HospitalInspections.org

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations observed in the fire-rated sheeting. This affected two of five floors at Rideout Memorial Hospital and one of five floors at Fremont Medical Center and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with Engineering Staff, penetrations were observed in the wall and ceiling sheathing which could potentially result in the spread of smoke and/or fire.

Rideout Memorial Hospital
1. On 4/24/12, at 11:05 a.m., there was an approximately one inch by six inch unsealed penetration in the wall behind the door in the Break Room on Second Floor. This Break Room was located in the smoke compartment identified as 2.1 on the facility floor plans.

Fremont Medical Center
2. On 4/25/12, at 10:38 a.m., the First Floor room identified as the Old CT Scan Room had a sprinkler escutcheon that had slipped down creating an approximately one-quarter inch by two inch unsealed penetration around the sprinkler pipe.

3. On 4/25/12, at 11:06 a.m., the first floor room identified as Mechanical Room 1 had three approximately one-half inch unsealed penetrations in the north wall approximately 60 inches up from the floor.


29753

Findings:

During a tour of the facilities with Engineering Staff, the ceiling and walls were observed.

Rideout Memorial Hospital
1. On 4/24/12 at 3:31 p.m., there was an approximately 1 inch penetration at the top right portion of the escutcheon ring in the Administration Office bathroom.

2. On 4/26/12 at 1:58 p.m. in the Breast Imaging area, there was an approximately 2 inch circular penetration in the wall beneath the work station near the staff handwash area.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. 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 affected four of five floors at Rideout Memorial Hospital and one of eight Outpatient Service buildings.

Findings:

During a tour of the facility with Engineering Staff, doors were inspected throughout the facility.

Rideout Memorial Hospital
1. On 4/24/12, at 12:47 p.m., the fire-rated door in the Second Floor Central Supply 2 Central Storage Room had an approximately four foot wide by five foot long by five foot tall storage rack with boxes on the shelf that was placed within the swing area of the door preventing it from being closed.

2. On 4/24/12, at 2:05 p.m., the First Floor Emergency Room Supervisor's Office had a chair placed within the swing area of the door. This door was being held open by a magnetic hold-open device designed to release upon activation of the fire alarm system.

3. On 4/24/12, at 2:07 p.m., the First Floor one hour fire-rated corridor door to the Emergency Medical Services Room was propped open with a floor stand.

4. On 4/24/12, at 2:45 p.m., the First Floor door separating the Kitchen from the Dining Room was held open with a wooden door wedge.



29753

Findings:

During a tour of the Rideout Memorial Hospital and the Ortho Clinic with Engineering Staff, the corridor doors were observed and tested.

Rideout Memorial Hospital
5. On 4/24/12 at 9:45 a.m., a doorstop held the door to the Pharmacy Director's Office open. The office was unattended at the time.

6. On 4/24/12 at 11:10 a.m., the door to the Physical, Occupational, and Speech Therapy Office was obstructed from closing by a transport chair.

7. On 4/24/12 at 1:57 p.m., a "potted plant" made of pens, and a hand sanitizer were on the ledge of the Radiology Reception area. The items were in the path of the drop-down emergency door.

8. On 4/24/12 at 2:45 p.m., a chair obstructed closure of the door to Room 102 (One West).

9. On 4/24/12 at 2:55 p.m., the Janitor Closet between 112 West and 110 West failed to latch when tested.

10. On 4/24/12 at 3:05 p.m., the door to the Shower Room by the elevator and the Biohazard Room (One West) failed to latch when tested.

11. On 4/25/12 at 10:40 a.m., a time clock obstructed closure of the drop-down emergency door at the lab window in the Lab Waiting Room.

Ortho Clinic
12. On 4/25/12 at 2:01 p.m., the door to Exam Room 2 failed to latch when tested.

Based on observation, the facility failed to insure that all exit signs would be placed in locations that would guide occupants of the building to a safe path to the public way. This was evidenced by an area that did not have an exit sign or signs directing the building's occupants in one of two potential egress routes. This affected one of five smoke compartments on the third floor of Rideout Memorial Hospital 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.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be the nearest exit is not apparent.

Findings:

During a tour of the facility with Engineering Staff, exit access was inspected.

Rideout Memorial Hospital
1. On 4/24/12, at 9:25 a.m., the path of egress on the Third Floor near the Nurses' Station in smoke compartment 3.1, did not have an exit sign visible when traveling south in the corridor if the cross corridor doors near the Medications room were closed. Staff ES 2 confirmed that an exit sign could not be seen when traveling in that direction with the doors closed.

Based on observation and interview, the facility failed to protect all hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and were not equipped with self-closing mechanisms on the doors. This affected one of five floors at the Fremont Medical Center and one of two floors at the Outpatient Surgery Center and Urology Clinic and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with Engineering Staff, hazardous area enclosures were observed in the following locations:

Fremont Medical Center
1. On 4/25/12, at 11:00 a.m., the two rooms identified on the facility's drawings as the First Floor Endoscopy Prep and Patient Room 110 were approximately 80 percent full of decorations. The decorations consisted of dried plants, plastic and fabric flowers, miscellaneous accessories, and cardboard storage boxes. These two rooms were used by a hospital volunteer organization. These rooms were unsprinklered and did not have doors with self-closing mechanisms on them.

Feather River Surgery
2. On 4/25/12, at 2:15 p.m., the First Floor one hour fire-rated door separating the pre and post operating areas from the Break Room had the self-closing device removed from the door.

Based on observation, document review, and interview, the facility failed to test its battery powered emergency illumination in accordance with 2000 NFPA 101. This was evidenced by the failure to provide documentation for the monthly and annual testing of its emergency egress lights and task lighting. This affected all staff and patients at two of eight outpatient buildings. This could potentially result in a failure to ensure backup lighting for egress and/or the orderly cessation of procedures in the event of a power outage.

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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility with Engineering Staff, emergency egress and task lighting was observed at the Cardiac Rehab Center.


Cardiac Rehabilitation
1. On 4/27/12, at 9:30 a.m., the facility failed to provide documentation for the monthly or annual testing of its emergency egress lighting units for the Cardiac Rehabilitation Center.



29753


Findings:
Cancer Center
During record review on 4/27/12, the emergency lighting units test documents were reviewed.

2. At 8:12 a.m., documents revealed that tests were not conducted in the months of July, October, and December 2011. Tests were also not conducted January 2012.

Based on observation, document review, and interview, the facility failed to test and maintain its exit signs. This was evidenced by the lack of documentation provided for monthly and annual testing of its exit signs and exit signs that failed to stay illuminated when tested. This affected one of eight outpatient buildings and could potentially result in exit signs failing to stay illuminated to guide the building's occupants to safety.

7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 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:

1. During document review on 4/27/12, at 9:30 a.m., the facility failed to provide documentation for monthly inspections or monthly and annual testing of its exit signs at Cardiac Rehabilitation, Feather River Surgery, the Urology Clinic, and the Urgent Care Center. ES1 confirmed that the monthly and annual testing was not being done at those locations.

During a tour of the facility with Engineering Staff, exit signs were tested.

Feather River Surgery
2. On 4/25/12, at 1:55 p.m., the exit sign located near the Pathology Pick-up Room did not stay illuminated when its internal battery back-up was tested.

3. On 4/25/12, at 2:03 p.m., the exit sign located near the Clean Utility Room did not stay illuminated when its internal battery back-up was tested.

Based on observation, document review, and interview, the facility failed to maintain all fire alarm system devices to provide audible notification to staff in all locations in accordance with 2000 NFPA 101. This was evidenced by an audible alarm device that failed to function in one of six smoke compartments on the first floor at the Fremont Medical Center. This could potentially result in the alarm not being heard by staff which may cause a delay in response to the fire emergency.
This was also evidenced by the failure to properly reset the fire alarm panel to transmit all fire alarm activity during testing at the Feather River Surgery Center and Urology Clinic. This affected all staff and residents in two of two smoke compartments at the Feather River Surgery Center and could potentially result in the monitoring company failing to receive notification of fire alarm activation.

NFPA 101 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."

Findings:

During fire alarm testing with Engineering Staff, fire alarm devices were tested.

Fremont Medical Center
1. On 4/26/12, at 1:48 p.m., the smoke detector near Patient Room 114 was activated. The cross corridor doors released from their magnetic hold-open devices and the alarm audible devices could be heard in other areas on the first floor. No audible alarm could be heard in smoke compartment 1.5. The manual pull station was activated with the same results. This smoke compartment only had one chime which was located at the Nurses' Station. After ES3 tapped the alarm audible device, it began to work.

Feather River Surgery Center/Urology Clinic
On 4/25/12, between 4:59 p.m. and 5:13 p.m., six fire alarm devices were tested.
On 4/26/12, between 2:19 p.m. and 2:36 p.m., three fire alarm devices were tested.

2. On 4/27/12, at 9:30 a.m., the facility provided the activity report for the fire alarm testing at the Feather River Surgery Center and the Urology Clinic which are located in the same building. This activity report showed only the first alarm activation on 4/25/12 at 4:59 p.m.
No fire alarm activation activity was received by the monitoring company on 4/25/12 after 4:59 p.m. through 4/26 at 3:16 p.m. at the Feather River Surgery Center/Urology Clinic.


When asked why fire alarm activity report did not show all alarm devices tested, ES1 stated that the fire alarm vendor would be contacted and would provide that information at a later time.
Documentation was provided on 5/2/12, at 11:19 a.m., from ES1 from the fire alarm vendor which stated that:

"The panel configuration at the above referenced is a main fire alarm panel with a four zone slave digital communicator. These units operate in conjunction with one another, but are reset independently. Resetting the fire alarm panel does not reset the communicator. A clear fire alarm panel does not mean the digital communicator has been reset.

A. "On 4/25, the scheduled timer test was not received on the designated telephone line. The "fail to communicate" signal was transmitted via the other telephone line, signifying that one of the two telephone lines had failed to transmit the test signal. The fact that the 'fail to communicate' signal was received at the central station showed that the panel was communicating on the remaining telephone line with good service."

B. "On 4/25, at 3:35 p.m., the system was put on test".

C. "At 4:59:07, a fire trouble was received at the central station".

D. "At 4:59:10, a fire trouble was received at the central station, which was the telephone line trouble that caused the original 'fail to communicate" signal'".

E. "The fire alarm panel was reset and cleared of the alarm condition, but the digital communicator was not reset and the alarm did not clear".

F. "The "failed to communicate" signal was cleared when the panel communicated on the unaffected phone line".

G. "The monitoring station software correctly identified the digital communicator as still in an alarm condition and generated a reminder every hour".

H. "On 4/26 at 3:16:40 a "fire restoral"signal was received, and the event log cleared".

During an interview with ES1 on 4/27/12, between 1:00 p.m. and 2:00 p.m., when asked, Staff ES1 stated that the facility did have a policy to dial 911 in the event of a fire. This surveyor reviewed Policy PP# EOC 201 for Code Red guidelines. This policy stated that the emergency numbers to call in a fire alert would be 911 and the Main Campus phone numbers.

Based on record review and interview, the facility failed to provide documentation of maintenance, inspection, and testing of smoke detectors in accordance with 2000 NFPA 72, 7-3.2.1.. This was evidenced by the failure to provide documentation for smoke-sensitivity testing. This affected all staff and patients at four of eight offsite outpatient services: the Feather River Surgery Center, the Urology Clinic, the Urgent Care Center, and the Cancer Center. This could potentially result in smoke detector nuisance alarms or no alarms in the event of fire or smoke.

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 with Engineering Staff, documentation for fire alarm system testing was reviewed.

On 4/26/12, at 8:13 a.m., the facility failed to provide documentation indicating that the smoke detectors had been tested for sensitivity within the past two years at the following locations:
1. Feather River Surgery and the Urology Clinic
2. Urgent Care Center

When asked, ES1 stated that the vendor would be contacted and the documentation provided, if available.


29753

Findings:

Cancer Center
During record review on 4/27/12, smoke detector sensitivity test documents were requested.

3. At 8:28 a.m., there were no documents available for review for the Cancer Center.
When interviewed, ES 3 stated he was unaware of the requirement.

Based on document review and staff interview, the facility failed to inspect, test, and maintain its automatic sprinkler system in accordance with 2000 NFPA 101, 4.6.12 and 1998 NFPA 25, 2-3 and table 2-1. This was evidenced by a lack of documentation provided for the annual sprinkler system inspection, sprinklers that were painted or loaded with debris, and noted deficiencies on an annual report that had not yet been repaired and the facility failed to provide documentation for one of four quarterly testings of the sprinkler system. These deficient practices affected three of five floors at Rideout Memorial Hospital, one of five floors at Fremont Medical Center, and one of eight outpatient services buildings and could potentially result in the spread of smoke and/or fire.

4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Findings:

Urgent Care Center
1. During record review on 4/27/12, at 9:30 a.m., the facility failed to provide documentation for the annual sprinkler system inspection and testing. ES1 stated that they would contact the vendor and if the testing had been done, the documentation would be provided to this surveyor.
During a tour of the facility with Engineering Staff on 4/25/12, at 4:15 p.m., the sprinkler system riser was inspected. There was no sprinkler system inspection certification tag visible on the riser.


29753

NFPA 13, 1999 Edition
5-9.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from an end wall. The distance from the wall to the sprinkler shall be measured perpendicular to the wall.

NFPA 25, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

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

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

Findings:

During a tour of the facilities with Engineering Staff, the sprinklers were observed.

Rideout Memorial Hospital
1. On 4/24/12 at 9:41 a.m., there was paint on the deflector in the Pharmacy bathroom.

2. On 4/24/12 at 10:08 a.m., there was paint on the deflector above the stalls in the Ladies' Public Restroom in Four Main.

3. On 4/24/12 at 10:09 a.m., there was paint on the deflector above the stalls in the Men's Public Restroom in Four Main.

4. On 4/24/12 at 10:35 a.m., there was paint on the deflector in the Four Main Locker Room.

5. On 4/24/12 at 10:44 a.m., one of two sprinklers in Room 475 was loaded with debris.

6. On 4/24/12 at 10:46 a.m., two of two sprinklers in Room 497 were loaded with debris.

7. On 4/24/12 at 10:55 a.m., there was paint on the deflector in the Janitor Closet across from Room 494.

8. On 4/24/12 at 10:56 a.m., there were paint and debris on the sprinkler in the bathroom of Room 493.

9. On 4/24/12 at 11:00 a.m., there was a bent deflector in the bathroom of Room 489.

10. On 4/24/12 at 11:02 a.m., there was paint on the deflector in the bathroom of Room 484.

11. On 4/24/12 at 11:18 a.m., approximately 95 percent of the deflector in the Patient Restroom across from Prep Room 1 (Second Floor) was covered with paint.

12. On 4/24/12 at 1:15 p.m., a sprinkler in the Second Floor Tower Surgery Clean Hold area (dumbwaiter closet) was located too close to the wall. The distance measured approximately 1-1/2 inches from the center line of the deflector. There was paint on the deflector.

13. On 4/24/12 at 2:10 p.m., two of two sprinklers in the First Floor X-ray Department Break Room were loaded with debris.

14. On 4/24/12 at 2:22 p.m., the sprinkler in the former Control Room in the Imaging Department Supervisor's Office was loaded with debris.

Fremont Medical Center
15. On 4/25/12 at 11:10 a.m., there was paint on the deflector in Room 2 of the Labor and Delivery Wing.

Cancer Center
16. On 4/26/12 at 4:15 p.m. during record review, documents revealed that the system failed to pass inspection. The Annual Inspection, Testing, and Maintenance Report dated 3/20/12 indicated the following: "(1) Head painted in Restroom. Adjust head in Hallway by ITV Room and (1) head in Conference Room #1. Add (1) head in Hallway going into Library head is 11'-0" off wall." The report also indicated: "10" Bell does not operate. Starts to ring then only vibrates."

When interviewed, ES 3 stated that the corrections have not yet been made.

17. On 4/27/12 at 8:27 a.m. during record review, documents revealed that quarterly testing was not conducted in Fourth Quarter 2011.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by a corridor door that required special knowledge to open the door from the egress side. This affected one of five floors at Rideout Memorial Hospital and could result in a delayed evacuation in the event of an emergency.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

3.3.121.1 Means of Egress, Accessible. A path of travel, usable by a person with a severe mobility impairment, that leads to a public way or an area of refuge.

7.2.1.5 Locks, Latches, and Alarm Devices.
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.

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.

Findings:

During a tour of the facility on 4/24/12, corridor doors were inspected throughout the facility.

Rideout Memorial Hospital
1. At 11:10 a.m., the corridor door separating Two North and Two West could only be opened by turning the door knob in a counter-clockwise direction. The door could not be opened when turning the knob in a clockwise direction. Staff ES2 confirmed that it was not working correctly.

Based on observation, the facility failed to provide proper storage for medical gas, in accordance with NFPA 99, as evidenced by the storage of full oxygen cylinders with empty oxygen cylinders in the same rack and by oxygen cylinders stored near bins of trash and biohazard materials within the same enclosure. This could result in staff not accessing the proper cylinder in the event of an emergency if empty and full cylinders are stored in the same rack, or could result in an oxygen-related hazard if oxygen cylinders are stored in the same enclosure with combustible materials. This affected one of five floors at Rideout Memorial Hospital.

NFPA 99, 1999 Edition

4-5.5.2.2 Storage of Cylinders and Containers Level 3.

(b) Nonflammable Gases.

1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.

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

8-3.1.11 Storage Requirements

(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:

1. A minimum distance of 20 ft (6.1 m), or

2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or

3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

Rideout Memorial Hospital
During a tour of the facilities with the Engineering Staff, the oxygen storage areas were observed.

1. On 4/24/12 at 10:20 a.m. in the CVICU, three empty oxygen E-tanks were stored in the same rack with eight full oxygen E-tanks. The cylinders were stored in the Biohazard Room approximately three feet from a trash bin and approximately four feet from a soiled linen bin.

2. On 4/24/12 at 11:20 a.m. in the Second Floor Tower PACU Soiled Utility Room, two empty oxygen E-tanks were stored in the same rack with one full oxygen E-tank. The cylinders were stored approximately 9 inches from a soiled linen bin in a storage room with one 45-gallon biohazard trash can, two 45-gallon trash cans, and a janitor cleaning cart.

Based on document review and interview, the facility failed to protect its anesthetizing locations in accordance with 1999 NFPA 99, the Standard for Healthcare Facilities. This was evidenced by the failure to maintain the relative humidity in four of four operating rooms. This affected one of five floors at Rideout Memorial Hospital and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review with Engineering Staff, documentation for humidity levels in operating rooms was reviewed.

1. On 4/27/12, at 1:30 p.m., documentation provided for humidity levels indicated that the levels dropped below 35 percent. The number of days per month in a three month period that humidity levels were below 35 percent in Operating Rooms 1, 2, 3, and 4 was as follows:

Rideout Memorial Hospital
Operating Room 1
January 2012: 16 days were below 35 percent. These days ranged between 20 and 33 percent relative humidity.

Operating Room 2
January 2012: 13 days were below 35 percent. These days ranged between 30 and 34 percent relative humidity.

Operating Room 3
January 2012: Nine days were below 35 percent. These days ranged between 28 and 33 percent relative humidity.

Operating Room 1
February 2012: 16 days below 35 percent. These days ranged between 24 and 33 percent relative humidity.

Operating Room 2
February 2012: Eight days were below 35 percent. These days ranged between 31 and 33 percent relative humidity.

Operating Room 3
February 2012: Nine days were below 35 percent. These days ranged between 25 and 32 percent relative humidity.

Operating Room 4
February 2012: Four days were below 35 percent. These days ranged between 24 and 30 percent relative humidity.

Operating Room 1
March 2012: Eight days were below 35 percent. These days ranged between 28 and 33 percent relative humidity.

Operating Room 3
March 2012: Six days were below 35 percent. These days ranged between 23 and 33 percent relative humidity.

Operating Room 4
March 2012: One day was documented at 30 percent relative humidity.

When asked what actions take place when the humidity levels are too low, ES1 stated that the mechanical ventilation system could not be adjusted to change the humidity levels.

Based on observation and interview, the facility failed to maintain its emergency generator in accordance with 1999 NFPA 99 and 1999 NFPA 110. This was evidenced by the facility's failure to maintain emergency generator alarm annunciators for four of six emergency generators. This was also evidenced by the faciliy's failure to provide battery-powered task lights for four of six emergency generators. This affected two of ten buildings observed and could result in delayed notification of a malfunctioning emergency generator and the generator location being left in darkness in the event of a power failure if the generator failed to function.

NFPA 99, 1999 edition
3-4.1.1.15 Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -- when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110:3-5.5.2]

NFPA 110, 5-3 Lighting.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.


Findings:

During a facility tour with Engineering Staff, the facility's emergency generators were observed.

Freemont Medical Center
1. On 4/25/12, between 9:30 a.m. and 12:00 p.m., there was one remote emergency generator alarm annunciator observed in the Registration area of the building near the Front Lobby. At 11:30 a.m., the facility's three diesel fueled emergency generators were observed. When asked, ES 1 stated that the generators supplied power to different parts of the building and that there was just one annunciator that was at a constantly attended location.
2. During an inspection of the generator enclosure for two generators near the outside Medical Gas Storage, this surveyor observed that there was no battery back-up task lighting in that location

Rideout Memorial Hospital
3. On 4/27/12, at 10:25 a.m., the facility's generators were inspected. When asked, ES1 stated the there was one generator annunciator for the three generators each of which supplied power to different portions of the facility. ES3 stated that there used to be one in the boiler room for the smaller generator.

4. During an inspection of the generator enclosure for two generators, this surveyor observed that there was no battery back-up task lighting in that location.

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. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, powerstrips that were plugged into each other, the permanent use of extension cords, and improper clearance in front of electrical panels. This affected four of five floors at Rideout Medical Center, two of five floors at Fremont Medical Center, and three of eight Outpatient Services Buildings, and could potentially result in the ignition of fire.

NFPA 70 National Electrical Code, 1999.
110-12 requires that electrical equipment be installed in a neat and workman like manner.

110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less.

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.

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 facilities with Engineering Staff, electrical wiring and equipment were inspected.

Rideout Memorial Hospital
1. On 4/24/12, at 9:12 a.m., the Fifth Floor Mechanical Room had boxes stored in front the the 480 volt electrical panel. ES2 stated that it looked like they had been moved temporarily off of a shelf to that location.

2. On 4/24/12, at 10:50 a.m., an office in the former GI Lab on the Second Floor had an unapproved extension cord that traveled under a floor mat and was plugged into a power strip. ES2 removed the cord at that time.

3. On 4/24/12, at 11:00 a.m., the Data IT Room on the Second Floor had an extension cord that traveled across the floor to an air conditioner. ES2 removed the extension cord at that time.

4. On 4/24/12, at 2:48 p.m., the First floor Annex Registration had three power strips that were plugged into each other in a series.

5. On 4/24/12, at 2:45 p.m., the First Floor Sterile Processing Break Room had a power strip that was suspended above the floor that was transferring tension to the plug terminals that had a toaster, a coffee pot, and a microwave oven plugged into it.

6. On 4/27/12, at 1:20 p.m., the First Floor Dining Room/Coffee Bar had a power strip plugged into a duplex fixed wall receptacle. This power strip had a 15 amp blender and a coffee grinder plugged into it. Power to this power strip was supplied by an extension cord that traveled approximately 25 feet to a double gang outlet near another cash register. This outlet had a power strip plugged into it with an approximately 13 amp food warmer that was plugged into the power strip.

Fremont Medical Center
7. On 4/25/12, at 10:00 a.m., the First Floor Laboratory Outlet Processing had a flexible type extension cord that traveled from a plug receptacle and junction box attached to the surface of the wall under a counter. The junction box had become partially unattached from the wall. The flexible cord, that was attached to the wall, traveled through a cabinet to a plug outlet and junction box above the counter top.

8. On 4/24/12, at 10:15 a.m., the First Floor Old Blood Draw reception desk had two power strips that were chained together.

9. On 4/25/12, at 10:25 a.m., the Dietary Office on the First Floor had a power strip that was suspended above the floor and was transferring tension to the plug terminals.

10. On 4/25/12, at 10:33 a.m., the First Floor IT Server Room had a power strip that was suspended above the floor transferring tension to the plug terminals.

11. On 4/25/12, at 11:20 a.m., the Second Floor D Wing Office counter top had a microwave oven and two coffee pots plugged into a power strip.

Feather River Surgery
12. On 4/25/12, at 1:45 p.m., the First Floor Surgery Reception area had a power strip that was suspended above the floor transferring tension to the plug terminals. This power strip traveled through the opened door of a cabinet so that the door would pinch the cord if closed completely.


29753

Findings:

During a tour of the facilities with Engineering Staff, the electrical wiring and equipment were observed.

Rideout Memorial Hospital
13. On 4/24/12 at 9:23 a.m., three power strips were connected to each other. A computer item was plugged into Power Strip #1, which was connected to Power Strip #2. A charger was plugged into Power Strip #2. Power Strip #2 was connected to Power Strip #3, which had computer equipment plugged into it. The power strips were located in the Fourth Floor Pharmacy Department at the pharmacist work island.

14. On 4/24/12 at 10:25 a.m. in the CVICU, a microwave oven in the CVICU Nourishment Room was plugged into a power strip that was suspended approximately 14 inches above the floor.

15. On 4/24/12 at 10:35 a.m. in the CVICU, two crash carts, both with defibrillators, suction machines, and two chargers were plugged into power strips at the nurses island.

Policy & Procedure document titled "Crash Cart Care, Locking, Emergency Medications, Supplies and Exchange - Hospitalwide" stated, "When not in use, the defibrillator is to be plugged into a red outlet."

16. On 4/24/12 at 10:50 a.m., two power strips were connected to each other at the Four Main Nurses' Station. Computer equipment was plugged into Power Strip #1, which was connected to Power Strip #2, also with computer equipment plugged into it. Power Strip #2 was suspended approximately 5 inches above the floor.

17. On 4/24/12 at 12:50 p.m., a microwave oven and a coffee pot were plugged into a power strip in the PACU coffee and food storage area.

18. On 4/24/12 at 12:56 p.m., computer equipment was plugged into a power strip in the PACU Charting Office that was suspended approximately 23 inches above the floor.

19. On 4/24/12 at 2:01 p.m., two power strips were connected to each other in the Radiology Receptionist area. Power Strip #1 with computer equipment was connected to Power Strip #2 with chargers plugged into it.

20. On 4/24/12 at 2:05 p.m., two power strips were connected to each other in the Radiologist Receptionist area. Power Strip #1 with computer equipment was connected to Power Strip #2, also with computer equipment plugged into it. Power Strip #1 was suspended approximately 16 inches above the floor.

21. On 4/24/12 at 2:12 p.m., an apartment-size refrigerator and two chargers were plugged into a surge protector in the X-ray Department Break Room.

22. On 4/24/12 at 2:20 p.m., two power strips were connected to each other in Radiologist Reading Room 1. Power Strip #1 with computer equipment was connected to Power Strip #2, also with computer equipment plugged into it.

23. On 4/24/12 at 2:27 p.m., two power strips were connected to each other at the PACS and RIS desk. Power Strip #1 with computer equipment was connected to Power Strip #2, also with computer equipment plugged into it.

24. On 4/24/12 at 2:49 p.m., two power strips were connected to each other in smoke compartment 1.2. A picture printer and a charger were plugged into Power Strip #1. Computer equipment was plugged into Power Strip #2.

25. On 4/24/12 at 2:58 p.m., a toaster in Room 118 (Employee Break Room) was plugged into a power strip.

26. On 4/24/12 at 3:15 p.m., a 12-amp lab procedure table in the One West Lab Procedure Room was plugged into a surge protector.

27. On 4/24/12 at 3:23 p.m., a personal-size refrigerator and a television in the Hospitalist Sleeping Room were plugged into a power strip that was suspended approximately 19 inches above the floor.

28. On 4/26/12 at 1:55 p.m. in the Breast Imaging Area, a 3-amp heater was observed operating approximately 2-1/2 inches from a plastic trash can with a plastic liner. The plastic trash can and liner were hot to the touch.

29. On 4/26/12 at 2:03 p.m. in the Stereotactic Room of the Breast Imaging Center, there were two approximately 1/8 inch frayed speaker wires above the seating area. An empty oxygen E-tank was in the right corner of the room.

Cancer Center
30. On 4/24/12 at 4:07 p.m., a power strip was plugged into an extension cord, which was connected to another power strip. Power Strip #1 was plugged into an extension cord. The extension cord was connected into Power Strip #2 with computer equipment plugged into it. The power strips and extension cord were located in an office near the area temporarily closed due to construction.

Fremont Medical Center
31. On 4/25/12 at 10:32 a.m. in the second Floor Labor and Delivery Unit, three power strips were connected to each other. A microwave oven, small refrigerator, and computer equipment were plugged into Power Strip #1, which was connected to Power Strip #2 with computer equipment. Power Strip #2 was connected to Power Strip #3 with a 3-amp heater, adding machine, and a lamp. The power strips were located in the Director of Perinatal Care's office.

32. On 4/25/12 at 11:50 a.m. in the First Floor Receiving Area, two power strips were banded together with two zip ties. A charger was plugged into Power Strip #1. Two chargers were plugged into Power Strip #2.

Outpatient Perinatal Programs
33. On 4/25/12 at 1:47 p.m. in the RN Office, a 12.5-amp heater and a charger were plugged into a 3-plug extension cord. The extension cord was connected to a power strip with computer equipment plugged into it.

Based on observation, the facility failed to maintain its alcohol based hand rub sanitizers (hand sanitizers), as evidenced by hand sanitizers that were mounted directly above an ignition source. This could result in the risk of an electrical fire, and affected one of five floors at Rideout Memorial Hospital and one of eight Outpatient Buildings.

Findings:

During a tour of the facility with Engineering Staff, alcohol based hand rub dispensers were observed.

Outpatient Perinatal Building
1. On 4/25/12 at 1:50 p.m., there was an ABHR dispenser mounted 10 inches above a light switch in the RN Office




25385


Rideout Memorial Hospital
2. On 4/24/12, at 10:02 a.m., there was an ABHR dispenser five inches adjacent to a light switch on the third floor in the Clean Utility Room.

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations observed in the fire-rated sheeting. This affected two of five floors at Rideout Memorial Hospital and one of five floors at Fremont Medical Center and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with Engineering Staff, penetrations were observed in the wall and ceiling sheathing which could potentially result in the spread of smoke and/or fire.

Rideout Memorial Hospital
1. On 4/24/12, at 11:05 a.m., there was an approximately one inch by six inch unsealed penetration in the wall behind the door in the Break Room on Second Floor. This Break Room was located in the smoke compartment identified as 2.1 on the facility floor plans.

Fremont Medical Center
2. On 4/25/12, at 10:38 a.m., the First Floor room identified as the Old CT Scan Room had a sprinkler escutcheon that had slipped down creating an approximately one-quarter inch by two inch unsealed penetration around the sprinkler pipe.

3. On 4/25/12, at 11:06 a.m., the first floor room identified as Mechanical Room 1 had three approximately one-half inch unsealed penetrations in the north wall approximately 60 inches up from the floor.


29753

Findings:

During a tour of the facilities with Engineering Staff, the ceiling and walls were observed.

Rideout Memorial Hospital
1. On 4/24/12 at 3:31 p.m., there was an approximately 1 inch penetration at the top right portion of the escutcheon ring in the Administration Office bathroom.

2. On 4/26/12 at 1:58 p.m. in the Breast Imaging area, there was an approximately 2 inch circular penetration in the wall beneath the work station near the staff handwash area.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. 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 affected four of five floors at Rideout Memorial Hospital and one of eight Outpatient Service buildings.

Findings:

During a tour of the facility with Engineering Staff, doors were inspected throughout the facility.

Rideout Memorial Hospital
1. On 4/24/12, at 12:47 p.m., the fire-rated door in the Second Floor Central Supply 2 Central Storage Room had an approximately four foot wide by five foot long by five foot tall storage rack with boxes on the shelf that was placed within the swing area of the door preventing it from being closed.

2. On 4/24/12, at 2:05 p.m., the First Floor Emergency Room Supervisor's Office had a chair placed within the swing area of the door. This door was being held open by a magnetic hold-open device designed to release upon activation of the fire alarm system.

3. On 4/24/12, at 2:07 p.m., the First Floor one hour fire-rated corridor door to the Emergency Medical Services Room was propped open with a floor stand.

4. On 4/24/12, at 2:45 p.m., the First Floor door separating the Kitchen from the Dining Room was held open with a wooden door wedge.



29753

Findings:

During a tour of the Rideout Memorial Hospital and the Ortho Clinic with Engineering Staff, the corridor doors were observed and tested.

Rideout Memorial Hospital
5. On 4/24/12 at 9:45 a.m., a doorstop held the door to the Pharmacy Director's Office open. The office was unattended at the time.

6. On 4/24/12 at 11:10 a.m., the door to the Physical, Occupational, and Speech Therapy Office was obstructed from closing by a transport chair.

7. On 4/24/12 at 1:57 p.m., a "potted plant" made of pens, and a hand sanitizer were on the ledge of the Radiology Reception area. The items were in the path of the drop-down emergency door.

8. On 4/24/12 at 2:45 p.m., a chair obstructed closure of the door to Room 102 (One West).

9. On 4/24/12 at 2:55 p.m., the Janitor Closet between 112 West and 110 West failed to latch when tested.

10. On 4/24/12 at 3:05 p.m., the door to the Shower Room by the elevator and the Biohazard Room (One West) failed to latch when tested.

11. On 4/25/12 at 10:40 a.m., a time clock obstructed closure of the drop-down emergency door at the lab window in the Lab Waiting Room.

Ortho Clinic
12. On 4/25/12 at 2:01 p.m., the door to Exam Room 2 failed to latch when tested.

Based on observation, the facility failed to insure that all exit signs would be placed in locations that would guide occupants of the building to a safe path to the public way. This was evidenced by an area that did not have an exit sign or signs directing the building's occupants in one of two potential egress routes. This affected one of five smoke compartments on the third floor of Rideout Memorial Hospital 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.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.
7.10.2* Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be the nearest exit is not apparent.

Findings:

During a tour of the facility with Engineering Staff, exit access was inspected.

Rideout Memorial Hospital
1. On 4/24/12, at 9:25 a.m., the path of egress on the Third Floor near the Nurses' Station in smoke compartment 3.1, did not have an exit sign visible when traveling south in the corridor if the cross corridor doors near the Medications room were closed. Staff ES 2 confirmed that an exit sign could not be seen when traveling in that direction with the doors closed.

Based on observation and interview, the facility failed to protect all hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and were not equipped with self-closing mechanisms on the doors. This affected one of five floors at the Fremont Medical Center and one of two floors at the Outpatient Surgery Center and Urology Clinic and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with Engineering Staff, hazardous area enclosures were observed in the following locations:

Fremont Medical Center
1. On 4/25/12, at 11:00 a.m., the two rooms identified on the facility's drawings as the First Floor Endoscopy Prep and Patient Room 110 were approximately 80 percent full of decorations. The decorations consisted of dried plants, plastic and fabric flowers, miscellaneous accessories, and cardboard storage boxes. These two rooms were used by a hospital volunteer organization. These rooms were unsprinklered and did not have doors with self-closing mechanisms on them.

Feather River Surgery
2. On 4/25/12, at 2:15 p.m., the First Floor one hour fire-rated door separating the pre and post operating areas from the Break Room had the self-closing device removed from the door.

Based on observation, document review, and interview, the facility failed to test its battery powered emergency illumination in accordance with 2000 NFPA 101. This was evidenced by the failure to provide documentation for the monthly and annual testing of its emergency egress lights and task lighting. This affected all staff and patients at two of eight outpatient buildings. This could potentially result in a failure to ensure backup lighting for egress and/or the orderly cessation of procedures in the event of a power outage.

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.

Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a tour of the facility with Engineering Staff, emergency egress and task lighting was observed at the Cardiac Rehab Center.


Cardiac Rehabilitation
1. On 4/27/12, at 9:30 a.m., the facility failed to provide documentation for the monthly or annual testing of its emergency egress lighting units for the Cardiac Rehabilitation Center.



29753


Findings:
Cancer Center
During record review on 4/27/12, the emergency lighting units test documents were reviewed.

2. At 8:12 a.m., documents revealed that tests were not conducted in the months of July, October, and December 2011. Tests were also not conducted January 2012.

Based on observation, document review, and interview, the facility failed to test and maintain its exit signs. This was evidenced by the lack of documentation provided for monthly and annual testing of its exit signs and exit signs that failed to stay illuminated when tested. This affected one of eight outpatient buildings and could potentially result in exit signs failing to stay illuminated to guide the building's occupants to safety.

7.10.9 Testing and Maintenance.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 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:

1. During document review on 4/27/12, at 9:30 a.m., the facility failed to provide documentation for monthly inspections or monthly and annual testing of its exit signs at Cardiac Rehabilitation, Feather River Surgery, the Urology Clinic, and the Urgent Care Center. ES1 confirmed that the monthly and annual testing was not being done at those locations.

During a tour of the facility with Engineering Staff, exit signs were tested.

Feather River Surgery
2. On 4/25/12, at 1:55 p.m., the exit sign located near the Pathology Pick-up Room did not stay illuminated when its internal battery back-up was tested.

3. On 4/25/12, at 2:03 p.m., the exit sign located near the Clean Utility Room did not stay illuminated when its internal battery back-up was tested.

Based on observation, document review, and interview, the facility failed to maintain all fire alarm system devices to provide audible notification to staff in all locations in accordance with 2000 NFPA 101. This was evidenced by an audible alarm device that failed to function in one of six smoke compartments on the first floor at the Fremont Medical Center. This could potentially result in the alarm not being heard by staff which may cause a delay in response to the fire emergency.
This was also evidenced by the failure to properly reset the fire alarm panel to transmit all fire alarm activity during testing at the Feather River Surgery Center and Urology Clinic. This affected all staff and residents in two of two smoke compartments at the Feather River Surgery Center and could potentially result in the monitoring company failing to receive notification of fire alarm activation.

NFPA 101 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."

Findings:

During fire alarm testing with Engineering Staff, fire alarm devices were tested.

Fremont Medical Center
1. On 4/26/12, at 1:48 p.m., the smoke detector near Patient Room 114 was activated. The cross corridor doors released from their magnetic hold-open devices and the alarm audible devices could be heard in other areas on the first floor. No audible alarm could be heard in smoke compartment 1.5. The manual pull station was activated with the same results. This smoke compartment only had one chime which was located at the Nurses' Station. After ES3 tapped the alarm audible device, it began to work.

Feather River Surgery Center/Urology Clinic
On 4/25/12, between 4:59 p.m. and 5:13 p.m., six fire alarm devices were tested.
On 4/26/12, between 2:19 p.m. and 2:36 p.m., three fire alarm devices were tested.

2. On 4/27/12, at 9:30 a.m., the facility provided the activity report for the fire alarm testing at the Feather River Surgery Center and the Urology Clinic which are located in the same building. This activity report showed only the first alarm activation on 4/25/12 at 4:59 p.m.
No fire alarm activation activity was received by the monitoring company on 4/25/12 after 4:59 p.m. through 4/26 at 3:16 p.m. at the Feather River Surgery Center/Urology Clinic.


When asked why fire alarm activity report did not show all alarm devices tested, ES1 stated that the fire alarm vendor would be contacted and would provide that information at a later time.
Documentation was provided on 5/2/12, at 11:19 a.m., from ES1 from the fire alarm vendor which stated that:

"The panel configuration at the above referenced is a main fire alarm panel with a four zone slave digital communicator. These units operate in conjunction with one another, but are reset independently. Resetting the fire alarm panel does not reset the communicator. A clear fire alarm panel does not mean the digital communicator has been reset.

A. "On 4/25, the scheduled timer test was not received on the designated telephone line. The "fail to communicate" signal was transmitted via the other telephone line, signifying that one of the two telephone lines had failed to transmit the test signal. The fact that the 'fail to communicate' signal was received at the central station showed that the panel was communicating on the remaining telephone line with good service."

B. "On 4/25, at 3:35 p.m., the system was put on test".

C. "At 4:59:07, a fire trouble was received at the central station".

D. "At 4:59:10, a fire trouble was received at the central station, which was the telephone line trouble that caused the original 'fail to communicate" signal'".

E. "The fire alarm panel was reset and cleared of the alarm condition, but the digital communicator was not reset and the alarm did not clear".

F. "The "failed to communicate" signal was cleared when the panel communicated on the unaffected phone line".

G. "The monitoring station software correctly identified the digital communicator as still in an alarm condition and generated a reminder every hour".

H. "On 4/26 at 3:16:40 a "fire restoral"signal was received, and the event log cleared".

During an interview with ES1 on 4/27/12, between 1:00 p.m. and 2:00 p.m., when asked, Staff ES1 stated that the facility did have a policy to dial 911 in the event of a fire. This surveyor reviewed Policy PP# EOC 201 for Code Red guidelines. This policy stated that the emergency numbers to call in a fire alert would be 911 and the Main Campus phone numbers.

Based on record review and interview, the facility failed to provide documentation of maintenance, inspection, and testing of smoke detectors in accordance with 2000 NFPA 72, 7-3.2.1.. This was evidenced by the failure to provide documentation for smoke-sensitivity testing. This affected all staff and patients at four of eight offsite outpatient services: the Feather River Surgery Center, the Urology Clinic, the Urgent Care Center, and the Cancer Center. This could potentially result in smoke detector nuisance alarms or no alarms in the event of fire or smoke.

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 with Engineering Staff, documentation for fire alarm system testing was reviewed.

On 4/26/12, at 8:13 a.m., the facility failed to provide documentation indicating that the smoke detectors had been tested for sensitivity within the past two years at the following locations:
1. Feather River Surgery and the Urology Clinic
2. Urgent Care Center

When asked, ES1 stated that the vendor would be contacted and the documentation provided, if available.


29753

Findings:

Cancer Center
During record review on 4/27/12, smoke detector sensitivity test documents were requested.

3. At 8:28 a.m., there were no documents available for review for the Cancer Center.
When interviewed, ES 3 stated he was unaware of the requirement.

Based on document review and staff interview, the facility failed to inspect, test, and maintain its automatic sprinkler system in accordance with 2000 NFPA 101, 4.6.12 and 1998 NFPA 25, 2-3 and table 2-1. This was evidenced by a lack of documentation provided for the annual sprinkler system inspection, sprinklers that were painted or loaded with debris, and noted deficiencies on an annual report that had not yet been repaired and the facility failed to provide documentation for one of four quarterly testings of the sprinkler system. These deficient practices affected three of five floors at Rideout Memorial Hospital, one of five floors at Fremont Medical Center, and one of eight outpatient services buildings and could potentially result in the spread of smoke and/or fire.

4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

Findings:

Urgent Care Center
1. During record review on 4/27/12, at 9:30 a.m., the facility failed to provide documentation for the annual sprinkler system inspection and testing. ES1 stated that they would contact the vendor and if the testing had been done, the documentation would be provided to this surveyor.
During a tour of the facility with Engineering Staff on 4/25/12, at 4:15 p.m., the sprinkler system riser was inspected. There was no sprinkler system inspection certification tag visible on the riser.


29753

NFPA 13, 1999 Edition
5-9.3.3 Minimum Distance from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from an end wall. The distance from the wall to the sprinkler shall be measured perpendicular to the wall.

NFPA 25, 1998 Edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

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

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

Findings:

During a tour of the facilities with Engineering Staff, the sprinklers were observed.

Rideout Memorial Hospital
1. On 4/24/12 at 9:41 a.m., there was paint on the deflector in the Pharmacy bathroom.

2. On 4/24/12 at 10:08 a.m., there was paint on the deflector above the stalls in the Ladies' Public Restroom in Four Main.

3. On 4/24/12 at 10:09 a.m., there was paint on the deflector above the stalls in the Men's Public Restroom in Four Main.

4. On 4/24/12 at 10:35 a.m., there was paint on the deflector in the Four Main Locker Room.

5. On 4/24/12 at 10:44 a.m., one of two sprinklers in Room 475 was loaded with debris.

6. On 4/24/12 at 10:46 a.m., two of two sprinklers in Room 497 were loaded with debris.

7. On 4/24/12 at 10:55 a.m., there was paint on the deflector in the Janitor Closet across from Room 494.

8. On 4/24/12 at 10:56 a.m., there were paint and debris on the sprinkler in the bathroom of Room 493.

9. On 4/24/12 at 11:00 a.m., there was a bent deflector in the bathroom of Room 489.

10. On 4/24/12 at 11:02 a.m., there was paint on the deflector in the bathroom of Room 484.

11. On 4/24/12 at 11:18 a.m., approximately 95 percent of the deflector in the Patient Restroom across from Prep Room 1 (Second Floor) was covered with paint.

12. On 4/24/12 at 1:15 p.m., a sprinkler in the Second Floor Tower Surgery Clean Hold area (dumbwaiter closet) was located too close to the wall. The distance measured approximately 1-1/2 inches from the center line of the deflector. There was paint on the deflector.

13. On 4/24/12 at 2:10 p.m., two of two sprinklers in the First Floor X-ray Department Break Room were loaded with debris.

14. On 4/24/12 at 2:22 p.m., the sprinkler in the former Control Room in the Imaging Department Supervisor's Office was loaded with debris.

Fremont Medical Center
15. On 4/25/12 at 11:10 a.m., there was paint on the deflector in Room 2 of the Labor and Delivery Wing.

Cancer Center
16. On 4/26/12 at 4:15 p.m. during record review, documents revealed that the system failed to pass inspection. The Annual Inspection, Testing, and Maintenance Report dated 3/20/12 indicated the following: "(1) Head painted in Restroom. Adjust head in Hallway by ITV Room and (1) head in Conference Room #1. Add (1) head in Hallway going into Library head is 11'-0" off wall." The report also indicated: "10" Bell does not operate. Starts to ring then only vibrates."

When interviewed, ES 3 stated that the corrections have not yet been made.

17. On 4/27/12 at 8:27 a.m. during record review, documents revealed that quarterly testing was not conducted in Fourth Quarter 2011.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by a corridor door that required special knowledge to open the door from the egress side. This affected one of five floors at Rideout Memorial Hospital and could result in a delayed evacuation in the event of an emergency.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

3.3.121.1 Means of Egress, Accessible. A path of travel, usable by a person with a severe mobility impairment, that leads to a public way or an area of refuge.

7.2.1.5 Locks, Latches, and Alarm Devices.
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.

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.

Findings:

During a tour of the facility on 4/24/12, corridor doors were inspected throughout the facility.

Rideout Memorial Hospital
1. At 11:10 a.m., the corridor door separating Two North and Two West could only be opened by turning the door knob in a counter-clockwise direction. The door could not be opened when turning the knob in a clockwise direction. Staff ES2 confirmed that it was not working correctly.

Based on observation, the facility failed to provide proper storage for medical gas, in accordance with NFPA 99, as evidenced by the storage of full oxygen cylinders with empty oxygen cylinders in the same rack and by oxygen cylinders stored near bins of trash and biohazard materials within the same enclosure. This could result in staff not accessing the proper cylinder in the event of an emergency if empty and full cylinders are stored in the same rack, or could result in an oxygen-related hazard if oxygen cylinders are stored in the same enclosure with combustible materials. This affected one of five floors at Rideout Memorial Hospital.

NFPA 99, 1999 Edition

4-5.5.2.2 Storage of Cylinders and Containers Level 3.

(b) Nonflammable Gases.

1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.

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

8-3.1.11 Storage Requirements

(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:

1. A minimum distance of 20 ft (6.1 m), or

2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or

3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

Rideout Memorial Hospital
During a tour of the facilities with the Engineering Staff, the oxygen storage areas were observed.

1. On 4/24/12 at 10:20 a.m. in the CVICU, three empty oxygen E-tanks were stored in the same rack with eight full oxygen E-tanks. The cylinders were stored in the Biohazard Room approximately three feet from a trash bin and approximately four feet from a soiled linen bin.

2. On 4/24/12 at 11:20 a.m. in the Second Floor Tower PACU Soiled Utility Room, two empty oxygen E-tanks were stored in the same rack with one full oxygen E-tank. The cylinders were stored approximately 9 inches from a soiled linen bin in a storage room with one 45-gallon biohazard trash can, two 45-gallon trash cans, and a janitor cleaning cart.

Based on document review and interview, the facility failed to protect its anesthetizing locations in accordance with 1999 NFPA 99, the Standard for Healthcare Facilities. This was evidenced by the failure to maintain the relative humidity in four of four operating rooms. This affected one of five floors at Rideout Memorial Hospital and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review with Engineering Staff, documentation for humidity levels in operating rooms was reviewed.

1. On 4/27/12, at 1:30 p.m., documentation provided for humidity levels indicated that the levels dropped below 35 percent. The number of days per month in a three month period that humidity levels were below 35 percent in Operating Rooms 1, 2, 3, and 4 was as follows:

Rideout Memorial Hospital
Operating Room 1
January 2012: 16 days were below 35 percent. These days ranged between 20 and 33 percent relative humidity.

Operating Room 2
January 2012: 13 days were below 35 percent. These days ranged between 30 and 34 percent relative humidity.

Operating Room 3
January 2012: Nine days were below 35 percent. These days ranged between 28 and 33 percent relative humidity.

Operating Room 1
February 2012: 16 days below 35 percent. These days ranged between 24 and 33 percent relative humidity.

Operating Room 2
February 2012: Eight days were below 35 percent. These days ranged between 31 and 33 percent relative humidity.

Operating Room 3
February 2012: Nine days were below 35 percent. These days ranged between 25 and 32 percent relative humidity.

Operating Room 4
February 2012: Four days were below 35 percent. These days ranged between 24 and 30 percent relative humidity.

Operating Room 1
March 2012: Eight days were below 35 percent. These days ranged between 28 and 33 percent relative humidity.

Operating Room 3
March 2012: Six days were below 35 percent. These days ranged between 23 and 33 percent relative humidity.

Operating Room 4
March 2012: One day was documented at 30 percent relative humidity.

When asked what actions take place when the humidity levels are too low, ES1 stated that the mechanical ventilation system could not be adjusted to change the humidity levels.

Based on observation and interview, the facility failed to maintain its emergency generator in accordance with 1999 NFPA 99 and 1999 NFPA 110. This was evidenced by the facility's failure to maintain emergency generator alarm annunciators for four of six emergency generators. This was also evidenced by the faciliy's failure to provide battery-powered task lights for four of six emergency generators. This affected two of ten buildings observed and could result in delayed notification of a malfunctioning emergency generator and the generator location being left in darkness in the event of a power failure if the generator failed to function.

NFPA 99, 1999 edition
3-4.1.1.15 Alarm Annunciator.
A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12.)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel -- when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. [110:3-5.5.2]

NFPA 110, 5-3 Lighting.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Exception: This requirement shall not apply to units housed outdoors.


Findings:

During a facility tour with Engineering Staff, the facility's emergency generators were observed.

Freemont Medical Center
1. On 4/25/12, between 9:30 a.m. and 12:00 p.m., there was one remote emergency generator alarm annunciator observed in the Registration area of the building near the Front Lobby. At 11:30 a.m., the facility's three diesel fueled emergency generators were observed. When asked, ES 1 stated that the generators supplied power to different parts of the building and that there was just one annunciator that was at a constantly attended location.
2. During an inspection of the generator enclosure for two generators near the outside Medical Gas Storage, this surveyor observed that there was no battery back-up task lighting in that location

Rideout Memorial Hospital
3. On 4/27/12, at 10:25 a.m., the facility's generators were inspected. When asked, ES1 stated the there was one generator annunciator for the three generators each of which supplied power to different portions of the facility. ES3 stated that there used to be one in the boiler room for the smaller generator.

4. During an inspection of the generator enclosure for two generators, this surveyor observed that there was no battery back-up task lighting in that location.

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. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, powerstrips that were plugged into each other, the permanent use of extension cords, and improper clearance in front of electrical panels. This affected four of five floors at Rideout Medical Center, two of five floors at Fremont Medical Center, and three of eight Outpatient Services Buildings, and could potentially result in the ignition of fire.

NFPA 70 National Electrical Code, 1999.
110-12 requires that electrical equipment be installed in a neat and workman like manner.

110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less.

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.

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 facilities with Engineering Staff, electrical wiring and equipment were inspected.

Rideout Memorial Hospital
1. On 4/24/12, at 9:12 a.m., the Fifth Floor Mechanical Room had boxes stored in front the the 480 volt electrical panel. ES2 stated that it looked like they had been moved temporarily off of a shelf to that location.

2. On 4/24/12, at 10:50 a.m., an office in the former GI Lab on the Second Floor had an unapproved extension cord that traveled under a floor mat and was plugged into a power strip. ES2 removed the cord at that time.

3. On 4/24/12, at 11:00 a.m., the Data IT Room on the Second Floor had an extension cord that traveled across the floor to an air conditioner. ES2 removed the extension cord at that time.

4. On 4/24/12, at 2:48 p.m., the First floor Annex Registration had three power strips that were plugged into each other in a series.

5. On 4/24/12, at 2:45 p.m., the First Floor Sterile Processing Break Room had a power strip that was suspended above the floor that was transferring tension to the plug terminals that had a toaster, a coffee pot, and a microwave oven plugged into it.

6. On 4/27/12, at 1:20 p.m., the First Floor Dining Room/Coffee Bar had a power strip plugged into a duplex fixed wall receptacle. This power strip had a 15 amp blender and a coffee grinder plugged into it. Power to this power strip was supplied by an extension cord that traveled approximately 25 feet to a double gang outlet near another cash register. This outlet had a power strip plugged into it with an approximately 13 amp food warmer that was plugged into the power strip.

Fremont Medical Center
7. On 4/25/12, at 10:00 a.m., the First Floor Laboratory Outlet Processing had a flexible type extension cord that traveled from a plug receptacle and junction box attached to the surface of the wall under a counter. The junction box had become partially unattached from the wall. The flexible cord, that was attached to the wall, traveled through a cabinet to a plug outlet and junction box above the counter top.

8. On 4/24/12, at 10:15 a.m., the First Floor Old Blood Draw reception desk had two power strips that were chained together.

9. On 4/25/12, at 10:25 a.m., the Dietary Office on the First Floor had a power strip that was suspended above the floor and was transferring tension to the plug terminals.

10. On 4/25/12, at 10:33 a.m., the First Floor IT Server Room had a power strip that was suspended above the floor transferring tension to the plug terminals.

11. On 4/25/12, at 11:20 a.m., the Second Floor D Wing Office counter top had a microwave oven and two coffee pots plugged into a power strip.

Feather River Surgery
12. On 4/25/12, at 1:45 p.m., the First Floor Surgery Reception area had a power strip that was suspended above the floor transferring tension to the plug terminals. This power strip traveled through the opened door of a cabinet so that the door would pinch the cord if closed completely.


29753

Findings:

During a tour of the facilities with Engineering Staff, the electrical wiring and equipment were observed.

Rideout Memorial Hospital
13. On 4/24/12 at 9:23 a.m., three power strips were connected to each other. A computer item was plugged into Power Strip #1, which was connected to Power Strip #2. A charger was plugged into Power Strip #2. Power Strip #2 was connected to Power Strip #3, which had computer equipment plugged into it. The power strips were located in the Fourth Floor Pharmacy Department at the pharmacist work island.

14. On 4/24/12 at 10:25 a.m. in the CVICU, a microwave oven in the CVICU Nourishment Room was plugged into a power strip that was suspended approximately 14 inches above the floor.

15. On 4/24/12 at 10:35 a.m. in the CVICU, two crash carts, both with defibrillators, suction machines, and two chargers were plugged into power strips at the nurses island.

Policy & Procedure document titled "Crash Cart Care, Locking, Emergency Medications, Supplies and Exchange - Hospitalwide" stated, "When not in use, the defibrillator is to be plugged into a red outlet."

16. On 4/24/12 at 10:50 a.m., two power strips were connected to each other at the Four Main Nurses' Station. Computer equipment was plugged into Power Strip #1, which was connected to Power Strip #2, also with computer equipment plugged into it. Power Strip #2 was suspended approximately 5 inches above the floor.

17. On 4/24/12 at 12:50 p.m., a microwave oven and a coffee pot were plugged into a power strip in the PACU coffee and food storage area.

18. On 4/24/12 at 12:56 p.m., computer equipment was plugged into a power strip in the PACU Charting Office that was suspended approximately 23 inches above the floor.

19. On 4/24/12 at 2:01 p.m., two power strips were connected to each other in the Radiology Receptionist area. Power Strip #1 with computer equipment was connected to Power Strip #2 with chargers plugged into it.

20. On 4/24/12 at 2:05 p.m., two power strips were connected to each other in the Radiologist Receptionist area. Power Strip #1 with computer equipment was connected to Power Strip #2, also with computer equipment plugged into it. Power Strip #1 was suspended approximately 16 inches above the floor.

21. On 4/24/12 at 2:12 p.m., an apartment-size refrigerator and two chargers were plugged into a surge protector in the X-ray Department Break Room.

22. On 4/24/12 at 2:20 p.m., two power strips were connected to each other in Radiologist Reading Room 1. Power Strip #1 with computer equipment was connected to Power Strip #2, also with computer equipment plugged into it.

23. On 4/24/12 at 2:27 p.m., two power strips were connected to each other at the PACS and RIS desk. Power Strip #1 with computer equipment was connected to Power Strip #2, also with computer equipment plugged into it.

24. On 4/24/12 at 2:49 p.m., two power strips were connected to each other in smoke compartment 1.2. A picture printer and a charger were plugged into Power Strip #1. Computer equipment was plugged into Power Strip #2.

25. On 4/24/12 at 2:58 p.m., a toaster in Room 118 (Employee Break Room) was plugged into a power strip.

26. On 4/24/12 at 3:15 p.m., a 12-amp lab procedure table in the One West Lab Procedure Room was plugged into a surge protector.

27. On 4/24/12 at 3:23 p.m., a personal-size refrigerator and a television in the Hospitalist Sleeping Room were plugged into a power strip that was suspended approximately 19 inches above the floor.

28. On 4/26/12 at 1:55 p.m. in the Breast Imaging Area, a 3-amp heater was observed operating approximately 2-1/2 inches from a plastic trash can with a plastic liner. The plastic trash can and liner were hot to the touch.

29. On 4/26/12 at 2:03 p.m. in the Stereotactic Room of the Breast Imaging Center, there were two approximately 1/8 inch frayed speaker wires above the seating area. An empty oxygen E-tank was in the right corner of the room.

Cancer Center
30. On 4/24/12 at 4:07 p.m., a power strip was plugged into an extension cord, which was connected to another power strip. Power Strip #1 was plugged into an extension cord. The extension cord was connected into Power Strip #2 with computer equipment plugged into it. The power strips and extension cord were located in an office near the area temporarily closed due to construction.

Fremont Medical Center
31. On 4/25/12 at 10:32 a.m. in the second Floor Labor and Delivery Unit, three power strips were connected to each other. A microwave oven, small refrigerator, and computer equipment were plugged into Power Strip #1, which was connected to Power Strip #2 with computer equipment. Power Strip #2 was connected to Power Strip #3 with a 3-amp heater, adding machine, and a lamp. The power strips were located in the Director of Perinatal Care's office.

32. On 4/25/12 at 11:50 a.m. in the First Floor Receiving Area, two power strips were banded together with two zip ties. A charger was plugged into Power Strip #1. Two chargers were plugged into Power Strip #2.

Outpatient Perinatal Programs
33. On 4/25/12 at 1:47 p.m. in the RN Office, a 12.5-amp heater and a charger were plugged into a 3-plug extension cord. The extension cord was connected to a power strip with computer equipment plugged into it.