HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations on the walls and ceilings at Mills Health Center that affected 2 of 6 floors in Building-1, 1 of 6 floors in Building-2, 2 of 5 floors in Building-3, and 1 of 2 floors in Building-4. This could result in the spread of fire and smoke and had the potential of harming patients, visitors, and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the facility's walls and ceilings were observed.

Mills Health Center, San Mateo - 4th Floor in Building-3 on 3/12/2012:
1. At 3:36 p.m., the Scheduling Center had 5 penetrations to a wall. The penetrations were located on the side of the wall by the cubicles partitions and were going through the wall to the break room. Two penetrations measured approximately 1-inch each and three penetrations measured approximately 1/2-inch each.

Mills Health Center, San Mateo - 2nd Floor in Building-1 on 3/13/2012:
2. At 8:45 a.m., the Emergency Department had a penetration to a wall in Room 2178. The penetration was located by a monitor and it measured approximately 1/2-inch.

3. At 8:52 a.m., the Emergency Department had 2 penetrations to a wall by the restroom, Room 2160. The penetrations measured approximately 1/2-inch each.

4. At 8:58 a.m., the Radiology Department had a penetration to a wall in exam Room 2143. The penetration was located adjacent to the door and was due to a detached door knob pad. The penetration measured approximately 2 x 2-inches.

Mills Health Center, San Mateo - 1st Floor in Building-4 on 3/13/2012:
5. At 10:02 a.m., the Pool Rehabilitation Area had 14 penetrations to a wall in Storage Room 1404. The penetrations measured approximately 1/2-inch each.

6. At 10:03 a.m., the Pool Rehabilitation Area had 6 penetrations to a wall in Storage Room 1402. The penetrations measured approximately 1/2-inch each.

Mills Health Center, San Mateo - 1st Floor in Building-3 on 3/13/2012:
7. At 10:16 a.m., the Adult Rehabilitation Unit had a penetration to a wall in Storage Room 1311. The penetration measured approximately 1-inch.

8. At 10:20 a.m., the Adult Rehabilitation Unit had a penetration to the ceiling in a storage room by Restroom 1331. The penetration measured approximately 1/2-inch and it surrounded an escutcheon ring.

Mills Health Center, San Mateo - 1st Floor in Building-2 on 3/13/2012:
9. At 10:36 a.m., the Infusion Center, located in the Cancer Center, had a penetration to a wall in Storage Room 1210. The penetration measured approximately 4 x 1-inches.

Mills Health Center, San Mateo - 1st Floor in Building-1 on 3/13/2012:
10. At 11:23 a.m., the Audiology Services Unit had 3 penetrations to a wall by the wheelchair storage area. The penetrations measured approximately 1/2-inch each.

Based on observation, the facility failed to maintain corridor doors as evidenced by a corridor door that failed to close and latch when tested. This affected occupants on 1 of 6 floors at the Mills-Peninsula Medical Center. 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.

Findings:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, corridor doors were inspected throughout the facility.

Mill-Peninsula Medical Center - on 3/12/12:
1. At 11:22 a.m., on the 4th floor West Wing, the corridor door to Patient Room 4776 could not be closed when tested by pulling the door shut. Staff confirmed that the door would not positively latch when closed.

Based on observation, the facility failed to maintain corridor doors to close and latch. This was evidenced by a door that failed to positive latch at Mills Health Center that affected 1 of 6 floors in Building 1. This could result in smoke and fire to travel throughout the facility in the event of a fire in the room.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the corridor doors were observed.

Mills Health Center, San Mateo - 5th Floor in Building-1 on 3/12/2012:
1. At 2:34 p.m., the Behavioral Health/Chemical Dependency Treatment Unit had a door opening into the corridor from Room 5171 that failed to positive latch.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by unsealed vertical openings and a door opening into a vertical shaft that did not have a self-closing device and that did not positive latch. This affected 3 of 5 floors in Building 3 at Mills Health Center. This could result in the passage of smoke or fire from one floor to another.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the vertical openings in the facility were observed.

Mills Health Center, San Mateo - 1st Floor in Building-3 on 3/13/2012:
1. At 10:23 a.m., the Adult Rehabilitation Unit had two unsealed vertical openings in the IT Equipment Room 1316A. The first opening ran through the basement floor via an unsealed conduit that measured approximately 1/2-inch. The second opening ran through the 2nd floor via an unsealed j-box that measured approximately 2 x 2-inches.

2. At 10:25 a.m., the Adult Rehabilitation Unit had an unprotected vertical shaft opening inside the Housekeeping closet, Room 1316B. The door to the vertical shaft opening did not have a self-closing device and the door did not positive latch.

Based on observation, the facility failed to maintain the integrity of the smoke barrier fire resistance rated construction as evidenced by unsealed pipes, conduits and wires penetrating the smoke barrier walls in 1 of 5 floors in Building 3 and 1 of 6 floors in Building 1. This failure could result in the spread of smoke and fire, in the event of a fire and could result in potential harm to patients, staff and visitors.

NFPA 101, Life Safety Code (2000) Edition
8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, bus 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 staff on March 12, 2012 through March 14, 2012, the smoke barrier walls were observed.

1. Mills Health Center, San Mateo - Lower Level Building 3 on 3/13/12:
At 9:40 a.m., the smoke barrier wall above the corridor door entering Surgery Suite West Wing had two conduits in the left side of the wall with an approximately 1/4 inch penetration around each conduit.

2. At 10:05 a.m., the smoke barrier wall located between Operating Rooms 3 and 4, had two hot water lines one on the left side and one on the right side of the wall with an approximately 1/4 inch penetration around each line.

3. At 10:30 a.m., the wall above the main corridor door entering the Surgery Suite had a four inch unsealed sleeve and an approximately 1/2 inch penetration around a conduit both located in the left side of the wall.


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4. Mills Health Center, San Mateo - 5th Floor in Building-1 on 3/12/2012:
At 2:58 p.m., the Behavioral Health/Chemical Dependency Treatment Unit had a penetration to the smoke barrier ceiling "tunnel construction" by the clean utility Room 5172. The penetration measured approximately 1/2-inch.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in three smoke barrier walls. This affected 2 of 6 floors in the Mills-Peninsula Medical Center Building and could result in the spread of smoke or fire to other smoke compartments.

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 facility tour with staff on March 12, 2012, through March 15, 2012, the smoke barrier walls in the facility were observed.

Mill-Peninsula Medical Center - on 3/12/12:
1. At 10:58 a.m., on the 4th floor West Wing, the fire rated wall above the smoke barrier doors near NSA 700 was observed. There was a one inch penetration through the wall at that location. The opening had not been sealed on either side of the wall.

2. At 1:32 p.m., on the 2nd floor West Wing, the fire barrier wall above the smoke barrier doors near Room 2785 was observed. There were four pipe conduits approximately four inches in diameter each. The fire caulking had fallen out of one of the four pipe conduits. Staff confirmed that the pipe was unsealed.

3. At 1:36 p.m., on the 2nd floor West Wing, the rated wall above the smoke barrier doors near Room 2715 was observed. There were two fire bricks missing from the IT trough that penetrated the wall. The missing bricks left an opening in the wall approximately two inches by three inches.

Based on observation, the facility failed to maintain fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by one fire door leaf that was equipped with latching hardware but failed to latch when tested. This affected 1 of 6 floors in the Mills-Peninsula Medical Center and could potentially result in the spread of smoke and/or fire from one compartment to another.

NFPA 101, Life Safety Code, 2000 Edition
8.2.4.3 Doors.
8.2.4.3.1 Doors in smoke partitions shall comply with 8.2.4.3.2 through 8.2.4.3.5.
8.2.4.3.4* Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.
NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
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.

Findings:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, the fire/smoke barrier doors were inspected.

Mill-Peninsula Medical Center - on 3/14/12:
1. At 9:02 a.m., on the 2nd floor in the Operating Suite, the left hand leaf of the fire door in the OR Core by OR 10 failed to positively latch when released. Upon activation of the fire alarm system the fire doors in the Core released and closed.

Based on observation, the facility failed to maintain its hazardous areas. This was evidenced by doors without a self-closing device. This affected 1 of 6 floors in Building 1 and 1 of 6 floors in Building 2 at Mills Health Center. This had the potential to allow the spread of smoke and fire.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, hazardous areas were observed.

Mills Health Center, San Mateo - 4th Floor in Building 1 on 3/12/2012:
1. At 3:57 p.m., the Medical Records Room, located in the Cardiology Suite, had a door that did not have a self-closing device. The room was greater than 50 square feet and had an abundant amount of combustibles.

Mills Health Center, San Mateo - 3rd Floor in Building 2 on 3/12/2012:
2. At 4:37 p.m., the large storage room had a door that did not have a self-closing device. The room was greater than 50 square feet and had a large amount of combustible storage.

Based on observation, the facility failed to maintain stairways as evidenced by debris found throughout a stairwell at Mills Health Center, affected 1 of 3 stairway exits in Building 2. This had the potential of interfering with egress during a fire emergency, rendering the stairway unsafe or non-usable for patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.2 Stairs.
7.2.2.1 General. Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of this subsection.

7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15,2012, the stairwell egress were observed.

Mills Health Center, San Mateo - Building 2 on 3/12/2012:
At 3:10 p.m., Stairwell-5 had debris between the 4th and 5th Floors. The debris included trash, plastic wrappers, feces, and clothing.

Based on interview and observation, the facility failed to maintain the emergency exits, as evidenced by one exit discharge that was obstructed by a gurney in the Operating Suite. This deficient condition affected 1 of 6 floors in the Mills-Peninsula Medical Center. This could lead to a delay in evacuating the residents in the event of an emergency.

NFPA 101 Life Safety Code, 2000 edition
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with staff on March 12, 2012, through March 15, 2012, the emergency exits were observed.

Mills-Peninsula Medical Center on 3/14/12:
1. At 8:45 a.m., on the 2nd floor in the Operating Suite, the exit door was blocked by a gurney. There was an Exit sign posted over the door. Staff stated that a gurney would not fit through the door but that staff would use the door as an emergency exit.

Based on observation, the facility failed to maintain emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This affected 1 of 6 floors in Building-1, 1 of 5 floors in Building 3, and the generator room at Mills Health Center. This could delay evacuation and result in the inability to work on the generators during a power outage, potentially causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15,2012, the emergency lighting units were tested and observed.

Mills Health Center, San Mateo - 7th Floor in Building-1 on 3/12/2012:
1. At 2:05 p.m., the machine room had a battery powered emergency lighting unit that failed to illuminate on the 7th floor.

Mills Health Center, San Mateo - 3rd Floor in Building-3 on 3/12/2012:
2. At 4:45 p.m., Stairway-9 had a battery powered emergency lighting unit that failed to illuminate on the 3rd floor.

Mills Health Center, San Mateo - Generator Room on 3/13/2012:
3. At 11:52 a.m., the generator room had 2 of 2 battery powered emergency lighting units that failed to illuminate.

Based on document review and interview, the facility failed to conduct quarterly fire drills for staff instruction of life safety as evidenced by the lack of staff participants in fire drills for the past year and by a staff member who did not know how to operate life safety equipment and did not know the duties as outlined in the fire safety plan. This deficient practice affected all floors and could result in a lack of response and knowledge in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff)with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During document review and interview on March 13, 2012 at 8:30 a.m., the fire drill records were reviewed and facility staff were interviewed.

Mill-Peninsula Medical Center:
1. Currently there are 1508 employees at the Mills-Peninsula Medical Center. During the first quarter of 2011, a total of 29 employees participated in the day, evening and NOC fire drills. In the second quarter, 27 employees participated, 20 employees participated in the third quarter drills and 10 employees participated in the fourth quarter fire drills conducted. In a staff interview, staff stated that the fire drills are held per unit and only the employees in that unit are trained. There were twelve fire drills conducted in the past year and of the 1508 employees at the Medical Center, 86 employees participated in those fire drills.






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Mills-Peninsula Medical Center, Burlingame - 4th Floor on 3/13/2012:
2. At 2:57 p.m., Housekeeping Staff 2 was asked how she would respond to a fire and to demonstrate how to activate the fire alarm system. The staff member did not know how to activate the manual fire alarm box and stated that she had never been trained on its usage and did not know RACE procedures (an outlined of the facility's fire safety plan).

Based on document review, and staff interview, the facility failed to conduct quarterly fire drills to ensure that staff members are aware of their duties and instructed in life safety procedures and devices. This was evidenced by the lack of staff participants in fire drills for the past year and staff members who did not know how to operate life safety equipment. This affected all floors in Buildings 1, 2, 3 and 4. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in potential harm to patients and staff.

NFPA 101, Life Safety Code(2000) Edition
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined
in the fire safety plan.

Findings:

During document review and interview on March 13, 2012, through March 14, 2012, at 8:30 a.m., the fire drill records were reviewed and staff interviewed.

Mills Health Center - on 3/13/12:
1. Currently there are 460 employees at the Mills Health Center. During the first quarter of 2011, a total of 20 employees participated in the day, evening and NOC fire drills. In the second quarter, 12 employees participated, 20 employees participated in the third quarter drills and 10 employees participated in the fourth quarter fire drills conducted. In a staff interview, staff stated that the fire drills are held per unit and only the employees in that unit are trained. There were twelve fire drills conducted in the past year and of the 460 employees at the Health Center, 62 employees participated in those fire drills.









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Mills Health Center, San Mateo - 4th Floor in Building-1 (1978) on 3/14/2012:
2. At 2:02 p.m., EVS Staff-1 was asked how she would respond to a fire and to demonstrate how to activate the fire alarm system. The staff member did not know how to activate the manual fire alarm box and stated that she had never been trained on its usage.

Based on observation and interview, the facility failed to maintain the integrity of the fire alarm system in accordance with NFPA 101 and NFPA 72. This was evidenced by failure of audible devices, visual devices and the failure to repair devices. This affected 1 of 6 floors in Building 1, 1 of 6 floors in Building 2, and 3 of 5 floors in Building 3. This had the potential of delaying the notification of a fire to the occupants and to first responders, increasing the risk of injury to patients, visitors and staff.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

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 manufacturers 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 the testing of the fire alarm system with staff on March 12, 2012 through March 14, 2012, the fire alarm devices were observed and staff were interviewed.

Mills Health Center, San Mateo - Fifth Floor Building 3 on 3/14/12:
1. At 1:54 p.m., the chime/strobe device located between Room 5164 and 5165 failed to annunciate an audible alarm during the testing of the fire alarm system.

2. At 1:55 p.m., the chime/strobe device located between Room 5160 and 5161 failed to annunciate an audible alarm during the testing of the fire alarm system.

Second Floor - Building 3 on 3/14/12:
3. At 2:13 p.m., the chime/strobe device located next to Room 2136, failed to annunciate an audible alarm during the testing of the fire alarm system.

4. At 2:15 p.m., the chime/strobe device located in the Radiology Control Room 2149, failed to annunciate an audible alarm during the testing of the fire alarm system.

Lower Level - Building 3 on 3/14/12:
5. At 2:40 p.m., the chime/strobe device located in the Surgery Suite next to Room G 137, failed to annunciate an audible alarm during the testing of the fire alarm system.

At 2:45 p.m., the chime/strobe device located in Sterile Processing Room 6. G 113, failed to activate the strobe (visual device) during the testing of the fire alarm system.

Lower Level - Building 1 on 3/14/12:
7. At 3:12 p.m. the chime/strobe in the back corridor of the Auxiliary office next to the Shop Cart room failed to annunciate an audible alarm during the testing of the fire alarm system.






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Mills Health Center, San Mateo - First Floor Building 2 on 3/14/12:
8. At 2:50 p.m., on the first floor in the Cancer Center the strobe in the Pantry room 12423, did not function upon activation of the fire alarm system.
9. The strobe in the corridor by room 1217 did not function upon activation of the fire alarm system.
10. The strobe in the corridor by room 1216 did not function upon activation of the fire alarm system.
11. The strobe in the corridor by the crash cart room failed to function upon activation of the fire alarm system.
12. The strobe in the infusion center failed to function upon activation of the fire alarm system.
13. Three strobes had stickers placed on them. During interview, staff stated that the devices with stickers had been identified as devices that failed during the facility's testing. Staff was asked when the testing was performed and he stated that the testing had been conducted about a month and a half ago and that he thought all devices had been repaired.

Mills Health Center, San Mateo - Lower Level Building 3 on 3/14/12:
14. At 3:12 p.m., on the lower level, the chime by the Linen Department made a muffled sound upon activation of the fire alarm system. The chime was difficult to hear.



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Mills Health Center, San Mateo - 2nd Floor in Building 1 on 3/14/2012:
15. At 2:13 p.m., the Radiology Department had a fire alarm audible device in the corridor by CT Room 2123 that failed to sound an alarm upon the activation of a water flow device.

Mills Health Center, San Mateo - 2nd Floor in Building 3 on 3/14/2012:
16. At 3:05 p.m., the Pediatric Rehabilitation Unit had a fire alarm audible device in the corridor by Storage Room 2316 that failed to sound an alarm upon the activation of a smoke detector device.

Based on observation, and interview, the facility failed to maintain the integrity of the fire alarm system in accordance with NFPA 101 and NFPA 72, as evidenced by the failure of one fire alarm system audible device and one smoke detector affecting 2 of 6 floors at Mills-Peninsula Medical Center. This could delay notification to the occupants of a fire or other emergency in the facility and could result in potential harm to the occupants.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Findings:

During the testing of the fire alarm system with staff on March 12, 2012 through March 14, 2012, the fire alarm devices were tested, and staff were interviewed.

Mills-Peninsula Medical Center - Fourth Floor on 3/14/12:
1. At 3:05 p.m., the chime/strobe device located in 4 East next to Room 4414 failed to annunciate an audible alarm during the testing of the fire alarm system.




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Mills-Peninsula Medical Center, Burlingame - 2nd Floor on 3/14/2012:
2. At 9:25 a.m., the Radiology Department had a non-functioning smoke detector in the Control Room Corridor. The smoke detector labeled "NIL06D095" failed to activate after spraying canned smoke.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by sprinkler heads with foreign material on them and affected 1 of 3 stairway exits in Building 1. This could result in the failure of the sprinkler system in the event of a fire.

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
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, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Findings:

During a tour of the facility with the Hospital Staff from March 12,2012 through March 15, 2012, the automatic sprinkler system was observed.

Mills Health Center, San Mateo - 5th Floor in Building 1 on 3/12/2012:
1. At 2:28 p.m., Stairwell 1, located by the Behavioral Health/Chemical Dependency Treatment Unit, had 2 of 2 sprinkler heads in the exit landing with foreign material that covered the components of the sprinkler heads.

Mills Health Center, San Mateo - 2nd Floor in Building 1 on 3/13/2012:
2. At 8:47 a.m., Stairwell 1, located by the Emergency Department, had 2 of 2 sprinkler heads in the exit landing with foreign material that covered the components of the sprinkler heads.

Based on observation, the facility failed to ensure there are no obstructions to the portable fire extinguishers as evidenced by a fire extinguisher that was obstructed. This deficient practice affected 1 of 6 floors in the Mills-Peninsula Medical Center and could result in a delay of access to a fire extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
4-3.2 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

Findings:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, the fire extinguishers were observed.

Mill-Peninsula Medical Center - on 3/12/12:
1. At 3:15 p.m., on the 1st floor in the Biohazardous Waste Room #0430, the access to the fire extinguisher was blocked by bins, buckets and boxes.

Based on observation and interview, the facility failed to safely maintain oxygen storage as evidenced by the failure to ensure light switches are installed at least 5 feet (60 inches) from the floor and failed to separate empty and full cylinders in accordance with NFPA 99 and failing to separate combustible storage in the oxygen supply room. This affected 3 of 6 floors in the Mills-Peninsula Building and had the potential for cylinder damage and the possible use of an empty cylinder in an emergency resulting in injury to the patients.

NFPA 99, Health Care Facilities (1999) Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials (see also 4-31.1.2(a)7).
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifold containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrapper shall be removed prior to storage.

NFPA 99, Health Care Facilities (1999) Edition
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for non Flammable gases less than 3000 ft (85 m 3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible 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 12, 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:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, the oxygen storage rooms were observed.

Mills - Peninsula Medical Center - Fifth Floor on 3/12/12:
1. At 11:21 a.m., the light switch in the designated Oxygen Storage Room 5476, was observed to be less than 5 feet from the floor. The light switch was mounted approximately 46 inches from the floor.

2. The oxygen storage room was also designated as a storage room and was filled with combustible material such as linen and non-oxygen related equipment that was covered with plastic.

Third Floor on 3/12/12:
3. At 11:50 a.m., the light switch in the designated Oxygen Storage Room 3476, was observed to be less than 5 feet from the floor. The light switch was mounted approximately 46 inches from the floor. The room was also designated as a storage room and was filled with combustible material such as linen and equipment that was covered with plastic.

4. At 1:35 p.m., the light switch in the designated Oxygen Storage Room 3705, was observed to be less than 5 feet from the floor. The light switch was mounted approximately 46 inches from the floor. The room was also designated as a storage room and was filled with combustible material such as linen and equipment.






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Mill-Peninsula Medical Center - on 3/12/12:
5. At 11:20 a.m., on the 2nd floor West Wing, in storage room 2727, there were four full oxygen tanks stored in a six space rack. During an interview with the Nurse Manager, she stated that the empty tanks are put back in the same rack with full tanks. The Nurse Manager stated that staff has been trained to check if the tank is empty or full before use.

6. At 11:35 a.m., on the 2nd floor West Wing, in storage room 2705, there were four full oxygen tanks stored in a six space rack. During an interview with the Nurse Manager, she stated that the empty tanks are brought back and placed in the same rack with full tanks

7. During document review on 3/13/12, the facility Policy for Oxygen - Safety Storage of Medical Gas Cylinders was reviewed. The policy provided did not state that empty and full cylinders should be stored in separate racks. Staff stated that they were unaware of the regulation.
.

Based on observation and interview, the facility failed to safely maintain oxygen storage as evidenced by the failure to ensure light switches are installed at least 5 feet (60 inches) from the floor and failed to separate empty and full cylinders in accordance with NFPA 99. This affected 2 of 5 floors in Building 3 and 1 of 6 floors in Building 1. This had the potential for cylinder damage and the possible use of an empty cylinder in an emergency resulting in injury to the patients.

NFPA 99, Health Care Facilities (1999) Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Findings:

During a tour of the facility with staff on March 12, 2012 through March 14, 2012, the oxygen storage rooms were observed.

Mills Health Center, San Mateo - Lower Level Building 3 on 3/13/12:
1. At 11:01 a.m., the light switches in Oxygen Storage room G 304 and G 305, were observed to be mounted approximately 46 inches from the floor and not the required 60 inches (5 feet) from the floor.



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Mills Health Center, San Mateo - Building 1 on 3/14/12:
2. At 10:45 a.m., on the 2nd floor in the Emergency Department Room B, there were seven E-oxygen tanks stored together in the same rack. One tank was full, one tank was half full, three tanks were two-thirds full, and one tank was empty. Director of Respiratory Therapy stated that the tanks are checked before use. Staff also stated that they were unaware that empty and full cylinders had to be stored separately.
The facility policy did not state that the empty and full cylinders had to be stored separately.

Based on document review and staff interview, the facility failed to maintain the relative humidity equal to or greater than 35% in the operating rooms. This was evidenced by one operating room documenting humidity levels as low as 15% and by 9 of 10 operating rooms that documented humidity levels below 35% in the past three months. This deficient practice affected 1 of 6 floors in the Mills-Peninsula Medical Center and could result in the ignition of a fire. A waiver provision for this deficiency was discussed with maintenance staff.

Findings

During document review on March 15, 2012, the Operating Room Humidity reports were reviewed between 10:00 a.m. and 2:00 p.m.
Mill-Peninsula Medical Center:
1. The humidity policy for the operating rooms states that the humidity range is between 30% to 60%. In the past three months, the humidity in the operating rooms has dropped as low as 15%. During staff interview, staff stated that the operating staff was responsible for overseeing the humidity in the operating rooms. Staff would not receive the signal that the humidity had dropped below 30% and the humidity would continue to drop. As of March 2012, the humidity in the operating rooms is being controlled and overseen by the engineering department.
In the past three months the following operating rooms dropped below 35%:
OR1 dropped below 35% 29 times in January and December.
OR2 dropped below 35% 21 times in January and December.
OR3 dropped below 35% 20 times in January and December.
OR5 dropped below 35% 7 times in January and December.
OR6 dropped below 35% 20 times in January and December.
OR7 dropped below 35% 19 times in January and December.
OR9 dropped below 35% 21 times in January and December.
OR10 dropped below 35% 12 times in January and December.

Based on observation and interview, the facility failed to maintain their the Emergency Power System (EPS) in accordance with NFPA 99. This was evidenced by a receptacle wall outlet supplied by the EPS without a distinctive colored cover plate, affected 1 of 7 floors in Building-1. This could delay the identification of receptacle outlets powered by the EPS during the loss of power.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.2.2.4 Wiring Requirements
(b) Receptacles 2. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the EPS was observed.

Mills Health Center, San Mateo - 1st Floor in Building-1 (1978) on 3/13/2012:
1. At 10:58 a.m., the Pharmacy Department had a receptacle wall outlet in the Chemo Prep Room with a white colored cover plate. The Chief of Engineer confirmed that the outlet was supplied by the EPS and all other EPS supplied outlets in the facility had a red colored cover plate.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, as evidenced by missing or damaged cover plates, appliances plugged into surge protectors instead of directly into an electrical receptacle and a non-functioning lock on a door to a cabinet containing energized cables. This failure affected 1 of 6 floors in Building 1 and 1 of 5 floors in Building-3. This could result in the increase risk of electric shock or an electrical fire
causing potential harm to the patients, staff and visitors.

NFPA 70, National Electrical Code, 1999 Edition
Article 110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
110-12 (c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

Article 370 - Outlet, Device, Pull and Junctions Boxes, Conduit Bodies and Fittings.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Article 400 - Flexible Cords and Cables.
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

Findings:

During a tour of the facility with staff on March 12, 2012 through March 14, 2012, the electrical wiring and equipment were observed.

Mills Health Center, San Mateo - Lower Level Building 3:
1. At 11:15 a.m. in the Shipping and Receiving Department Room G 308, a refrigerator was plugged into a power strip and not directly into the wall electrical receptacle.

2. At 11:20 a.m., in the lower level Clean Linen Storage Room (the room was not identified by a number) there were two electrical cover plates missing, one on the left wall next to the corridor door and one in the back of the room behind a desk.

3. At 11:35 a.m., in the Cardiovascular Rehabilitation Office G 422, the electrical cover plate was missing in the left wall.







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Mills Health Center, San Mateo - 2nd Floor in Building-3 (1928) on 3/13/2012:
4. At 9:22 a.m., the Pediatric Rehabilitation Unit had a non-functioning door lock to a cabinet located in the corridor by Room 2319. The cabinet contained electrical cables with black tape covering its energized parts.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations on the walls and ceilings at Mills Health Center that affected 2 of 6 floors in Building-1, 1 of 6 floors in Building-2, 2 of 5 floors in Building-3, and 1 of 2 floors in Building-4. This could result in the spread of fire and smoke and had the potential of harming patients, visitors, and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the facility's walls and ceilings were observed.

Mills Health Center, San Mateo - 4th Floor in Building-3 on 3/12/2012:
1. At 3:36 p.m., the Scheduling Center had 5 penetrations to a wall. The penetrations were located on the side of the wall by the cubicles partitions and were going through the wall to the break room. Two penetrations measured approximately 1-inch each and three penetrations measured approximately 1/2-inch each.

Mills Health Center, San Mateo - 2nd Floor in Building-1 on 3/13/2012:
2. At 8:45 a.m., the Emergency Department had a penetration to a wall in Room 2178. The penetration was located by a monitor and it measured approximately 1/2-inch.

3. At 8:52 a.m., the Emergency Department had 2 penetrations to a wall by the restroom, Room 2160. The penetrations measured approximately 1/2-inch each.

4. At 8:58 a.m., the Radiology Department had a penetration to a wall in exam Room 2143. The penetration was located adjacent to the door and was due to a detached door knob pad. The penetration measured approximately 2 x 2-inches.

Mills Health Center, San Mateo - 1st Floor in Building-4 on 3/13/2012:
5. At 10:02 a.m., the Pool Rehabilitation Area had 14 penetrations to a wall in Storage Room 1404. The penetrations measured approximately 1/2-inch each.

6. At 10:03 a.m., the Pool Rehabilitation Area had 6 penetrations to a wall in Storage Room 1402. The penetrations measured approximately 1/2-inch each.

Mills Health Center, San Mateo - 1st Floor in Building-3 on 3/13/2012:
7. At 10:16 a.m., the Adult Rehabilitation Unit had a penetration to a wall in Storage Room 1311. The penetration measured approximately 1-inch.

8. At 10:20 a.m., the Adult Rehabilitation Unit had a penetration to the ceiling in a storage room by Restroom 1331. The penetration measured approximately 1/2-inch and it surrounded an escutcheon ring.

Mills Health Center, San Mateo - 1st Floor in Building-2 on 3/13/2012:
9. At 10:36 a.m., the Infusion Center, located in the Cancer Center, had a penetration to a wall in Storage Room 1210. The penetration measured approximately 4 x 1-inches.

Mills Health Center, San Mateo - 1st Floor in Building-1 on 3/13/2012:
10. At 11:23 a.m., the Audiology Services Unit had 3 penetrations to a wall by the wheelchair storage area. The penetrations measured approximately 1/2-inch each.

Based on observation, the facility failed to maintain corridor doors as evidenced by a corridor door that failed to close and latch when tested. This affected occupants on 1 of 6 floors at the Mills-Peninsula Medical Center. 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.

Findings:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, corridor doors were inspected throughout the facility.

Mill-Peninsula Medical Center - on 3/12/12:
1. At 11:22 a.m., on the 4th floor West Wing, the corridor door to Patient Room 4776 could not be closed when tested by pulling the door shut. Staff confirmed that the door would not positively latch when closed.

Based on observation, the facility failed to maintain corridor doors to close and latch. This was evidenced by a door that failed to positive latch at Mills Health Center that affected 1 of 6 floors in Building 1. This could result in smoke and fire to travel throughout the facility in the event of a fire in the room.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the corridor doors were observed.

Mills Health Center, San Mateo - 5th Floor in Building-1 on 3/12/2012:
1. At 2:34 p.m., the Behavioral Health/Chemical Dependency Treatment Unit had a door opening into the corridor from Room 5171 that failed to positive latch.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by unsealed vertical openings and a door opening into a vertical shaft that did not have a self-closing device and that did not positive latch. This affected 3 of 5 floors in Building 3 at Mills Health Center. This could result in the passage of smoke or fire from one floor to another.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the vertical openings in the facility were observed.

Mills Health Center, San Mateo - 1st Floor in Building-3 on 3/13/2012:
1. At 10:23 a.m., the Adult Rehabilitation Unit had two unsealed vertical openings in the IT Equipment Room 1316A. The first opening ran through the basement floor via an unsealed conduit that measured approximately 1/2-inch. The second opening ran through the 2nd floor via an unsealed j-box that measured approximately 2 x 2-inches.

2. At 10:25 a.m., the Adult Rehabilitation Unit had an unprotected vertical shaft opening inside the Housekeeping closet, Room 1316B. The door to the vertical shaft opening did not have a self-closing device and the door did not positive latch.

Based on observation, the facility failed to maintain the integrity of the smoke barrier fire resistance rated construction as evidenced by unsealed pipes, conduits and wires penetrating the smoke barrier walls in 1 of 5 floors in Building 3 and 1 of 6 floors in Building 1. This failure could result in the spread of smoke and fire, in the event of a fire and could result in potential harm to patients, staff and visitors.

NFPA 101, Life Safety Code (2000) Edition
8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, bus 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 staff on March 12, 2012 through March 14, 2012, the smoke barrier walls were observed.

1. Mills Health Center, San Mateo - Lower Level Building 3 on 3/13/12:
At 9:40 a.m., the smoke barrier wall above the corridor door entering Surgery Suite West Wing had two conduits in the left side of the wall with an approximately 1/4 inch penetration around each conduit.

2. At 10:05 a.m., the smoke barrier wall located between Operating Rooms 3 and 4, had two hot water lines one on the left side and one on the right side of the wall with an approximately 1/4 inch penetration around each line.

3. At 10:30 a.m., the wall above the main corridor door entering the Surgery Suite had a four inch unsealed sleeve and an approximately 1/2 inch penetration around a conduit both located in the left side of the wall.


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4. Mills Health Center, San Mateo - 5th Floor in Building-1 on 3/12/2012:
At 2:58 p.m., the Behavioral Health/Chemical Dependency Treatment Unit had a penetration to the smoke barrier ceiling "tunnel construction" by the clean utility Room 5172. The penetration measured approximately 1/2-inch.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in three smoke barrier walls. This affected 2 of 6 floors in the Mills-Peninsula Medical Center Building and could result in the spread of smoke or fire to other smoke compartments.

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 facility tour with staff on March 12, 2012, through March 15, 2012, the smoke barrier walls in the facility were observed.

Mill-Peninsula Medical Center - on 3/12/12:
1. At 10:58 a.m., on the 4th floor West Wing, the fire rated wall above the smoke barrier doors near NSA 700 was observed. There was a one inch penetration through the wall at that location. The opening had not been sealed on either side of the wall.

2. At 1:32 p.m., on the 2nd floor West Wing, the fire barrier wall above the smoke barrier doors near Room 2785 was observed. There were four pipe conduits approximately four inches in diameter each. The fire caulking had fallen out of one of the four pipe conduits. Staff confirmed that the pipe was unsealed.

3. At 1:36 p.m., on the 2nd floor West Wing, the rated wall above the smoke barrier doors near Room 2715 was observed. There were two fire bricks missing from the IT trough that penetrated the wall. The missing bricks left an opening in the wall approximately two inches by three inches.

Based on observation, the facility failed to maintain fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by one fire door leaf that was equipped with latching hardware but failed to latch when tested. This affected 1 of 6 floors in the Mills-Peninsula Medical Center and could potentially result in the spread of smoke and/or fire from one compartment to another.

NFPA 101, Life Safety Code, 2000 Edition
8.2.4.3 Doors.
8.2.4.3.1 Doors in smoke partitions shall comply with 8.2.4.3.2 through 8.2.4.3.5.
8.2.4.3.4* Door clearances shall be in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.
NFPA 80 Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
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.

Findings:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, the fire/smoke barrier doors were inspected.

Mill-Peninsula Medical Center - on 3/14/12:
1. At 9:02 a.m., on the 2nd floor in the Operating Suite, the left hand leaf of the fire door in the OR Core by OR 10 failed to positively latch when released. Upon activation of the fire alarm system the fire doors in the Core released and closed.

Based on observation, the facility failed to maintain its hazardous areas. This was evidenced by doors without a self-closing device. This affected 1 of 6 floors in Building 1 and 1 of 6 floors in Building 2 at Mills Health Center. This had the potential to allow the spread of smoke and fire.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, hazardous areas were observed.

Mills Health Center, San Mateo - 4th Floor in Building 1 on 3/12/2012:
1. At 3:57 p.m., the Medical Records Room, located in the Cardiology Suite, had a door that did not have a self-closing device. The room was greater than 50 square feet and had an abundant amount of combustibles.

Mills Health Center, San Mateo - 3rd Floor in Building 2 on 3/12/2012:
2. At 4:37 p.m., the large storage room had a door that did not have a self-closing device. The room was greater than 50 square feet and had a large amount of combustible storage.

Based on observation, the facility failed to maintain stairways as evidenced by debris found throughout a stairwell at Mills Health Center, affected 1 of 3 stairway exits in Building 2. This had the potential of interfering with egress during a fire emergency, rendering the stairway unsafe or non-usable for patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
7.2.2 Stairs.
7.2.2.1 General. Stairs used as a component in the means of egress shall conform to the general requirements of Section 7.1 and to the special requirements of this subsection.

7.1.10 Means of Egress Reliability.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15,2012, the stairwell egress were observed.

Mills Health Center, San Mateo - Building 2 on 3/12/2012:
At 3:10 p.m., Stairwell-5 had debris between the 4th and 5th Floors. The debris included trash, plastic wrappers, feces, and clothing.

Based on interview and observation, the facility failed to maintain the emergency exits, as evidenced by one exit discharge that was obstructed by a gurney in the Operating Suite. This deficient condition affected 1 of 6 floors in the Mills-Peninsula Medical Center. This could lead to a delay in evacuating the residents in the event of an emergency.

NFPA 101 Life Safety Code, 2000 edition
7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)
7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with staff on March 12, 2012, through March 15, 2012, the emergency exits were observed.

Mills-Peninsula Medical Center on 3/14/12:
1. At 8:45 a.m., on the 2nd floor in the Operating Suite, the exit door was blocked by a gurney. There was an Exit sign posted over the door. Staff stated that a gurney would not fit through the door but that staff would use the door as an emergency exit.

Based on observation, the facility failed to maintain emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This affected 1 of 6 floors in Building-1, 1 of 5 floors in Building 3, and the generator room at Mills Health Center. This could delay evacuation and result in the inability to work on the generators during a power outage, potentially causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15,2012, the emergency lighting units were tested and observed.

Mills Health Center, San Mateo - 7th Floor in Building-1 on 3/12/2012:
1. At 2:05 p.m., the machine room had a battery powered emergency lighting unit that failed to illuminate on the 7th floor.

Mills Health Center, San Mateo - 3rd Floor in Building-3 on 3/12/2012:
2. At 4:45 p.m., Stairway-9 had a battery powered emergency lighting unit that failed to illuminate on the 3rd floor.

Mills Health Center, San Mateo - Generator Room on 3/13/2012:
3. At 11:52 a.m., the generator room had 2 of 2 battery powered emergency lighting units that failed to illuminate.

Based on document review and interview, the facility failed to conduct quarterly fire drills for staff instruction of life safety as evidenced by the lack of staff participants in fire drills for the past year and by a staff member who did not know how to operate life safety equipment and did not know the duties as outlined in the fire safety plan. This deficient practice affected all floors and could result in a lack of response and knowledge in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff)with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During document review and interview on March 13, 2012 at 8:30 a.m., the fire drill records were reviewed and facility staff were interviewed.

Mill-Peninsula Medical Center:
1. Currently there are 1508 employees at the Mills-Peninsula Medical Center. During the first quarter of 2011, a total of 29 employees participated in the day, evening and NOC fire drills. In the second quarter, 27 employees participated, 20 employees participated in the third quarter drills and 10 employees participated in the fourth quarter fire drills conducted. In a staff interview, staff stated that the fire drills are held per unit and only the employees in that unit are trained. There were twelve fire drills conducted in the past year and of the 1508 employees at the Medical Center, 86 employees participated in those fire drills.






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Mills-Peninsula Medical Center, Burlingame - 4th Floor on 3/13/2012:
2. At 2:57 p.m., Housekeeping Staff 2 was asked how she would respond to a fire and to demonstrate how to activate the fire alarm system. The staff member did not know how to activate the manual fire alarm box and stated that she had never been trained on its usage and did not know RACE procedures (an outlined of the facility's fire safety plan).

Based on document review, and staff interview, the facility failed to conduct quarterly fire drills to ensure that staff members are aware of their duties and instructed in life safety procedures and devices. This was evidenced by the lack of staff participants in fire drills for the past year and staff members who did not know how to operate life safety equipment. This affected all floors in Buildings 1, 2, 3 and 4. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in potential harm to patients and staff.

NFPA 101, Life Safety Code(2000) Edition
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
19.7.1.2* Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined
in the fire safety plan.

Findings:

During document review and interview on March 13, 2012, through March 14, 2012, at 8:30 a.m., the fire drill records were reviewed and staff interviewed.

Mills Health Center - on 3/13/12:
1. Currently there are 460 employees at the Mills Health Center. During the first quarter of 2011, a total of 20 employees participated in the day, evening and NOC fire drills. In the second quarter, 12 employees participated, 20 employees participated in the third quarter drills and 10 employees participated in the fourth quarter fire drills conducted. In a staff interview, staff stated that the fire drills are held per unit and only the employees in that unit are trained. There were twelve fire drills conducted in the past year and of the 460 employees at the Health Center, 62 employees participated in those fire drills.









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Mills Health Center, San Mateo - 4th Floor in Building-1 (1978) on 3/14/2012:
2. At 2:02 p.m., EVS Staff-1 was asked how she would respond to a fire and to demonstrate how to activate the fire alarm system. The staff member did not know how to activate the manual fire alarm box and stated that she had never been trained on its usage.

Based on observation and interview, the facility failed to maintain the integrity of the fire alarm system in accordance with NFPA 101 and NFPA 72. This was evidenced by failure of audible devices, visual devices and the failure to repair devices. This affected 1 of 6 floors in Building 1, 1 of 6 floors in Building 2, and 3 of 5 floors in Building 3. This had the potential of delaying the notification of a fire to the occupants and to first responders, increasing the risk of injury to patients, visitors and staff.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

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 manufacturers 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 the testing of the fire alarm system with staff on March 12, 2012 through March 14, 2012, the fire alarm devices were observed and staff were interviewed.

Mills Health Center, San Mateo - Fifth Floor Building 3 on 3/14/12:
1. At 1:54 p.m., the chime/strobe device located between Room 5164 and 5165 failed to annunciate an audible alarm during the testing of the fire alarm system.

2. At 1:55 p.m., the chime/strobe device located between Room 5160 and 5161 failed to annunciate an audible alarm during the testing of the fire alarm system.

Second Floor - Building 3 on 3/14/12:
3. At 2:13 p.m., the chime/strobe device located next to Room 2136, failed to annunciate an audible alarm during the testing of the fire alarm system.

4. At 2:15 p.m., the chime/strobe device located in the Radiology Control Room 2149, failed to annunciate an audible alarm during the testing of the fire alarm system.

Lower Level - Building 3 on 3/14/12:
5. At 2:40 p.m., the chime/strobe device located in the Surgery Suite next to Room G 137, failed to annunciate an audible alarm during the testing of the fire alarm system.

At 2:45 p.m., the chime/strobe device located in Sterile Processing Room 6. G 113, failed to activate the strobe (visual device) during the testing of the fire alarm system.

Lower Level - Building 1 on 3/14/12:
7. At 3:12 p.m. the chime/strobe in the back corridor of the Auxiliary office next to the Shop Cart room failed to annunciate an audible alarm during the testing of the fire alarm system.






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Mills Health Center, San Mateo - First Floor Building 2 on 3/14/12:
8. At 2:50 p.m., on the first floor in the Cancer Center the strobe in the Pantry room 12423, did not function upon activation of the fire alarm system.
9. The strobe in the corridor by room 1217 did not function upon activation of the fire alarm system.
10. The strobe in the corridor by room 1216 did not function upon activation of the fire alarm system.
11. The strobe in the corridor by the crash cart room failed to function upon activation of the fire alarm system.
12. The strobe in the infusion center failed to function upon activation of the fire alarm system.
13. Three strobes had stickers placed on them. During interview, staff stated that the devices with stickers had been identified as devices that failed during the facility's testing. Staff was asked when the testing was performed and he stated that the testing had been conducted about a month and a half ago and that he thought all devices had been repaired.

Mills Health Center, San Mateo - Lower Level Building 3 on 3/14/12:
14. At 3:12 p.m., on the lower level, the chime by the Linen Department made a muffled sound upon activation of the fire alarm system. The chime was difficult to hear.



29626

Mills Health Center, San Mateo - 2nd Floor in Building 1 on 3/14/2012:
15. At 2:13 p.m., the Radiology Department had a fire alarm audible device in the corridor by CT Room 2123 that failed to sound an alarm upon the activation of a water flow device.

Mills Health Center, San Mateo - 2nd Floor in Building 3 on 3/14/2012:
16. At 3:05 p.m., the Pediatric Rehabilitation Unit had a fire alarm audible device in the corridor by Storage Room 2316 that failed to sound an alarm upon the activation of a smoke detector device.

Based on observation, and interview, the facility failed to maintain the integrity of the fire alarm system in accordance with NFPA 101 and NFPA 72, as evidenced by the failure of one fire alarm system audible device and one smoke detector affecting 2 of 6 floors at Mills-Peninsula Medical Center. This could delay notification to the occupants of a fire or other emergency in the facility and could result in potential harm to the occupants.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

Findings:

During the testing of the fire alarm system with staff on March 12, 2012 through March 14, 2012, the fire alarm devices were tested, and staff were interviewed.

Mills-Peninsula Medical Center - Fourth Floor on 3/14/12:
1. At 3:05 p.m., the chime/strobe device located in 4 East next to Room 4414 failed to annunciate an audible alarm during the testing of the fire alarm system.




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Mills-Peninsula Medical Center, Burlingame - 2nd Floor on 3/14/2012:
2. At 9:25 a.m., the Radiology Department had a non-functioning smoke detector in the Control Room Corridor. The smoke detector labeled "NIL06D095" failed to activate after spraying canned smoke.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by sprinkler heads with foreign material on them and affected 1 of 3 stairway exits in Building 1. This could result in the failure of the sprinkler system in the event of a fire.

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
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, pendent, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, or in the improper orientation.

Findings:

During a tour of the facility with the Hospital Staff from March 12,2012 through March 15, 2012, the automatic sprinkler system was observed.

Mills Health Center, San Mateo - 5th Floor in Building 1 on 3/12/2012:
1. At 2:28 p.m., Stairwell 1, located by the Behavioral Health/Chemical Dependency Treatment Unit, had 2 of 2 sprinkler heads in the exit landing with foreign material that covered the components of the sprinkler heads.

Mills Health Center, San Mateo - 2nd Floor in Building 1 on 3/13/2012:
2. At 8:47 a.m., Stairwell 1, located by the Emergency Department, had 2 of 2 sprinkler heads in the exit landing with foreign material that covered the components of the sprinkler heads.

Based on observation, the facility failed to ensure there are no obstructions to the portable fire extinguishers as evidenced by a fire extinguisher that was obstructed. This deficient practice affected 1 of 6 floors in the Mills-Peninsula Medical Center and could result in a delay of access to a fire extinguisher in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 edition
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.
4-3.2 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

Findings:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, the fire extinguishers were observed.

Mill-Peninsula Medical Center - on 3/12/12:
1. At 3:15 p.m., on the 1st floor in the Biohazardous Waste Room #0430, the access to the fire extinguisher was blocked by bins, buckets and boxes.

Based on observation and interview, the facility failed to safely maintain oxygen storage as evidenced by the failure to ensure light switches are installed at least 5 feet (60 inches) from the floor and failed to separate empty and full cylinders in accordance with NFPA 99 and failing to separate combustible storage in the oxygen supply room. This affected 3 of 6 floors in the Mills-Peninsula Building and had the potential for cylinder damage and the possible use of an empty cylinder in an emergency resulting in injury to the patients.

NFPA 99, Health Care Facilities (1999) Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials (see also 4-31.1.2(a)7).
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifold containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrapper shall be removed prior to storage.

NFPA 99, Health Care Facilities (1999) Edition
8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for non Flammable gases less than 3000 ft (85 m 3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible 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 12, 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:

During a tour of the facility with staff on March 12, 2012 through March 15, 2012, the oxygen storage rooms were observed.

Mills - Peninsula Medical Center - Fifth Floor on 3/12/12:
1. At 11:21 a.m., the light switch in the designated Oxygen Storage Room 5476, was observed to be less than 5 feet from the floor. The light switch was mounted approximately 46 inches from the floor.

2. The oxygen storage room was also designated as a storage room and was filled with combustible material such as linen and non-oxygen related equipment that was covered with plastic.

Third Floor on 3/12/12:
3. At 11:50 a.m., the light switch in the designated Oxygen Storage Room 3476, was observed to be less than 5 feet from the floor. The light switch was mounted approximately 46 inches from the floor. The room was also designated as a storage room and was filled with combustible material such as linen and equipment that was covered with plastic.

4. At 1:35 p.m., the light switch in the designated Oxygen Storage Room 3705, was observed to be less than 5 feet from the floor. The light switch was mounted approximately 46 inches from the floor. The room was also designated as a storage room and was filled with combustible material such as linen and equipment.






27254

Mill-Peninsula Medical Center - on 3/12/12:
5. At 11:20 a.m., on the 2nd floor West Wing, in storage room 2727, there were four full oxygen tanks stored in a six space rack. During an interview with the Nurse Manager, she stated that the empty tanks are put back in the same rack with full tanks. The Nurse Manager stated that staff has been trained to check if the tank is empty or full before use.

6. At 11:35 a.m., on the 2nd floor West Wing, in storage room 2705, there were four full oxygen tanks stored in a six space rack. During an interview with the Nurse Manager, she stated that the empty tanks are brought back and placed in the same rack with full tanks

7. During document review on 3/13/12, the facility Policy for Oxygen - Safety Storage of Medical Gas Cylinders was reviewed. The policy provided did not state that empty and full cylinders should be stored in separate racks. Staff stated that they were unaware of the regulation.
.

Based on observation and interview, the facility failed to safely maintain oxygen storage as evidenced by the failure to ensure light switches are installed at least 5 feet (60 inches) from the floor and failed to separate empty and full cylinders in accordance with NFPA 99. This affected 2 of 5 floors in Building 3 and 1 of 6 floors in Building 1. This had the potential for cylinder damage and the possible use of an empty cylinder in an emergency resulting in injury to the patients.

NFPA 99, Health Care Facilities (1999) Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

Findings:

During a tour of the facility with staff on March 12, 2012 through March 14, 2012, the oxygen storage rooms were observed.

Mills Health Center, San Mateo - Lower Level Building 3 on 3/13/12:
1. At 11:01 a.m., the light switches in Oxygen Storage room G 304 and G 305, were observed to be mounted approximately 46 inches from the floor and not the required 60 inches (5 feet) from the floor.



27254

Mills Health Center, San Mateo - Building 1 on 3/14/12:
2. At 10:45 a.m., on the 2nd floor in the Emergency Department Room B, there were seven E-oxygen tanks stored together in the same rack. One tank was full, one tank was half full, three tanks were two-thirds full, and one tank was empty. Director of Respiratory Therapy stated that the tanks are checked before use. Staff also stated that they were unaware that empty and full cylinders had to be stored separately.
The facility policy did not state that the empty and full cylinders had to be stored separately.

Based on document review and staff interview, the facility failed to maintain the relative humidity equal to or greater than 35% in the operating rooms. This was evidenced by one operating room documenting humidity levels as low as 15% and by 9 of 10 operating rooms that documented humidity levels below 35% in the past three months. This deficient practice affected 1 of 6 floors in the Mills-Peninsula Medical Center and could result in the ignition of a fire. A waiver provision for this deficiency was discussed with maintenance staff.

Findings

During document review on March 15, 2012, the Operating Room Humidity reports were reviewed between 10:00 a.m. and 2:00 p.m.
Mill-Peninsula Medical Center:
1. The humidity policy for the operating rooms states that the humidity range is between 30% to 60%. In the past three months, the humidity in the operating rooms has dropped as low as 15%. During staff interview, staff stated that the operating staff was responsible for overseeing the humidity in the operating rooms. Staff would not receive the signal that the humidity had dropped below 30% and the humidity would continue to drop. As of March 2012, the humidity in the operating rooms is being controlled and overseen by the engineering department.
In the past three months the following operating rooms dropped below 35%:
OR1 dropped below 35% 29 times in January and December.
OR2 dropped below 35% 21 times in January and December.
OR3 dropped below 35% 20 times in January and December.
OR5 dropped below 35% 7 times in January and December.
OR6 dropped below 35% 20 times in January and December.
OR7 dropped below 35% 19 times in January and December.
OR9 dropped below 35% 21 times in January and December.
OR10 dropped below 35% 12 times in January and December.

Based on observation and interview, the facility failed to maintain their the Emergency Power System (EPS) in accordance with NFPA 99. This was evidenced by a receptacle wall outlet supplied by the EPS without a distinctive colored cover plate, affected 1 of 7 floors in Building-1. This could delay the identification of receptacle outlets powered by the EPS during the loss of power.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.2.2.4 Wiring Requirements
(b) Receptacles 2. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable.

Findings:

During a tour of the facility with the Hospital Staff from March 12, 2012 through March 15, 2012, the EPS was observed.

Mills Health Center, San Mateo - 1st Floor in Building-1 (1978) on 3/13/2012:
1. At 10:58 a.m., the Pharmacy Department had a receptacle wall outlet in the Chemo Prep Room with a white colored cover plate. The Chief of Engineer confirmed that the outlet was supplied by the EPS and all other EPS supplied outlets in the facility had a red colored cover plate.

Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with NFPA 70, as evidenced by missing or damaged cover plates, appliances plugged into surge protectors instead of directly into an electrical receptacle and a non-functioning lock on a door to a cabinet containing energized cables. This failure affected 1 of 6 floors in Building 1 and 1 of 5 floors in Building-3. This could result in the increase risk of electric shock or an electrical fire
causing potential harm to the patients, staff and visitors.

NFPA 70, National Electrical Code, 1999 Edition
Article 110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
110-12 (c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasive, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

Article 370 - Outlet, Device, Pull and Junctions Boxes, Conduit Bodies and Fittings.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Article 400 - Flexible Cords and Cables.
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

Findings:

During a tour of the facility with staff on March 12, 2012 through March 14, 2012, the electrical wiring and equipment were observed.

Mills Health Center, San Mateo - Lower Level Building 3:
1. At 11:15 a.m. in the Shipping and Receiving Department Room G 308, a refrigerator was plugged into a power strip and not directly into the wall electrical receptacle.

2. At 11:20 a.m., in the lower level Clean Linen Storage Room (the room was not identified by a number) there were two electrical cover plates missing, one on the left wall next to the corridor door and one in the back of the room behind a desk.

3. At 11:35 a.m., in the Cardiovascular Rehabilitation Office G 422, the electrical cover plate was missing in the left wall.







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Mills Health Center, San Mateo - 2nd Floor in Building-3 (1928) on 3/13/2012:
4. At 9:22 a.m., the Pediatric Rehabilitation Unit had a non-functioning door lock to a cabinet located in the corridor by Room 2319. The cabinet contained electrical cables with black tape covering its energized parts.