HospitalInspections.org

Facility failed to provide fire sprinkler system for one room in this three story building in accordance with the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 4/08/14 that on the third level, the "COMM ROOM" did not have a fire sprinkler.

Facility failed to maintain hazardous room in accordance with the 2000 edition of NFPA 101. Findings included the following:

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the facility fail to provide a door closer for the Soiled Work Room on the 1st floor located within NICU suite at the Heart Hospital.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, register nurse, the facility manager, and the electrician during the hours of the inspection from 09:00 am to 10:300 pm on 04/09/2014 that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the 1st floor above the ceiling of the west smoke barrier cross corridor doors at the patient Building A.
This is not in accordance with NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the 1st floor above the ceiling of the west smoke barrier cross corridor doors between the ER and Radiology suite at the Bay Area Medical Center.
This is not in accordance with NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were smoke barrier cross corridor doors was not fully closed located at the following locations: 1) The smoke barrier cross corridor doors on 2nd floor at the Heart hospital 2) The smoke barrier cross corridor doors on 3rd floor into the administration area at the Heart hospital.
This is not in accordance with NFPA 101, 2000: 19.3.7.6.

Facility failed to maintain hazardous area in accordance with NFPA 101. Findings included the following:

Surveyor observed between 1:30 and 2:00pm on 4/08/14 that in the first floor surgical suite, the soiled utility room door did not have self-closing device.

Facility failed to maintain fire alarm panel identification in accordance with NFPA 70. Findings included the following:


Surveyor observed between 10:00 and 11:00 am on 2/08/14, that in the IT room on the first floor, the main fire alarm control panel (FACP) did not have label identifying the electrical circuit powering the device.




In addition in this room, the subpanel PPEM, circuit 26 did not have a red color identifying it as providing power to the FACP.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were following issues:

1.) The was no permanent label for FACP inside the life safety panel.


" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "

Facility failed to provide fire sprinkler system for one room in this three story building in accordance with the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 4/08/14 that on the third level, the "COMM ROOM" did not have a fire sprinkler.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the sprinkler escutcheon plate was missing at the following locations: 1) Cath Lab on the 3rd floor at the Heart hospital. 2) ICU equipment storage room on the 3rd floor at the Heart hospital. 3) Director of patient service on the 3rd floor at the Heart hospital.

Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the sprinkler escutcheon plate was missing at the following locations: 1) HR office on the 1st floor at the Bay Area Medical Center. 2) Case manager Office on 1st floor at the Bay Area Medical Center. 3) Vestibule into the lobby on 1st floor at the Bay Area Medical Center. 4) The receiving office on the 1st floor at the Bay Area Medical Center.

This is not in accordance with NFPA 101, 2000: 19.3.5 and NFPA 13.
Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

Facility failed to maintain ventilation of a janitor closet in accordance with NFPA 90A. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 4/09/14 that on the third floor north, the ES Closet did not have exhaust. This does not meet ventilation table for janitors closet referenced in NFPA 90A.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were the following issues.

A.) The med gas cylinders stored in the open was not protected.

See NFPA 99, 2002: 5.1.3.5.4.Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were following issues:

1.) The facility failed to provide battery powered lighting units battery at the generator location. This is not in accordance with NFPA 99, 1999: 3-4.2.2.2.(b)5. " The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location "

Facility failed to maintain essential electrical system (EES)wiring in accordance with NFPA 99. Findings included the following:

Surveyor observed between 10 am and 11:45 am on 4/08/14 that in the first floor IT ROOM, that subpanel PPEM and on the third floor, panel board PP3AEM had flex conduit which is not in accoredance with NFPA 99, 1999: 3-4.2.2.4(d) Mechanical protection of teh Emrgency System.

In addition on the third floor, electrical panels LE3AEM and LS 38- EM had nurse calling circuits and AS38-EM had plug/nurse station powered by life safety branch of EES. These items shall be powered by the critical branch in accordanc with NFPA 99, 1999: 3-4.2.2.2(b) critical branch 5. Nurse call systems and 9. Additional task illumination, receptacles for effective faclity operation.

Facility failed to maintain electrical wiring and panel board identification in accordance with the National Elecrical Code, NFPA 70. Findings included the following:

Surveyor observed between 10 and 11:45 am on 4/08/14 that essential electrical panels on the first floor, IT ROOM Panel PPEm and on 3rd floor, electrical panels PP3AEm and were not identified completely. They shall be labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve NFPA 70, 1999: 110-22, 700-9(a). . Additionally, the panel directories need to be upedated as necessary. Panel directories need to be labeled to legibly identify the purpose or use of each circuit - NFPA 70,1999: 384-13.

In additon, in the 3rd floor mechanical room, an open J-box for the nurse call system was observed.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the facility failed to provide receptacles powered from critical branch for the crash cart on the 2nd floor within the ICU suite at the Heart Hospital.
The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that that equipment branch electrical panel located at the vacuum pump room supply power to medical gas alarm panel which shall be on Life Safety Branch panel in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:
The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that electrical panel within the NICU suite at the Bay Area Medical Center supply power to medical gas alarm panel which shall be on Life Safety Branch panel in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.

Facility failed to provide fire sprinkler system for one room in this three story building in accordance with the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 4/08/14 that on the third level, the "COMM ROOM" did not have a fire sprinkler.

Facility failed to maintain hazardous room in accordance with the 2000 edition of NFPA 101. Findings included the following:

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the facility fail to provide a door closer for the Soiled Work Room on the 1st floor located within NICU suite at the Heart Hospital.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, register nurse, the facility manager, and the electrician during the hours of the inspection from 09:00 am to 10:300 pm on 04/09/2014 that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the 1st floor above the ceiling of the west smoke barrier cross corridor doors at the patient Building A.
This is not in accordance with NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that that the facility fail to provide fire caulk for the penetration located at the smoke barriers walls at the following locations: 1) On the 1st floor above the ceiling of the west smoke barrier cross corridor doors between the ER and Radiology suite at the Bay Area Medical Center.
This is not in accordance with NFPA 101, 2000: 19.3.7.3 and 8.3.6.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were smoke barrier cross corridor doors was not fully closed located at the following locations: 1) The smoke barrier cross corridor doors on 2nd floor at the Heart hospital 2) The smoke barrier cross corridor doors on 3rd floor into the administration area at the Heart hospital.
This is not in accordance with NFPA 101, 2000: 19.3.7.6.

Facility failed to maintain hazardous area in accordance with NFPA 101. Findings included the following:

Surveyor observed between 1:30 and 2:00pm on 4/08/14 that in the first floor surgical suite, the soiled utility room door did not have self-closing device.

Facility failed to maintain fire alarm panel identification in accordance with NFPA 70. Findings included the following:


Surveyor observed between 10:00 and 11:00 am on 2/08/14, that in the IT room on the first floor, the main fire alarm control panel (FACP) did not have label identifying the electrical circuit powering the device.




In addition in this room, the subpanel PPEM, circuit 26 did not have a red color identifying it as providing power to the FACP.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were following issues:

1.) The was no permanent label for FACP inside the life safety panel.


" NFPA 72, 2002: 4.4.1.4.2.2 -The electrical connection between the panel/breaker and the FACP must be cross referenced correctly. " The circuit breaker at the electrical panel board for the fire alarm shall have a red marking, shall be accessible only to authorized personnel, and shall be identified as "FIRE ALARM CIRCUIT CONTROL" " - NFPA 72, 2002: 4.4.1.4.2.2. " The location of the circuit disconnecting means shall be permanently identified at the fire alarm control unit. " - NFPA 72, 2002: 4.4.1.4.2.3 "

Facility failed to provide fire sprinkler system for one room in this three story building in accordance with the Life Safety Code, NFPA (National Fire Protection Association) 101. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 4/08/14 that on the third level, the "COMM ROOM" did not have a fire sprinkler.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the sprinkler escutcheon plate was missing at the following locations: 1) Cath Lab on the 3rd floor at the Heart hospital. 2) ICU equipment storage room on the 3rd floor at the Heart hospital. 3) Director of patient service on the 3rd floor at the Heart hospital.

Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the sprinkler escutcheon plate was missing at the following locations: 1) HR office on the 1st floor at the Bay Area Medical Center. 2) Case manager Office on 1st floor at the Bay Area Medical Center. 3) Vestibule into the lobby on 1st floor at the Bay Area Medical Center. 4) The receiving office on the 1st floor at the Bay Area Medical Center.

This is not in accordance with NFPA 101, 2000: 19.3.5 and NFPA 13.
Escutcheons are part of the listed assembly per 1999 NFPA 13 ?3-2.7.2.

Facility failed to maintain ventilation of a janitor closet in accordance with NFPA 90A. Findings included the following:

Surveyor observed between 11:00 and 11:45 am on 4/09/14 that on the third floor north, the ES Closet did not have exhaust. This does not meet ventilation table for janitors closet referenced in NFPA 90A.

Based on observation the facility failed to provide adequate medical gas system.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were the following issues.

A.) The med gas cylinders stored in the open was not protected.

See NFPA 99, 2002: 5.1.3.5.4.Cylinder stored in the open shall be protected to against extreme of weather and from the ground beneath to prevent rusting, against accumulation of ice or snow, screened against continuous exposure to direct ray of sun in those localities where extreme temperature prevail.

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that there were following issues:

1.) The facility failed to provide battery powered lighting units battery at the generator location. This is not in accordance with NFPA 99, 1999: 3-4.2.2.2.(b)5. " The emergency generator location shall have task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location and essential automatic transfer switch location "

Facility failed to maintain essential electrical system (EES)wiring in accordance with NFPA 99. Findings included the following:

Surveyor observed between 10 am and 11:45 am on 4/08/14 that in the first floor IT ROOM, that subpanel PPEM and on the third floor, panel board PP3AEM had flex conduit which is not in accoredance with NFPA 99, 1999: 3-4.2.2.4(d) Mechanical protection of teh Emrgency System.

In addition on the third floor, electrical panels LE3AEM and LS 38- EM had nurse calling circuits and AS38-EM had plug/nurse station powered by life safety branch of EES. These items shall be powered by the critical branch in accordanc with NFPA 99, 1999: 3-4.2.2.2(b) critical branch 5. Nurse call systems and 9. Additional task illumination, receptacles for effective faclity operation.

Facility failed to maintain electrical wiring and panel board identification in accordance with the National Elecrical Code, NFPA 70. Findings included the following:

Surveyor observed between 10 and 11:45 am on 4/08/14 that essential electrical panels on the first floor, IT ROOM Panel PPEm and on 3rd floor, electrical panels PP3AEm and were not identified completely. They shall be labeled "LIFE SAFETY", "CRITICAL" or "EQUIPMENT", as applicable to identify which branch they serve NFPA 70, 1999: 110-22, 700-9(a). . Additionally, the panel directories need to be upedated as necessary. Panel directories need to be labeled to legibly identify the purpose or use of each circuit - NFPA 70,1999: 384-13.

In additon, in the 3rd floor mechanical room, an open J-box for the nurse call system was observed.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:

The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that the facility failed to provide receptacles powered from critical branch for the crash cart on the 2nd floor within the ICU suite at the Heart Hospital.
The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that that equipment branch electrical panel located at the vacuum pump room supply power to medical gas alarm panel which shall be on Life Safety Branch panel in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.

Facility failed to maintain essential electrical system wiring in accordance with the 1999 edition of the Standard for Health Care, NFPA 99. Findings included the following:
The inspector observed, while accompanied by the Director of the staffing officer, the facility quality manager, the facility manager, and the electrician during the hours of the inspection from 08:30 am to 3:00 pm on 04/08/2014 that electrical panel within the NICU suite at the Bay Area Medical Center supply power to medical gas alarm panel which shall be on Life Safety Branch panel in accordance with NFPA 99, 1999: 3-4.2.2.2 (a) Life Safety Branch.