HospitalInspections.org

Based on observation, the facility failed to maintain a two hour fire barrier as evidenced by a fire barrier door frame label that was painted over. There is a potential for an unrated door frame to be improperly modified. This could result in the spread of fire or smoke, in the event of a fire, affecting 2 of 71 smoke compartments.

NFPA 101 (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:

(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirements of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.

(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provision of 7.2.1.

NFPA 80 (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility two hour barriers were observed.

At 8:15 a.m., the door frame rating label in the 5th east and 5th Annex two-hour barrier was painted over. Staff 60 confirmed the rating label was painted over.

Based on observation, the facility failed to maintain the building construction as evidenced by unsealed penetrations and an open ceiling access door. This affected 3 of 71 smoke compartments which had the potential to allow the spread of smoke during a fire and harm to the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility walls and ceilings were observed.

7/26/11
5th Floor - Annex
At 8:47 a.m., above door 5S1/01 on the Annex side of the door in the main hospital, there was an unsealed one-half inch by one inch penetration in the wall above a conduit that penetrated the wall. Staff 60 confirmed there was an unsealed penetration in the wall.

At 1:57 p.m., on the wall conference room side of the inner office in the Nuclear Medicine Conference/Break Room there was an approximately one and one-half inch by one and one' half inch unsealed penetration in the wall. Staff 60 confirmed there was an unsealed penetration in the wall.

5th Floor - East
At 2:48 p.m., in the housekeeping room adjacent to room 548 in the main hospital, there was an unsealed one and one-half inch by eighteen inch penetration and damaged area in the corner of the wall just above the floor that was consistent with where the rim of the janitor cart met the wall. Staff 60 confirmed there was an unsealed penetration in the wall.

7/27/11
3rd Floor - Central
At 9:25 a.m., in the 3rd Central IT closet in the main hospital, the access door to the area above the solid ceiling was open creating an open penetration in the ceiling. Staff 60 confirmed the ceiling access door was open.

Based on observation, the facility failed to maintain the corridor walls as evidenced by unsealed corridor wall penetrations. This affected 2 of 71 Smoke Compartments in the main hospital, the Diagnostic Center, the California Cancer Center (CCC) and had the potential to transmit smoke and causing harm to the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridor walls and ceilings were observed.

7/26/11
1st Floor - East
At 9:28 a.m., in the 1 east corridor leading to the sliding door exit in the main hospital building, non-rated ceiling tiles were observed in the 1-hour rated drop ceiling. Staff 60 confirmed there were non-rated ceiling tiles in the rated corridor ceiling.

7/27/11
At 11:12 a.m., on the corridor side of the Utility Room wall at the 2nd north nurse station in the main hospital, there was an unsealed five inch circular penetration through the corridor wall with a conduit running through the unsealed penetration. Staff 60 confirmed there was an unsealed penetration in the corridor wall.

8/1/11
Diagnostic Center
At 5:25 p.m., on the Women's dressing room side of the corridor wall, there was an unsealed two inch gap around a pipe and wires that penetrated the wall. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

At 5:40 p.m., on the corridor side of the corridor wall and the Utility Room, there was an unsealed two inch gap around a pipe and wires that penetrated the wall. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

8/2/11
California Cancer Center
At 9:20 a.m., on the corridor side of the Block Room in the CCC, there were five unsealed penetrations through the corridor wall with pipes running through the unsealed penetration with an approximately one inch gap around each pipe. Staff 62 confirmed there were unsealed penetration in the 1-hour corridor wall.

8/2/11
Sierra Community Health Center
At 11:25 a.m., on the corridor side of the medical Room in the Sierra Community Health Center, there was an unsealed one-half circular penetration through the corridor wall with wires running through the unsealed penetration. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

At 11:27 a.m., in the corridor wall separating the corridor from the IT room in the Sierra Community Health Center, there was an approximately two inch by five inch unsealed penetration through the corridor wall. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

At 11:35 a.m., in the corridor wall separating the corridor from room 114 in the Sierra Community Health Center, there was an approximately three inch by three inch unsealed penetration through the corridor wall with wires running through the unsealed penetration. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

Based on observation, the facility failed to maintain the corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to latch or were obstructed from closing and by the failure to provide documentation for the testing and maintenance of roll down doors. This affected 11 of 71 smoke compartments, the California Cancer Center (CCC) and could result in the spread of smoke or fire, in the event of a fire.

NFPA 80 (1999 Edition), 15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

NFPA 101 (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridor doors were observed.

7/26/11
1) At 9:50 a.m., the corridor door to the UCSF GI Research Clinic in the main hospital was not a self-closing door. The corridor was a one-hour rated corridor. Staff 60 confirmed the door was not a self-closing door.

7/27/11
2a) 2nd Floor - Central
At 11:19 a.m., the corridor door to the Housekeeping Closet in the 2nd Central area adjacent to the nurse station in the main hospital failed to latch. The door was impeded from latching by paper stuffed into the strike plate and taped over. Staff 60 confirmed the door was impeded from latching.

7/29/11
8th Floor - 10 Story Building
b) At 8:40 a.m., the corridor door to patient room H801 in the main hospital was impeded from closing by the privacy curtain adjacent to the door. Staff 60 confirmed the privacy curtain impeded the door from closing.

c) At 8:45 a.m., the corridor door to the Men's restroom adjacent to door H8035T failed to fully close and latch without assistance. Staff 60 confirmed the door failed to fully close and latch without assistance.

4th Floor - 10 Story Building
d) At 11:20 a.m., the corridor door to patient room H468 in the main hospital was impeded from closing by two chairs stacked in front of the door. Staff 60 confirmed the chairs impeded the door from closing.

8/2/11
California Cancer Center
e) At 9:00 a.m., the self-closer to the corridor door to the med room at the nurse station in the CCC had been removed. Staff 62 confirmed the closer had been removed.

f) At 9:05 a.m., the corridor door to the Janitor's room adjacent to the accelerators in the CCC failed to fully close and latch without assistance. Staff 62 confirmed the door failed to fully close and latch without assistance.

g) At 9:25 a.m., the corridor door to the Chart/Conference Room (old infusion room) in the CCC failed to fully close and latch without assistance. Staff 62 confirmed the door failed to fully close and latch without assistance.

3) At 11:00 a.m., the facility failed to provide documentation for the testing and maintenance of the roll down door to the reception area and the roll down door to the old pharmacy area. Staff 62 confirmed the documents were not available for review.


29752

7/26/11
TCCB (Trauma Critical Care Building) - Fourth Floor
4a) At 10:11 a.m., the utility room corridor Door 3007A failed to latch in three of three attempts.

4b) At 2:52 p.m., a waiting room corridor door at the Rotunda was obstructed from closing by a trash container that was holding the door in a fully open position.

7/27/11
4c) TCCB - Second Floor
At 11:49 a.m., a corridor door for Room 2233B, Surgery Conference Room, failed to latch in three of three attempts.

Ten Story Building - 7 th Floor
4d) At 4:30 p.m. the clean linen room corridor door H9034 failed to latch in three of three attempts. The latching hardware was misaligned.

7/28/11
Laboratory
4e) At 3:36 p.m., the dark room door failed to fully in three of three attempts. The door frame obstructed the door from fully closing.

7/29/11
4f) TCCB - Basement
At 12:10 p.m., the clean linen double door (0124B) failed to latch upon closing.

Based on observation, the facility failed to maintain the trash chute as evidenced by an unsealed penetration in the trash chute enclosure. This affected 2 of 71 smoke compartments and had the potential to fail to contain smoke during a fire leading to harm of the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility trash chutes were observed.

7/29/11
6th Floor - 10 Story Building
At 9:09 a.m., there was an unsealed, one inch gap around the trash chute where the trash chute penetrated the ceiling above the area behind door H6186. Staff 60 confirmed there was an unsealed gap around the trash chute where the chute penetrated the ceiling.

Based on observation, the facility failed to mark access to exits as evidenced by exit signs that were obstructed from view, no exit signs posted, a corridor that was not an exit and not identified as not an exit, and an exit sign directing occupants to an elevator. This could delay evacuation, in the event of a fire, affecting visitors and staff in 5 of 71 smoke compartments.

NFPA 101 (2000 Edition) 7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:

NO
EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridors and exit signs were observed.

7/26/11
At 10:20 a.m., there were no exit signs visible when standing in the corridor outside the Endoscopy Recovery Room in the main hospital building. Staff 60 confirmed there were no exit signs visible when standing in the corridor outside the Endoscopy Recovery Room.

At 10:50 a.m., there was no exit sign posted above the exit adjacent to room 9 in the Short Stay Endoscopy area in the main hospital building. Staff 60 confirmed there was no exit sign posted at the exit.

Basement - 5 Story Building
At 11:05 a.m., when standing in the corridor looking towards stairwell "J" there was no exit sign posted in the corridor adjacent to stairwell "J" in the 5 story building basement of the main hospital indicating an exit. Staff 60 confirmed there was no exit sign posted in the corridor adjacent to the exit.

Basement - TCCB
At 11:28 a.m., when standing in the Resident Sleeping corridor looking towards the old morgue area, there was no exit sign posted in the corridor. An exit sign was only visible when looking in one of two directions in the corridor. Staff 60 confirmed there was no exit sign posted in the corridor leading to the old morgue area exit.

8/2/11
Sierra Community Health Center
At 11:13 a.m., there was an approximately 10 foot dead-end corridor adjacent to Treatment Room 5 in the Sierra Community Health Center. The corridor was not marked "NO EXIT." Staff 58 confirmed the corridor was not identified.


29752


7/26/11
TCCB (Trauma Critical Care Building) Rotunda - Fourth Floor
At 2:50 p.m., the exit signage for the stairwell on the fourth floor was obstructed by a sign that was hanging in front of the exit sign as viewed from the corridor outside the waiting room in the Rotunda area of the TCCB

7/27/11
TCCB - Second Floor
At 11:38 a.m., the exit signage for the stairwell on the second floor was obstructed by a sign that was hanging in front of the exit sign as viewed outside the waiting room from the corridor. This is located in the Rotunda area of the TCCB.

Based on observation, the facility failed to maintain the smoke barriers as evidenced by unsealed penetrations in smoke barriers and an unprotected smoke barrier. This affected 4 of 71 smoke compartments, the Diagnostic Center and the Community Behavioral Health Center and had the potential to fail to contain smoke during a fire which could cause harm to the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility smoke barriers were observed.

7/26/11
1) 1st Floor - 5 Story Building
At 10:20 a.m., remodeling construction was observed in the old MRI and a portion of the Endoscopy area. Drawings provided by the facility identified as "CR-5-1" showed a smoke barrier separating the old MRI area and a 1-hour rated corridor between the old MRI area and Suite 2 (S2), the Endoscopy area, in smoke compartment 5 (C5). The smoke barrier doors in the old MRI smoke barrier had been removed and the area was open to the 1-hour rated corridor adjacent to the Endoscopy area. Doors were not installed on the Endoscopy side of the corridor and ceilings were not installed in the rooms without corridor doors on the Endoscopy side of the corridor. Smoke could travel unobstructed from the old MRI area into the Endoscopy area through the open smoke barrier, through the open 1-hour corridor doors into the room and through the open ceiling into the Endoscopy area. Staff 63 confirmed there was unprotected open area between the smoke compartments.

7/27/11
2) Surgery Scheduling
At 10:50 a.m., there was an approximately three foot by eighteen inch unsealed penetration in the smoke barrier above the drop ceiling separating the corridor from the Surgery Scheduling office. Staff 60 confirmed there was an unsealed penetration in the smoke barrier.

Stepdown Unit
3) At 2:50 p.m., there was an approximately eight inch by eight inch unsealed penetration, an approximately one inch irregular unsealed penetration, an approximately one-half inch unsealed gap around a conduit and blue wires through an approximately eight inch by eight inch unsealed penetration in the smoke barrier of the Step Down unit in the main hospital building. Staff 60 confirmed there were unsealed penetrations in the smoke barrier.

7/28/11
4) Community Behavioral Health Center
At 11:55 a.m., in the smoke barrier above the recreation therapy storage area at the Community Behavioral Health Center, there was and unsealed two inch by five inch penetration in the smoke barrier with blue wires running through the penetration. There were three two inch by five inch unsealed penetrations in the barrier with conduits running through the penetration. Staff 60 confirmed there were unsealed penetrations in the smoke barrier.

7/29/11
5) 4th Floor - 10 Story Building
At 10:55 a.m., there was an approximately two inch by eighteen inch unsealed penetration in the smoke barrier above the drop ceiling in the 10-story 4th Floor Conference room in the main hospital building that separated the conference room from the Resident Sleeping area. Staff 60 and 62 confirmed there were an unsealed penetrations in the smoke barrier.

8/1/11
Diagnostic Center
6) At 5:25 p.m., there was an approximately six inch by eighteen inch unsealed penetration in the south lobby wall of the Diagnostic Center above the drop ceiling. There were pipes running through the unsealed penetration in the wall. Staff 58 confirmed there was an unsealed penetration in the smoke barrier.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by barrier doors that were not self-closing or failed to latch. This could result in the spread of fire or smoke, in the event of a fire, affecting 6 of 71 smoke compartments.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility smoke barriers were observed.

7/29/11
1st Floor - 10 Story Building
1) At 2:30 p.m., the new corridor door to the new Medical Staff office in the main hospital building was not self-closing. Drawings provided by the facility identified as "CR-10-1" showed a smoke barrier separating the new Medical Staff Office in S3 and the corridor in S6. Staff 60 confirmed the door in the smoke barrier was not a self-closing door.

Surveyor 29752:

7/27/11
2nd Floor - TCCB (Trauma Critical Care Building)
2) At 3:22 p.m., a smoke barrier door between sterile processing and sterile storage failed to latch when closed. The door latch hardware was taped over.

7/28/11
Basement - TCCB
3) At 1:35 p.m., the smoke barrier door between the warehouse corridor and the test kitchen exit access corridor failed to self close and latch.

During fire alarm testing with Staff 58 the smoke barrier doors in corridors were tested.

8/1/11
4) 5th Floor - 5 Story Building
At 11:24 a.m. the corridor door on the side nearest room 540 failed to fully close and latch in three of three attempts.

Based on observation, the facility failed to protect the hazardous areas from other areas as evidenced by self closing corridor doors that failed to close or failed to latch. This could result in the spread of smoke and fire, in the event of a fire affecting 4 of 71 smoke compartments, the Laboratory, and the California Cancer Center.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility hazardous areas were observed.

7/26/11
5th Floor - 5 Story East
1) At 3:04 p.m., the self-closing corridor door to the linen room adjacent to room 551 in the main hospital building failed to fully close and latch without assistance. Staff 60 confirmed the door failed to fully close and latch without assistance.

7/27/11
2) At 11:23 a.m., the walls surrounding the Station 2 Infectious Waste room in the central corridor of the main hospital building failed to extend to the roof above. Staff 60 confirmed the walls failed to extend to the ceiling above and was scheduled for repair.

7/29/11
8th Floor - 10 Story Building
3) At 9:03 a.m., the self-closing corridor door to the soiled utility room H8040 in the main hospital building failed to fully close and latch without assistance. Staff 60 confirmed the door failed to fully close and latch without assistance. The soiled linen chute, which was not equipped with a lock, was inside the room.

8/2/11
California Cancer Center
4) At 9:28 a.m., there were approximately 16 unsealed pipes and conduits penetrating the wall between the PG&E room and the CCC. There was an approximately one inch unsealed gap around each pipe and conduit. Staff 62 confirmed there were unsealed penetrations in the room.


29752

7/27/11
Surgery - Second Floor of 5 Story Building
5) At 3:52 p.m., the door for Pathology was self closing but failed to self close completely and the hazardous storage cabinet was left open. The door to pathology remained open approximately 1/4" in three of three attempts. There were four one-gallon plastic containers of Formalin stored in cabinet below the counter inside the room. There was a steel flammables storage cabinet inside this room with the door left open approximately 1/4". There were two 1/2 gallon containers of xylene, one half gallon container of Rapid Fix, and four one pint containers of isopropyl alcohol. This room is a hazardous storage area due to storage of flammable and combustible liquids. The floor plans provided by the facility do not indicate that this room is protected as a fire rated enclosure.

Laboratory
7/28/11
6) At 3:53 p.m., the anteroom door for the AFB Lab did not latch. The door was retested three times and failed to latch each time.

7) At 3:56 p.m., the PCR (Preliminary Chain Reaction) door was obstructed from closing by a door wedge.

Based on observation, the facility failed to maintain the exit stairwells as evidenced by a stairwell door frame label painted over. This affected 6 of 71 smoke compartments and had the potential to allow the spread of smoke and fire due to unrated door frames leading to harm of the patients.

NFPA 101 (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:

NFPA 80 (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility stairwells were observed.

5th Floor - 5 Story Building
At 8:15 a.m., the door frame rating label in the stairwell adjacent to the 5th east and 5th Annex two-hour barrier was painted over. Staff 60 confirmed the rating label was painted over.

Based on observation, the facility failed to maintain readily available exits as evidenced by obstructed egress access and obstructed exit doors. This could result in a delay of evacuation, in the event of a fire, affecting 4 of 71 smoke compartments.
NFPA 101 (2000 Edition) 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Exception: As modified by 19.2.2 through 19.2.11
Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 7/26/11 and 8/2/11, the facility exits and exit access were observed.

7/26/11
1st Floor - 5 Story East
1) At 9:47 a.m., access to the exit from the Angiography Room in the main hospital building was obstructed by equipment stored in front of the door. Staff 60 confirmed access to the exit was obstructed.

2) At 10:20 a.m., the exit sign adjacent to the elevators near the Endoscopy Recovery Room in the main hospital building directed occupants to the elevators. Due to construction, the exit was not accessible. Staff 60 confirmed the exit was not accessible.


29752

7/27/11
2nd Floor - TCCB (Trauma Critical Care Building)
3) At 11:11 a.m., on the 2nd floor of the TCCB, the clean corridor exit access was obstructed by a patio table and chairs, There was approximately three feet of clearance between the table with chairs and the corridor wall.

7/29/11
1st Floor - TCCB
4) At 8:42 a.m., in the Emergency Department, there was a gurney with a patient stored in front of an exit access door (between Sub-Wait room and the Cast Suture area). At this location there are two four foot wide opposite swinging doors between Suite 5 and the exit access corridor. Only one could be used for egress when the fire alarm system is activated and the doors are released. When the second door closed it acted as a barrier to egress from the suite. There was approximately one foot of clearance between the barrier door and the gurney when the door was closed.

During an interview at 8:45 a.m., the Emergency Department Manager stated that patients were treated while on the gurneys and in many instances they remained in place until discharged. There were 6 gurneys lined up along the same side of the exit access between exam room doorways. He stated that these are normally stored at this location while the patients are being seen. They may remain at that same location with the patient the entire time they are there for treatment.

Based on record review, observation and interview, the facility failed to ensure that emergency egress lighting was tested in accordance with NFPA 101. This was evidenced by no records of testing the emergency lighting located in the Laboratory. This could result in an interruption of emergency lighting and delay evacuation, in the event of a fire. This affected 24 of 24 lights located across the Lab.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During record review on 7/26/11 there were no inspection or testing records available for fluorescent ceiling light fixtures with battery type emergency lighting.

7/28/11
During the facility tour on 7/28/11, the battery type emergency lighting were observed within the overhead lighting fixtures throughout the lab

At 4:20 p.m., there were twenty-four fluorescent fixtures with a red indicator light on each battery powered light fixtures.
During an interview at 4:25 p.m., Staff 57 reported there were no records for testing the battery power for the lights. There were no other records for inspection and testing of the lights.

Based on observation, the facility failed to maintain the emergency exit signs as evidenced by the failure to provide documentation for the testing of the exit signs, and exit sign that was expired and an exit sign that was not fully illuminated. This affected the Sierra Community Health Center, the Diagnostic Center and the California Cancer Center and had the potential for the sign to not be legible and delaying egress from the building and causing harm to the patients.

NFPA 101 (2000 Edition) 7.9.3 Periodic testing of emergency lighting equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

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

NFPA 101 (2000 Edition) 7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance
with 7.9.3.

Findings:

During the facility tour with Staff 58 and 62 on August 1 and 2, 2011, the facility exit signs were observed.

8/2/11

Diagnostic Center
1) At 5:37 p.m., the self-illuminated exit sign in the south side room adjacent to the copy machine expired 6/2001. Staff 58 confirmed the exit sign was expired.

2) At 5:45 p.m., the Diagnostic Center was unable to provide documentation confirming the exit signs were tested monthly and annually to confirm the battery backup in the signs were functional. Staff 58 was unable to provide documentation for testing the exit signs with battery backup.

California Cancer Center
3) At 10:05 a.m., Staff 62 was asked if the exit signs were tested monthly and annually in the CCC to confirm the battery backup in the signs were functional. Staff 62 was unable to provide documentation for testing the exit signs with battery backup.

Sierra Community Health Center
4) At 11:15 a.m., Staff 58 was asked if the exit signs were tested monthly and annually at the Sierra Community Health Center to confirm the battery backup in the signs were functional. Staff 58 was unable to provide documentation for testing the exit signs with battery backup.

5) At 11:19 a.m., exit sign #15 in the Physical Therapy area of the Sierra Community Health Center was not fully illuminated. One of two bulbs in the sign was not functioning. Staff 58 confirmed only one light in the sign was functional and the sign was not fully illuminated.

Based on record review and interview, the facility failed to ensure all staff were trained for emergency response during fire drills. This was evidenced by incomplete documentation of staff participation in fire drills at the main hospital and by incomplete documentation of fire drills quarterly on each shift at the behavioral health center. There was insufficient documentation that all staff participated in fire drills and practiced emergency response procedures. This could result in a delayed response by staff if they are not familiar with their roles and responsibilities. There was an increased potential for the spread of fire or smoke, in the event of a fire, affecting the entire hospital and the community behavioral center.

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.

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 from 7/25/11 and 7/28/11, the main hospital and community behavioral health center fire drill report logs were requested.

7/28/11
Community Behavioral Health Center
1a) At 9:00 a.m., the facility failed to provide documentation for 2 of 4 A.M. shift drills. The facility failed to provide a drill for the 2nd quarter (April-June) of 2011 and the 3rd quarter (July-September) of 2010. Staff 60 confirmed the drill reports were not available.

1b) At 9:00 a.m., the facility failed to provide documentation for 3 of 4 P.M. shift drills. The facility failed to provide a drill for the 2nd quarter (April-June) of 2011, the 3rd quarter (July-September) of 2010 and the 4th quarter (October-December) of 2010. Staff 60 confirmed the drill reports were not available.

1c) At 9:00 a.m., the facility failed to provide documentation for 2 of 4 N.O.C. shift drills. The facility failed to provide a drill for the 2nd quarter (April-June) of 2011 and the 4th quarter (October-December) of 2010. Staff 60 confirmed the drill reports were not available.


29752

7/26/11
Trauma Critical Care Building - 10 Story Building - 5 Story Building (hospital)
2) At 1:45 p.m., fire drill documents during the second quarter were conducted at the end of June without any additional observations. Staff observations were conducted inconsistently in the second quarter of 2011 and randomly throughout the hospital during the last year. There was insufficient documentation that all staff participated in fire drills and practiced emergency response procedures.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by batteries that were past due for replacement, the failure to provide documentation for the annual inspection and testing of a fire alarm system, the failure to provide a smoke detector at an unattended alarm panel, an obstructed manual fire alarm box, a failure to provide a manual fire alarm box in an egress access corridor, a fire barrier curtain that was obstructed from closing, and by an elevator smoke barrier curtain that failed to deploy. This could result in a delay in notification and evacuation and the spread of fire or smoke, in the event of a fire. This affected 11 of 71 hospital smoke compartments, the Diagnostic Center, the Ambulatory Care Clinic, the Surgical Services Building and the Community Behavioral Health Center, and had the potential for fire alarm system failure and delay in alarm activation leading to harm to the patients.

NFPA 72 (1999 Edition), 1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

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

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72 (1999 Edition) 7-3 Inspection and Testing Frequency.

7-3.1* Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
Extended intervals shall not exceed 18 months.

Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. The requirements of Table 7-3.1 shall apply.

NFPA 72 (1999 Edition) 7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

NFPA 72 (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) Sealed lead acid batteries are to be replaced every 4 years.

NFPA 72 (1999 Edition), 7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the information regarding tests and all the applicable information requested in figure 7-5.2.2.

(1) Date
(2) Test Frequency
(3) Name of Property
(4) Address
(5) Name of person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section_____ ."
(8) Functional Test of Detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/success-fully retested, device abandoned in place)

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between July 26 and August 2, 2011, the fire alarm controlled building systems and notification devices were observed.

7/26/11
1) 3rd Floor - TCCB
At 1:59 p.m., access to the manual fire alarm box adjacent to the Nuclear Medicine reception desk in the main hospital building was obstructed by a literature rack. Staff 60 confirmed the rack chair obstructed access to the manual fire alarm box.

7/28/11
Community Behavioral Health Center
2) At 2:42 p.m., there was no automatic smoke detection or automatic heat detection in the IT Room at the Community Behavioral Health Center where the fire alarm communication panel was located. The room was not constantly attended. Staff 60 and 62 confirmed there was no automatic smoke detection or automatic heat detection in the IT Room.

7/29/11
2nd Floor - Ten Story Building
3) At 1:18 p.m. on July 29, 2011, the two batteries in the large fire alarm panel located in room 10S2/01 in the main hospital building were dated 3-20-07, approximately 5 months past due for replacement. Staff 60 confirmed the batteries were sealed lead acid batteries and confirmed the batteries were dated 3-20-07.

8/1/11
Surgical Services Building
4) At 2:35 p.m., there was no automatic smoke detection or automatic heat detection in the Fire Alarm Panel Room at the Surgical Services Building. The room was not constantly attended. Staff 58 confirmed there was no automatic smoke detection or automatic heat detection in the Panel Room.

5) At 3:15 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the Surgical Services Building. Staff 58 confirmed the documentation was not available.

Diagnostic Center.
6) At 6:00 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the Diagnostic Center. Staff 58 confirmed the documentation was not available.

8/2/11
ACC Building
7) At 3:15 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the ACC Building. Staff 58 confirmed the documentation was not available.

Sierra Community Health Center
8) At 3:30 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the Sierra Community Health Center. Staff 58 confirmed the documentation was not available.


29752

7/27/11
Fourth Floor - TCCB
9) At 11:42 a.m., a metal waste container was obstructing the door panel for a recessed sliding fire curtain. The waste container was approximately 30 gallon capacity and was placed directly against the swinging panel for the fire curtain.

8/1/11
Fourth Floor - Ten Story Building
10) At 5:07 p.m., the smoke barrier curtain for one of two elevators was obstructed from activating with the fire alarm system. This was described by staff as Elevator 8. The curtain for the second elevator deployed properly upon activation by a nearby smoke detector. The curtain door panel was jammed against the frame in the ceiling. It was pried open to allow the smoke barrier curtain to drop.

8/2/11
Third Floor - Annex
11) At 9:13 a.m., there was no pull station in the exit access corridor on the third floor of the Annex building. The nearest pull station was on the opposite side of a self closing smoke barrier door in the corridor heading into the Five Story building. This pull station was not visible from either of the two intersecting corridors of the annex. This floor was occupied by office staff and attendees for the classrooms.

Based on observation and interview, the facility failed to maintain the smoke detectors as evidenced by the failure to provide documentation for the testing of the single station smoke alarms and system smoke alarms. This affected the Sierra Health Care Center, the California Cancer Center (CCC) and had the potential for detector failure.

NFPA 101 (2000 Edition), 4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 (1999 Edition) 7-1.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (1999 Edition), 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-3.3 Single station smoke detectors installed in one- and two-family dwelling units shall be inspected, tested, and maintained as specified in Chapter 8. Single station detectors installed on other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26 and 8/2/11, the fire alarm sytem and smoke alarms were observed.

8/1/11
Sierra Health Center
At 4:40 p.m., an AC powered single station smoke alarm was observed in the corridor adjacent to room 116 in the Sierra Health Center. Molded letters on the alarm stated "Test Weekly." Staff 58 stated there were no records available for review and was not sure if the smoke alarm was still functional.

8/2/11
California Cancer Center
At 10:15 a.m. on August 2, 2011, the CCC failed to provide documentation for the sensitivity testing of the smoke alarms. Staff 62 stated there were no records available for review.

Based on observation, the facility failed to maintain the automatic fire sprinkler system as evidenced by the failure to provide spare sprinkler heads representative of the types and temperature ratings of the system sprinklers,quick response sprinkler heads in a smoke compartment which also contained standard sprinkler heads, quick response sprinkler heads in smoke compartments which also contained standard sprinkler heads, the failure to provide documentation for quarterly and annual sprinkler inspection and tests, a water gong that failed to operate properly and a sprinkler valve that was not labeled This affected 45 of 71 smoke compartments, Ambulatory Care Clinic (ACC), the Diagnostic Center, the California Cancer Clinic (CCC) and the Surgical Services Building and had the potential for fire sprinkler system failure, the potential to be unable to replace sprinkler heads when needed and the failure to identify system component due to not being labeled. This could lead to harm to the patients.

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

NFPA 13 (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartment space shall be changed.
NFPA 25 (1998 Edition) 1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
NFPA 25 (1998 Edition) 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
NFPA 25 (1998 Edition) 2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.

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

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

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

NFPA 25 (1998 Edition), 2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler
NFPA 25 (1998 Edition), 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
NFPA 25 (1998 Edition), 2-2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. Hangers and seismic braces shall not be damaged or loose. Hangers and seismic braces that are damaged or loose shall be replaced or refastened.
Exception No. 1: *Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Hangers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
NFPA 25 (1998 Edition) 2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
NFPA 25 (1998 Edition) 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
NFPA 25 (1998 Edition) 2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
NFPA 25 (1998 Edition), 2-4.1.4 A supply of at least 6 spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not exposed to moisture, dust, corrosion or a temperature exceeding 100 degrees F (38 degrees C).

Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

NFPA 25 (1998 Edition) 9-3.5 Maintenance. The operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.
NFPA 25 (1998 Edition) 9-4.1.2* Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

NFPA 25 (1998 Edition) 9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

NFPA 25 (1998 Edition) 9-4.4.1.5 Strainers, filters, and restricted orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
NFPA 25 (1998 Edition) 9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
NFPA 25 (1998 Edition) 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25 (1998 Edition) 10-2.2* Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Findings:
During the facility tour with Staff 57, 58, 59, 60, 61, 62 and 63 between 7/27/11 and 8/2/11, the fire sprinkler systems were observed.

7/27/11
1) At 9:44 a.m., quick response sprinkler heads were observed in the 3rd east staff lounge in the main hospital building. The smoke compartment also contained standard response sprinkler heads. Staff 60 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.

2) At 9:48 a.m., quick response sprinkler heads were observed in room 351 in the main hospital building. The smoke compartment also contained standard response sprinkler heads. Staff 60 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.

3) At 1:47 p.m., in the Pharmacy Administrative Office in the 10 story building of the main hospital, there was a valve in the fire sprinkler system that was not labeled as to the function of the valve. Staff 60 confirmed there was no identification sign on the valve.

4) At 2:09 p.m., quick response sprinkler heads were observed in the Case Management Conference Room in the basement of the main hospital building. The smoke compartment also contained standard response sprinkler heads. Staff 60 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.

5) At 2:20 p.m., the spare sprinkler head box for the 10 story and 5 story buildings of the main hospital was observed in the old boiler room. The box contained standard response sprinkler heads, no recessed heads and and only one quick response sprinkler head. Quick response heads and recessed heads were observed throughout the facility during the tour between July 25 and July 27. Quick response sprinkler heads observed included green colored heads and red colored pendent, red colored side mount, red colored side mount pendent, upright red colored and recessed heads. Staff 60 confirmed the spare head box failed to stock spare sprinklers proportionally representative of the types and temperature ratings of the system sprinklers.

8/1/11
6) At 2:35 p.m., the Surgical Services Building inspector test valve (ITV) was activated. The water gong activated for a few seconds and then went to a thudding sound as if the clanger was stuck. Staff 58 confirmed the water gong was not working properly. The alarm activated at the monitoring station.
7) At 3:15 p.m., the facility failed to provide documentation for 4 of 4 quarterly fire sprinkler inspections during the previous 12 months for the Surgical Services Building including documentation the system was free of physical damage, that the valves were inspected, inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no documentation of the quarterly sprinkler tests and inspections available.
8) At 3:15 p.m., the facility failed to provide documentation for the annual inspection of the fire sprinkler system for the Surgical Services Building that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves . Staff 58 confirmed there was no documentation available for the annual sprinkler tests and maintenance.
9) At 6:00 p.m., the facility failed to provide documentation for 4 of 4 quarterly fire sprinkler inspections during the previous 12 months for the Diagnostic Center Building including documentation the system was free of physical damage, that the valves were inspected, inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no documentation of the quarterly sprinkler tests and inspections available.
10) At 6:00 p.m., the facility failed to provide documentation for the annual inspection of the fire sprinkler system for the Diagnostic Center Building that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves . Staff 58 confirmed there was no documentation available for the annual sprinkler tests and maintenance.
8/2/11
11) At 3:15 p.m., the facility failed to provide documentation for 4 of 4 quarterly fire sprinkler inspections during the previous 12 months for the ACC Building including documentation the system was free of physical damage, that the valves were inspected, inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no documentation of the quarterly sprinkler tests and inspections available.
12) At 3:15 p.m., the facility failed to provide documentation for the annual inspection of the fire sprinkler system for the ACC Building that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves . Staff 58 confirmed there was no documentation available for the annual sprinkler tests and maintenance.
13) At 10:15 a.m., the facility failed to provide documentation for the 3rd quarter (July-September) 2010, the 1st quarter (January-March) and the second quarter (April-June) 2011 sprinkler system inspection and test records for the California Cancer Center. There was no evidence the alarms where inspected to assure they were free of physical damage, there was no evidence of testing of the sprinkler system alarms, there was no evidence that the valves were inspected and there was no evidence the the fire department connections were inspected. Staff 62 confirmed the were no documents available for review.

14) At 10:15 a.m., the facility failed to provide documentation for the 5-year automatic sprinkler inspection. Staff 62 confirmed the were no documents available for review.

15) At 3:30 p.m., the facility failed to provide documentation for the 4th quarter (October-December) 2010 and the second quarter (April-June) 2011 sprinkler system inspection and test records for the Sierra Community Health Center. There was no evidence the alarms where inspected to assure they were free of physical damage, there was no evidence of testing of the sprinkler system alarms, there was no evidence that the valves were inspected and there was no evidence the the fire department connections were inspected. Staff 57 confirmed the were no documents and that there were no other documents available for review.


29752

7/28/11
TCCB
1st Floor Behavioral Unit
2nd, 3rd, 4th, and 5th floor Rotunda/Waiting area corridors
16) At 11:18 a.m., there were no replacement sprinkler heads for the Rotunda waiting area corridors and no spare tamper proof sprinkler head replacements for the Behavioral Unit. Staff 57 stated that there were no other storage locations for these sprinkler heads.

Based on observation, the facility failed to maintain the fire extinguishers as evidenced by obstructed access to an extinguisher and an extinguisher with a missing tamper indicator. This affected 2 of 71 smoke compartments, the Ambulatory Care Clinic (ACC) and the Community Behavioral Health Center (CBHC) and had the potential for fire extinguisher failure and delay in fire suppression leading to harm to the patients.

NFPA 10 (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.

NFPA 10 (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

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

NFPA 10 (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the fire extinguishers were observed.

7/26/11
1) At 9:05 a.m., the fire extinguisher in the Med East Pantry of the main hospital building was missing the tamper indicator. Staff 60 confirmed the fire extinguisher was missing the tamper indicator.

7/27/11
2) At 1:40 p.m., access to the fire extinguisher in the MDF Room in the 10 story building of the main hospital was blocked by a trash can, forcing occupants to reach over the trash can if the extinguisher was needed. Staff 60 confirmed the access was blocked by the trash can.

7/28/11
3) At 11:35 a.m., access to the fire extinguisher in the Medical Records office at the CBHC was blocked by a secure shredding receptacle, forcing occupants to reach over the trash can if the extinguisher was needed. Staff 60 confirmed the access was blocked by the receptacle.

8/2/11
4) At 2:50 p.m., the fire extinguisher in the 2nd floor electrical room of the ACC building had a broken tamper indicator. Staff 58 confirmed the fire extinguisher tamper indicator was broken.

Based on observation, the facility failed to maintain the designated smoking areas as evidenced by the failure to provide a container into which ashtrays could be emptied. This affected the Community Behavioral Health Center (CBHC) and had the potential for fire and harm to the patients.

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the designated smoke areas were observed.

7/28/11
At 8:40 a.m., the designated smoking area at the CBHC was observed. The facility failed to provide a container into which the open face ashtray could be emptied. Staff 60 and 62 confirmed there was no container into which the ashtray could be emptied.

Based on observation, interview and document review, the facility failed to maintain the fire dampers as evidenced by the failure to provide documentation for the testing and maintenance of all dampers in the facility, the failure to provide lettering on duct service openings adjacent to dampers, the failure to provide dampers and dampers that were closed. This affected 50 of 71 smoke compartments, the Diagnostic Center, the Ambulatory Care Clinic (ACC), the California Cancer Center (CCC), the Surgical Services Building and the Community Behavioral Health Center (CBHC) which had the potential to fail to contain smoke in a fire leading to harm of the residents.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.3.5 Air duct coverings shall not be installed so as to conceal or prevent the use of any service opening.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.10.2 Ceiling Cavity Plenum. (f) Where the plenum is a part of a floor-ceiling or roof-ceiling assembly that has been tested or investigated and assigned a fire resistance rating of 1 hour or more, the assembly shall meet the requirements of 3-3.3.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.11.1* Egress Corridors. Egress corridors in health care, detention and correctional, and residential occupancies shall
not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 3-3.1.2 Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire
resistance rating and in which other openings are required to be protected.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
Findings:
During the document review and facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility maintenance records were reviewed and the dampers were observed.

7/26/11
1) At 8:51 a.m., fusible link dampers were observed in the corridors and Mechanical Room in the Med East area of the main hospital building. The dampers were not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

2) At 11:35 a.m., the duct access panel adjacent to the damper above door 5SO/20 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

3) At 1:45 p.m., the duct access panels adjacent to the damper on both sides of the barrier above the Nuclear Medicine Injection Lab in the main hospital building were not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panels to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

4) At 1:49 p.m., the duct access panel adjacent to the damper in the mechanical room adjacent to the Nuclear Medicine Injection Lab in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

5) At 1:54 p.m., the duct access panel adjacent to the damper above door 5SO/02 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

6) At 2:08 p.m., the duct access panel adjacent to the damper between the old Nuclear Medicine Hot Lab and the corridor in the main hospital building open and was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

7) At 3:25 p.m., the area above the corridor ceilings in the 5-story building of the main hospital were noted to be an air plenum. The ducts in the ceiling of the corridor separating the plenum and the corridor were equipped with fusible link fire dampers. The air ducts between the patient rooms and the plenum were observed not to have dampers. Staff 60 confirmed the air ducts between the rooms and the plenums were not dampered.

8) At 3:25 p.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffles to patient rooms 520, 523, 525, 527 and 530 were closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffles were closed.

9) At 3:55 p.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffles to patient rooms 402, 403, 443, 444 and 446 were closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffles were closed.

7/27/11
10) At 8:30 a.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffle to patient room 451 was closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffle was closed.

11) At 8:40 a.m., the duct access panel adjacent to the damper in the 4th Central mechanical room adjacent to room 420 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

12) At 8:48 a.m., 2 of 2 duct access panels adjacent to the dampers in the 3rd Central mechanical room adjacent to room 320 in the main hospital building were not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panels to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

13) At 8:48 a.m., the large damper in the 3rd Central mechanical room adjacent to room 320 in the main hospital building was covered with insulation. The insulation had the potential for preventing the damper from fully closing. Staff 60 confirmed there was insulation on the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

14) At 9:10 a.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffles to patient rooms 306 and 307 were closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffles were closed.

15) At 9:23 a.m., 2 of 2 dampers in the 3rd Central elevator alcove in the 5-story building of the main hospital were closed which did not allow for the circulation of air in the corridor. Staff 60 confirmed the dampers were closed.

16) At 9:30 a.m., the duct access panel adjacent to the damper in the 3rd floor mechanical room adjacent to room 350 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

17) At 9:32 a.m., the duct access panel adjacent to the damper above door 5S3/05 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

18) At 10:43 a.m., the dampers in the 2nd floor Central elevator alcove in the 5-story building of the main hospital was closed which did not allow for the circulation of air in the corridor. Staff 60 confirmed the damper was closed.

19) At 10:58 a.m., the high duct access panel adjacent to the damper in the 2nd floor Central Mechanical Room 5S2/17 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

20) At 11:27 a.m., the damper was missing in the corridor ceiling air duct adjacent to room 240 and smoke barrier door 5S2/07 in the 5-story building of the main hospital. Staff 60 confirmed the damper was missing.

21) At 11:34 a.m., the duct access panel adjacent to the damper above door 5S2/05 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

22) At 11:36 a.m., the damper was missing in the corridor ceiling air duct adjacent that supplied air to the 2E nurse station. The vent was above desk facing the corridor and was open from the plenum into the nurse station. Staff 60 confirmed the damper was missing.

7/28/11
23) At 10:35 a.m., damper test records for the CBHC facility were provided. The records documented damper testing was started on July 19, 2011. Staff 62 stated testing was not complete and that there were no prior records available documenting testing and maintenance of the dampers.

7/29/11
24) At 9:15 a.m., the area above the corridor ceilings in the 10-story building of the main hospital were noted to be an air plenum. The ducts in the ceiling of the corridor separating the plenum and the corridor were equipped with fusible link fire dampers. The air ducts between the patient rooms and the plenum were observed to have dampers with fusible links. The dampers were not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

25) At 9:36 a.m., the duct access panel adjacent to the damper adjacent to door H6102 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

26) At 9:47 a.m., 1 of 4 duct access panels adjacent to door H6145 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper.

27) At 9:53 a.m., the duct access panel adjacent to the damper adjacent to door H6172 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

28) At 9:58 a.m., 2 of 2 duct access panels adjacent to the dampers in the 6th floor Mechanical Room in the 10 story building of the main hospital were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the damper. The dampers were not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

29) At 10:10 a.m., the duct access panel adjacent to the damper adjacent to door 10S6/04 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

30) At 10:59 a.m., an air duct was observed to penetrate the wall separating the 4th floor conference room in the 10-story building from the mechanical room. On page CR-10-4 of the drawings provided by the facility, the separation wall was shown as being a smoke barrier and a 1-hour fire separation. There was no evidence of a damper in the wall or in the corridor/conference room wall. Staff 58 confirmed there was no evidence of dampers in the walls.

31) At 2:27 p.m., the damper in the cafeteria vestibule adjacent to the Chief Infomation Office in the 10-story building of the main hospital was closed, which did not allow for the circulation of air in the corridor. Staff 58 confirmed the damper was closed.

8/1/11
32) At 5:20 p.m., the Diagnostic Center failed to provide documentation for the testing and maintenance of the damper above the reception area. Staff 58 stated the records for the damper were not available.

8/2/11
33) At 9:28 a.m., the duct access panel adjacent to the damper in the PG&E room in the CCC Building was not identified indicating a damper within the duct. Staff 62 confirmed there was no lettering on the access panel to note the presence of the dampers.

34) At 10:00 a.m., the CCC facility failed to provide documentation for the testing and maintenance of the dampers in the building. Staff 62 stated there were no records for the dampers.

35) At 2:00 p.m., the duct access panel adjacent to the damper above room 15, the duct access panel adjacent to the damper above room 16, and the duct access panel adjacent to the damper above room 17 in the Surgical Services Building were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the dampers.

36) At 2:12 p.m., the duct access panel adjacent to damper FSD18, FSD19 and FSD21 in the Surgical Services Building were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the dampers.

37) At 2:20 p.m., 2 of 2 duct access panels adjacent to the dampers in the 2nd floor mechanical room in the ACC Building were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the dampers.

Based on observation, the facility failed to maintain the trash chutes as evidenced by the failure to provide a self-closing corridor door to a room containing the trash chute and a trash chute sprinkler head that was covered with foreign material. This affected 11 of 71 smoke compartment and had the potential to fail to contain smoke and fire leading to harm of the residents.

NFPA 82 "Standard on Incinerators and Waste and Linen Handling Systems and Equipment" (1999 Edition)

3-2.1 General. General access gravity chutes shall be permitted to be supplied with unlocked doors and shall be permitted to be available to all occupants at all times. A trash or linen gravity chute shall be permitted to be installed as a limited access gravity chute by installing a key in either the chute intake door or the entry door into the service room. Limited access waste chutes shall be installed so that they can only be used by authorized personnel. A gravity waste or linen chute also shall be permitted to to be used to interface with a pneumatic transport system.

3-2.4.3.2 Service Opening Room Key. If entrance to a limited-access service opening is gained by key, the service opening door shall not require a key to be opened. One opening or the other shall be keyed. Keying shall be required only for limited-access installations.

3-2.5.1 Gravity Chute. Gravity chutes shall be protected internally by automatic sprinklers. This protection requires that a sprinkler be installed at or above the top service opening of the chute. In addition, a sprinkler shall be installed within the chute at alternate floor levels in buildings over two stories in height with a mandatory sprinkler located at the lowest service level. Sprinkler system installation shall comply with NFPA 13, Standard for the Installation of Sprinkler Systems.

3-2.5.2 Chute Sprinkler Head Protection. Automatic sprinkler installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

NFPA 13, Standard for the Installation of Sprinkler Systems (1999 Edition) 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 of 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), 2-2.1.1 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.

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

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

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility trash chutes were observed.

7/26/11
1) At 8:56 a.m., corridor door H4146 was self-locking and opened to the alcove containing the door to the trash chute which was not equipped with keyed lock. The trash chute was limited access. The corridor door to the unlocked trash chute door was not self-closing. Staff 60 confirmed the chute door was not equipped with a lock and the corridor door to the chute was not self-closing.

2) At 11:36 a.m., the sprinkler head in the 2nd floor trash chute of the 10 story building in the main hospital building was covered with foreign material. Staff 60 confirmed the sprinkler head was covered with foreign material.

Based on observation and interview, the facility failed to provide flame resistant draperies and curtains as evidenced by curtains with no tags identifying them as being flame resistant and the failure to have documents from the manufacturer identifying them as being flame resistant. This affected the Sierra Community Health Center and had the potential for the spread of fire leading to harm to the patients.

NFPA 101 (2000 Edition), 10.3.1 Where required by the applicable provision of this Code, draperies, curtain, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings:

During the facility tour with Staff 58 on 8/2/11, the facility drapes and curtains were observed.

8/2/11
At 11:18 a.m., the privacy curtains in the Physical Therapy area of the Sierra Community Center were not labeled as being flame resistant. Staff 58 confirmed the curtains were not labeled and stated the documents from the manufacturer attesting to the flame resistance were not available.

Based on observation, the facility failed to store mobile trash collection receptacles with a capacity greater than 32 gallons in a room protected as a hazardous area as evidenced by mobile receptacles greater than 32 gallons stored in a corridor. This affected 1 of 71 smoke compartments and had the potential for the spread of fire leading to harm of the patients.

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridors were observed.

7/29/11
At 1:53 p.m., there were two, approximately gray colored 44-gallon containers used to collect paper for secure shredding adjacent to the Post Op Nurse Station B in the main hospital building. Staff 60 confirmed the containers were not stored in an area protected as hazardous storage.

Based on observation, the facility failed to maintain the oxygen storage areas as evidenced by oxygen cylinders stored within 5 feet of combustible material. This affected 1 of 71 smoke compartments and the Ambulatory Care Clinic (ACC) and had the potential for a fire and harm to the residents.

NFPA 99, Standard for Healthcare Facilities, (1999 Edition) 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

NFPA 99, Standard for Healthcare Facilities, (1999 Edition) 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:

1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation
of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the oxygen storage areas were observed.

7/27/11
1) At 2:52 p.m., in the Stepdown 1 storage room in the main hospital building, marked "Film Processing Room" on the map provided by the facility, there was a blanket stored over the valves on top of two oxygen E cylinders. Staff 60 confirmed there was a blanket stored on top of the cylinders.

8/2/11
2) At 2:25 p.m., in the Dental medical gas system room in the ACC Building, there was an H cylinder of nitrous oxide connected to the system that was not secured in place. Staff 58 confirmed the H cylinder was not secured.

Based on document review, the facility failed to provide documentation for action taken in six Operating Rooms (OR) when the relative humidity dropped below 35%. This deficient practice could result in an electrical fire from static electricity in an low humidity setting.

NFPA 99 (1999 Edition) 5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review on July 27, 2011, the OR logs were reviewed.
At 2:45 p.m., the humidity logs provided by the facility documented relative humidity levels in the Operating Room suites below 35 percent for the following days: 5-24-11 OR-1 28%, OR-9 28%, OR-11 29%; 4-9-11 3rd Floor Labor and Delivery OR-3 29.8%; 3-1-11 3rd Floor Labor and Delivery OR- 2 and OR-3 29%. The facility failed to provide documentation for action taken in the Operating Rooms when the humidity levels fell below 35%. At 8:00 a.m. on July 27, 2011, documentation of action taken in the OR was requested again and the facility failed to provide documentation for action taken in the OR when the relative humidity dropped below 35%.

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 2 of 71 smoke compartments and the Community Behavioral Health Center (CBHC) and had the potential for a fire and harm to the residents.

NFPA 30 (1996 Edition) 4-8.5 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to: open flames; lightning; smoking; cutting or welding; hot sources; frictional heat; static electricity; electrical or mechanical sparks; spontaneous heating, including heat-producing chemical reactions; and radiant heat.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility ABHR dispensers were observed.

7/26/11
1) At 9:35 a.m., the ABHR dispenser located in room 151 of the main hospital building was mounted above a light switch. Staff 60 confirmed the dispenser was mounted above the light switch.

7/28/11
2) At 1:20 p.m., the ABHR dispenser located in the Case Management office at the CBHC was mounted above a light switch. Staff 62 confirmed the dispenser was mounted above the light switch.

7/29/11
3) At 11:19 a.m., the ABHR dispenser located in room H469 of the main hospital building was mounted above a light switch. Staff 60 confirmed the dispenser was mounted above the light switch.

Based on interview and document review, the facility failed to maintain the emergency generators as evidenced by the failure to provide documentation for 21 of 52 weekly generator inspections including testing the specific gravity in the generator batteries. This had the potential for generator failure leading to harm of the patients and affected 71 of 71 smoke compartments.

Findings:

During the document review between 7/25/11 and 8/2/11, the facility generator test and inspection logs were reviewed.

7/25/11
1) At 1:15 p.m., the Main Hospital facility failed to provide documentation for weekly inspections of the emergency generators due on or about 8-10-10, 8-17-10, 8-24-10, 8-31-10, 9-14-10, 9-21-01, 9-28-10, 10-12-10, 10-19-10, 10-26-10, 11-9-10, 11-16-10, 11-23-10, 11-30-10, 12-14-10, 12-21-10, 12-28-10, 1-4-11, 1-25-11, 2-8-11 and 2-15-11.

At 4:50 p.m., Staff 59 confirmed the weekly inspections were not done. Staff 59 stated that on review in February 2011, it was noted that weekly inspections were not being done and had instituted weekly inspections starting the end of February 2011.

7/28/11
2) At 10:20 a.m., the CBHC facility failed to provide documentation for weekly testing of the specific gravity of the emergency generator battery since March 15, 2011. This was approximately 19 of 52 weeks due on or about 3-22-11, 3-29-11, 4-5-11, 4-12-11, 4-19-11, 4-26-11, 5-3-11, 5-10-11, 5-17-11, 5-24-11, 5-31-11, 6-7-11, 6-14-11, 6-21-11, 6-28-11, 7-5-11, 7-12-11, 7-19-11, and 7-26-11. Staff 62 confirmed the weekly testing of the specific gravity was not done. Staff 62 stated that he was given a new form to use for documenting the weekly inspections of the generator and the new form did not include testing the specific gravity of the generator battery as was required on the previous form.

Based on observation, the facility failed to maintain the electrical system as evidenced by damaged electrical receptacles, the use of surge protectors to extend power and provide additional outlets instead of providing fixed wired receptacles, and receptacles with ground-fault interrupter protection (gfi) that failed to reset when tested. This affected 12 of 71 smoke compartments and the Community Behavioral Health Center (CBHC) and had the potential for electrical shock and/or fire and harm to the patients.

NFPA 70 (1999 Edition), article 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.

NFPA 70, National Electrical Code (1999 Edition), article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

NFPA 70, National Electrical Code (1999 Edition), article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 70 (1999 edition) Section 410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

NFPA 70 (1999 Edition) 517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or by an isolated power system if such interruption cannot be tolerated.

Exception: Branch circuits supplying only listed, fixed, therapeutic and diagnostic equipment shall be permitted to be supplied from a normal grounded service, single- or 3-phase system provided that

(a) Wiring for grounded and isolated circuits does not occupy the same raceway, and

(b) All conductive surfaces of the equipment are grounded.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility electrical system was observed.

7/26/11
1) At 9:22 a.m., the electrical receptacle with gfi protection identified as C-8 in the Med East patient bath in the main hospital building failed to reset when tested. Staff 60 confirmed the gfi failed to reset when tested.

2) At 9:45 a.m., access to breakers A and B at the Angiography Tech Station in the main hospital building was obstructed by equipment and the apron cart. Staff 60 confirmed access to the breakers was obstructed by the equipment and the cart.

3) At 1:56 p.m., electrical receptacle B7-19 and the receptacle adjacent to the inner office inside the Nuclear Medicine Conference/Break Room in the main hospital building were damaged around the ground port. Staff 60 confirmed the electrical receptacles were damaged around the ground port.

4) At 1:56 p.m., the cable TV receptacle in the Nuclear Medicine Conference/Break Room in the main hospital building was missing the cover plate. Staff 1 confirmed the receptacle was missing the cover plate.

5) At 3:25 p.m., the electrical receptacle with the red on the corridor wall adjacent to room 522 in the main hospital building was not flush with the wall. Staff 1 60 confirmed the receptacle was not flush with the wall.

7/27/11
6) At 8:27 a.m., the northeast electrical receptacle with the gfi in the 4th East Break room in the 5-story building of the main hospital was damaged around the ground port. Staff 60 confirmed the electrical receptacle was damaged around the ground port.

7) At 9:03 a.m., the electrical receptacle in the foyer to the Nurse Manager office in 3 Central of the 5-story building in the main hospital was damaged around the ground port. Staff 60 confirmed the electrical receptacle was damaged around the ground port.

8) At 9:42 a.m., the electrical receptacle adjacent to the door in the 3 east staff lounge in the 5 story building of the main hospital building was damaged around the ground port. Staff 60 confirmed the electrical receptacle was damaged around the ground port.

9) At 10:10 a.m., 4 of 4 electrical receptacles observed in the NICU physician lounge in the main hospital building were damaged around the ground port. Staff 60 confirmed the electrical receptacles were damaged around the ground port.

10) At 2:00 p.m., electrical receptacle BC-30 on the corridor wall in the Pharmacy Administration area in the main hospital building was damaged around the ground port. Staff 60 confirmed the receptacle was damaged around the ground port.

7/28/11
11) At 12:00 p.m., there was a pencil sharpener plugged into a surge protector adjacent to the refrigerator in the Recreation Therapy room at the CBHC. The surge protector was used as a substitute for additional fixed wired electrical receptacles and used to extend power to the work deck. There were no visible receptacles on the wall. Staff 62 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

12) At 1:56 p.m., the electrical receptacle in the restroom of the employee lounge area in the Men's/Women's Locker area at the CBHC was damaged around the ground port. Staff 62 confirmed the receptacle was damaged around the ground port.


29752

NFPA 70 1999 Edition
Section 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.

NFPA 99 1999 Edition Electrical Systems
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 70 110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of he electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.


Findings:

7/26/11

Fourth Floor - TCCB (Trauma Critical Care Building)
13) At 9:29 a.m., there were a total of six work stations on wheels plugged into two multi-outlet extension cords. One multi-outlet extension cord was plugged into another which was plugged into a wall outlet.

Third Floor - TCCB
14) At 10:21 a.m., in room 3767A (Surgery Scheduling) there was a micro-wave plugged into a multi-outlet extension cord which was plugged into a wall outlet.

15) At 10:24 a.m., in room 3757A there was a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet.

7/27/11

Second Floor - TCCB
16) At 1:39 p.m., in room 2234A (Resident Call Room) there was a laptop computer plugged into a brown extension cord which was plugged into a wall outlet.

17) At 1:41 p.m., in room 2231A (Neurosurgery office) there was a refrigerator, a micro-wave, and a floor heater plugged into a multi-outlet extension cord which was plugged into a wall outlet.

18) At 1:50 p.m., in room 2229 (Anesthesia office) there was a water cooler and a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet.

Second Floor - Five Story Building
19) At 4:12 p.m., in OR Room 3 there was a cauterizer / Electrical surgical generator which plugged into a yellow extension cord which was plugged into a wall outlet.

20) At 4:26 p.m., in OR Room 6 there was a patient thermal blanket system plugged into a multi-outlet extension cord, which was plugged into an electrical outlet.

21) At 4:35 p.m., access to electrical breaker panels 2AA for OR's 8, 10, 5, 7, 6 was obstructed by two procedure carts and two fiber optic light carts. The carts were stored within one foot of the electrical panels.

Ninth Floor - Ten Story Building
22) At 4:38 p.m., in the Clinical Supervisor's Office, there was a refrigerator plugged into multi-outlet extension cord.

7/28/11
Seventh Floor - Ten Story Building
23) At 9:08 a.m., in the Neurosurgery Conference Room, there was a television and computer plugged into a multi-outlet extension cord which was plugged into another multi-outlet extension cord which was plugged into a wall outlet.

24) At 9:39 a.m., in 7 West Oncology Medication Room, a Follet medication refrigerator and a Pyxis Computer were plugged into a multi-outlet extension cord which was plugged into a wall outlet.

25) At 9:42 a.m., in 7 West Staff Lounge, a toaster and a coffee maker were plugged into a multi-outlet extension cord which was plugged into a wall outlet.

7/29/11

Floor One - TCCB
26) At 8:17 a.m., in the ED Directors Office there was a refrigerator and a coffee maker plugged into a multi-outlet extension cord which was plugged into a wall outlet.

27) At 8:42 a.m., in Room 1219A, Clinical Co-coordinator's Office, there was a micro-wave plugged into a blue extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet. There were three refrigerators and a water cooler that were also plugged into the same multi-outlet extension cord.

28) At 10:15 a.m., in Room 1107A EMS and Law Enforcement staff lounge there was a coffee maker plugged into a multi-outlet extension cord which was plugged into a wall outlet.

Basement - TCCB
29) At 11:26 a.m., in the Traction office 0202A, there was a micro-wave plugged into a multi-outlet extension cord which was plugged into a wall outlet. There was also a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet.

30) At 11:34 a.m., in Traction office 0205A, there was computer equipment that was plugged into a multi-outlet extension cord which was plugged into another multi-outlet extension cord that was plugged into a wall outlet.

First Level - Five Story
31) At 14:48 a.m., in the NW corner of the Cafeteria there was an electrical wall outlet next to a dining booth that was missing the cover plate.

8/2/11

First Level - ACC (Ambulatory Care Clinic) Building
32) At 2:38 p.m., in the first floor conference room there were 11 monitors and 11 computers plugged into three multi-outlet extension cords which were plugged into one multi-outlet extension cord which was plugged into one electrical outlet.

Based on record review, observation and interview, the facility failed to provide notification and documentation of an approved fire watch. This was evidenced by disabled smoke detectors in the egress corridors outside of a construction area, no notification to the Department of Public Health of impairments to the alarm system, and no fire watch logs. This could result in a delayed activation of the fire alarm system and the spread of fire or smoke, in the event of a fire. This affected 2 of 71 smoke compartments.

Findings:

During fire alarm testing and during interviews the fire alarm system in the corridor next to the construction area on the First Floor of the 5 Story Building was evaluated.

8/2/11
1st Floor - 5 Story Building
1) At 10:10 a.m., smoke detector 82 (labeled as N15L04D82) located in front of the corridor doors at the temporary wall for the construction area did not activate the fire alarm system after it was sprayed with canned smoke. The smoke detector lights were not blinking indicating that the detector was disabled.

2) At 10:13 a.m., a second smoke detector 81 in the same corridor was found to be disabled.

3) At 10:20 a.m., smoke detectors 107, 108, 16, 83, and 106 were also disabled in . Staff 62 (Construction Foreman) stated that the smoke detectors in the corridors around the construction area had been disabled to ensure that no false alarms occurred.

4) During an interview on 8/2/11at 10:26 a.m., staff 62 stated that the smoke detectors around this area are disabled for construction activities from 6 a.m. until 3 p.m. daily. He stated that they assign construction workers to keep a continuous fire watch inside the containment walls during working hours but he indicated that they do not keep a fire watch log. There were no other records available.

On 8/2/11 at 4 p.m., staff 58 stated that Security does the corridor fire watch but does not keep a fire watch log. There were no other records available.

Based on observation, the facility failed to maintain a two hour fire barrier as evidenced by a fire barrier door frame label that was painted over. There is a potential for an unrated door frame to be improperly modified. This could result in the spread of fire or smoke, in the event of a fire, affecting 2 of 71 smoke compartments.

NFPA 101 (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:

(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirements of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.

(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provision of 7.2.1.

NFPA 80 (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility two hour barriers were observed.

At 8:15 a.m., the door frame rating label in the 5th east and 5th Annex two-hour barrier was painted over. Staff 60 confirmed the rating label was painted over.

Based on observation, the facility failed to maintain the building construction as evidenced by unsealed penetrations and an open ceiling access door. This affected 3 of 71 smoke compartments which had the potential to allow the spread of smoke during a fire and harm to the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility walls and ceilings were observed.

7/26/11
5th Floor - Annex
At 8:47 a.m., above door 5S1/01 on the Annex side of the door in the main hospital, there was an unsealed one-half inch by one inch penetration in the wall above a conduit that penetrated the wall. Staff 60 confirmed there was an unsealed penetration in the wall.

At 1:57 p.m., on the wall conference room side of the inner office in the Nuclear Medicine Conference/Break Room there was an approximately one and one-half inch by one and one' half inch unsealed penetration in the wall. Staff 60 confirmed there was an unsealed penetration in the wall.

5th Floor - East
At 2:48 p.m., in the housekeeping room adjacent to room 548 in the main hospital, there was an unsealed one and one-half inch by eighteen inch penetration and damaged area in the corner of the wall just above the floor that was consistent with where the rim of the janitor cart met the wall. Staff 60 confirmed there was an unsealed penetration in the wall.

7/27/11
3rd Floor - Central
At 9:25 a.m., in the 3rd Central IT closet in the main hospital, the access door to the area above the solid ceiling was open creating an open penetration in the ceiling. Staff 60 confirmed the ceiling access door was open.

Based on observation, the facility failed to maintain the corridor walls as evidenced by unsealed corridor wall penetrations. This affected 2 of 71 Smoke Compartments in the main hospital, the Diagnostic Center, the California Cancer Center (CCC) and had the potential to transmit smoke and causing harm to the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridor walls and ceilings were observed.

7/26/11
1st Floor - East
At 9:28 a.m., in the 1 east corridor leading to the sliding door exit in the main hospital building, non-rated ceiling tiles were observed in the 1-hour rated drop ceiling. Staff 60 confirmed there were non-rated ceiling tiles in the rated corridor ceiling.

7/27/11
At 11:12 a.m., on the corridor side of the Utility Room wall at the 2nd north nurse station in the main hospital, there was an unsealed five inch circular penetration through the corridor wall with a conduit running through the unsealed penetration. Staff 60 confirmed there was an unsealed penetration in the corridor wall.

8/1/11
Diagnostic Center
At 5:25 p.m., on the Women's dressing room side of the corridor wall, there was an unsealed two inch gap around a pipe and wires that penetrated the wall. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

At 5:40 p.m., on the corridor side of the corridor wall and the Utility Room, there was an unsealed two inch gap around a pipe and wires that penetrated the wall. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

8/2/11
California Cancer Center
At 9:20 a.m., on the corridor side of the Block Room in the CCC, there were five unsealed penetrations through the corridor wall with pipes running through the unsealed penetration with an approximately one inch gap around each pipe. Staff 62 confirmed there were unsealed penetration in the 1-hour corridor wall.

8/2/11
Sierra Community Health Center
At 11:25 a.m., on the corridor side of the medical Room in the Sierra Community Health Center, there was an unsealed one-half circular penetration through the corridor wall with wires running through the unsealed penetration. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

At 11:27 a.m., in the corridor wall separating the corridor from the IT room in the Sierra Community Health Center, there was an approximately two inch by five inch unsealed penetration through the corridor wall. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

At 11:35 a.m., in the corridor wall separating the corridor from room 114 in the Sierra Community Health Center, there was an approximately three inch by three inch unsealed penetration through the corridor wall with wires running through the unsealed penetration. Staff 58 confirmed there was an unsealed penetration in the 1-hour corridor wall.

Based on observation, the facility failed to maintain the corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to latch or were obstructed from closing and by the failure to provide documentation for the testing and maintenance of roll down doors. This affected 11 of 71 smoke compartments, the California Cancer Center (CCC) and could result in the spread of smoke or fire, in the event of a fire.

NFPA 80 (1999 Edition), 15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

NFPA 101 (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridor doors were observed.

7/26/11
1) At 9:50 a.m., the corridor door to the UCSF GI Research Clinic in the main hospital was not a self-closing door. The corridor was a one-hour rated corridor. Staff 60 confirmed the door was not a self-closing door.

7/27/11
2a) 2nd Floor - Central
At 11:19 a.m., the corridor door to the Housekeeping Closet in the 2nd Central area adjacent to the nurse station in the main hospital failed to latch. The door was impeded from latching by paper stuffed into the strike plate and taped over. Staff 60 confirmed the door was impeded from latching.

7/29/11
8th Floor - 10 Story Building
b) At 8:40 a.m., the corridor door to patient room H801 in the main hospital was impeded from closing by the privacy curtain adjacent to the door. Staff 60 confirmed the privacy curtain impeded the door from closing.

c) At 8:45 a.m., the corridor door to the Men's restroom adjacent to door H8035T failed to fully close and latch without assistance. Staff 60 confirmed the door failed to fully close and latch without assistance.

4th Floor - 10 Story Building
d) At 11:20 a.m., the corridor door to patient room H468 in the main hospital was impeded from closing by two chairs stacked in front of the door. Staff 60 confirmed the chairs impeded the door from closing.

8/2/11
California Cancer Center
e) At 9:00 a.m., the self-closer to the corridor door to the med room at the nurse station in the CCC had been removed. Staff 62 confirmed the closer had been removed.

f) At 9:05 a.m., the corridor door to the Janitor's room adjacent to the accelerators in the CCC failed to fully close and latch without assistance. Staff 62 confirmed the door failed to fully close and latch without assistance.

g) At 9:25 a.m., the corridor door to the Chart/Conference Room (old infusion room) in the CCC failed to fully close and latch without assistance. Staff 62 confirmed the door failed to fully close and latch without assistance.

3) At 11:00 a.m., the facility failed to provide documentation for the testing and maintenance of the roll down door to the reception area and the roll down door to the old pharmacy area. Staff 62 confirmed the documents were not available for review.


29752

7/26/11
TCCB (Trauma Critical Care Building) - Fourth Floor
4a) At 10:11 a.m., the utility room corridor Door 3007A failed to latch in three of three attempts.

4b) At 2:52 p.m., a waiting room corridor door at the Rotunda was obstructed from closing by a trash container that was holding the door in a fully open position.

7/27/11
4c) TCCB - Second Floor
At 11:49 a.m., a corridor door for Room 2233B, Surgery Conference Room, failed to latch in three of three attempts.

Ten Story Building - 7 th Floor
4d) At 4:30 p.m. the clean linen room corridor door H9034 failed to latch in three of three attempts. The latching hardware was misaligned.

7/28/11
Laboratory
4e) At 3:36 p.m., the dark room door failed to fully in three of three attempts. The door frame obstructed the door from fully closing.

7/29/11
4f) TCCB - Basement
At 12:10 p.m., the clean linen double door (0124B) failed to latch upon closing.

Based on observation, the facility failed to maintain the trash chute as evidenced by an unsealed penetration in the trash chute enclosure. This affected 2 of 71 smoke compartments and had the potential to fail to contain smoke during a fire leading to harm of the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility trash chutes were observed.

7/29/11
6th Floor - 10 Story Building
At 9:09 a.m., there was an unsealed, one inch gap around the trash chute where the trash chute penetrated the ceiling above the area behind door H6186. Staff 60 confirmed there was an unsealed gap around the trash chute where the chute penetrated the ceiling.

Based on observation, the facility failed to mark access to exits as evidenced by exit signs that were obstructed from view, no exit signs posted, a corridor that was not an exit and not identified as not an exit, and an exit sign directing occupants to an elevator. This could delay evacuation, in the event of a fire, affecting visitors and staff in 5 of 71 smoke compartments.

NFPA 101 (2000 Edition) 7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:

NO
EXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of 3/8 in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO.
Exception: This requirement shall not apply to approved existing signs.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridors and exit signs were observed.

7/26/11
At 10:20 a.m., there were no exit signs visible when standing in the corridor outside the Endoscopy Recovery Room in the main hospital building. Staff 60 confirmed there were no exit signs visible when standing in the corridor outside the Endoscopy Recovery Room.

At 10:50 a.m., there was no exit sign posted above the exit adjacent to room 9 in the Short Stay Endoscopy area in the main hospital building. Staff 60 confirmed there was no exit sign posted at the exit.

Basement - 5 Story Building
At 11:05 a.m., when standing in the corridor looking towards stairwell "J" there was no exit sign posted in the corridor adjacent to stairwell "J" in the 5 story building basement of the main hospital indicating an exit. Staff 60 confirmed there was no exit sign posted in the corridor adjacent to the exit.

Basement - TCCB
At 11:28 a.m., when standing in the Resident Sleeping corridor looking towards the old morgue area, there was no exit sign posted in the corridor. An exit sign was only visible when looking in one of two directions in the corridor. Staff 60 confirmed there was no exit sign posted in the corridor leading to the old morgue area exit.

8/2/11
Sierra Community Health Center
At 11:13 a.m., there was an approximately 10 foot dead-end corridor adjacent to Treatment Room 5 in the Sierra Community Health Center. The corridor was not marked "NO EXIT." Staff 58 confirmed the corridor was not identified.


29752


7/26/11
TCCB (Trauma Critical Care Building) Rotunda - Fourth Floor
At 2:50 p.m., the exit signage for the stairwell on the fourth floor was obstructed by a sign that was hanging in front of the exit sign as viewed from the corridor outside the waiting room in the Rotunda area of the TCCB

7/27/11
TCCB - Second Floor
At 11:38 a.m., the exit signage for the stairwell on the second floor was obstructed by a sign that was hanging in front of the exit sign as viewed outside the waiting room from the corridor. This is located in the Rotunda area of the TCCB.

Based on observation, the facility failed to maintain the smoke barriers as evidenced by unsealed penetrations in smoke barriers and an unprotected smoke barrier. This affected 4 of 71 smoke compartments, the Diagnostic Center and the Community Behavioral Health Center and had the potential to fail to contain smoke during a fire which could cause harm to the patients.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility smoke barriers were observed.

7/26/11
1) 1st Floor - 5 Story Building
At 10:20 a.m., remodeling construction was observed in the old MRI and a portion of the Endoscopy area. Drawings provided by the facility identified as "CR-5-1" showed a smoke barrier separating the old MRI area and a 1-hour rated corridor between the old MRI area and Suite 2 (S2), the Endoscopy area, in smoke compartment 5 (C5). The smoke barrier doors in the old MRI smoke barrier had been removed and the area was open to the 1-hour rated corridor adjacent to the Endoscopy area. Doors were not installed on the Endoscopy side of the corridor and ceilings were not installed in the rooms without corridor doors on the Endoscopy side of the corridor. Smoke could travel unobstructed from the old MRI area into the Endoscopy area through the open smoke barrier, through the open 1-hour corridor doors into the room and through the open ceiling into the Endoscopy area. Staff 63 confirmed there was unprotected open area between the smoke compartments.

7/27/11
2) Surgery Scheduling
At 10:50 a.m., there was an approximately three foot by eighteen inch unsealed penetration in the smoke barrier above the drop ceiling separating the corridor from the Surgery Scheduling office. Staff 60 confirmed there was an unsealed penetration in the smoke barrier.

Stepdown Unit
3) At 2:50 p.m., there was an approximately eight inch by eight inch unsealed penetration, an approximately one inch irregular unsealed penetration, an approximately one-half inch unsealed gap around a conduit and blue wires through an approximately eight inch by eight inch unsealed penetration in the smoke barrier of the Step Down unit in the main hospital building. Staff 60 confirmed there were unsealed penetrations in the smoke barrier.

7/28/11
4) Community Behavioral Health Center
At 11:55 a.m., in the smoke barrier above the recreation therapy storage area at the Community Behavioral Health Center, there was and unsealed two inch by five inch penetration in the smoke barrier with blue wires running through the penetration. There were three two inch by five inch unsealed penetrations in the barrier with conduits running through the penetration. Staff 60 confirmed there were unsealed penetrations in the smoke barrier.

7/29/11
5) 4th Floor - 10 Story Building
At 10:55 a.m., there was an approximately two inch by eighteen inch unsealed penetration in the smoke barrier above the drop ceiling in the 10-story 4th Floor Conference room in the main hospital building that separated the conference room from the Resident Sleeping area. Staff 60 and 62 confirmed there were an unsealed penetrations in the smoke barrier.

8/1/11
Diagnostic Center
6) At 5:25 p.m., there was an approximately six inch by eighteen inch unsealed penetration in the south lobby wall of the Diagnostic Center above the drop ceiling. There were pipes running through the unsealed penetration in the wall. Staff 58 confirmed there was an unsealed penetration in the smoke barrier.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by barrier doors that were not self-closing or failed to latch. This could result in the spread of fire or smoke, in the event of a fire, affecting 6 of 71 smoke compartments.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility smoke barriers were observed.

7/29/11
1st Floor - 10 Story Building
1) At 2:30 p.m., the new corridor door to the new Medical Staff office in the main hospital building was not self-closing. Drawings provided by the facility identified as "CR-10-1" showed a smoke barrier separating the new Medical Staff Office in S3 and the corridor in S6. Staff 60 confirmed the door in the smoke barrier was not a self-closing door.

Surveyor 29752:

7/27/11
2nd Floor - TCCB (Trauma Critical Care Building)
2) At 3:22 p.m., a smoke barrier door between sterile processing and sterile storage failed to latch when closed. The door latch hardware was taped over.

7/28/11
Basement - TCCB
3) At 1:35 p.m., the smoke barrier door between the warehouse corridor and the test kitchen exit access corridor failed to self close and latch.

During fire alarm testing with Staff 58 the smoke barrier doors in corridors were tested.

8/1/11
4) 5th Floor - 5 Story Building
At 11:24 a.m. the corridor door on the side nearest room 540 failed to fully close and latch in three of three attempts.

Based on observation, the facility failed to protect the hazardous areas from other areas as evidenced by self closing corridor doors that failed to close or failed to latch. This could result in the spread of smoke and fire, in the event of a fire affecting 4 of 71 smoke compartments, the Laboratory, and the California Cancer Center.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility hazardous areas were observed.

7/26/11
5th Floor - 5 Story East
1) At 3:04 p.m., the self-closing corridor door to the linen room adjacent to room 551 in the main hospital building failed to fully close and latch without assistance. Staff 60 confirmed the door failed to fully close and latch without assistance.

7/27/11
2) At 11:23 a.m., the walls surrounding the Station 2 Infectious Waste room in the central corridor of the main hospital building failed to extend to the roof above. Staff 60 confirmed the walls failed to extend to the ceiling above and was scheduled for repair.

7/29/11
8th Floor - 10 Story Building
3) At 9:03 a.m., the self-closing corridor door to the soiled utility room H8040 in the main hospital building failed to fully close and latch without assistance. Staff 60 confirmed the door failed to fully close and latch without assistance. The soiled linen chute, which was not equipped with a lock, was inside the room.

8/2/11
California Cancer Center
4) At 9:28 a.m., there were approximately 16 unsealed pipes and conduits penetrating the wall between the PG&E room and the CCC. There was an approximately one inch unsealed gap around each pipe and conduit. Staff 62 confirmed there were unsealed penetrations in the room.


29752

7/27/11
Surgery - Second Floor of 5 Story Building
5) At 3:52 p.m., the door for Pathology was self closing but failed to self close completely and the hazardous storage cabinet was left open. The door to pathology remained open approximately 1/4" in three of three attempts. There were four one-gallon plastic containers of Formalin stored in cabinet below the counter inside the room. There was a steel flammables storage cabinet inside this room with the door left open approximately 1/4". There were two 1/2 gallon containers of xylene, one half gallon container of Rapid Fix, and four one pint containers of isopropyl alcohol. This room is a hazardous storage area due to storage of flammable and combustible liquids. The floor plans provided by the facility do not indicate that this room is protected as a fire rated enclosure.

Laboratory
7/28/11
6) At 3:53 p.m., the anteroom door for the AFB Lab did not latch. The door was retested three times and failed to latch each time.

7) At 3:56 p.m., the PCR (Preliminary Chain Reaction) door was obstructed from closing by a door wedge.

Based on observation, the facility failed to maintain the exit stairwells as evidenced by a stairwell door frame label painted over. This affected 6 of 71 smoke compartments and had the potential to allow the spread of smoke and fire due to unrated door frames leading to harm of the patients.

NFPA 101 (2000 Edition) 8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following:

NFPA 80 (1999 Edition) 1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility stairwells were observed.

5th Floor - 5 Story Building
At 8:15 a.m., the door frame rating label in the stairwell adjacent to the 5th east and 5th Annex two-hour barrier was painted over. Staff 60 confirmed the rating label was painted over.

Based on observation, the facility failed to maintain readily available exits as evidenced by obstructed egress access and obstructed exit doors. This could result in a delay of evacuation, in the event of a fire, affecting 4 of 71 smoke compartments.
NFPA 101 (2000 Edition) 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7. Exception: As modified by 19.2.2 through 19.2.11
Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 7/26/11 and 8/2/11, the facility exits and exit access were observed.

7/26/11
1st Floor - 5 Story East
1) At 9:47 a.m., access to the exit from the Angiography Room in the main hospital building was obstructed by equipment stored in front of the door. Staff 60 confirmed access to the exit was obstructed.

2) At 10:20 a.m., the exit sign adjacent to the elevators near the Endoscopy Recovery Room in the main hospital building directed occupants to the elevators. Due to construction, the exit was not accessible. Staff 60 confirmed the exit was not accessible.


29752

7/27/11
2nd Floor - TCCB (Trauma Critical Care Building)
3) At 11:11 a.m., on the 2nd floor of the TCCB, the clean corridor exit access was obstructed by a patio table and chairs, There was approximately three feet of clearance between the table with chairs and the corridor wall.

7/29/11
1st Floor - TCCB
4) At 8:42 a.m., in the Emergency Department, there was a gurney with a patient stored in front of an exit access door (between Sub-Wait room and the Cast Suture area). At this location there are two four foot wide opposite swinging doors between Suite 5 and the exit access corridor. Only one could be used for egress when the fire alarm system is activated and the doors are released. When the second door closed it acted as a barrier to egress from the suite. There was approximately one foot of clearance between the barrier door and the gurney when the door was closed.

During an interview at 8:45 a.m., the Emergency Department Manager stated that patients were treated while on the gurneys and in many instances they remained in place until discharged. There were 6 gurneys lined up along the same side of the exit access between exam room doorways. He stated that these are normally stored at this location while the patients are being seen. They may remain at that same location with the patient the entire time they are there for treatment.

Based on record review, observation and interview, the facility failed to ensure that emergency egress lighting was tested in accordance with NFPA 101. This was evidenced by no records of testing the emergency lighting located in the Laboratory. This could result in an interruption of emergency lighting and delay evacuation, in the event of a fire. This affected 24 of 24 lights located across the Lab.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.

Findings:

During record review on 7/26/11 there were no inspection or testing records available for fluorescent ceiling light fixtures with battery type emergency lighting.

7/28/11
During the facility tour on 7/28/11, the battery type emergency lighting were observed within the overhead lighting fixtures throughout the lab

At 4:20 p.m., there were twenty-four fluorescent fixtures with a red indicator light on each battery powered light fixtures.
During an interview at 4:25 p.m., Staff 57 reported there were no records for testing the battery power for the lights. There were no other records for inspection and testing of the lights.

Based on observation, the facility failed to maintain the emergency exit signs as evidenced by the failure to provide documentation for the testing of the exit signs, and exit sign that was expired and an exit sign that was not fully illuminated. This affected the Sierra Community Health Center, the Diagnostic Center and the California Cancer Center and had the potential for the sign to not be legible and delaying egress from the building and causing harm to the patients.

NFPA 101 (2000 Edition) 7.9.3 Periodic testing of emergency lighting equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

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

NFPA 101 (2000 Edition) 7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance
with 7.9.3.

Findings:

During the facility tour with Staff 58 and 62 on August 1 and 2, 2011, the facility exit signs were observed.

8/2/11

Diagnostic Center
1) At 5:37 p.m., the self-illuminated exit sign in the south side room adjacent to the copy machine expired 6/2001. Staff 58 confirmed the exit sign was expired.

2) At 5:45 p.m., the Diagnostic Center was unable to provide documentation confirming the exit signs were tested monthly and annually to confirm the battery backup in the signs were functional. Staff 58 was unable to provide documentation for testing the exit signs with battery backup.

California Cancer Center
3) At 10:05 a.m., Staff 62 was asked if the exit signs were tested monthly and annually in the CCC to confirm the battery backup in the signs were functional. Staff 62 was unable to provide documentation for testing the exit signs with battery backup.

Sierra Community Health Center
4) At 11:15 a.m., Staff 58 was asked if the exit signs were tested monthly and annually at the Sierra Community Health Center to confirm the battery backup in the signs were functional. Staff 58 was unable to provide documentation for testing the exit signs with battery backup.

5) At 11:19 a.m., exit sign #15 in the Physical Therapy area of the Sierra Community Health Center was not fully illuminated. One of two bulbs in the sign was not functioning. Staff 58 confirmed only one light in the sign was functional and the sign was not fully illuminated.

Based on record review and interview, the facility failed to ensure all staff were trained for emergency response during fire drills. This was evidenced by incomplete documentation of staff participation in fire drills at the main hospital and by incomplete documentation of fire drills quarterly on each shift at the behavioral health center. There was insufficient documentation that all staff participated in fire drills and practiced emergency response procedures. This could result in a delayed response by staff if they are not familiar with their roles and responsibilities. There was an increased potential for the spread of fire or smoke, in the event of a fire, affecting the entire hospital and the community behavioral center.

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.

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 from 7/25/11 and 7/28/11, the main hospital and community behavioral health center fire drill report logs were requested.

7/28/11
Community Behavioral Health Center
1a) At 9:00 a.m., the facility failed to provide documentation for 2 of 4 A.M. shift drills. The facility failed to provide a drill for the 2nd quarter (April-June) of 2011 and the 3rd quarter (July-September) of 2010. Staff 60 confirmed the drill reports were not available.

1b) At 9:00 a.m., the facility failed to provide documentation for 3 of 4 P.M. shift drills. The facility failed to provide a drill for the 2nd quarter (April-June) of 2011, the 3rd quarter (July-September) of 2010 and the 4th quarter (October-December) of 2010. Staff 60 confirmed the drill reports were not available.

1c) At 9:00 a.m., the facility failed to provide documentation for 2 of 4 N.O.C. shift drills. The facility failed to provide a drill for the 2nd quarter (April-June) of 2011 and the 4th quarter (October-December) of 2010. Staff 60 confirmed the drill reports were not available.


29752

7/26/11
Trauma Critical Care Building - 10 Story Building - 5 Story Building (hospital)
2) At 1:45 p.m., fire drill documents during the second quarter were conducted at the end of June without any additional observations. Staff observations were conducted inconsistently in the second quarter of 2011 and randomly throughout the hospital during the last year. There was insufficient documentation that all staff participated in fire drills and practiced emergency response procedures.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by batteries that were past due for replacement, the failure to provide documentation for the annual inspection and testing of a fire alarm system, the failure to provide a smoke detector at an unattended alarm panel, an obstructed manual fire alarm box, a failure to provide a manual fire alarm box in an egress access corridor, a fire barrier curtain that was obstructed from closing, and by an elevator smoke barrier curtain that failed to deploy. This could result in a delay in notification and evacuation and the spread of fire or smoke, in the event of a fire. This affected 11 of 71 hospital smoke compartments, the Diagnostic Center, the Ambulatory Care Clinic, the Surgical Services Building and the Community Behavioral Health Center, and had the potential for fire alarm system failure and delay in alarm activation leading to harm to the patients.

NFPA 72 (1999 Edition), 1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

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

NFPA 101 (2000 Edition) 9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72 (1999 Edition) 7-3 Inspection and Testing Frequency.

7-3.1* Visual Inspection. Visual inspection shall be performed in accordance with the schedules in Section 7-3 or more often if required by the authority having jurisdiction. The visual inspection shall be made to ensure that there are no changes that affect equipment performance.

Exception No. 1: Devices or equipment that is inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be inspected during scheduled shutdowns if approved by the authority having jurisdiction.
Extended intervals shall not exceed 18 months.

Exception No. 2: If automatic inspection is performed at a frequency of not less than weekly by a remotely monitored fire alarm control unit specifically listed for such application, the visual inspection frequency shall be permitted to be annual. The requirements of Table 7-3.1 shall apply.

NFPA 72 (1999 Edition) 7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

NFPA 72 (1999 Edition) Table 7-3.2 Testing Frequencies, Item 6(d)(1) Sealed lead acid batteries are to be replaced every 4 years.

NFPA 72 (1999 Edition), 7-5.2.2 A permanent record of all inspections, testing and maintenance shall be provided that includes the information regarding tests and all the applicable information requested in figure 7-5.2.2.

(1) Date
(2) Test Frequency
(3) Name of Property
(4) Address
(5) Name of person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address and telephone number
(6) Name, address, and representative of approving agency (ies)
(7) Designation of the detector(s) tested, for example, "Tests performed in accordance with Section_____ ."
(8) Functional Test of Detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/success-fully retested, device abandoned in place)

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between July 26 and August 2, 2011, the fire alarm controlled building systems and notification devices were observed.

7/26/11
1) 3rd Floor - TCCB
At 1:59 p.m., access to the manual fire alarm box adjacent to the Nuclear Medicine reception desk in the main hospital building was obstructed by a literature rack. Staff 60 confirmed the rack chair obstructed access to the manual fire alarm box.

7/28/11
Community Behavioral Health Center
2) At 2:42 p.m., there was no automatic smoke detection or automatic heat detection in the IT Room at the Community Behavioral Health Center where the fire alarm communication panel was located. The room was not constantly attended. Staff 60 and 62 confirmed there was no automatic smoke detection or automatic heat detection in the IT Room.

7/29/11
2nd Floor - Ten Story Building
3) At 1:18 p.m. on July 29, 2011, the two batteries in the large fire alarm panel located in room 10S2/01 in the main hospital building were dated 3-20-07, approximately 5 months past due for replacement. Staff 60 confirmed the batteries were sealed lead acid batteries and confirmed the batteries were dated 3-20-07.

8/1/11
Surgical Services Building
4) At 2:35 p.m., there was no automatic smoke detection or automatic heat detection in the Fire Alarm Panel Room at the Surgical Services Building. The room was not constantly attended. Staff 58 confirmed there was no automatic smoke detection or automatic heat detection in the Panel Room.

5) At 3:15 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the Surgical Services Building. Staff 58 confirmed the documentation was not available.

Diagnostic Center.
6) At 6:00 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the Diagnostic Center. Staff 58 confirmed the documentation was not available.

8/2/11
ACC Building
7) At 3:15 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the ACC Building. Staff 58 confirmed the documentation was not available.

Sierra Community Health Center
8) At 3:30 p.m., the facility failed to provide documentation for the annual inspection and testing of the fire alarm control panel, the annual charger and discharge test of the sealed lead acid batteries, the annual testing of the Initiating Devices including all smoke detectors, and the alarm notification devices including the audio and visual alarm notification devices for the Sierra Community Health Center. Staff 58 confirmed the documentation was not available.


29752

7/27/11
Fourth Floor - TCCB
9) At 11:42 a.m., a metal waste container was obstructing the door panel for a recessed sliding fire curtain. The waste container was approximately 30 gallon capacity and was placed directly against the swinging panel for the fire curtain.

8/1/11
Fourth Floor - Ten Story Building
10) At 5:07 p.m., the smoke barrier curtain for one of two elevators was obstructed from activating with the fire alarm system. This was described by staff as Elevator 8. The curtain for the second elevator deployed properly upon activation by a nearby smoke detector. The curtain door panel was jammed against the frame in the ceiling. It was pried open to allow the smoke barrier curtain to drop.

8/2/11
Third Floor - Annex
11) At 9:13 a.m., there was no pull station in the exit access corridor on the third floor of the Annex building. The nearest pull station was on the opposite side of a self closing smoke barrier door in the corridor heading into the Five Story building. This pull station was not visible from either of the two intersecting corridors of the annex. This floor was occupied by office staff and attendees for the classrooms.

Based on observation and interview, the facility failed to maintain the smoke detectors as evidenced by the failure to provide documentation for the testing of the single station smoke alarms and system smoke alarms. This affected the Sierra Health Care Center, the California Cancer Center (CCC) and had the potential for detector failure.

NFPA 101 (2000 Edition), 4.6.12.2 Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed.

NFPA 101 (2000 Edition) 9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 (1999 Edition) 7-1.1 Scope. Chapter 7 shall cover the minimum requirements for the inspection, testing, and maintenance of the fire alarm systems described in Chapter 1, 3 and 5 and for their initiation and notification components described in Chapter 2 and 4. The testing and maintenance requirements for one- and two-family dwelling units shall be located in Chapter 8. Single station detectors used for other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7. More stringent inspection, testing, or maintenance procedures that are required by other parties shall be permitted.

NFPA 72 (1999 Edition), 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No.1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

7-3.3 Single station smoke detectors installed in one- and two-family dwelling units shall be inspected, tested, and maintained as specified in Chapter 8. Single station detectors installed on other than one- and two-family dwelling units shall be tested and maintained in accordance with Chapter 7.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26 and 8/2/11, the fire alarm sytem and smoke alarms were observed.

8/1/11
Sierra Health Center
At 4:40 p.m., an AC powered single station smoke alarm was observed in the corridor adjacent to room 116 in the Sierra Health Center. Molded letters on the alarm stated "Test Weekly." Staff 58 stated there were no records available for review and was not sure if the smoke alarm was still functional.

8/2/11
California Cancer Center
At 10:15 a.m. on August 2, 2011, the CCC failed to provide documentation for the sensitivity testing of the smoke alarms. Staff 62 stated there were no records available for review.

Based on observation, the facility failed to maintain the automatic fire sprinkler system as evidenced by the failure to provide spare sprinkler heads representative of the types and temperature ratings of the system sprinklers,quick response sprinkler heads in a smoke compartment which also contained standard sprinkler heads, quick response sprinkler heads in smoke compartments which also contained standard sprinkler heads, the failure to provide documentation for quarterly and annual sprinkler inspection and tests, a water gong that failed to operate properly and a sprinkler valve that was not labeled This affected 45 of 71 smoke compartments, Ambulatory Care Clinic (ACC), the Diagnostic Center, the California Cancer Clinic (CCC) and the Surgical Services Building and had the potential for fire sprinkler system failure, the potential to be unable to replace sprinkler heads when needed and the failure to identify system component due to not being labeled. This could lead to harm to the patients.

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

NFPA 13 (1999 Edition) 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartment space shall be changed.
NFPA 25 (1998 Edition) 1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.
NFPA 25 (1998 Edition) 1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
NFPA 25 (1998 Edition) 2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. Table 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Exception: Valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9.

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

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

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

NFPA 25 (1998 Edition), 2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler
NFPA 25 (1998 Edition), 2-2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:* Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
NFPA 25 (1998 Edition), 2-2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level. Hangers and seismic braces shall not be damaged or loose. Hangers and seismic braces that are damaged or loose shall be replaced or refastened.
Exception No. 1: *Hangers and seismic braces installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Hangers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
NFPA 25 (1998 Edition) 2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
NFPA 25 (1998 Edition) 2-2.7* Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
NFPA 25 (1998 Edition) 2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
NFPA 25 (1998 Edition), 2-4.1.4 A supply of at least 6 spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not exposed to moisture, dust, corrosion or a temperature exceeding 100 degrees F (38 degrees C).

Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

NFPA 25 (1998 Edition) 9-3.5 Maintenance. The operating stems of outside screw and yoke valves shall be lubricated annually. The valve then shall be completely closed and reopened to test its operation and distribute the lubricant.
NFPA 25 (1998 Edition) 9-4.1.2* Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

NFPA 25 (1998 Edition) 9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

NFPA 25 (1998 Edition) 9-4.4.1.5 Strainers, filters, and restricted orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.
NFPA 25 (1998 Edition) 9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
NFPA 25 (1998 Edition) 9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

NFPA 25 (1998 Edition) 10-2.2* Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

Findings:
During the facility tour with Staff 57, 58, 59, 60, 61, 62 and 63 between 7/27/11 and 8/2/11, the fire sprinkler systems were observed.

7/27/11
1) At 9:44 a.m., quick response sprinkler heads were observed in the 3rd east staff lounge in the main hospital building. The smoke compartment also contained standard response sprinkler heads. Staff 60 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.

2) At 9:48 a.m., quick response sprinkler heads were observed in room 351 in the main hospital building. The smoke compartment also contained standard response sprinkler heads. Staff 60 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.

3) At 1:47 p.m., in the Pharmacy Administrative Office in the 10 story building of the main hospital, there was a valve in the fire sprinkler system that was not labeled as to the function of the valve. Staff 60 confirmed there was no identification sign on the valve.

4) At 2:09 p.m., quick response sprinkler heads were observed in the Case Management Conference Room in the basement of the main hospital building. The smoke compartment also contained standard response sprinkler heads. Staff 60 confirmed there were quick response sprinkler heads and standard response sprinkler heads in the smoke compartment.

5) At 2:20 p.m., the spare sprinkler head box for the 10 story and 5 story buildings of the main hospital was observed in the old boiler room. The box contained standard response sprinkler heads, no recessed heads and and only one quick response sprinkler head. Quick response heads and recessed heads were observed throughout the facility during the tour between July 25 and July 27. Quick response sprinkler heads observed included green colored heads and red colored pendent, red colored side mount, red colored side mount pendent, upright red colored and recessed heads. Staff 60 confirmed the spare head box failed to stock spare sprinklers proportionally representative of the types and temperature ratings of the system sprinklers.

8/1/11
6) At 2:35 p.m., the Surgical Services Building inspector test valve (ITV) was activated. The water gong activated for a few seconds and then went to a thudding sound as if the clanger was stuck. Staff 58 confirmed the water gong was not working properly. The alarm activated at the monitoring station.
7) At 3:15 p.m., the facility failed to provide documentation for 4 of 4 quarterly fire sprinkler inspections during the previous 12 months for the Surgical Services Building including documentation the system was free of physical damage, that the valves were inspected, inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no documentation of the quarterly sprinkler tests and inspections available.
8) At 3:15 p.m., the facility failed to provide documentation for the annual inspection of the fire sprinkler system for the Surgical Services Building that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves . Staff 58 confirmed there was no documentation available for the annual sprinkler tests and maintenance.
9) At 6:00 p.m., the facility failed to provide documentation for 4 of 4 quarterly fire sprinkler inspections during the previous 12 months for the Diagnostic Center Building including documentation the system was free of physical damage, that the valves were inspected, inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no documentation of the quarterly sprinkler tests and inspections available.
10) At 6:00 p.m., the facility failed to provide documentation for the annual inspection of the fire sprinkler system for the Diagnostic Center Building that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves . Staff 58 confirmed there was no documentation available for the annual sprinkler tests and maintenance.
8/2/11
11) At 3:15 p.m., the facility failed to provide documentation for 4 of 4 quarterly fire sprinkler inspections during the previous 12 months for the ACC Building including documentation the system was free of physical damage, that the valves were inspected, inspection of the hydraulic nameplate and there was no evidence that the fire department connections were inspected. Staff 58 confirmed there was no documentation of the quarterly sprinkler tests and inspections available.
12) At 3:15 p.m., the facility failed to provide documentation for the annual inspection of the fire sprinkler system for the ACC Building that included inspection of the sprinkler pipes and fittings, the inspection of the spare sprinkler heads, inspection of the sprinkler pipe hangers and seismic braces and maintenance and lubrication of the valves . Staff 58 confirmed there was no documentation available for the annual sprinkler tests and maintenance.
13) At 10:15 a.m., the facility failed to provide documentation for the 3rd quarter (July-September) 2010, the 1st quarter (January-March) and the second quarter (April-June) 2011 sprinkler system inspection and test records for the California Cancer Center. There was no evidence the alarms where inspected to assure they were free of physical damage, there was no evidence of testing of the sprinkler system alarms, there was no evidence that the valves were inspected and there was no evidence the the fire department connections were inspected. Staff 62 confirmed the were no documents available for review.

14) At 10:15 a.m., the facility failed to provide documentation for the 5-year automatic sprinkler inspection. Staff 62 confirmed the were no documents available for review.

15) At 3:30 p.m., the facility failed to provide documentation for the 4th quarter (October-December) 2010 and the second quarter (April-June) 2011 sprinkler system inspection and test records for the Sierra Community Health Center. There was no evidence the alarms where inspected to assure they were free of physical damage, there was no evidence of testing of the sprinkler system alarms, there was no evidence that the valves were inspected and there was no evidence the the fire department connections were inspected. Staff 57 confirmed the were no documents and that there were no other documents available for review.


29752

7/28/11
TCCB
1st Floor Behavioral Unit
2nd, 3rd, 4th, and 5th floor Rotunda/Waiting area corridors
16) At 11:18 a.m., there were no replacement sprinkler heads for the Rotunda waiting area corridors and no spare tamper proof sprinkler head replacements for the Behavioral Unit. Staff 57 stated that there were no other storage locations for these sprinkler heads.

Based on observation, the facility failed to maintain the fire extinguishers as evidenced by obstructed access to an extinguisher and an extinguisher with a missing tamper indicator. This affected 2 of 71 smoke compartments, the Ambulatory Care Clinic (ACC) and the Community Behavioral Health Center (CBHC) and had the potential for fire extinguisher failure and delay in fire suppression leading to harm to the patients.

NFPA 10 (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.

NFPA 10 (1998 Edition), 4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire Extinguishers shall be inspected at more frequent intervals when circumstances require.

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

NFPA 10 (1998 Edition) 4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

NFPA 10 (1998 Edition) 4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the fire extinguishers were observed.

7/26/11
1) At 9:05 a.m., the fire extinguisher in the Med East Pantry of the main hospital building was missing the tamper indicator. Staff 60 confirmed the fire extinguisher was missing the tamper indicator.

7/27/11
2) At 1:40 p.m., access to the fire extinguisher in the MDF Room in the 10 story building of the main hospital was blocked by a trash can, forcing occupants to reach over the trash can if the extinguisher was needed. Staff 60 confirmed the access was blocked by the trash can.

7/28/11
3) At 11:35 a.m., access to the fire extinguisher in the Medical Records office at the CBHC was blocked by a secure shredding receptacle, forcing occupants to reach over the trash can if the extinguisher was needed. Staff 60 confirmed the access was blocked by the receptacle.

8/2/11
4) At 2:50 p.m., the fire extinguisher in the 2nd floor electrical room of the ACC building had a broken tamper indicator. Staff 58 confirmed the fire extinguisher tamper indicator was broken.

Based on observation, the facility failed to maintain the designated smoking areas as evidenced by the failure to provide a container into which ashtrays could be emptied. This affected the Community Behavioral Health Center (CBHC) and had the potential for fire and harm to the patients.

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the designated smoke areas were observed.

7/28/11
At 8:40 a.m., the designated smoking area at the CBHC was observed. The facility failed to provide a container into which the open face ashtray could be emptied. Staff 60 and 62 confirmed there was no container into which the ashtray could be emptied.

Based on observation, interview and document review, the facility failed to maintain the fire dampers as evidenced by the failure to provide documentation for the testing and maintenance of all dampers in the facility, the failure to provide lettering on duct service openings adjacent to dampers, the failure to provide dampers and dampers that were closed. This affected 50 of 71 smoke compartments, the Diagnostic Center, the Ambulatory Care Clinic (ACC), the California Cancer Center (CCC), the Surgical Services Building and the Community Behavioral Health Center (CBHC) which had the potential to fail to contain smoke in a fire leading to harm of the residents.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.3.5 Air duct coverings shall not be installed so as to conceal or prevent the use of any service opening.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.10.2 Ceiling Cavity Plenum. (f) Where the plenum is a part of a floor-ceiling or roof-ceiling assembly that has been tested or investigated and assigned a fire resistance rating of 1 hour or more, the assembly shall meet the requirements of 3-3.3.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 2-3.11.1* Egress Corridors. Egress corridors in health care, detention and correctional, and residential occupancies shall
not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 3-3.1.2 Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire
resistance rating and in which other openings are required to be protected.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems (1999 Edition), 3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.
Findings:
During the document review and facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility maintenance records were reviewed and the dampers were observed.

7/26/11
1) At 8:51 a.m., fusible link dampers were observed in the corridors and Mechanical Room in the Med East area of the main hospital building. The dampers were not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

2) At 11:35 a.m., the duct access panel adjacent to the damper above door 5SO/20 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

3) At 1:45 p.m., the duct access panels adjacent to the damper on both sides of the barrier above the Nuclear Medicine Injection Lab in the main hospital building were not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panels to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

4) At 1:49 p.m., the duct access panel adjacent to the damper in the mechanical room adjacent to the Nuclear Medicine Injection Lab in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

5) At 1:54 p.m., the duct access panel adjacent to the damper above door 5SO/02 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

6) At 2:08 p.m., the duct access panel adjacent to the damper between the old Nuclear Medicine Hot Lab and the corridor in the main hospital building open and was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

7) At 3:25 p.m., the area above the corridor ceilings in the 5-story building of the main hospital were noted to be an air plenum. The ducts in the ceiling of the corridor separating the plenum and the corridor were equipped with fusible link fire dampers. The air ducts between the patient rooms and the plenum were observed not to have dampers. Staff 60 confirmed the air ducts between the rooms and the plenums were not dampered.

8) At 3:25 p.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffles to patient rooms 520, 523, 525, 527 and 530 were closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffles were closed.

9) At 3:55 p.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffles to patient rooms 402, 403, 443, 444 and 446 were closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffles were closed.

7/27/11
10) At 8:30 a.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffle to patient room 451 was closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffle was closed.

11) At 8:40 a.m., the duct access panel adjacent to the damper in the 4th Central mechanical room adjacent to room 420 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

12) At 8:48 a.m., 2 of 2 duct access panels adjacent to the dampers in the 3rd Central mechanical room adjacent to room 320 in the main hospital building were not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panels to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

13) At 8:48 a.m., the large damper in the 3rd Central mechanical room adjacent to room 320 in the main hospital building was covered with insulation. The insulation had the potential for preventing the damper from fully closing. Staff 60 confirmed there was insulation on the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

14) At 9:10 a.m., the ducts between the above corridor plenum and the patient rooms in the 5-story building of the main hospital were equipped with baffles that could be adjusted to control the flow of air into or from the room. The baffles to patient rooms 306 and 307 were closed causing the air in the rooms to be re-circulated in the room and causing the egress corridor to be used as an air plenum. Staff 60 confirmed the baffles were closed.

15) At 9:23 a.m., 2 of 2 dampers in the 3rd Central elevator alcove in the 5-story building of the main hospital were closed which did not allow for the circulation of air in the corridor. Staff 60 confirmed the dampers were closed.

16) At 9:30 a.m., the duct access panel adjacent to the damper in the 3rd floor mechanical room adjacent to room 350 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

17) At 9:32 a.m., the duct access panel adjacent to the damper above door 5S3/05 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

18) At 10:43 a.m., the dampers in the 2nd floor Central elevator alcove in the 5-story building of the main hospital was closed which did not allow for the circulation of air in the corridor. Staff 60 confirmed the damper was closed.

19) At 10:58 a.m., the high duct access panel adjacent to the damper in the 2nd floor Central Mechanical Room 5S2/17 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

20) At 11:27 a.m., the damper was missing in the corridor ceiling air duct adjacent to room 240 and smoke barrier door 5S2/07 in the 5-story building of the main hospital. Staff 60 confirmed the damper was missing.

21) At 11:34 a.m., the duct access panel adjacent to the damper above door 5S2/05 in the main hospital building was not identified indicating a damper within the duct. Staff 60 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

22) At 11:36 a.m., the damper was missing in the corridor ceiling air duct adjacent that supplied air to the 2E nurse station. The vent was above desk facing the corridor and was open from the plenum into the nurse station. Staff 60 confirmed the damper was missing.

7/28/11
23) At 10:35 a.m., damper test records for the CBHC facility were provided. The records documented damper testing was started on July 19, 2011. Staff 62 stated testing was not complete and that there were no prior records available documenting testing and maintenance of the dampers.

7/29/11
24) At 9:15 a.m., the area above the corridor ceilings in the 10-story building of the main hospital were noted to be an air plenum. The ducts in the ceiling of the corridor separating the plenum and the corridor were equipped with fusible link fire dampers. The air ducts between the patient rooms and the plenum were observed to have dampers with fusible links. The dampers were not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

25) At 9:36 a.m., the duct access panel adjacent to the damper adjacent to door H6102 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

26) At 9:47 a.m., 1 of 4 duct access panels adjacent to door H6145 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper.

27) At 9:53 a.m., the duct access panel adjacent to the damper adjacent to door H6172 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

28) At 9:58 a.m., 2 of 2 duct access panels adjacent to the dampers in the 6th floor Mechanical Room in the 10 story building of the main hospital were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the damper. The dampers were not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

29) At 10:10 a.m., the duct access panel adjacent to the damper adjacent to door 10S6/04 in the 10-story building of the main hospital building was not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panel to note the presence of the damper. The damper was not on the list of dampers tested by the vendor. Staff 59 stated the vendor list of dampers had been reviewed and noted that all dampers in the facility were not listed as having been tested by the vendor. Staff 59 stated the facility was conducting an inventory of the dampers for the vendor to test.

30) At 10:59 a.m., an air duct was observed to penetrate the wall separating the 4th floor conference room in the 10-story building from the mechanical room. On page CR-10-4 of the drawings provided by the facility, the separation wall was shown as being a smoke barrier and a 1-hour fire separation. There was no evidence of a damper in the wall or in the corridor/conference room wall. Staff 58 confirmed there was no evidence of dampers in the walls.

31) At 2:27 p.m., the damper in the cafeteria vestibule adjacent to the Chief Infomation Office in the 10-story building of the main hospital was closed, which did not allow for the circulation of air in the corridor. Staff 58 confirmed the damper was closed.

8/1/11
32) At 5:20 p.m., the Diagnostic Center failed to provide documentation for the testing and maintenance of the damper above the reception area. Staff 58 stated the records for the damper were not available.

8/2/11
33) At 9:28 a.m., the duct access panel adjacent to the damper in the PG&E room in the CCC Building was not identified indicating a damper within the duct. Staff 62 confirmed there was no lettering on the access panel to note the presence of the dampers.

34) At 10:00 a.m., the CCC facility failed to provide documentation for the testing and maintenance of the dampers in the building. Staff 62 stated there were no records for the dampers.

35) At 2:00 p.m., the duct access panel adjacent to the damper above room 15, the duct access panel adjacent to the damper above room 16, and the duct access panel adjacent to the damper above room 17 in the Surgical Services Building were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the dampers.

36) At 2:12 p.m., the duct access panel adjacent to damper FSD18, FSD19 and FSD21 in the Surgical Services Building were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the dampers.

37) At 2:20 p.m., 2 of 2 duct access panels adjacent to the dampers in the 2nd floor mechanical room in the ACC Building were not identified indicating a damper within the duct. Staff 58 confirmed there was no lettering on the access panels to note the presence of the dampers.

Based on observation, the facility failed to maintain the trash chutes as evidenced by the failure to provide a self-closing corridor door to a room containing the trash chute and a trash chute sprinkler head that was covered with foreign material. This affected 11 of 71 smoke compartment and had the potential to fail to contain smoke and fire leading to harm of the residents.

NFPA 82 "Standard on Incinerators and Waste and Linen Handling Systems and Equipment" (1999 Edition)

3-2.1 General. General access gravity chutes shall be permitted to be supplied with unlocked doors and shall be permitted to be available to all occupants at all times. A trash or linen gravity chute shall be permitted to be installed as a limited access gravity chute by installing a key in either the chute intake door or the entry door into the service room. Limited access waste chutes shall be installed so that they can only be used by authorized personnel. A gravity waste or linen chute also shall be permitted to to be used to interface with a pneumatic transport system.

3-2.4.3.2 Service Opening Room Key. If entrance to a limited-access service opening is gained by key, the service opening door shall not require a key to be opened. One opening or the other shall be keyed. Keying shall be required only for limited-access installations.

3-2.5.1 Gravity Chute. Gravity chutes shall be protected internally by automatic sprinklers. This protection requires that a sprinkler be installed at or above the top service opening of the chute. In addition, a sprinkler shall be installed within the chute at alternate floor levels in buildings over two stories in height with a mandatory sprinkler located at the lowest service level. Sprinkler system installation shall comply with NFPA 13, Standard for the Installation of Sprinkler Systems.

3-2.5.2 Chute Sprinkler Head Protection. Automatic sprinkler installed in gravity chute service openings shall be recessed out of the chute area through which the material travels.

NFPA 13, Standard for the Installation of Sprinkler Systems (1999 Edition) 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 of 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), 2-2.1.1 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.

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

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

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility trash chutes were observed.

7/26/11
1) At 8:56 a.m., corridor door H4146 was self-locking and opened to the alcove containing the door to the trash chute which was not equipped with keyed lock. The trash chute was limited access. The corridor door to the unlocked trash chute door was not self-closing. Staff 60 confirmed the chute door was not equipped with a lock and the corridor door to the chute was not self-closing.

2) At 11:36 a.m., the sprinkler head in the 2nd floor trash chute of the 10 story building in the main hospital building was covered with foreign material. Staff 60 confirmed the sprinkler head was covered with foreign material.

Based on observation and interview, the facility failed to provide flame resistant draperies and curtains as evidenced by curtains with no tags identifying them as being flame resistant and the failure to have documents from the manufacturer identifying them as being flame resistant. This affected the Sierra Community Health Center and had the potential for the spread of fire leading to harm to the patients.

NFPA 101 (2000 Edition), 10.3.1 Where required by the applicable provision of this Code, draperies, curtain, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings:

During the facility tour with Staff 58 on 8/2/11, the facility drapes and curtains were observed.

8/2/11
At 11:18 a.m., the privacy curtains in the Physical Therapy area of the Sierra Community Center were not labeled as being flame resistant. Staff 58 confirmed the curtains were not labeled and stated the documents from the manufacturer attesting to the flame resistance were not available.

Based on observation, the facility failed to store mobile trash collection receptacles with a capacity greater than 32 gallons in a room protected as a hazardous area as evidenced by mobile receptacles greater than 32 gallons stored in a corridor. This affected 1 of 71 smoke compartments and had the potential for the spread of fire leading to harm of the patients.

Findings:
During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility corridors were observed.

7/29/11
At 1:53 p.m., there were two, approximately gray colored 44-gallon containers used to collect paper for secure shredding adjacent to the Post Op Nurse Station B in the main hospital building. Staff 60 confirmed the containers were not stored in an area protected as hazardous storage.

Based on observation, the facility failed to maintain the oxygen storage areas as evidenced by oxygen cylinders stored within 5 feet of combustible material. This affected 1 of 71 smoke compartments and the Ambulatory Care Clinic (ACC) and had the potential for a fire and harm to the residents.

NFPA 99, Standard for Healthcare Facilities, (1999 Edition) 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

NFPA 99, Standard for Healthcare Facilities, (1999 Edition) 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:

1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation
of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the oxygen storage areas were observed.

7/27/11
1) At 2:52 p.m., in the Stepdown 1 storage room in the main hospital building, marked "Film Processing Room" on the map provided by the facility, there was a blanket stored over the valves on top of two oxygen E cylinders. Staff 60 confirmed there was a blanket stored on top of the cylinders.

8/2/11
2) At 2:25 p.m., in the Dental medical gas system room in the ACC Building, there was an H cylinder of nitrous oxide connected to the system that was not secured in place. Staff 58 confirmed the H cylinder was not secured.

Based on document review, the facility failed to provide documentation for action taken in six Operating Rooms (OR) when the relative humidity dropped below 35%. This deficient practice could result in an electrical fire from static electricity in an low humidity setting.

NFPA 99 (1999 Edition) 5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During document review on July 27, 2011, the OR logs were reviewed.
At 2:45 p.m., the humidity logs provided by the facility documented relative humidity levels in the Operating Room suites below 35 percent for the following days: 5-24-11 OR-1 28%, OR-9 28%, OR-11 29%; 4-9-11 3rd Floor Labor and Delivery OR-3 29.8%; 3-1-11 3rd Floor Labor and Delivery OR- 2 and OR-3 29%. The facility failed to provide documentation for action taken in the Operating Rooms when the humidity levels fell below 35%. At 8:00 a.m. on July 27, 2011, documentation of action taken in the OR was requested again and the facility failed to provide documentation for action taken in the OR when the relative humidity dropped below 35%.

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 2 of 71 smoke compartments and the Community Behavioral Health Center (CBHC) and had the potential for a fire and harm to the residents.

NFPA 30 (1996 Edition) 4-8.5 Control of Ignition Sources. Precautions shall be taken to prevent the ignition of flammable vapors. Sources of ignition include, but are not limited to: open flames; lightning; smoking; cutting or welding; hot sources; frictional heat; static electricity; electrical or mechanical sparks; spontaneous heating, including heat-producing chemical reactions; and radiant heat.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility ABHR dispensers were observed.

7/26/11
1) At 9:35 a.m., the ABHR dispenser located in room 151 of the main hospital building was mounted above a light switch. Staff 60 confirmed the dispenser was mounted above the light switch.

7/28/11
2) At 1:20 p.m., the ABHR dispenser located in the Case Management office at the CBHC was mounted above a light switch. Staff 62 confirmed the dispenser was mounted above the light switch.

7/29/11
3) At 11:19 a.m., the ABHR dispenser located in room H469 of the main hospital building was mounted above a light switch. Staff 60 confirmed the dispenser was mounted above the light switch.

Based on interview and document review, the facility failed to maintain the emergency generators as evidenced by the failure to provide documentation for 21 of 52 weekly generator inspections including testing the specific gravity in the generator batteries. This had the potential for generator failure leading to harm of the patients and affected 71 of 71 smoke compartments.

Findings:

During the document review between 7/25/11 and 8/2/11, the facility generator test and inspection logs were reviewed.

7/25/11
1) At 1:15 p.m., the Main Hospital facility failed to provide documentation for weekly inspections of the emergency generators due on or about 8-10-10, 8-17-10, 8-24-10, 8-31-10, 9-14-10, 9-21-01, 9-28-10, 10-12-10, 10-19-10, 10-26-10, 11-9-10, 11-16-10, 11-23-10, 11-30-10, 12-14-10, 12-21-10, 12-28-10, 1-4-11, 1-25-11, 2-8-11 and 2-15-11.

At 4:50 p.m., Staff 59 confirmed the weekly inspections were not done. Staff 59 stated that on review in February 2011, it was noted that weekly inspections were not being done and had instituted weekly inspections starting the end of February 2011.

7/28/11
2) At 10:20 a.m., the CBHC facility failed to provide documentation for weekly testing of the specific gravity of the emergency generator battery since March 15, 2011. This was approximately 19 of 52 weeks due on or about 3-22-11, 3-29-11, 4-5-11, 4-12-11, 4-19-11, 4-26-11, 5-3-11, 5-10-11, 5-17-11, 5-24-11, 5-31-11, 6-7-11, 6-14-11, 6-21-11, 6-28-11, 7-5-11, 7-12-11, 7-19-11, and 7-26-11. Staff 62 confirmed the weekly testing of the specific gravity was not done. Staff 62 stated that he was given a new form to use for documenting the weekly inspections of the generator and the new form did not include testing the specific gravity of the generator battery as was required on the previous form.

Based on observation, the facility failed to maintain the electrical system as evidenced by damaged electrical receptacles, the use of surge protectors to extend power and provide additional outlets instead of providing fixed wired receptacles, and receptacles with ground-fault interrupter protection (gfi) that failed to reset when tested. This affected 12 of 71 smoke compartments and the Community Behavioral Health Center (CBHC) and had the potential for electrical shock and/or fire and harm to the patients.

NFPA 70 (1999 Edition), article 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.

NFPA 70, National Electrical Code (1999 Edition), article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

NFPA 70, National Electrical Code (1999 Edition), article 110-26(3)(b) Clear Spaces. Working space required by this section shall not be used for storage.

NFPA 70 (1999 edition) 370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

NFPA 70 (1999 Edition) 400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

NFPA 70 (1999 edition) Section 410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

NFPA 70 (1999 Edition) 517-20. Wet Locations.
(a) All receptacles and fixed equipment within the area of the wet location shall have ground-fault circuit-interrupter protection for personnel if interruption of power under fault conditions can be tolerated, or by an isolated power system if such interruption cannot be tolerated.

Exception: Branch circuits supplying only listed, fixed, therapeutic and diagnostic equipment shall be permitted to be supplied from a normal grounded service, single- or 3-phase system provided that

(a) Wiring for grounded and isolated circuits does not occupy the same raceway, and

(b) All conductive surfaces of the equipment are grounded.

Findings:

During the facility tour with Staff 57, 58, 59,60, 61, 62 and 63 between 7/26/11 and 8/2/11, the facility electrical system was observed.

7/26/11
1) At 9:22 a.m., the electrical receptacle with gfi protection identified as C-8 in the Med East patient bath in the main hospital building failed to reset when tested. Staff 60 confirmed the gfi failed to reset when tested.

2) At 9:45 a.m., access to breakers A and B at the Angiography Tech Station in the main hospital building was obstructed by equipment and the apron cart. Staff 60 confirmed access to the breakers was obstructed by the equipment and the cart.

3) At 1:56 p.m., electrical receptacle B7-19 and the receptacle adjacent to the inner office inside the Nuclear Medicine Conference/Break Room in the main hospital building were damaged around the ground port. Staff 60 confirmed the electrical receptacles were damaged around the ground port.

4) At 1:56 p.m., the cable TV receptacle in the Nuclear Medicine Conference/Break Room in the main hospital building was missing the cover plate. Staff 1 confirmed the receptacle was missing the cover plate.

5) At 3:25 p.m., the electrical receptacle with the red on the corridor wall adjacent to room 522 in the main hospital building was not flush with the wall. Staff 1 60 confirmed the receptacle was not flush with the wall.

7/27/11
6) At 8:27 a.m., the northeast electrical receptacle with the gfi in the 4th East Break room in the 5-story building of the main hospital was damaged around the ground port. Staff 60 confirmed the electrical receptacle was damaged around the ground port.

7) At 9:03 a.m., the electrical receptacle in the foyer to the Nurse Manager office in 3 Central of the 5-story building in the main hospital was damaged around the ground port. Staff 60 confirmed the electrical receptacle was damaged around the ground port.

8) At 9:42 a.m., the electrical receptacle adjacent to the door in the 3 east staff lounge in the 5 story building of the main hospital building was damaged around the ground port. Staff 60 confirmed the electrical receptacle was damaged around the ground port.

9) At 10:10 a.m., 4 of 4 electrical receptacles observed in the NICU physician lounge in the main hospital building were damaged around the ground port. Staff 60 confirmed the electrical receptacles were damaged around the ground port.

10) At 2:00 p.m., electrical receptacle BC-30 on the corridor wall in the Pharmacy Administration area in the main hospital building was damaged around the ground port. Staff 60 confirmed the receptacle was damaged around the ground port.

7/28/11
11) At 12:00 p.m., there was a pencil sharpener plugged into a surge protector adjacent to the refrigerator in the Recreation Therapy room at the CBHC. The surge protector was used as a substitute for additional fixed wired electrical receptacles and used to extend power to the work deck. There were no visible receptacles on the wall. Staff 62 confirmed the use of the surge protector and stated he did not have documentation that adding the additional receptacles through the use of the surge protector was approved and installed in accordance with NFPA 70, National Electrical Code.

12) At 1:56 p.m., the electrical receptacle in the restroom of the employee lounge area in the Men's/Women's Locker area at the CBHC was damaged around the ground port. Staff 62 confirmed the receptacle was damaged around the ground port.


29752

NFPA 70 1999 Edition
Section 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.

NFPA 99 1999 Edition Electrical Systems
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 70 110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of he electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.


Findings:

7/26/11

Fourth Floor - TCCB (Trauma Critical Care Building)
13) At 9:29 a.m., there were a total of six work stations on wheels plugged into two multi-outlet extension cords. One multi-outlet extension cord was plugged into another which was plugged into a wall outlet.

Third Floor - TCCB
14) At 10:21 a.m., in room 3767A (Surgery Scheduling) there was a micro-wave plugged into a multi-outlet extension cord which was plugged into a wall outlet.

15) At 10:24 a.m., in room 3757A there was a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet.

7/27/11

Second Floor - TCCB
16) At 1:39 p.m., in room 2234A (Resident Call Room) there was a laptop computer plugged into a brown extension cord which was plugged into a wall outlet.

17) At 1:41 p.m., in room 2231A (Neurosurgery office) there was a refrigerator, a micro-wave, and a floor heater plugged into a multi-outlet extension cord which was plugged into a wall outlet.

18) At 1:50 p.m., in room 2229 (Anesthesia office) there was a water cooler and a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet.

Second Floor - Five Story Building
19) At 4:12 p.m., in OR Room 3 there was a cauterizer / Electrical surgical generator which plugged into a yellow extension cord which was plugged into a wall outlet.

20) At 4:26 p.m., in OR Room 6 there was a patient thermal blanket system plugged into a multi-outlet extension cord, which was plugged into an electrical outlet.

21) At 4:35 p.m., access to electrical breaker panels 2AA for OR's 8, 10, 5, 7, 6 was obstructed by two procedure carts and two fiber optic light carts. The carts were stored within one foot of the electrical panels.

Ninth Floor - Ten Story Building
22) At 4:38 p.m., in the Clinical Supervisor's Office, there was a refrigerator plugged into multi-outlet extension cord.

7/28/11
Seventh Floor - Ten Story Building
23) At 9:08 a.m., in the Neurosurgery Conference Room, there was a television and computer plugged into a multi-outlet extension cord which was plugged into another multi-outlet extension cord which was plugged into a wall outlet.

24) At 9:39 a.m., in 7 West Oncology Medication Room, a Follet medication refrigerator and a Pyxis Computer were plugged into a multi-outlet extension cord which was plugged into a wall outlet.

25) At 9:42 a.m., in 7 West Staff Lounge, a toaster and a coffee maker were plugged into a multi-outlet extension cord which was plugged into a wall outlet.

7/29/11

Floor One - TCCB
26) At 8:17 a.m., in the ED Directors Office there was a refrigerator and a coffee maker plugged into a multi-outlet extension cord which was plugged into a wall outlet.

27) At 8:42 a.m., in Room 1219A, Clinical Co-coordinator's Office, there was a micro-wave plugged into a blue extension cord which was plugged into a multi-outlet extension cord which was plugged into a wall outlet. There were three refrigerators and a water cooler that were also plugged into the same multi-outlet extension cord.

28) At 10:15 a.m., in Room 1107A EMS and Law Enforcement staff lounge there was a coffee maker plugged into a multi-outlet extension cord which was plugged into a wall outlet.

Basement - TCCB
29) At 11:26 a.m., in the Traction office 0202A, there was a micro-wave plugged into a multi-outlet extension cord which was plugged into a wall outlet. There was also a refrigerator plugged into a multi-outlet extension cord which was plugged into a wall outlet.

30) At 11:34 a.m., in Traction office 0205A, there was computer equipment that was plugged into a multi-outlet extension cord which was plugged into another multi-outlet extension cord that was plugged into a wall outlet.

First Level - Five Story
31) At 14:48 a.m., in the NW corner of the Cafeteria there was an electrical wall outlet next to a dining booth that was missing the cover plate.

8/2/11

First Level - ACC (Ambulatory Care Clinic) Building
32) At 2:38 p.m., in the first floor conference room there were 11 monitors and 11 computers plugged into three multi-outlet extension cords which were plugged into one multi-outlet extension cord which was plugged into one electrical outlet.

Based on record review, observation and interview, the facility failed to provide notification and documentation of an approved fire watch. This was evidenced by disabled smoke detectors in the egress corridors outside of a construction area, no notification to the Department of Public Health of impairments to the alarm system, and no fire watch logs. This could result in a delayed activation of the fire alarm system and the spread of fire or smoke, in the event of a fire. This affected 2 of 71 smoke compartments.

Findings:

During fire alarm testing and during interviews the fire alarm system in the corridor next to the construction area on the First Floor of the 5 Story Building was evaluated.

8/2/11
1st Floor - 5 Story Building
1) At 10:10 a.m., smoke detector 82 (labeled as N15L04D82) located in front of the corridor doors at the temporary wall for the construction area did not activate the fire alarm system after it was sprayed with canned smoke. The smoke detector lights were not blinking indicating that the detector was disabled.

2) At 10:13 a.m., a second smoke detector 81 in the same corridor was found to be disabled.

3) At 10:20 a.m., smoke detectors 107, 108, 16, 83, and 106 were also disabled in . Staff 62 (Construction Foreman) stated that the smoke detectors in the corridors around the construction area had been disabled to ensure that no false alarms occurred.

4) During an interview on 8/2/11at 10:26 a.m., staff 62 stated that the smoke detectors around this area are disabled for construction activities from 6 a.m. until 3 p.m. daily. He stated that they assign construction workers to keep a continuous fire watch inside the containment walls during working hours but he indicated that they do not keep a fire watch log. There were no other records available.

On 8/2/11 at 4 p.m., staff 58 stated that Security does the corridor fire watch but does not keep a fire watch log. There were no other records available.