HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of its building construction as evidenced by unsealed penetrations. This affected three of ten buildings and could result in the spread of smoke or fire to other locations in the facility.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, Engineering Staff 1, and the Chief Health Facility's Manager (CHFM) between 6/8/15 and 6/12/15, the building construction was observed.

Rideout Hospital
6/9/15
1. At 8:34 a.m., there were two 1/2 inch unsealed penetrations in the south wall and one 1/2 inch unsealed penetration in the west wall of Room 2115 (2W).

2. At 1:32 p.m., there was an approximately 2 1/2 inch unsealed penetration in the south outside wall of the chemistry station in the Lab. There were approximately 15 wires coming through the unsealed penetration with a gap of approximately 1/2 inch around the wires.



29753

Cancer Center
6/9/15
1. At 9:12 a.m., there were two 1/2 inch unsealed penetration in the northeast wall of the Equipment Room inside of the PET CT Scanner Room.

Nuclear Medicine
6/10/15
2. At 10:42 a.m., there was a 1/2 inch unsealed penetration in the east wall of the patient changing area.

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to latch or were impeded from closing. This affected two of ten buildings and could result in a delay to contain smoke or fire to a room.

NFPA 101 Life Safety Code, 2000 Edition
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 3/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.4. All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

NFPA 101, Life Safety Code
A.19.3.6.3.3. Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, and CHFM between 6/8/15 and 6/12/15, the doors in the facility were observed.

Rideout Hospital
6/8/15
1. At 4:04 p.m., the corridor door to Room 312 (3 west) did not latch when tested. Two attempts were made without the door latching.

2. At 4:09 p.m., the self-closing corridor door to Room 3076 did not latch when tested. Three attempts were made without the door latching.

3. At 4:17 p.m., the corridor door to Room 310 was impeded from closing by a chair located in front of the door.

4. At 4:21 p.m., the self-closing door to Room 3084 (Bio-hazard Room) did not latch when tested. Three attempts were made without the door latching.

6/9/15
5. At 8:49 a.m., the self-closing double doors to the 2 North Linen Room did not latch when tested.

6. At 10:21 a.m., the double doors to the Operating Room Admitting Office were impeded from closing by a trash can located in front of each door.

Fremont
6/11/15
7. At 8:30 a.m., the self-closing corridor door to the Security Office did not latch when tested. Three attempts were made without the door latching.

Based on observation, the facility failed to maintain all exits free and clear of obstructions as evidenced by a storage bin that was placed at an exit door. This could result in delayed evacuation in the event of an emergency, and affected one of ten buildings.

NFPA 101, Life Safety Code, 2000 Edition
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.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

Findings:

During a tour of the facility with Engineering Staff I on 6/10/15, the egress paths were observed.

Feather River Surgery Center
6/10/15
1. At 8:58 a.m., there was a trash bin that was stored near the exit door near the Housekeeping Room and the Biohazard Waste Storage Room. The floor-level exit sign was obscured from view because of the placement of the trash bin.

Based on observation and interview, the facility failed to maintain the integrity of the fire-resistance rated construction of its smoke barrier walls as evidenced by an unsealed penetration. This penetration could result in a reduction in the facility's staff ability to protect in place and increase the risk of injury to the the patients due to smoke and/or fire. This affected one of ten buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, CHFM, and Engineering Staff 1 on 6/10/15, the smoke barrier walls were observed and a staff person was interviewed.

Rideout Hospital
6/10/15
1. At 1:40 p.m., there was an approximately 2 feet by 4 inch section of the drywall in the south smoke barrier wall near the Emergency Department and expansion wall.

At 1:42 p.m., the CHFM said that he was not aware that the section of drywall that was missing. A staff person was called to repair the missing section.

Based on observation, the facility failed to maintain a hazardous area greater than 50 square feet in size, as evidenced by doors that were not equipped with a self-closing device. This could result in the spread of smoke and/or fire and affected two of ten buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not morethan 48 in. (122 cm) above the bottom of the door.

NFPA 101, Life Safety Code, 2000 Edition
8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, CHFM, and Engineering Staff 1 on 6/9/15, all hazardous areas were observed.

Rideout Hospital
6/9/15
1. At 8:54 a.m., there was no self-closing mechanism on the door to Room 2135 (2N). The room contained an approximately 300 gallon container full of linen wrapped in plastic bags and was greater than 100 square feet.


29753

Cancer Center
6/9/15
2. At 9:01 a.m., there was no self-closing mechanism on the door to the Medical Records Room. The room measured greater than 50 square feet in size and contained over 50 paper record files.

Based on observation and interview, the facility failed to maintain its exit signs. This was evidenced by exit signs equipped with an internal power source that failed to illuminate when tested. This affected one of ten buildings and could result in a delay in evacuation due to limited exit sign visibility during an electrical emergency.

NFPA 101 Life Safety Code, 2000 edition
7.10.9.2 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 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a facility tour with the Life Safety Officer, Emergency Preparedness Staff 1, and the CHFM between 6/8/15 and 6/12/15, the exit signs equipped with a battery back-up power supply were observed and tested, documents were reviewed, and a staff person was interviewed.

Rideout Hospital
6/8/15
1. At 2:40 p.m., the exit sign equipped with an internal power source on the 4th floor near the Pharmacy elevator did not illuminate when the test button was pressed.

6/9/15
2. At 10:33 a.m., the exit sign equipped with an internal power source on the 1st floor near the exit to the loading dock did not illuminate when the test button was pressed.

At 10:47 a.m., the CHFM said during an interview that the exit signs were tested monthly and annually.

6/12/15
At 4:11 p.m., the exit sign testing documents indicated that the signs were tested monthly for 30 seconds and annually for 90 minutes.

Based on observation and interview, the facility failed to ensure that the fire alarm system was installed to cover all areas and properly maintained. This was evidenced by a strobe that failed to illuminate and the absence of automatic notification devices located on one section of two floors in the Fremont Building. This had the potential for occupants to not be notified of smoke or fire in the building, increasing the risk for injury. This affected one of ten buildings.
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NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protective's
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Findings:

During a tour of the facility with the Life Safety Officer, Engineer Staff 2, Emergency Preparedness Staff 1, and CHFM on 6/8/15 to 6/12/15, the fire alarm system was tested and observed, and staff were interviewed.

Rideout Hospital
6/10/15
1. At 8:56 a.m., the strobe near the Locker Room in the Pharmacy did not illuminate when tested.

Based on observation and interview, the facility failed to maintain its smoke detectors and provide smoke detectors in all required areas as evidenced by a smoke detector that failed to activate the fire alarm system when tested, and by the failure to provide a smoke detector on both sides of smoke barrier doors. Smoke detectors that fail and that are not in all required areas could potentially cause harm to patients by failing to notify the occupants of the presence of smoke. This affected two of ten buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

19.2.2.2.6* Any door in an exit passageway, stairway enclosure,
horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the
entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly
releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-3.2* Smoke detectors shall be installed in all areas where required by applicable laws, codes, or standards.

2-3.4.1.2 If the intent is to protect against a specific hazard, the detector(s) shall be permitted to be installed closer to the hazard in a position where the detector can intercept the smoke.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, and the CHFM between 6/8/15 and 6/12/15, the smoke detectors were tested, smoke detectors were noted, and a staff member was interviewed.

Rideout
6/10/15
1. At 9:48 a.m., smoke detector 2537 in the Lab near the Receiving Station did not activated when tested with canned smoke. Four attempts were made without the alarm being activated.

Fremont
2. At 9:06 a.m., on the first floor Labor and Delivery there was no smoke detector on the north side of the cross corridor smoke barrier doors near Patient Room 118.
There was a ceiling smoke detector near Patent Room 116 on the south side of the same smoke barrier doors. There were two additional smoke detectors located on both sides of the cross corridor smoke barrier doors near the Room Identified on the facility diagram as the Breakroom.
These cross corridor doors were being held open with magnetic hold open devices that would release the doors upon activation of the manual pull station or smoke detection.
This affected one of six smoke compartments on the first floor of the Fremont Building. The census was 22 patients in that smoke compartment.

At 9:45 a.m., the facility decided to initiate a fire watch until they installed smoke detectors in the occupied area.

At 11:15 a.m., the facility installed battery-powered smoke detectors in all of the rooms and the corridor of the occupied compartment on the first floor.

At 1:35 p.m. to 3:28 p.m., 15 staff were interviewed and asked what action they would take if they heard the battery-powered smoke detector beep and 15 of 15 staff would activate the fire alarm system and follow the facility's fire protocols (RACE- Rescue, Alarm, Contain, Evacuate, PASS-Pull, Aim, Squeeze, Sweep, and Code RED, code word for fire).

Fremont
6/12/15
3. At 8:38 a.m., a test of the a battery-powered smoke detector on the first floor caused staff to come and check the problem immediately and staff appeared to be prepared for a fire.

At 8:50 a.m., the facility abated the fire watch.

Based on observation, interview, and document review, the facility failed to maintain its automatic sprinkler system. This was evidenced by failing to test one main drain and by no sign displayed near an inspector's test valve. This could result in the failure of the sprinkler system in the event of a fire and a delay locating the inspector's test valve and affected one of ten buildings.
NFPA 101, Life Safety Code, 2000 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
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.
2-3.2 Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

NFPA 25 (1998 Edition), 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the
pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
1-4.2 The responsibility for properly maintaining a water-based fire protection system shall be that of the owner(s) of the property. By means of periodic inspections, tests, and maintenance, the equipment shall be shown to be in good operating condition, or any defects or impairments shall be revealed.
Inspection, testing, and maintenance shall be implemented in accordance with procedures meeting or exceeding those established in this document and in accordance with the manufacturer's instructions. These tasks shall be performed by personnel who have developed competence through training and experience.
Exception: Where the owner is not the occupant, the owner shall be permitted to pass on the authority for inspecting, testing, and maintaining the fire protection systems to the occupant, management firm, or managing individual through specific provisions in the lease, written use agreement, or management contract.

NFPA 13 Standard for the Installation of Sprinkler Systems 1999 Edition
5-5.5.3* Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.

NFPA 13, Standard for the installation of sprinkler systems, 1999 edition
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

Findings:

During a tour of the facility with the Life Safety Officer, Engineer Staff 1, Emergency Preparedness Staff 1, and CHFM on 6/8/15 to 6/12/15, the sprinkler system was observed, records were reviewed, and staff were interviewed.

Rideout Hospital
6/9/15
1. At 11:25 a.m., there was no identification sign near the inspector's test valve near the kitchen dock.

At 11:26 a.m., the CHFM said during an interview that he was unable to locate the sign.


29753

Cancer Center
6/9/15
2. At 9:07 a.m., the drop-down sprinkler in the Storage Room located near the Reading Room was obstructed by an approximately 24" by 4" light fixture. The distance between the light fixture and the sprinkler measured less than two inches and impeded the sprinkler spray pattern.

Rideout Hospital
6/10/15
3. At 3:52 p.m., there was no documented evidence of testing the 2 inch main drain for the dietary system for 2014 and 2015. The documents revealed that the sprinkler inspection, testing, and maintenance were performed on 3/13/15 and revealed that the "6 inch Dietary System" failed to pass inspection. The document indicated that the "2 inch main drain cannot be tested." It was noted on the document, "Overflows the floor sink when only opened 1/4 of the way, floods office." A follow-up inspection, testing, and maintenance document dated 4/24/15, indicated, "2 inch main drain cannot be tested. It was noted on the document, "Overflows floor sink when only opened 1/4 of the way, floods office. Original condition." The document further indicated that the system passed inspection and "All corrections completed 4/24/15."

At 3:53 p.m., Staff 1 said during an interview that he was unable to locate any documented evidence that the main drain was tested.

Based on observation, the facility failed to maintain all fire extinguishers as evidenced by two fire extinguishers that were obscured from view. This could result in a delay in extinguishing a fire during a fire emergency. This affected two of ten buildings.
NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

1.5.7 Portable fire extinguishers other than wheeled extinguisher shall be installed securely on the hanger, or in the bracket supplied by the extinguisher manufacturer, or in a listed bracket approved for such purpose, or placed in cabinets or wall recesses. Wheeled fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with facility with the Life Safety Officer, Emergency Preparedness Staff 1, Engineering Staff 1, and CHFM on 6/9/15, the fire extinguishers were observed.

Cancer Center
6/9/15
1. At 10:13 a.m., inside the Wellness Center, the fire extinguisher was mounted in a recessed cabinet. There was no sign designating the location of the fire extinguisher. Further, there was no sign on the corridor door designating the location of the fire extinguisher inside the room.

2. At 10:15 a.m., inside the Staff Lounge near the Wellness Center, there was no sign on the corridor door designating the location of the fire extinguisher inside the room.



26387

Rideout
6/9/15
4. At 2:21 p.m., the fire extinguisher in the Radiology Electrical Room was not mounted securely. The fire extinguisher was hanging on the bracket by the back portion of the handle.

Based on observation, the facility failed to maintain the storage of oxygen cylinders as evidenced by the storage of empty and full cylinders in the same rack. This could result in confusion and delay if a full cylinder is needed hurriedly in the event of an emergency, and affected one of ten buildings.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-5.5.2.2 Storage of Cylinders and Containers
(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.

NFPA 99 Standard for Health Care Facilities (1999 Edition)
21-1.2.6 OGA Publications, Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.
Pamphlet G-4 1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.
Finding:

During a tour of the facility with Engineering Staff 1 on 6/9/15, the oxygen storage rack was observed.

Mobile Pet Unit
6/9/15
1. At 8:42 a.m., there was an oxygen cylinder storage rack that contained 5 oxygen E-cylinders in the Mobile Pet Unit. One of the 5 cylinders was empty.

Based on observation and interview, the facility failed to provide clear and unimpeded acess to emergency oxygen valves as evidenced by equipment placed in front of an emergency oxygen valve. This could potentially delay shutting off oxygen during a fire emergency and cause potential harm to patients. This affected one of ten buildings.
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NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled ' ' SOURCE VALVE FOR THE (SOURCE NAME). ' '
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, and the CHFM on 6/10/15, the emergency oxygen shut off valves were observed and a staff person was interviewed.

Rideout Hospital
6/10/15
1. At 8:42 a.m., the oxygen shut off valve near Room 491 was impeded from access with an unattended bed in front of the device.

At 8:43 a.m., Registered Nurse 1 said during an interview that the Room was being cleaned and they just put the bed there until they were done cleaning.

Based on observation, the facility failed to maintain its smoke barrier walls as evidenced by an unsealed pipe traveling through a wall. This affected one of ten buildings, and could result in the spread of smoke or fire to other portions of the building.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, and CHFM on 6/9/15, the facility's smoke barrier walls were observed.

Rideout Hospital
6/9/15
1. At 2:48 p.m., there was an approximately one inch orange conduit pipe that was unsealed traveling through the west wall of the IDF Room.

Based on document review and interview, the facility failed to maintain the emergency generators as evidenced by weekly inspections that were not conducted for 14 of 52 weeks. This could result in failure of the generators in the event of an emergency and affected 10 of 10 buildings.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4 Operational Inspection and Testing.
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak
load shaving, such use shall be recorded and shall be permitted to be
substituted for scheduled operations and testing of the generator set,
provided the appropriate data are recorded.

Finding:

During document review with Engineering Staff 1 on 6/11/15, the generator inspection records were reviewed and a staff person was interviewed.

ALL FACILITIES
A review of the emergency generator maintenance documents on 6/11/15, indicated the following:

1. At 2:26 p.m., there was no documented evidence of a weekly inspection during the weeks of 1/28/15, 3/25/15, 4/1/15, 4/15/15, and 4/29/15.

2. At 2:30 p.m., there was no documented evidence of a weekly inspection during the weeks of 5/11/15, 5/18/15, 5/25/15, and 5/25/15.

3. At 2:32 p.m., there was no documented evidence of a weekly inspection during the weeks of 9/22/14, 9/29/14, 10/14/14, and 10/21/14.

4. At 2:35 p.m., there was no documented evidence of a weekly inspection during the week of 12/31/14. No further documentation was provided during the survey.

At 2:38 p.m., Staff 1 said during an interview that he was unable to locate any documented evidence of an inspection for the weeks missing. He said that all of the information that he was aware of was in the books provided.

Based on observation, the facility failed to maintain its electrical equipment as evidenced by appliances plugged into a surge protectors, surge protectors plugged into other surge protectors, utilizing extension cords, and utilizing a plug adapter. This increases the risk of an electrical fire and potential harm to the patients. This affected two of ten buildings.
NFPA 101, Life Safety Code, 2000 Edition
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, Engineering Staff 1, and the CHFM between 6/8/15 and 6/12/15, the electrical system components were observed.

Rideout Hospital
6/8/15
1. At 3:48 p.m., there were two black extension cords in the 3 Main Information Room that were plugged into a three plug adapter without over current protection.

6/9/15
2. At 8:17 a.m., there was a surge protector that was plugged into another surge protector under the desk of the 2 North Nursing Station.

3. At 10:29 a.m., the Medication Room Rapids machine was plugged into a surge protector in the Emergency Department.

4. At 10:38 a.m., there was a refrigerator that was plugged into a surge protector in the Central Supply Supervisor's Office.

5. At 10:47 a.m., there was a surge protector that was plugged into another surge protector in the Pathologist's Office.

6. At 1:08 p.m., there was a blue extension cord in use in the Chef's Office in the kitchen.

7. At 1:45 p.m., there was an extension cord in use in the Lab Break Room.

8. At 2:06 p.m., there was a surge protector that was plugged into another surge protector in the X-ray Breakroom.

9. At 2:28 p.m., there was a black extension cord in use near the north wall of the Microbiology Room.



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Rideout Hospital
6/9/15
10. At 2:54 p.m., there was a refrigerator that was plugged into a surge protector in the Rehab Room.

11. At 3:09 p.m., there was a 5.5 amp blanket warmer and a printer that were plugged into a surge protector in the Cardiology Reception Area.

Cancer Center
6/10/15
12. At 9:35 a.m., the computer equipment was plugged into a surge protector that was connected to an Uninterruptible Power Source in the Radiation Oncology Dosimetry Office.

13. At 10:03 a.m., there were two vending machines that were plugged into a surge protector in the Staff Break Room.

Based on observation, the facility failed to maintain the installation of alcohol-based hand rub dispensers. This was evidenced by the mounting of an alcohol-based hand rub dispenser over an ignition source. This affected one of ten buildings and could result in an alcohol-based hand rub ignited fire.

Findings:

During a tour of the facility with Life Safety Officer, Emergency Preparedness Staff 1, and the CHFM on 6/9/15, the alcohol-based hand rub dispensers in the facility were observed.

Rideout Hospital
6/9/15
1. At 10:39 a.m., the alcohol-based hand rub dispenser in the Central Supply Supervisor's Office was mounted approximately two inches above a light switch.

Based on observation and interview, the facility failed to maintain the integrity of the fire-resistance rated construction of its smoke barrier walls as evidenced by an unsealed penetration. This penetration could result in a reduction in the facility's staff ability to protect in place and increase the risk of injury to the the patients due to smoke and/or fire. This affected one of ten buildings.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

NFPA 101, Life Safety Code (2000 Edition)
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, CHFM, and Engineering Staff 1 on 6/10/15, the smoke barrier walls were observed and a staff person was interviewed.

Rideout Hospital
6/10/15
1. At 1:40 p.m., there was an approximately 2 feet by 4 inch section of the drywall in the south smoke barrier wall near the Emergency Department and expansion wall.

At 1:42 p.m., the CHFM said that he was not aware that the section of drywall that was missing. A staff person was called to repair the missing section.

Based on observation and interview, the facility failed to ensure that the fire alarm system was installed to cover all areas and properly maintained. This was evidenced by a strobe that failed to illuminate and the absence of automatic notification devices located on one section of two floors in the Fremont Building. This had the potential for occupants to not be notified of smoke or fire in the building, increasing the risk for injury. This affected one of ten buildings.
.
NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protective's
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated.

NFPA 72, National Fire Alarm Code (1999 Edition)
Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

Findings:

During a tour of the facility with the Life Safety Officer, Engineer Staff 2, Emergency Preparedness Staff 1, and CHFM on 6/8/15 to 6/12/15, the fire alarm system was tested and observed, and staff were interviewed.

Rideout Hospital
6/10/15
1. At 8:56 a.m., the strobe near the Locker Room in the Pharmacy did not illuminate when tested.

Based on observation, the facility failed to maintain all fire extinguishers as evidenced by two fire extinguishers that were obscured from view. This could result in a delay in extinguishing a fire during a fire emergency. This affected two of ten buildings.
NFPA 101, Life Safety Code, 2000 Edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition) 4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

1.5.7 Portable fire extinguishers other than wheeled extinguisher shall be installed securely on the hanger, or in the bracket supplied by the extinguisher manufacturer, or in a listed bracket approved for such purpose, or placed in cabinets or wall recesses. Wheeled fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with facility with the Life Safety Officer, Emergency Preparedness Staff 1, Engineering Staff 1, and CHFM on 6/9/15, the fire extinguishers were observed.

Cancer Center
6/9/15
1. At 10:13 a.m., inside the Wellness Center, the fire extinguisher was mounted in a recessed cabinet. There was no sign designating the location of the fire extinguisher. Further, there was no sign on the corridor door designating the location of the fire extinguisher inside the room.

2. At 10:15 a.m., inside the Staff Lounge near the Wellness Center, there was no sign on the corridor door designating the location of the fire extinguisher inside the room.



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Rideout
6/9/15
4. At 2:21 p.m., the fire extinguisher in the Radiology Electrical Room was not mounted securely. The fire extinguisher was hanging on the bracket by the back portion of the handle.

Based on observation, the facility failed to maintain its smoke barrier walls as evidenced by an unsealed pipe traveling through a wall. This affected one of ten buildings, and could result in the spread of smoke or fire to other portions of the building.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Life Safety Officer, Emergency Preparedness Staff 1, and CHFM on 6/9/15, the facility's smoke barrier walls were observed.

Rideout Hospital
6/9/15
1. At 2:48 p.m., there was an approximately one inch orange conduit pipe that was unsealed traveling through the west wall of the IDF Room.