HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction, as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 1 of 5 floors in the Main Hospital and 1 of 2 smoke compartments in Quest Imaging. This could result in the spread of smoke and fire to other locations in the facility.

Findings:

During a tour of the facility with Staff 1, Staff 2, and Staff 3, from October 15, 2012, through October 16, 2012, the building construction was observed in the hospital building and off site locations.

San Joaquin Hospital
October 15, 2012
At 3:51 p.m., there was an approximately 1 1/2 inch unsealed pipe, in the North wall, of the EVS Main Storage.



29751

Quest Imaging Center
October 16, 2012
At 10:30 a.m., there was an unsealed penetration around the escutcheon ring, for a sprinkler in front of the X ray room door.

Based on observation, the facility failed to maintain the integrity of the corridor, as evidenced by a penetration in the ceiling. This would allow the spread of smoke and fire to other areas and could cause potential harm to patients in the event of evacuation during a fire.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 16, 2012, the corridor construction was observed.

San Joaquin Hospital
October 16, 2012

At 8:59 a.m., there was an approximately 2 inch by 2 inch penetration in the ceiling, in the corridor near the Spector Link box, outside of Room 5128 (CDC 5 West) .

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by corridor doors that failed to latch and by corridor doors that were impeded from closing. This affected 3 of 5 floors and had the potential to allow the spread of smoke and fire that could cause harm to the patients.

Findings:

During a tour of the facility with Staff 1 and Staff 2, from October 15, 2012, through October 18, 2012, the corridor doors were observed.

San Joaquin Hospital
October 15, 2012
At 3:16 p.m., the corridor door to Room 4124 was impeded from closing by an unattended linen cart that was in front of the door.

October 16, 2012
At 8:42 a.m., the self-closing corridor door to Room 5216 failed to fully close and latch without assistance. Two attempts were made without the door latching.

At 9:10 a.m., the self-closing corridor door to the Medication Room, CDC 5 West, failed to close and latch. The door latched during 1 of 4 attempts.

At 9:40 a.m., the self closing corridor door to the Staff Lounge, near Room 4235, failed to latch when tested. Two attempts were made without the door latching.

At 2:06 p.m., the self-closing door to the kitchen office was impeded from closing by a brown rubber wedge, placed under the door.

At 2:55 p.m., the self-closing corridor door to the Case Cart Room failed to latch when tested. Four attempts were made to close and latch the door.
At 2:56 p.m., Staff 1a was interviewed. She said that the door has not latched properly for about two weeks.

October 17, 2012
At 9:14 a.m., the North self-closing corridor door to the Operating Room, near the Decontamination Room, failed to latch when tested.

At 1:30 p.m., the Housekeeping closet door, (1-21, near the west exit) on the first floor, failed to latch when tested. Three attempts were made without the door latching.

Based on observation, the facility failed to ensure doors in hazardous area enclosures were not held open. This was evidenced by doors that were impeded from closing in two areas. This failure affected the entire facility and had the potential to allow unauthorized persons to enter hazardous areas. This could result in potential injury or a failure of a protected system.

7.2.1.8.1* A door normally required to be kept closed shall
not be secured in the open position at any time and shall be
self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a tour of the facility with the Staff 3 on October 18, 2012, the generator rooms and main riser room were observed.

Main Hospital
At 9:10 a.m., the doors to the room housing Generator 1 and the main riser/pump sprinkler room were propped open. The self-closing doors were open approximately two inches to accommodate a power cord used by a mobile surgical cleaning unit. These two rooms were located at the rear of the hospital parallel to a public street.

Based on observation, the facility failed to display exits signs in all egress pathways. This was evidenced by no sign displayed in 1 of 3 egress paths in the Main Hospital and 1 of 2 egress paths in the Bariatric Center. This could delay egress and cause potential harm to patients and staff in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with Staff 1, Staff 2, Staff 3, and Staff 4, from October 15, 201, through October 16, 2012, the egress paths and exit signs were observed.

San Joaquin Hospital
October 15, 2012
At 4:02 p.m., there was no exit sign displayed near the west exit of the Employees Cafeteria. Staff 1 confirmed that the west exit was an egress door and marked on the evacuation plan. The room was over 1000 square feet in size.


29751

Bariatric Center
October 16, 2012
At 9:40 a.m., there was no exit sign displayed near the door, across from the receptionist desk. The door was listed as an exit on the evacuation map.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This affected two of five floors in the main hospital, and could result in the spread of smoke and fire to other 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 tour of the facility with Staff 1 and Staff 2, on October 16, 2012, and October 17, 2012, the smoke barrier walls were observed.

October 16, 2012
At 8:37 a.m., there was an approximately three inch (round) unsealed pipe around blue wires, in the west smoke barrier wall near Room 5221. The unsealed opening was approximately 3 inches.

October 17, 2012
At 10:47 a.m., there was an approximately 2 1/2 inch round unsealed pipe around blue wires, in the west smoke barrier wall in the Cath Lab (tower I). The unsealed opening was approximately 2 inches.

Based on observation and interview, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested and a door that was impeded from closing. This affected 3 of 5 floors within the facility and could result in the spread of smoke and fire during a fire emergency.

Findings:

During fire alarm testing with Staff 1 and Staff 2 on October 15, 2012, and October 17, 2012, the smoke barrier doors were observed and a staff person was interviewed.

San Joaquin Hospital
October 15, 2012

At 3:07 p.m., there was an unattended janitor cart in front of the smoke barrier door near Room 5101.

At 3:08 p.m., Staff 1b said during an interview that he placed the cart in front of the door for a couple of minutes.

San Joaquin Hospital
October 16, 2012

At 9:59 a.m., the west smoke barrier door near Med Surg and the south side of Elevator 3 and 4. Two attempts were made without the door latching.

At 11:06 a.m., the south smoke barrier door in Maternity Care on the third floor and near Room 3226 was not latching when tested. Three attempts were made without the door latching.

At 1:50 p.m., the west smoke barrier door in the Basement and near elevator B was not latching when tested. The air prevented the door from closing and revealed an approximate 6 inch gap between the doors.

San Joaquin Hospital
October 17, 2012

At 9:14 a.m., both smoke barrier doors in the (south side) Operating Room near the clean supply Room were not latching when tested. Two attempts were made without the doors latching.

At 9:16 a.m., the north smoke barrier door in the (north side) Operating Room failed to latch when tested. Three attempts were made without the door latching.

Surveyor: Leggett, Jerry
Based on observation and interview, the facility failed to protect its hazardous areas. This was evidenced by rooms which contained combustible storage and posed a greater than normal hazard, with doors that failed to self close and latch. This affected one of five floors within the facility, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 17, 2012, the hazardous areas were observed.

San Joaquin Hospital
October 17, 2012
At 11:24 a.m., the door to the Pathology Lab, in the Laboratory, was missing hardware. The door failed to close and latch when tested. The arm to the self closure device was missing. The room was over 50 square feet in size, and contained a flammable storage cabinet full of flammable hazards.

During an interview at 11:25 a.m., Staff 1d said that the Pathology Lab door has not self closed for over one year.

A 4:04 p.m., the door to the Case Cart Storage Supply Room, in the basement, did not latch when tested. The room was over 100 square feet and contained over 100 large cardboard boxes of supplies.

Based on document review, the facility failed to vary times for fire drills held during four of four quarters on each shift. This could result in a delay in staff response in the event of a fire, and could result in potential harm to patients.

Findings:

During document review on October 15, 2012, the records for the quarterly fire drills were reviewed.

San Joaquin Hospital
October 15, 2012
At 8.45 a.m., records show PM and NOC shift drill times vary less than one hour throughout 2012. PM shift drills were held between 8:25 p.m. and 9:00 p.m. in February, May, August, and November of 2012. NOC shift drills were held between 3:00 a.m. and 3:20 a.m., in March, June, August, and November of 2012.

Based on observation, the facility failed to maintain the fire alarm system in accordance with the NFPA 72. This was evidenced by failing to keep manual fire alarm pull stations and notification devices free from obstructions. This could delay activation of the fire alarm system, and delay notification for patients and staff in the event of a fire.

NFPA 72 National Fire Alarm Code (1999 Edition) section 2-8.2.1
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour with facility Staff 1 and Staff 2, on October 16, 2012, and October 17, 2012, the fire alarm system and components were observed.

San Joaquin Hospital
October 16, 2012
At 2:27 p.m., there was a chime/strobe that was impeded from view in the food storage room, in the kitchen. There were three large cardboard boxes in front of the device. Staff 2 remove the boxes upon discovery.

October 17, 2012
At 10:59 a.m., there was a manual fire alarm pull station device near Room C in the Emergency Department. There were two carts placed in front of the manual pull station.

Based on document review, the facility failed to maintain their smoke detectors in accordance with NFPA 72. This was evidenced by no records for the smoke sensitivity testing of their smoke detectors. This affected five floors of the main hospital (Tower I) and 4 of 4 outpatient service facilities. This had the potential to delay the initiation and notification of the fire alarm system in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.2.8 Where a complete smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all occupiable areas, common areas, and work spaces in those environments suitable for proper smoke detector operation.

NFPA 72 National Fire Alarm Code, 1999 Edition.
Table 7-2.2 Test Methods
g. Smoke Detectors
1. Systems Detectors The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a) Calibrated test method
(b) Manufacturer ' s calibrated sensitivity test instrument
(c) Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.

Findings:

During document review with Staff 3, on October 18, 2012, the records for the alarm system were reviewed.

At 10:30 a.m., there were no records indicating that sensitivity testing had been performed on Main Hospital Tower 1 smoke detectors and all patient service off site locations. During an interview the Safety Officer and Director of Facilities stated that sensitivity testing was not done.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by an impeded sprinkler and by a sprinkler that was covered with foreign matter. This affected 1 of 5 floors in the Main Hospital and 1 of 2 smoke compartments in the Quest Imaging Center. This could prevent the sprinkler from extinguishing the fire in the event of a fire, or potentially delay the activation of the sprinkler system.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected tested, and maintained in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance, for Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2-2.1 Sprinklers.
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with Staff 1, Staff 2, and Staff 3 on October 16, 2012, and October 17, 2012, the sprinkler system was observed.

San Joaquin Hospital
October 17, 2012
At 9:03 a.m., there were three orthopedic pads (approximately 3 feet by 16 inches) that were impeding a sprinkler head in the Equipment Room in the Operating Room Suite. The pads were approximately 6 inches from the North sprinkler head.


29751

Quest Imaging Center
October 16, 2012
At 4:00 p.m., a sprinkler bulb and deflector were covered with foreign matter in the designated smoking area. This could delay activation of the sprinkler in the event of a fire.

Based on observation, the facility failed to maintain the fire extinguishers according to NFPA 10. This was evidenced by the failure to mount the extinguishers or ensure they were secured from falling. This affected 1 of 5 floors in the Main Hospital and increased the risk of damage to the extinguishers, or delay in accessing an extinguisher in the event of a fire.

NFPA 10, Fire Extinguishers, 1999 Edition,
1.5.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14. kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 Kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.

Findings:

During a tour of the facility with Staff 3, on October 18, 2012, the fire extinguishers in the Tower 1 generator room were observed.

San Joaquin Hospital
At 8:55 a.m., ten fire extinguishers were unsecured, standing upright on the ground in the Tower 1 generator room. One fire extinguisher was unsecured standing upright on a cabinet in the generator room.

Based on observation and interview, the facility failed to maintain one trash chute. This was evidenced by a chute fire barrier door that was impeded from closing. This could allow for the spread of smoke and fire in the event of a fire in this hazardous area.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 17, 2012, the trash chutes were observed in the main hospital.

October 17, 2012
At 3:21 p.m., there was a trash chute room, near the decontamination room, in the basement. There were over 60 bags of trash backed up in the chute from the receiving receptacle. The chute was backed up with blue trash bags and was impeded from closing.

During an interview at 3:24 p.m., Staff 1e reported that the chute is normally checked every two hours. The staff assigned to check the chute might have been called to service other areas as needed.

Based on observation and interview, the facility failed to maintain their storage of oxygen gas. This was evidenced by one oxygen storage room that had an electrical wall fixture below five feet high and by one door that failed to latch. This affected two of five floors in the Hospital building, and could result in an increased risk of an electrical fire fueled by oxygen.

NFPA 99, Standard For Health Care Facilities, 1999 edition
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 16, 2012 and October 17, 2012, the oxygen storage rooms were observed.

San Joaquin Hospital
October 16, 2012
At 9:35 a.m., the self-closing door to Room 4235 (tower II), Oxygen Storage, did not latch when tested. The room contained over 14 e-cylinders of oxygen.

At 9:36 a.m., Staff 1c said during an interview that he just noticed that the door was not latching today and was going to turn in a work order to have it repaired.

October 17, 2012
At 9:26 a.m., the light switch in the oxygen storage room, near the Surgical ICU, was mounted 48 inches above the floor. There were sixteen oxygen E cylinders located inside the room.

Based on observation, the facility failed to maintain their medical gas system and to ensure ready access to emergency oxygen valves. This could delay personnel from shutting off oxygen during a fire emergency. This effected five of five floors in the Main Hospital.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."

(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.


Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 17, 2012, the emergency oxygen shut off valves were observed.

San Joaquin Hospital
October 17, 2012
At 9:00 a.m., there was bed on wheels and a cart impeding access to the Medical Gas shut off valve outside of Operating Room 7 in the Operating Suite.

At 2:48 p.m., there was a gurney that was impeding access to the Medical Gas shut off valve in the Cath Lab near Cath Lab 1.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into surge protectors, by the use of extension cords, by multi-plug adapters without over current protection, and by surge protectors plugged into surge protectors. This affected two of five floors in the Hospital, and could result in an electrical fire.

NFPA 70, National Electrical Code, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 16, 2012, and October 17, 2012, the electrical equipment and wiring was observed.

San Joaquin Hospital
October 16, 2012
At 8:32 a.m., there was a white extension cord, in use, in Room 5234 (Rehab Services Director Office). A lamp was plugged into the extension cord.

At 2:12 p.m., there was a surge protector that was plugged into another surge protector, under the desk in the kitchen office.

At 2:38 p.m., there was a six plug adapter, in use, in the Materials Management Server Room. There was a printer that was plugged into a surge protector that was plugged into a surge protector connected to the six plug adapter.

At 2:49 p.m., there was a surge protector that was plugged into another surge protector, under the desk in the Purchasing and Materials Management Room.

October 17, 2012
At 1:42 p.m., there was a refrigerator that was plugged into a surge protector and not directly into an electrical receptacle, in the Emergency Room Doctor's Office.

Based on observation, the facility failed to maintain the Alcohol Based Hand Rub (ABHR) dispensers, as evidenced by dispensers installed adjacent to an ignition source. This affected one of five floors in the Main Hospital, and 1 of 2 smoke compartments in the Quest Imaging Center. This had the potential to increase the risk of electrical shock or to ignite a fire.

Findings:

During a tour of the facility with Staff 1, Staff 2, and Staff 3, on October 15, 2012, and October 16, 2012, the ABHR dispensers were observed.

San Joaquin Hospital
October 15, 2012
At 2:59 p.m., the ABHR dispenser was mounted directly over an electrical receptacle/outlet, located in the corridor near Room 5112.



29751

Quest Imaging Center
October 16, 2012
At 10:34 a.m., there was an ABHR dispenser that was installed adjacent to a light switch in X Ray Room 1.

Based on observation, the facility failed to maintain the integrity of their building construction, as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 1 of 5 floors in the Main Hospital and 1 of 2 smoke compartments in Quest Imaging. This could result in the spread of smoke and fire to other locations in the facility.

Findings:

During a tour of the facility with Staff 1, Staff 2, and Staff 3, from October 15, 2012, through October 16, 2012, the building construction was observed in the hospital building and off site locations.

San Joaquin Hospital
October 15, 2012
At 3:51 p.m., there was an approximately 1 1/2 inch unsealed pipe, in the North wall, of the EVS Main Storage.



29751

Quest Imaging Center
October 16, 2012
At 10:30 a.m., there was an unsealed penetration around the escutcheon ring, for a sprinkler in front of the X ray room door.

Based on observation, the facility failed to maintain the integrity of the corridor, as evidenced by a penetration in the ceiling. This would allow the spread of smoke and fire to other areas and could cause potential harm to patients in the event of evacuation during a fire.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 16, 2012, the corridor construction was observed.

San Joaquin Hospital
October 16, 2012

At 8:59 a.m., there was an approximately 2 inch by 2 inch penetration in the ceiling, in the corridor near the Spector Link box, outside of Room 5128 (CDC 5 West) .

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke. This was evidenced by corridor doors that failed to latch and by corridor doors that were impeded from closing. This affected 3 of 5 floors and had the potential to allow the spread of smoke and fire that could cause harm to the patients.

Findings:

During a tour of the facility with Staff 1 and Staff 2, from October 15, 2012, through October 18, 2012, the corridor doors were observed.

San Joaquin Hospital
October 15, 2012
At 3:16 p.m., the corridor door to Room 4124 was impeded from closing by an unattended linen cart that was in front of the door.

October 16, 2012
At 8:42 a.m., the self-closing corridor door to Room 5216 failed to fully close and latch without assistance. Two attempts were made without the door latching.

At 9:10 a.m., the self-closing corridor door to the Medication Room, CDC 5 West, failed to close and latch. The door latched during 1 of 4 attempts.

At 9:40 a.m., the self closing corridor door to the Staff Lounge, near Room 4235, failed to latch when tested. Two attempts were made without the door latching.

At 2:06 p.m., the self-closing door to the kitchen office was impeded from closing by a brown rubber wedge, placed under the door.

At 2:55 p.m., the self-closing corridor door to the Case Cart Room failed to latch when tested. Four attempts were made to close and latch the door.
At 2:56 p.m., Staff 1a was interviewed. She said that the door has not latched properly for about two weeks.

October 17, 2012
At 9:14 a.m., the North self-closing corridor door to the Operating Room, near the Decontamination Room, failed to latch when tested.

At 1:30 p.m., the Housekeeping closet door, (1-21, near the west exit) on the first floor, failed to latch when tested. Three attempts were made without the door latching.

Based on observation, the facility failed to ensure doors in hazardous area enclosures were not held open. This was evidenced by doors that were impeded from closing in two areas. This failure affected the entire facility and had the potential to allow unauthorized persons to enter hazardous areas. This could result in potential injury or a failure of a protected system.

7.2.1.8.1* A door normally required to be kept closed shall
not be secured in the open position at any time and shall be
self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a tour of the facility with the Staff 3 on October 18, 2012, the generator rooms and main riser room were observed.

Main Hospital
At 9:10 a.m., the doors to the room housing Generator 1 and the main riser/pump sprinkler room were propped open. The self-closing doors were open approximately two inches to accommodate a power cord used by a mobile surgical cleaning unit. These two rooms were located at the rear of the hospital parallel to a public street.

Based on observation, the facility failed to display exits signs in all egress pathways. This was evidenced by no sign displayed in 1 of 3 egress paths in the Main Hospital and 1 of 2 egress paths in the Bariatric Center. This could delay egress and cause potential harm to patients and staff in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with Staff 1, Staff 2, Staff 3, and Staff 4, from October 15, 201, through October 16, 2012, the egress paths and exit signs were observed.

San Joaquin Hospital
October 15, 2012
At 4:02 p.m., there was no exit sign displayed near the west exit of the Employees Cafeteria. Staff 1 confirmed that the west exit was an egress door and marked on the evacuation plan. The room was over 1000 square feet in size.


29751

Bariatric Center
October 16, 2012
At 9:40 a.m., there was no exit sign displayed near the door, across from the receptionist desk. The door was listed as an exit on the evacuation map.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This affected two of five floors in the main hospital, and could result in the spread of smoke and fire to other 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 tour of the facility with Staff 1 and Staff 2, on October 16, 2012, and October 17, 2012, the smoke barrier walls were observed.

October 16, 2012
At 8:37 a.m., there was an approximately three inch (round) unsealed pipe around blue wires, in the west smoke barrier wall near Room 5221. The unsealed opening was approximately 3 inches.

October 17, 2012
At 10:47 a.m., there was an approximately 2 1/2 inch round unsealed pipe around blue wires, in the west smoke barrier wall in the Cath Lab (tower I). The unsealed opening was approximately 2 inches.

Based on observation and interview, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested and a door that was impeded from closing. This affected 3 of 5 floors within the facility and could result in the spread of smoke and fire during a fire emergency.

Findings:

During fire alarm testing with Staff 1 and Staff 2 on October 15, 2012, and October 17, 2012, the smoke barrier doors were observed and a staff person was interviewed.

San Joaquin Hospital
October 15, 2012

At 3:07 p.m., there was an unattended janitor cart in front of the smoke barrier door near Room 5101.

At 3:08 p.m., Staff 1b said during an interview that he placed the cart in front of the door for a couple of minutes.

San Joaquin Hospital
October 16, 2012

At 9:59 a.m., the west smoke barrier door near Med Surg and the south side of Elevator 3 and 4. Two attempts were made without the door latching.

At 11:06 a.m., the south smoke barrier door in Maternity Care on the third floor and near Room 3226 was not latching when tested. Three attempts were made without the door latching.

At 1:50 p.m., the west smoke barrier door in the Basement and near elevator B was not latching when tested. The air prevented the door from closing and revealed an approximate 6 inch gap between the doors.

San Joaquin Hospital
October 17, 2012

At 9:14 a.m., both smoke barrier doors in the (south side) Operating Room near the clean supply Room were not latching when tested. Two attempts were made without the doors latching.

At 9:16 a.m., the north smoke barrier door in the (north side) Operating Room failed to latch when tested. Three attempts were made without the door latching.

Surveyor: Leggett, Jerry
Based on observation and interview, the facility failed to protect its hazardous areas. This was evidenced by rooms which contained combustible storage and posed a greater than normal hazard, with doors that failed to self close and latch. This affected one of five floors within the facility, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 17, 2012, the hazardous areas were observed.

San Joaquin Hospital
October 17, 2012
At 11:24 a.m., the door to the Pathology Lab, in the Laboratory, was missing hardware. The door failed to close and latch when tested. The arm to the self closure device was missing. The room was over 50 square feet in size, and contained a flammable storage cabinet full of flammable hazards.

During an interview at 11:25 a.m., Staff 1d said that the Pathology Lab door has not self closed for over one year.

A 4:04 p.m., the door to the Case Cart Storage Supply Room, in the basement, did not latch when tested. The room was over 100 square feet and contained over 100 large cardboard boxes of supplies.

Based on document review, the facility failed to vary times for fire drills held during four of four quarters on each shift. This could result in a delay in staff response in the event of a fire, and could result in potential harm to patients.

Findings:

During document review on October 15, 2012, the records for the quarterly fire drills were reviewed.

San Joaquin Hospital
October 15, 2012
At 8.45 a.m., records show PM and NOC shift drill times vary less than one hour throughout 2012. PM shift drills were held between 8:25 p.m. and 9:00 p.m. in February, May, August, and November of 2012. NOC shift drills were held between 3:00 a.m. and 3:20 a.m., in March, June, August, and November of 2012.

Based on observation, the facility failed to maintain the fire alarm system in accordance with the NFPA 72. This was evidenced by failing to keep manual fire alarm pull stations and notification devices free from obstructions. This could delay activation of the fire alarm system, and delay notification for patients and staff in the event of a fire.

NFPA 72 National Fire Alarm Code (1999 Edition) section 2-8.2.1
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour with facility Staff 1 and Staff 2, on October 16, 2012, and October 17, 2012, the fire alarm system and components were observed.

San Joaquin Hospital
October 16, 2012
At 2:27 p.m., there was a chime/strobe that was impeded from view in the food storage room, in the kitchen. There were three large cardboard boxes in front of the device. Staff 2 remove the boxes upon discovery.

October 17, 2012
At 10:59 a.m., there was a manual fire alarm pull station device near Room C in the Emergency Department. There were two carts placed in front of the manual pull station.

Based on document review, the facility failed to maintain their smoke detectors in accordance with NFPA 72. This was evidenced by no records for the smoke sensitivity testing of their smoke detectors. This affected five floors of the main hospital (Tower I) and 4 of 4 outpatient service facilities. This had the potential to delay the initiation and notification of the fire alarm system in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
9.6.2.8 Where a complete smoke detection system is required by another section of this Code, automatic detection of smoke in accordance with NFPA 72, National Fire Alarm Code, shall be provided in all occupiable areas, common areas, and work spaces in those environments suitable for proper smoke detector operation.

NFPA 72 National Fire Alarm Code, 1999 Edition.
Table 7-2.2 Test Methods
g. Smoke Detectors
1. Systems Detectors The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a) Calibrated test method
(b) Manufacturer ' s calibrated sensitivity test instrument
(c) Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.

Findings:

During document review with Staff 3, on October 18, 2012, the records for the alarm system were reviewed.

At 10:30 a.m., there were no records indicating that sensitivity testing had been performed on Main Hospital Tower 1 smoke detectors and all patient service off site locations. During an interview the Safety Officer and Director of Facilities stated that sensitivity testing was not done.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by an impeded sprinkler and by a sprinkler that was covered with foreign matter. This affected 1 of 5 floors in the Main Hospital and 1 of 2 smoke compartments in the Quest Imaging Center. This could prevent the sprinkler from extinguishing the fire in the event of a fire, or potentially delay the activation of the sprinkler system.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

12-1 General. A sprinkler system installed in accordance with this standard shall be properly inspected tested, and maintained in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance, for Water Based Fire Protection Systems, to provide at least the same level of performance and protection as designed.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2-2.1 Sprinklers.
2-2.1.1* Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with Staff 1, Staff 2, and Staff 3 on October 16, 2012, and October 17, 2012, the sprinkler system was observed.

San Joaquin Hospital
October 17, 2012
At 9:03 a.m., there were three orthopedic pads (approximately 3 feet by 16 inches) that were impeding a sprinkler head in the Equipment Room in the Operating Room Suite. The pads were approximately 6 inches from the North sprinkler head.


29751

Quest Imaging Center
October 16, 2012
At 4:00 p.m., a sprinkler bulb and deflector were covered with foreign matter in the designated smoking area. This could delay activation of the sprinkler in the event of a fire.

Based on observation, the facility failed to maintain the fire extinguishers according to NFPA 10. This was evidenced by the failure to mount the extinguishers or ensure they were secured from falling. This affected 1 of 5 floors in the Main Hospital and increased the risk of damage to the extinguishers, or delay in accessing an extinguisher in the event of a fire.

NFPA 10, Fire Extinguishers, 1999 Edition,
1.5.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14. kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 Kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.

Findings:

During a tour of the facility with Staff 3, on October 18, 2012, the fire extinguishers in the Tower 1 generator room were observed.

San Joaquin Hospital
At 8:55 a.m., ten fire extinguishers were unsecured, standing upright on the ground in the Tower 1 generator room. One fire extinguisher was unsecured standing upright on a cabinet in the generator room.

Based on observation and interview, the facility failed to maintain one trash chute. This was evidenced by a chute fire barrier door that was impeded from closing. This could allow for the spread of smoke and fire in the event of a fire in this hazardous area.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 17, 2012, the trash chutes were observed in the main hospital.

October 17, 2012
At 3:21 p.m., there was a trash chute room, near the decontamination room, in the basement. There were over 60 bags of trash backed up in the chute from the receiving receptacle. The chute was backed up with blue trash bags and was impeded from closing.

During an interview at 3:24 p.m., Staff 1e reported that the chute is normally checked every two hours. The staff assigned to check the chute might have been called to service other areas as needed.

Based on observation and interview, the facility failed to maintain their storage of oxygen gas. This was evidenced by one oxygen storage room that had an electrical wall fixture below five feet high and by one door that failed to latch. This affected two of five floors in the Hospital building, and could result in an increased risk of an electrical fire fueled by oxygen.

NFPA 99, Standard For Health Care Facilities, 1999 edition
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 16, 2012 and October 17, 2012, the oxygen storage rooms were observed.

San Joaquin Hospital
October 16, 2012
At 9:35 a.m., the self-closing door to Room 4235 (tower II), Oxygen Storage, did not latch when tested. The room contained over 14 e-cylinders of oxygen.

At 9:36 a.m., Staff 1c said during an interview that he just noticed that the door was not latching today and was going to turn in a work order to have it repaired.

October 17, 2012
At 9:26 a.m., the light switch in the oxygen storage room, near the Surgical ICU, was mounted 48 inches above the floor. There were sixteen oxygen E cylinders located inside the room.

Based on observation, the facility failed to maintain their medical gas system and to ensure ready access to emergency oxygen valves. This could delay personnel from shutting off oxygen during a fire emergency. This effected five of five floors in the Main Hospital.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled "SOURCE VALVE FOR THE (SOURCE NAME)."

(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.


Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 17, 2012, the emergency oxygen shut off valves were observed.

San Joaquin Hospital
October 17, 2012
At 9:00 a.m., there was bed on wheels and a cart impeding access to the Medical Gas shut off valve outside of Operating Room 7 in the Operating Suite.

At 2:48 p.m., there was a gurney that was impeding access to the Medical Gas shut off valve in the Cath Lab near Cath Lab 1.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into surge protectors, by the use of extension cords, by multi-plug adapters without over current protection, and by surge protectors plugged into surge protectors. This affected two of five floors in the Hospital, and could result in an electrical fire.

NFPA 70, National Electrical Code, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a tour of the facility with Staff 1 and Staff 2, on October 16, 2012, and October 17, 2012, the electrical equipment and wiring was observed.

San Joaquin Hospital
October 16, 2012
At 8:32 a.m., there was a white extension cord, in use, in Room 5234 (Rehab Services Director Office). A lamp was plugged into the extension cord.

At 2:12 p.m., there was a surge protector that was plugged into another surge protector, under the desk in the kitchen office.

At 2:38 p.m., there was a six plug adapter, in use, in the Materials Management Server Room. There was a printer that was plugged into a surge protector that was plugged into a surge protector connected to the six plug adapter.

At 2:49 p.m., there was a surge protector that was plugged into another surge protector, under the desk in the Purchasing and Materials Management Room.

October 17, 2012
At 1:42 p.m., there was a refrigerator that was plugged into a surge protector and not directly into an electrical receptacle, in the Emergency Room Doctor's Office.