., the following devices failed when tested.

1. At 12:48 p.m. the chime by room 205 failed to emit a signal upon activation of the fire alarm system.
2. At 12: 50 p.m. the chime across from 201 failed to emit a signal upon activation of the fire alarm system.
3. At 12:52 p.m. the chime by door 237 failed to emit a signal upon activation of the fire alarm system.
4. At 12:5 4 p.m. the chime by room 224 failed to emit a signal upon activation of the fire alarm system.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, National Electrical Code (1999 edition), a evidenced by surge protectors attached to building surfaces and surge protectors plugged into surge protectors. This could cause a fire from overloaded circuits.

NFPA 70, National Electrical Code 1999 Edition
400-8. USES NOT PERMITTED. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On March 9, 2010 during a tour of the facility from 8:30 a.m. to 2:00 p.m. the electrical wiring and equipment was observed.

1. At 11:52 a.m. on Unit W-1 in room 1156 there were 2 surge protectors attached to the building surface above the head of the bed.
2. At 12:17 p.m. on Unit B in office 246 there was a surge protector plugged into a surge protector.