HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their fire barrier walls on the horizontal corridor connections by providing at least a 2-hour fire barrier wall rating. This was evidenced by penetrations in a fire barrier wall, affecting 2 of 4 towers in the Main Hospital Building. This had the potential to allow the spread of smoke and fire from one building to another building, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the fire barrier walls were observed.


Main Hospital (McLeod & West Tower)

On 05/10/2011, at 1:32 p.m., the fire barrier wall, located on the 3rd Floor between McLeod Tower and West Tower by Elevator 9, had two penetrations that were observed above the drop down ceilings from the West Tower. The first penetration measured approximately 1-inch and the second penetration measured approximately 1/2-inch.

South Tower on 5/10/11-

4. At 9:40 a.m., there were eight approximately 1/2 inch unsealed penetrations in the center of the back wall of the Birth Certificate Room in the Birth Center.

5. At 9:45 a.m., there was an approximately 1 and 1/4 inch unsealed penetration in the center of the right wall of the Form Room in the Birth Center.













29665

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected 3 of 43 smoke compartments in the main hospital and one of six clinics. This could result in the spread of smoke and fire, in the event of a fire.


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


Findings:

During the facility tour with Engineering Staff, from 5/9/11 to 5/12/11, the walls and ceilings in the Main Hospital and six outpatient clinics were observed.

McLeod Tower on 5/10/11

1. At 8:50 a.m., there was an approximately 1/4 inch penetration in the front wall of the cashier ' s office in the lobby.

2. At 9:26 a.m., there was an approximately 1 foot by 8 inch penetration in the back wall of the electrical closet on the second floor, in the behavioral health department. There were main power conduits going through the penetration.

Adam Tower on 5/10/11

3. At 2:22 p.m., there was an approximately 1 foot by 7 inch penetration in the left wall of the environmental services closet on the second floor, in the kitchen. There were copper water pipes going through the penetration. There was an approximately 4 inch penetration in the front wall, above the door. There was unapproved foam-like caulking material, with air bubbles, around the penetration.
During an interview at 2:23 p.m., Staff 1 stated that the foam-like caulking material is no longer used for maintenance of the facility, and it had been replaced by an approved fire-rated caulking material.

Based on observation, the facility failed to maintain the integrity of the construction of the corridor walls as evidenced by unsealed penetrations in the facility's corridor walls that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the corridor walls and were observed.

Main Hospital (McLeod Tower)

On 05/10/2011, at 1:40 p.m., there was a penetration in the corridor wall, located on the 3rd Floor of the McLeod Tower by the Nuclear Medicine Room 2. The penetration was located above the drop down ceiling, measuring approximately 1/2 inch.

South Tower on 5/10/11

5. At 9:40 a.m., the self-closing door failed to fully close and positive latch to the Breast Pump Room on the fourth floor.

West Tower on 5/11/11

6. During fire alarm testing at 1:30 p.m., the double doors to Nursing Administration, on the third floor, were released from their magnetic hold-open devices. The double doors, equipped with self-closing devices, closed but failed to latch.

Behavioral Health San Marcos on 5/12/11

7. At 8:16 a.m., the double doors to the East side of the staff room were equipped with self-closing devices. The right side closed but failed to latch.

8. At 8:23 a.m., the door to the women ' s restroom was equipped with a self-closing device. The door closed but failed to latch.












29626

Based on observation, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to positive latch and corridor doors with penetrations. These findings could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 5 of 43 smoke compartments and 1 outpatient clinic.
.

Findings:

During the facility tour with staff, from 5/9/11 to 5/12/11, the corridor doors in the Main Hospital and six outpatient clinics were observed.

Findings:

Main Hospital, West Tower

1. On 05/11/2011, at 1:29 p.m., the doors leading into the administration offices from the corridor, located on the 3rd Floor in the West Tower, failed to positively latch 2 of 2 leaf doors. Both doors were equipped with latching mechanisms.



29665

McLeod Tower on 5/10/11

2. At 10:02 a.m., the door to the Imaging Supervisor ' s office, on the third floor, was equipped with a self-closing device. The door closed but failed to latch.

Adam ' s Wing on 5/10/11

3. At 1:30 p.m., the door to Room 441, on the fourth floor, was equipped with a self-closing device. The door closed but failed to latch.

4. At 1:36 p.m., the door to Kaiser Services, on the third floor, was equipped with a self-closing device. The door closed but failed to latch.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls as evidenced by penetrations in the smoke barrier wall. These penetrations could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 3 of 43 smoke compartments.


Findings:

During the facility tour with the Plant Operations Manager on May 9, 2011 through May 13, 2011, the smoke barrier walls were observed.

Main Hospital (McLeod Tower)

1. On 05/10/2011, at 8:30 a.m., the smoke barrier wall by Room 908, located on the 9th Floor in the McLeod Tower, had two penetrations above the drop down ceiling. The penetrations surrounded conduits and measured approximately 1/4-inch each.



West Tower on 5/10/11

2. At 2:10 p.m., there was an approximately 1 inch circular unsealed penetration above the dropped ceiling surrounding a group of cables in the center of the west side of the smoke barrier wall, FD2051A on the sixth floor.

3. At 2:20 p.m., there was an approximately 1/2 inch unsealed penetration above the dropped ceiling surrounding the fourth pipe from the lower west wall in the smoke barrier wall, FD2052A on the sixth floor.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to fully close and positive latch upon closure. These finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 43 smoke compartments.


Findings:

During the facility tour and fire alarm testing with the Plant Operations Manager on May 9, 2011 through May 13, 2011, the smoke barrier doors were observed.

Main Hospital West Tower on May 11, 2011

1. At 10:30 a.m., the smoke barrier double door FD2086 in third floor, both leaves A and B failed to fully close and positive latch. The Plant Operations Manager confirmed that the smoke barrier double door FD2086 failed to fully close and positive latch.


29626

Main Hospital (West Tower)

2. On 05/11/2011, at 1:24 p.m., the smoke barrier door by Room 31 in the Emergency Department, located on the 3rd Floor in the West Tower, failed to positively latch 1 of 2 leaf doors. Both doors were equipped with latching mechanisms.

Based on observation, the facility failed to maintain hazardous areas with 1-hour rated construction and failed to ensure hazardous areas were separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by one hazardous area with a self-closing doors that was held open by an unapproved mechanism. This affected 1 of 43 smoke compartments, and could result in the spread of fire from a hazardous area to other areas of the facility.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.



Findings:

During the facility tour from 5/9/11 to 5/12/11, the hazardous areas were observed in the Main Hospital and outpatient clinics. Soiled linen and trash storage areas, and combustible storage rooms greater than 50 square feet in size, are considered hazardous areas.

Adam Tower on 5/10/11

At 2:15 p.m., the kitchen dry storage area, on the second floor, was more than 50 square feet in size and contained more than 45 cardboard boxes. The door, equipped with a self-closing device, was tied open with a wire.

Based on observation, the facility failed to maintain emergency lighting. This was evidenced by an emergency lighting unit that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the illumination throughout egress paths were observed.

Main Hospital (West Tower)

On 05/10/2011, at 3:02 p.m., the emergency lighting unit on the 2nd Floor in Stairwell 1 failed to illuminate 1 of 2 light bulbs.

2. On 05/11/2011, at 10:36 a.m., an environmental service staff on the 6th Floor in the McLeod Tower was asked to talk about her responsibilities in a fire emergency. The staff member stated that she had not gone through fire safety training since she had started working 2-weeks ago.
Escondido Surgery Center on 05/12/11

3. At 2:07 p.m., fire drill documents titled " Fire Drill/Disaster In-service Participation " were provided and reviewed. There were fire drill sign up sheets for 11/5/10 and 9/17/10. There were no documents for fire drills conducted during the first quarter of 2011 or the second quarter of 2010.










29626

Based on observation, record review and interview, the facility failed to conduct fire drills quarterly as evidenced by missing documentation of fire drills. These findings could result in the failure of any one facility staff member from accomplishing all of the tasks expected of him or her in the event of a fire and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 43 smoke compartments on the main campus and 1 of 6 off-site locations.

Findings:

During observation, record review and interview with facility staff on May 9, 2011, through May 13, 2011 records were reviewed, staff observed and staff interviewed.

Main Hospital (West & McLeod Towers)

1. On 05/10/2011, at 2:04 p.m., a front desk staff on the 3rd Floor in the West Tower was asked to explain fire emergency procedures and to demonstrate how to use a fire extinguisher. The staff member could not explain how to use a fire extinguisher and stated that no training had been provided on its use.

South Tower on 5/11/11

3. At 1:15 p.m., the pull station (131-260) M1-13 was identified as 301 when read back during fire alarm testing.

West Tower on 5/11/11

4. At 1:25 p.m., the pull station (133-101) was identified as M1-1 when read back during fire alarm testing.

Adams Tower on 5/11/11

5. At 2:01 p.m., At !:15 p.m., the pull station was blocked by two food carts in the Kitchen.

Escondido Surgery Center on 5/12/11

6. At 10:20 p.m., two manual pull stations were blocked by chairs in the Lobby.









29626

Outpatient Services @ 120 Craven Road (Suites 103, 105, 109, & 207)

7. On 05/12/2011, at 7:11 a.m., the batteries in the fire alarm panel on the 1st Floor were not dated and no documentation was provided that gave the date when batteries had been installed.

8. On 05/12/2011, at 7:30 a.m., the batteries in the fire alarm panel on the 2nd Floor were dated July 2006. No documentation was provided that gave manufactures specifications that the batteries and would last more than 4 years.








29665

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by two areas where the fire alarm could not be heard, by expired fire alarm panel batteries, by obstructed pull stations, inaccurate identification on pull stations and by inaccurate time readings on a fire alarm panel. This affected 5 of 43 smoke compartments in the main hospital, and 4 outpatient clinics. This could result in a failure of the alarm system or a delay in notification, in the event of a fire.

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

NFPA 72, National Fire Alarm Code, 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.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During the facility tour from 5/9/11 to 5/12/11, the fire alarm system was observed in the Main Hospital and in six outpatient clinics.

McLeod Tower on 5/11/11

1. At 10:09 a.m., there was no fire alarm audible device at the nurses ' station on the eighth floor. There were two audible/visual devices on opposite ends of the hallway, in each smoke compartment. During fire alarm testing, the devices were activated. At the nurses ' station, no alarm could be seen or heard. Two nurses stated that they could not hear the alarm during testing.

2. At 10:59 a.m., there was no fire alarm audible devices at the nurses ' station on the fifth floor. There were two audible/visual devices on opposite ends of the hallway, in each smoke compartment. During fire alarm testing, the devices were activated. At the nurses ' station, no alarm could be seen or heard.

Based on record review, the facility failed to provide sensitivity testing records for their system based smoke detection devices in the surgery center. This was evidenced by no documentation that the smoke detector sensitivity testing had been conducted on all devices. This had the potential for a smoke detector to fail in the event of a fire that could result in harm to patients and staff.

NFPA 72 National Fire Alarm Code, 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 be replaced.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the records for the fire alarm system were reviewed

Outpatient Services @ 343 E. 2nd Avenue (Surgery Center)

On 05/16/2011, at 10:48 a.m., the smoke alarm sensitivity testing was received, showing that 22 of 37 smoke detectors had not been tested.

Main Hospital, McLeod Tower on 5/11/11

7. At 9:25 a.m., there were 4 of 4 sprinklers with a build up of debris in the OR Staff Lounge L0408.

8. At 9:30 a.m., there were 3 of 3 sprinklers with a build up of debris in the OR Women's Locker Room .

9. On 05/11/2011, between the hours of 1:45 p.m. and 3:30 p.m., five inspector test valves (ITV) were tested. The quarterly reports from 01/08/2010 through 04/01/2011 showed that four ITV had been tested; thus, 1 of 5 ITV had not been tested in the past 15 months.

10. On 05/11/2011, at 2:30 p.m., the ITV located on the 1st Floor in the Medical Records Storage failed to activate the alarm after opening the valve and allowing the water to run for approximately 99 seconds. The Plant Operations Manager immediately set-up a fire watch and the ITV was operational at 4:00 p.m.






29626

Based on document review, observation, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by failing to conduct a quarterly testing of the automatic sprinkler system, failing to test all devices that include tamper switch testing and all water flow alarm activation times, an inspector test valve (ITV) that failed to activate the fire alarm system, a fire alarm panel with a troubled signal, sprinkler heads with a build-up of debris and an ITV that failed to activate during fire alarm testing. This deficient practice affected all patients, staff and visitors in all smoke compartments that could result in the failure of the sprinkler system in the event of a fire.

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

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

2-3.3 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.

3-3.3 Alarm Devices. Where provided, waterflow alarm and supervisory devices shall be tested on a quarterly basis.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the records for the testing and maintenance of the automatic sprinkler system were reviewed and the system was observed.

Main Hospital

1. On 05/9/2011, at 2:25 p.m., the records for automatic sprinkler system maintenance were reviewed. The quarterly inspections of the sprinkler system were performed by Simplex Grinnell on following dates: 01/08/2010, 04/08/2010, 07/23/2010, 10/07/2010, and 04/01/2011. No quarterly report was provided for the 1st quarter of 2011; thus, showing no record that the system was tested for 6 months between 10/07/2010 and 04/01/2011. The Manager of Facility Operations stated on 05/12/2011, at 3:30 p.m. that all the quarterly reports for that past year that the facility had in its possession were provided to the surveyor.

Outpatient Services, 120 Craven Road (Suites 103, 105, 109, & 207)

2. On 05/12/2011, at 7:10 a.m., the fire alarm panel showed the following troubled signal: " TROUBL SUPERVISORY 0S-Y-VALVE-STREET Z04 INVALID REPLY " and " TROUBLE IN SYSTEM GROUND FAULT. " The sprinkler system quarterly reports showed that the same trouble signal had been identified by Simplex Grinnell on 05/17/2010, 08/30/2010, 11/18/2010, and 02/15/2011.

3. On 05/12/2011, at 7:35 a.m., the Post Indicator Valve (PIV) tamper switch was not tested during survey because Staff did not have a key to the padlock and did not know how to test the tamper switch.

4. On 05/12/2011, at 7:00 a.m., the 5-Year Certification on the sprinkler system was requested. On 05/16/2011, at 10:48 a.m., the 5-Year Inspection report for the sprinkler system was received from the Plant Operations Manager. The inspection report showed that the system failed on 12/07/2010 by Cosco Fire Protection; thus, the sprinkler system does not have a 5-Year Certification.

Outpatient Services @ 125 Vallecitos De Oro (Suites A-D)

5. On 05/12/2011, at 1:30 p.m., the records for automatic sprinkler system were requested and reviewed. The quarterly inspections of the sprinkler system were performed by Knight Security and Fire Systems on following dates: 05/10/2010 and 05/10/2011. No quarterly reports were provided between these dates; thus, showing no record that the system had been tested quarterly within this 12 month period. The Manager of Facility Operations stated that the quarterly reports provided were the only inspections that had been done.

Escondido Surgery Center on 5/12/11 -

6. At 10:40 p.m., there were 1 of 2 sprinklers heads with a build-up of lint and debris in the Doctors Lounge.

Main Hospital

5. On 05/11/2011, at 9:50 a.m., there was a fire extinguisher by Room 911A on the 9th Floor that was mounted approximately 64 inches above the floor.

6. On 05/11/2011, at 10:21 a.m., there was a fire extinguisher by Room 722 on the 7th Floor that was mounted approximately 67 inches above the floor.

7. On 05/11/2011, at 10:33 a.m., there was a fire extinguisher by Room 605 on the 6th Floor that was mounted approximately 67 inches above the floor.

8. On 05/11/2011, at 1:14 p.m., there was a fire extinguisher in the Microbiology Laboratory on the 3rd Floor that was mounted approximately 67 inches above the floor.

9.On 05/11/2011, at 1:15 p.m., there was a fire extinguisher in the Chemistry Laboratory on the 3rd Floor that was mounted approximately 70 inches above the floor.

10. On 05/11/2011, at 1:52 p.m., there was a fire extinguisher in the Kitchen on the 2nd Floor that was mounted approximately 70 inches above the floor.










29665

Based on observation and interview, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were obstructed, by fire extinguishers installed over 60 inches above the floor, and by a fire extinguisher that was missing monthly inspections. This affected 9 of 43 smoke compartments at the main hospital. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.


NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1.6 General Requirements
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).
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.

Findings:

During the facility tour from 5/9/11 - 5/12/11, the fire extinguishers were observed in the main hospital and in six outpatient clinics.

McLeod Tower on 5/10/11

1. At 9:30 a.m., the fire extinguisher at the behavioral health nurses ' station, on the second floor, was mounted approximately 72 inches above the floor. The fire extinguisher was serviced on 1/6/11 and the tag indicated monthly inspections on 2/1/11 and 5/3/11. There were no monthly checks indicated for March or April of 2011.

2. At 10:02 a.m., the fire extinguisher mounted on the left wall of the I.R. Suite, on the third floor, was obstructed by two carbon dioxide e-tanks.

3. At 10:35 a.m., the fire extinguisher was under the desk and hidden from view in the MRI trailor.

Adams Tower on 5/10/11

4. At 10:35 a.m., the fire extinguisher was blocked from access by two carts in the Kitchen.

Based on observation, the facility failed to ensure that the compressed gas cylinders were secured. This was evidenced by unsecured compressed gas cylinders and loosely chained gas cylinders. This finding could result in a fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with the Plant Operations District Director and the Plant Operations Manager on May 9, 2011 through May 13, 2011, the facilities compressed gas cylinder storage areas were observed.

On May 11, 2011:

1. At 4:05 p.m., there were 24 E oxygen cylinders unsecured and 10 H tanks loosely secured with one chain in the compressed gas bulk storage area.

2. At 4:10 p.m., there were 10 E cylinders unsecured in the secondary compressed gas bulk storage area.

Based on observation, the facility failed to maintain their oxygen storage area in accordance with NFPA 99. This was evidenced by electrical receptacle outlets in the oxygen storage area that were installed less than 152 cm (5 ft) above the floor. This had the potential for an H-size cylinder to break the receptacle outlet that could result in fire and explosion.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the oxygen storage room was observed.

Outpatient Services, 343 E. 2nd Avenue (Surgery Center)

On 05/12/2011, at 10:42 a.m., the oxygen storage room outside the facility had four receptacle outlets installed approximately 50 inches from the floor and H-cylinder tanks were placed adjacent to the outlets.

South Tower on 5/10/11 -

6. At 10:00 a.m., there was a microwave, a toaster and a toaster oven plugged into a multi-outlet adaptor not directly into the wall in the Birth Center Women's Lounge .
patsy
7. At 10:01 a.m., there was a refrigerator and a microwave plugged into a multi-outlet adaptor not directly into the wall in 3rd Floor Corporate Health Office.

McLeod Tower on 5/11/11

8. At 9:20 a.m., there were three recycle bins full of recycled paper in the Electrical Room EC410.










29665

Based on observation, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by the use of surge protectors, and by exposed electrical boxes. This affected 6 of 43 smoke compartments in the main hospital and one of six outpatient clinics. This could result in an increased risk of an electrical fire.

NFPA 70, National Electric Code, 1999 edition.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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

Findings:

During the facility tour from 5/9/11 - 5/12/11, the electrical wiring was observed in the main hospital and in six outpatient clinics.

McLeod Tower on 5/10/11

1. At 8:35 a.m., a receptacle outlet, on the left wall of the Clinical Education Classroom in the lobby, had a loose coverplate that was held on by tape.
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2. At 8:45 a.m., there was a refrigerator and a microwave plugged into a six-plug wall adaptor, with surge protection, in the dietician ' s office in the lobby.

Adam ' s Wing on 5/10/11

3. At 1:23 p.m., there was a refrigerator plugged into a six-plug surge protector in the perinatology office, on the fourth floor.

West Tower on 5/11/11

4. At 9:15 a.m., there was a red emergency receptacle outlet without a coverplate, in the corridor across from OR 1 on the fourth floor.

Behavioral Health San Marcos on 5/12/11

5. At 8:20 a.m., there were two refrigerators plugged into a six plug surge protector in the program nurse ' s office.

Based on observation, the facility failed to maintain the integrity of their fire barrier walls on the horizontal corridor connections by providing at least a 2-hour fire barrier wall rating. This was evidenced by penetrations in a fire barrier wall, affecting 2 of 4 towers in the Main Hospital Building. This had the potential to allow the spread of smoke and fire from one building to another building, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the fire barrier walls were observed.


Main Hospital (McLeod & West Tower)

On 05/10/2011, at 1:32 p.m., the fire barrier wall, located on the 3rd Floor between McLeod Tower and West Tower by Elevator 9, had two penetrations that were observed above the drop down ceilings from the West Tower. The first penetration measured approximately 1-inch and the second penetration measured approximately 1/2-inch.

South Tower on 5/10/11-

4. At 9:40 a.m., there were eight approximately 1/2 inch unsealed penetrations in the center of the back wall of the Birth Certificate Room in the Birth Center.

5. At 9:45 a.m., there was an approximately 1 and 1/4 inch unsealed penetration in the center of the right wall of the Form Room in the Birth Center.













29665

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected 3 of 43 smoke compartments in the main hospital and one of six clinics. This could result in the spread of smoke and fire, in the event of a fire.


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


Findings:

During the facility tour with Engineering Staff, from 5/9/11 to 5/12/11, the walls and ceilings in the Main Hospital and six outpatient clinics were observed.

McLeod Tower on 5/10/11

1. At 8:50 a.m., there was an approximately 1/4 inch penetration in the front wall of the cashier ' s office in the lobby.

2. At 9:26 a.m., there was an approximately 1 foot by 8 inch penetration in the back wall of the electrical closet on the second floor, in the behavioral health department. There were main power conduits going through the penetration.

Adam Tower on 5/10/11

3. At 2:22 p.m., there was an approximately 1 foot by 7 inch penetration in the left wall of the environmental services closet on the second floor, in the kitchen. There were copper water pipes going through the penetration. There was an approximately 4 inch penetration in the front wall, above the door. There was unapproved foam-like caulking material, with air bubbles, around the penetration.
During an interview at 2:23 p.m., Staff 1 stated that the foam-like caulking material is no longer used for maintenance of the facility, and it had been replaced by an approved fire-rated caulking material.

Based on observation, the facility failed to maintain the integrity of the construction of the corridor walls as evidenced by unsealed penetrations in the facility's corridor walls that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the corridor walls and were observed.

Main Hospital (McLeod Tower)

On 05/10/2011, at 1:40 p.m., there was a penetration in the corridor wall, located on the 3rd Floor of the McLeod Tower by the Nuclear Medicine Room 2. The penetration was located above the drop down ceiling, measuring approximately 1/2 inch.

South Tower on 5/10/11

5. At 9:40 a.m., the self-closing door failed to fully close and positive latch to the Breast Pump Room on the fourth floor.

West Tower on 5/11/11

6. During fire alarm testing at 1:30 p.m., the double doors to Nursing Administration, on the third floor, were released from their magnetic hold-open devices. The double doors, equipped with self-closing devices, closed but failed to latch.

Behavioral Health San Marcos on 5/12/11

7. At 8:16 a.m., the double doors to the East side of the staff room were equipped with self-closing devices. The right side closed but failed to latch.

8. At 8:23 a.m., the door to the women ' s restroom was equipped with a self-closing device. The door closed but failed to latch.












29626

Based on observation, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to positive latch and corridor doors with penetrations. These findings could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 5 of 43 smoke compartments and 1 outpatient clinic.
.

Findings:

During the facility tour with staff, from 5/9/11 to 5/12/11, the corridor doors in the Main Hospital and six outpatient clinics were observed.

Findings:

Main Hospital, West Tower

1. On 05/11/2011, at 1:29 p.m., the doors leading into the administration offices from the corridor, located on the 3rd Floor in the West Tower, failed to positively latch 2 of 2 leaf doors. Both doors were equipped with latching mechanisms.



29665

McLeod Tower on 5/10/11

2. At 10:02 a.m., the door to the Imaging Supervisor ' s office, on the third floor, was equipped with a self-closing device. The door closed but failed to latch.

Adam ' s Wing on 5/10/11

3. At 1:30 p.m., the door to Room 441, on the fourth floor, was equipped with a self-closing device. The door closed but failed to latch.

4. At 1:36 p.m., the door to Kaiser Services, on the third floor, was equipped with a self-closing device. The door closed but failed to latch.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls as evidenced by penetrations in the smoke barrier wall. These penetrations could result in the spread of smoke and fire from one smoke compartment to the next smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 3 of 43 smoke compartments.


Findings:

During the facility tour with the Plant Operations Manager on May 9, 2011 through May 13, 2011, the smoke barrier walls were observed.

Main Hospital (McLeod Tower)

1. On 05/10/2011, at 8:30 a.m., the smoke barrier wall by Room 908, located on the 9th Floor in the McLeod Tower, had two penetrations above the drop down ceiling. The penetrations surrounded conduits and measured approximately 1/4-inch each.



West Tower on 5/10/11

2. At 2:10 p.m., there was an approximately 1 inch circular unsealed penetration above the dropped ceiling surrounding a group of cables in the center of the west side of the smoke barrier wall, FD2051A on the sixth floor.

3. At 2:20 p.m., there was an approximately 1/2 inch unsealed penetration above the dropped ceiling surrounding the fourth pipe from the lower west wall in the smoke barrier wall, FD2052A on the sixth floor.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to fully close and positive latch upon closure. These finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 43 smoke compartments.


Findings:

During the facility tour and fire alarm testing with the Plant Operations Manager on May 9, 2011 through May 13, 2011, the smoke barrier doors were observed.

Main Hospital West Tower on May 11, 2011

1. At 10:30 a.m., the smoke barrier double door FD2086 in third floor, both leaves A and B failed to fully close and positive latch. The Plant Operations Manager confirmed that the smoke barrier double door FD2086 failed to fully close and positive latch.


29626

Main Hospital (West Tower)

2. On 05/11/2011, at 1:24 p.m., the smoke barrier door by Room 31 in the Emergency Department, located on the 3rd Floor in the West Tower, failed to positively latch 1 of 2 leaf doors. Both doors were equipped with latching mechanisms.

Based on observation, the facility failed to maintain hazardous areas with 1-hour rated construction and failed to ensure hazardous areas were separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by one hazardous area with a self-closing doors that was held open by an unapproved mechanism. This affected 1 of 43 smoke compartments, and could result in the spread of fire from a hazardous area to other areas of the facility.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code?.



Findings:

During the facility tour from 5/9/11 to 5/12/11, the hazardous areas were observed in the Main Hospital and outpatient clinics. Soiled linen and trash storage areas, and combustible storage rooms greater than 50 square feet in size, are considered hazardous areas.

Adam Tower on 5/10/11

At 2:15 p.m., the kitchen dry storage area, on the second floor, was more than 50 square feet in size and contained more than 45 cardboard boxes. The door, equipped with a self-closing device, was tied open with a wire.

Based on observation, the facility failed to maintain emergency lighting. This was evidenced by an emergency lighting unit that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the illumination throughout egress paths were observed.

Main Hospital (West Tower)

On 05/10/2011, at 3:02 p.m., the emergency lighting unit on the 2nd Floor in Stairwell 1 failed to illuminate 1 of 2 light bulbs.

2. On 05/11/2011, at 10:36 a.m., an environmental service staff on the 6th Floor in the McLeod Tower was asked to talk about her responsibilities in a fire emergency. The staff member stated that she had not gone through fire safety training since she had started working 2-weeks ago.
Escondido Surgery Center on 05/12/11

3. At 2:07 p.m., fire drill documents titled " Fire Drill/Disaster In-service Participation " were provided and reviewed. There were fire drill sign up sheets for 11/5/10 and 9/17/10. There were no documents for fire drills conducted during the first quarter of 2011 or the second quarter of 2010.










29626

Based on observation, record review and interview, the facility failed to conduct fire drills quarterly as evidenced by missing documentation of fire drills. These findings could result in the failure of any one facility staff member from accomplishing all of the tasks expected of him or her in the event of a fire and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 43 smoke compartments on the main campus and 1 of 6 off-site locations.

Findings:

During observation, record review and interview with facility staff on May 9, 2011, through May 13, 2011 records were reviewed, staff observed and staff interviewed.

Main Hospital (West & McLeod Towers)

1. On 05/10/2011, at 2:04 p.m., a front desk staff on the 3rd Floor in the West Tower was asked to explain fire emergency procedures and to demonstrate how to use a fire extinguisher. The staff member could not explain how to use a fire extinguisher and stated that no training had been provided on its use.

South Tower on 5/11/11

3. At 1:15 p.m., the pull station (131-260) M1-13 was identified as 301 when read back during fire alarm testing.

West Tower on 5/11/11

4. At 1:25 p.m., the pull station (133-101) was identified as M1-1 when read back during fire alarm testing.

Adams Tower on 5/11/11

5. At 2:01 p.m., At !:15 p.m., the pull station was blocked by two food carts in the Kitchen.

Escondido Surgery Center on 5/12/11

6. At 10:20 p.m., two manual pull stations were blocked by chairs in the Lobby.









29626

Outpatient Services @ 120 Craven Road (Suites 103, 105, 109, & 207)

7. On 05/12/2011, at 7:11 a.m., the batteries in the fire alarm panel on the 1st Floor were not dated and no documentation was provided that gave the date when batteries had been installed.

8. On 05/12/2011, at 7:30 a.m., the batteries in the fire alarm panel on the 2nd Floor were dated July 2006. No documentation was provided that gave manufactures specifications that the batteries and would last more than 4 years.








29665

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by two areas where the fire alarm could not be heard, by expired fire alarm panel batteries, by obstructed pull stations, inaccurate identification on pull stations and by inaccurate time readings on a fire alarm panel. This affected 5 of 43 smoke compartments in the main hospital, and 4 outpatient clinics. This could result in a failure of the alarm system or a delay in notification, in the event of a fire.

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

NFPA 72, National Fire Alarm Code, 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.

Table 7-3.2
6. Batteries d. Sealed-Lead Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During the facility tour from 5/9/11 to 5/12/11, the fire alarm system was observed in the Main Hospital and in six outpatient clinics.

McLeod Tower on 5/11/11

1. At 10:09 a.m., there was no fire alarm audible device at the nurses ' station on the eighth floor. There were two audible/visual devices on opposite ends of the hallway, in each smoke compartment. During fire alarm testing, the devices were activated. At the nurses ' station, no alarm could be seen or heard. Two nurses stated that they could not hear the alarm during testing.

2. At 10:59 a.m., there was no fire alarm audible devices at the nurses ' station on the fifth floor. There were two audible/visual devices on opposite ends of the hallway, in each smoke compartment. During fire alarm testing, the devices were activated. At the nurses ' station, no alarm could be seen or heard.

Based on record review, the facility failed to provide sensitivity testing records for their system based smoke detection devices in the surgery center. This was evidenced by no documentation that the smoke detector sensitivity testing had been conducted on all devices. This had the potential for a smoke detector to fail in the event of a fire that could result in harm to patients and staff.

NFPA 72 National Fire Alarm Code, 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 be replaced.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the records for the fire alarm system were reviewed

Outpatient Services @ 343 E. 2nd Avenue (Surgery Center)

On 05/16/2011, at 10:48 a.m., the smoke alarm sensitivity testing was received, showing that 22 of 37 smoke detectors had not been tested.

Main Hospital, McLeod Tower on 5/11/11

7. At 9:25 a.m., there were 4 of 4 sprinklers with a build up of debris in the OR Staff Lounge L0408.

8. At 9:30 a.m., there were 3 of 3 sprinklers with a build up of debris in the OR Women's Locker Room .

9. On 05/11/2011, between the hours of 1:45 p.m. and 3:30 p.m., five inspector test valves (ITV) were tested. The quarterly reports from 01/08/2010 through 04/01/2011 showed that four ITV had been tested; thus, 1 of 5 ITV had not been tested in the past 15 months.

10. On 05/11/2011, at 2:30 p.m., the ITV located on the 1st Floor in the Medical Records Storage failed to activate the alarm after opening the valve and allowing the water to run for approximately 99 seconds. The Plant Operations Manager immediately set-up a fire watch and the ITV was operational at 4:00 p.m.






29626

Based on document review, observation, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by failing to conduct a quarterly testing of the automatic sprinkler system, failing to test all devices that include tamper switch testing and all water flow alarm activation times, an inspector test valve (ITV) that failed to activate the fire alarm system, a fire alarm panel with a troubled signal, sprinkler heads with a build-up of debris and an ITV that failed to activate during fire alarm testing. This deficient practice affected all patients, staff and visitors in all smoke compartments that could result in the failure of the sprinkler system in the event of a fire.

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

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

2-3.3 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.

3-3.3 Alarm Devices. Where provided, waterflow alarm and supervisory devices shall be tested on a quarterly basis.

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the records for the testing and maintenance of the automatic sprinkler system were reviewed and the system was observed.

Main Hospital

1. On 05/9/2011, at 2:25 p.m., the records for automatic sprinkler system maintenance were reviewed. The quarterly inspections of the sprinkler system were performed by Simplex Grinnell on following dates: 01/08/2010, 04/08/2010, 07/23/2010, 10/07/2010, and 04/01/2011. No quarterly report was provided for the 1st quarter of 2011; thus, showing no record that the system was tested for 6 months between 10/07/2010 and 04/01/2011. The Manager of Facility Operations stated on 05/12/2011, at 3:30 p.m. that all the quarterly reports for that past year that the facility had in its possession were provided to the surveyor.

Outpatient Services, 120 Craven Road (Suites 103, 105, 109, & 207)

2. On 05/12/2011, at 7:10 a.m., the fire alarm panel showed the following troubled signal: " TROUBL SUPERVISORY 0S-Y-VALVE-STREET Z04 INVALID REPLY " and " TROUBLE IN SYSTEM GROUND FAULT. " The sprinkler system quarterly reports showed that the same trouble signal had been identified by Simplex Grinnell on 05/17/2010, 08/30/2010, 11/18/2010, and 02/15/2011.

3. On 05/12/2011, at 7:35 a.m., the Post Indicator Valve (PIV) tamper switch was not tested during survey because Staff did not have a key to the padlock and did not know how to test the tamper switch.

4. On 05/12/2011, at 7:00 a.m., the 5-Year Certification on the sprinkler system was requested. On 05/16/2011, at 10:48 a.m., the 5-Year Inspection report for the sprinkler system was received from the Plant Operations Manager. The inspection report showed that the system failed on 12/07/2010 by Cosco Fire Protection; thus, the sprinkler system does not have a 5-Year Certification.

Outpatient Services @ 125 Vallecitos De Oro (Suites A-D)

5. On 05/12/2011, at 1:30 p.m., the records for automatic sprinkler system were requested and reviewed. The quarterly inspections of the sprinkler system were performed by Knight Security and Fire Systems on following dates: 05/10/2010 and 05/10/2011. No quarterly reports were provided between these dates; thus, showing no record that the system had been tested quarterly within this 12 month period. The Manager of Facility Operations stated that the quarterly reports provided were the only inspections that had been done.

Escondido Surgery Center on 5/12/11 -

6. At 10:40 p.m., there were 1 of 2 sprinklers heads with a build-up of lint and debris in the Doctors Lounge.

Main Hospital

5. On 05/11/2011, at 9:50 a.m., there was a fire extinguisher by Room 911A on the 9th Floor that was mounted approximately 64 inches above the floor.

6. On 05/11/2011, at 10:21 a.m., there was a fire extinguisher by Room 722 on the 7th Floor that was mounted approximately 67 inches above the floor.

7. On 05/11/2011, at 10:33 a.m., there was a fire extinguisher by Room 605 on the 6th Floor that was mounted approximately 67 inches above the floor.

8. On 05/11/2011, at 1:14 p.m., there was a fire extinguisher in the Microbiology Laboratory on the 3rd Floor that was mounted approximately 67 inches above the floor.

9.On 05/11/2011, at 1:15 p.m., there was a fire extinguisher in the Chemistry Laboratory on the 3rd Floor that was mounted approximately 70 inches above the floor.

10. On 05/11/2011, at 1:52 p.m., there was a fire extinguisher in the Kitchen on the 2nd Floor that was mounted approximately 70 inches above the floor.










29665

Based on observation and interview, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were obstructed, by fire extinguishers installed over 60 inches above the floor, and by a fire extinguisher that was missing monthly inspections. This affected 9 of 43 smoke compartments at the main hospital. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.


NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1.6 General Requirements
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).
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.

Findings:

During the facility tour from 5/9/11 - 5/12/11, the fire extinguishers were observed in the main hospital and in six outpatient clinics.

McLeod Tower on 5/10/11

1. At 9:30 a.m., the fire extinguisher at the behavioral health nurses ' station, on the second floor, was mounted approximately 72 inches above the floor. The fire extinguisher was serviced on 1/6/11 and the tag indicated monthly inspections on 2/1/11 and 5/3/11. There were no monthly checks indicated for March or April of 2011.

2. At 10:02 a.m., the fire extinguisher mounted on the left wall of the I.R. Suite, on the third floor, was obstructed by two carbon dioxide e-tanks.

3. At 10:35 a.m., the fire extinguisher was under the desk and hidden from view in the MRI trailor.

Adams Tower on 5/10/11

4. At 10:35 a.m., the fire extinguisher was blocked from access by two carts in the Kitchen.

Based on observation, the facility failed to ensure that the compressed gas cylinders were secured. This was evidenced by unsecured compressed gas cylinders and loosely chained gas cylinders. This finding could result in a fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During the facility tour with the Plant Operations District Director and the Plant Operations Manager on May 9, 2011 through May 13, 2011, the facilities compressed gas cylinder storage areas were observed.

On May 11, 2011:

1. At 4:05 p.m., there were 24 E oxygen cylinders unsecured and 10 H tanks loosely secured with one chain in the compressed gas bulk storage area.

2. At 4:10 p.m., there were 10 E cylinders unsecured in the secondary compressed gas bulk storage area.

Based on observation, the facility failed to maintain their oxygen storage area in accordance with NFPA 99. This was evidenced by electrical receptacle outlets in the oxygen storage area that were installed less than 152 cm (5 ft) above the floor. This had the potential for an H-size cylinder to break the receptacle outlet that could result in fire and explosion.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with Hospital Staff on May 9, 2011 through May 13, 2011, the oxygen storage room was observed.

Outpatient Services, 343 E. 2nd Avenue (Surgery Center)

On 05/12/2011, at 10:42 a.m., the oxygen storage room outside the facility had four receptacle outlets installed approximately 50 inches from the floor and H-cylinder tanks were placed adjacent to the outlets.

South Tower on 5/10/11 -

6. At 10:00 a.m., there was a microwave, a toaster and a toaster oven plugged into a multi-outlet adaptor not directly into the wall in the Birth Center Women's Lounge .
patsy
7. At 10:01 a.m., there was a refrigerator and a microwave plugged into a multi-outlet adaptor not directly into the wall in 3rd Floor Corporate Health Office.

McLeod Tower on 5/11/11

8. At 9:20 a.m., there were three recycle bins full of recycled paper in the Electrical Room EC410.










29665

Based on observation, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by the use of surge protectors, and by exposed electrical boxes. This affected 6 of 43 smoke compartments in the main hospital and one of six outpatient clinics. This could result in an increased risk of an electrical fire.

NFPA 70, National Electric Code, 1999 edition.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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

Findings:

During the facility tour from 5/9/11 - 5/12/11, the electrical wiring was observed in the main hospital and in six outpatient clinics.

McLeod Tower on 5/10/11

1. At 8:35 a.m., a receptacle outlet, on the left wall of the Clinical Education Classroom in the lobby, had a loose coverplate that was held on by tape.
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2. At 8:45 a.m., there was a refrigerator and a microwave plugged into a six-plug wall adaptor, with surge protection, in the dietician ' s office in the lobby.

Adam ' s Wing on 5/10/11

3. At 1:23 p.m., there was a refrigerator plugged into a six-plug surge protector in the perinatology office, on the fourth floor.

West Tower on 5/11/11

4. At 9:15 a.m., there was a red emergency receptacle outlet without a coverplate, in the corridor across from OR 1 on the fourth floor.

Behavioral Health San Marcos on 5/12/11

5. At 8:20 a.m., there were two refrigerators plugged into a six plug surge protector in the program nurse ' s office.