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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by an unsealed penetration in a facility wall. This affected the Precision Health Imaging Center. This could result in the expedited spread of smoke or fire to other areas of the facility.

Findings:

During a tour of the facility with staff on 8/8/17, the walls were observed.

Precision Health Imaging Center:

1. At 1:52 p.m., there was an approximately 14 inch by 14 inch penetration in the wall of the MRI Computer Room.

Based on observation, the facility failed to maintain the emergency battery backup lighting. This was evidenced by a battery-powered emergency lighting unit that failed to illuminate when tested. This could result in a loss of emergency lighting and decreased visibility in the event of an emergency. This affected one of two floors in the Stanislaus Surgical Hospital.

NFPA 101, Life Safety Code, 2012 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with staff on 8/7/17, the emergency backup lighting system was observed and tested.

Stanislaus Surgical Hospital:

1. At 1:25 p.m., a battery-powered emergency lighting unit, located in the Endoscopy Room on the first floor, failed to illuminate when tested by the Director of Plant Operations 1.

Based on observation and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by operating rooms that were not equipped with battery-powered emergency lighting units. This affected one of two floors in the Stanislaus Surgical Hospital and Coffee Road Surgery Center. This could result in a loss of emergency lighting and visibility during a procedure, in the event of a power failure.

NFPA 99, 2012 Edition
3.3.17 Battery-Powered Lighting Units. Individual unit equipment for backup illumination consisting of a rechargeable battery, battery-charging means, provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both, and relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment. [70, 2011] (ELS)

6.3.2.2.11 Battery-Powered Lighting Units.
6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.
6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.
6.3.2.2.11.3 The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.
6.3.2.2.11.4 Units shall be capable of providing lighting for 1 1/2 hours.
6.3.2.2.11.5 Units shall be tested monthly for 30 seconds, and annually for 30 minutes.

NFPA 70, 2011 Edition
517.63 Grounded Power Systems in Anesthetizing Locations.
(A) Battery-Powered Lighting Units. One or more battery-powered lighting units shall be provided and shall be permitted to be wired to the critical lighting circuit in the area and connected ahead of any local switches.

Findings:

During a tour of the facility and interview with staff on 8/7/17 and 8/8/17, the operating rooms were observed.

Stanislaus Surgical Hospital:

1. On 8/7/17, at 11:25 a.m., no battery back-up light was observed in Operating Room 8 located in the Stanislaus Surgical Hospital. During an interview at that time, Director of Plant Operations 1 stated that there were no battery back-up lights in all eight of eight operating rooms. A portable flash light was provided in each of the operating rooms.

Coffee Road Surgery Center - Second Floor:

2. On 8/8/17, at 10:32 a.m., no battery back-up lights were observed in two of two operating rooms located on the Second Floor of the Clinic at Coffee Road Surgery Center. The findings were acknowledged by Director of Plant Operations 1.

Based on document review and interview, the facility failed to maintain the fire alarm system. This was evidenced by the failure to complete an annual fire alarm system test and inspection within the past 12 months. This could result in a malfunctioning fire alarm system, in the event of a fire, and affected the Valley Hyperbaric Oxygen Center.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

9.6.1.3 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 and signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
14.3 Inspection.
14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.

Table 14.3.1 Visual Inspection Frequencies

14.4.5* Testing Frequency. Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.

Table 14.4.5 Testing Frequencies

14.6.2.4* A record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 14.6.2.4:
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing 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
(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) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer's published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During document review and interview with staff on 8/9/17, the fire alarm system inspection reports were requested and staff interviewed.

Valley Hyperbaric Oxygen Center:

1. At 3:16 p.m., the document provided for the annual fire alarm system inspection report was dated 5/25/16. The facility was approximately two months overdue for an annual fire alarm system test and inspection. The finding was acknowledged by the Director of Plant Operations 1.

Based on record review and interview, the facility failed to provide a written protocol to ensure that if the fire system was out of service for more than four hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by incomplete documentation. This affected the Stanislaus Surgical Hospital, Coffee Road Surgery Center, Valley Hyperbaric Oxygen Center and Precision Health Imaging Center. This could result in the AHJ being unable to exercise oversight in the event of a fire alarm system disruption in service.

Findings:

During record review and interview with staff on 8/8/17, the fire alarm system fire watch policy was reviewed.

All Buildings:

1. At 8:33 a.m., the documentation provided for an approved fire watch for the fire alarm system did not include guidance for the notification of the California Department of Public Health (CDPH) if the fire alarm system was out of service for more than four hours in a 24 hour period. During an interview, Director of Plant Operations I confirmed the finding and stated that they will update their fire watch policy.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to maintain a specialized sprinkler wrench with the spare sprinkler heads, failure to complete all monthly visual inspections of the sprinkler system components, failure to complete quarterly sprinkler system inspections, failure to complete semi-annual waterflow tests, failure to complete an annual sprinkler system test and inspection, and failure to complete a five year certification on the sprinkler system. This could result in a malfunctioning automatic fire sprinkler system, in the event of a fire, and a delay in extinguishing a fire. This affected the Stanislaus Surgical Hospital, Coffee Road Surgery Center, Valley Hyperbaric Oxygen Center, and Precision Health Imaging Center.

NFPA 101, Life Safety Code, 2012 Edition
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1 Sprinklers.
5.2.1.1* Sprinklers shall be inspected from the floor level annually.

5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)*Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.1.1.3* Any sprinkler that has been installed in the incorrect orientation shall be replaced.

5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.

5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

5.2.1.1.6* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.

5.2.1.1.7 Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

5.2.1.2* The minimum clearance required by the installation standard shall be maintained below all sprinkler deflectors.

5.2.1.3 Stock, furnishings, or equipment closer to the sprinkler deflector than permitted by the clearance rules of the installation standard shall be corrected.

5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6

5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.

5.2.3* Hangers and Seismic Braces. Sprinkler pipe hangers and seismic braces shall be inspected annually from the floor level.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible.

5.3.2* Gauges.
5.3.2.1 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge.

5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.

8.3.3 Annual Flow Testing.
8.3.3.1* An annual test of each pump assembly shall be conducted by qualified personnel under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices.

8.3.3.1.1 If available suction supplies do not allow flowing of 150 percent of the rated pump capacity, the fire pump shall be permitted to operate at maximum allowable discharge.

8.3.3.1.2* The annual test shall be conducted as described in 8.3.3.1.2.1, 8.3.3.1.2.2, or 8.3.3.1.2.3.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.

NFPA 72, National Fire Alarm Code and Signaling, 2010 Edition
17.12 Sprinkler Waterflow Alarm-Initiating Devices.
17.12.1* The provisions of Section 17.12 shall apply to devices that initiate an alarm indicating a flow of water in a sprinkler system.

17.12.2* Activation of the initiating device shall occur within 90 seconds of waterflow at the alarm-initiating device when flow occurs that is equal to or greater than that from a single sprinkler of the smallest orifice size installed in the system.

Findings:

During a tour of the facility, document review, and interview with staff on 8/8/17 to 8/9/17, the automatic sprinkler system test and inspection records were reviewed, sprinklers observed, and staff interviewed.

Stanislaus Surgical Hospital:
8/8/17

1. At 8:40 a.m., there were no records of monthly visual inspections of the sprinkler system gauges and valves for the months of January, February, April, May, and July of 2017; and August, October, and November of 2016. When interviewed, Director of Plant Operations 1 acknowledged the finding and stated that he was not aware of the monthly visual inspection requirement. Visual inspections of the gauges and control valves were completed during quarterly sprinkler system inspections.

Coffee Road Surgery Center:
8/8/17

2. At 11:15 a.m., there were no records that indicated four of four quarterly sprinkler system inspections, two of two semi-annual waterflow tests, and monthly inspections of the sprinkler system gauges and valves were completed during the past 12 months. The findings were acknowledged by the Director of Plant Operations 1.

Precision Health Imaging Center:
8/8/17

3. At 1:44 p.m., there was no specialized sprinkler wrench located in or near the red metal box that contained the spare sprinkler heads. When interviewed, the Director of Plant Operations 1 acknowledged that the specialized sprinkler wrench was missing.

4. At 2:30 p.m., there were no records of monthly visual inspections of the sprinkler system gauges and valves for the months of January, February, April, May, and July of 2017; and August, October, and November of 2016. When interviewed, Director of Plant Operations 1 acknowledged the finding and stated that he was not aware of the monthly visual inspection requirement. Visual inspections of the gauges and control valves were completed during quarterly sprinkler system inspections.

Valley Hyperbaric Oxygen Center:
8/9/17

5. At 3:20 p.m., there were no records that indicated the facility completed monthly inspections of the sprinkler system gauges and valves, four of four quarterly sprinkler system inspections, two of two semi-annual waterflow tests, an annual sprinkler system test and inspection, and a five year certification for the sprinkler system. The Director of Plant Operations 1 acknowledged the findings.

Based on document review, the facility failed to provide a written protocol to ensure that if the automatic sprinkler system went out of service for more than 10 hours in a 24-hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by incomplete documentation. This affected the Stanislaus Surgical Hospital, Clinic at Coffee Road Surgery Center, Valley Hyperbaric Oxygen Center, and Precision Health Imaging Center. This could result in the AHJ being unable to exercise oversight in the event of an automatic fire sprinkler system disruption in service.

Findings:

During document review with staff on 8/8/17, the facility's fire watch policy for the automatic sprinkler system was reviewed.

All Buildings:

1. At 8:33 a.m., the documentation provided for an approved fire watch for the automatic sprinkler system did not include guidance for the notification of the California Department of Public Health (CDPH) if the automatic sprinkler system was out of service for more than 10 hours in a 24 hour period. Upon interview, Director of Plant Operations I confirmed the finding and stated that they will update their fire watch policy.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by fire extinguishers that were mounted greater than 60 inches from floor level, by a fire extinguisher that was obstructed, and by unsecured fire extinguishers. This could result in a delay in accessing a portable fire extinguisher in the event of a fire, or could result in fire extinguishers being knocked over and damaged. This affected the Stanislaus Surgical Hospital.

NFPA 101, Life Safety Code, 2012 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.

6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.

6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

6.1.3.8.2 Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be installed so that the top of the fire extinguisher is not more than 31?2 ft (1.07 m) above the floor.

6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).

Findings:

During a tour of the facility with staff on 8/7/17, the fire extinguishers were observed.

Stanislaus Surgical Hospital:

1. At 10:48 a.m., the fire extinguisher in the Electrical Room I.D.F. 2.1, on the second floor, was mounted approximately 62.5 inches from floor level. The measurement was confirmed by the Director of Plant Operations 1.

2. At 10:54 a.m., there were five fire extinguishers in the Maintenance Shop located on the second floor sitting on the floor unsecured. When interviewed, Director of Plant Operations 1 stated that the fire extinguishers were spares.

3. At 10:58 a.m., the access to the fire extinguisher located in the Penthouse was obstructed by a red metal cart. The red metal cart was positioned directly in front of the fire extinguisher. The finding was acknowledged by the Director of Plant Operations 1.

4. At 11:06 a.m., the fire extinguisher in the Data Communication Room on the first floor was mounted approximately 63 inches from floor level.

Based on observation, and interview, the facility failed to maintain their doors. This was evidenced by doors that that failed to latch when closed. This could result in the faster spread of smoke or fire, in the event of a fire. This affected one of two floors in the Stanislaus Surgical Hospital, Precision Health Imaging Center, and Valley Hyperbaric Oxygen Center.

NFPA 101, Life Safety Code, 2012 Edition
8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requirements of NFPA 80, Standard for Fire Doors and Other Opening Protective's, except as otherwise specified in this Code.

NFPA 80, Standard for Fire Doors and Fire Windows, 2010 Edition
5.2.14.1 Self-closing devices shall be kept in working condition at all times.

Findings:

During a tour of the facility with staff on 8/7/17 to 8/9/17, the doors in the facility were observed and staff was interviewed.

Stanislaus Surgical Hospital:
8/7/17

1. At 11:29 a.m., the door to the Sterile Supply room, located on the first floor, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close.

2. At 12:04 p.m., the door to the back hallway from the Sterilization Processing Room, located on the first floor, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close. When interviewed, the Director of Plant Operations 1 stated that the self-closing device needed adjustment.

3. At 1:18 p.m., the door to the Staff Lounge, located on the first floor, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close. When interviewed, the Director of Plant Operations 1 stated that the self-closing device needed adjustment.

4. At 1:32 p.m., the door to the Administrative Women's Bathroom, located on the first floor, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close.

5. At 1:43 p.m., the door to the Janitor's Closet, located in the kitchen on the first floor, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close.

Precision Health Imaging Center:
8/8/17

6. At 1:48 p.m., the door to the Digital Room needed added force to open and close the door. The door did not open and close freely.

Valley Hyperbaric Oxygen Center:
8/9/17

7. At 8:37 a.m., the door to the public bathroom, located in the waiting area, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by an unsealed penetration in a smoke barrier wall. This could result in the faster spread of smoke or fire, in the event of a fire. This affected one of two floors in the Stanislaus Surgical Hospital.

NFPA 101, Life Safety Code, 2012 Edition
8.5.6 Penetrations.
8.5.6.1 The provisions of 8.5.6 shall govern the materials and methods of construction used to protect through-penetrations and membrane penetrations of smoke barriers.

8.5.6.2 Penetrations for cables, cable trays, conduits, pipes, tubes, vents, wires, and similar items to accommodate electrical, mechanical, plumbing, and communications systems that pass through a wall, floor, or floor/ceiling assembly constructed as a smoke barrier, or through the ceiling membrane of the roof/ceiling of a smoke barrier assembly, shall be protected by a system or material capable of restricting the transfer of smoke.

8.5.6.3 Where a smoke barrier is also constructed as a fire barrier, the penetrations shall be protected in accordance with the requirements of 8.3.5 to limit the spread of fire for a time period equal to the fire resistance rating of the assembly and 8.5.6 to restrict the transfer of smoke, unless the requirements of 8.5.6.4 are met.

19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1?2-hour fire resistance rating, unless otherwise permitted by one of the following:
(1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply:
(a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c).
(b) Not less than two separate smoke compartments shall be provided on each floor.
(2) Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier.

Findings:

During a tour of the facility with staff on 8/8/17, the separation walls were observed.

Stanislaus Surgical Hospital:

1. At 10:02 a.m., there was an approximately 1/2 inch penetration around a conduit pipe in the smoke barrier wall near the laboratory on the first floor. The Director of Plant Operations 1 acknowledged the finding.

Based on document review and staff interview, the facility failed to maintain the electrical outlets. This was evidenced by the failure to complete annual tension and polarity tests of the electrical receptacle outlets. This affected Coffee Road Surgery Center, Precision Health Imaging Center, and Valley Hyperbaric Oxygen Center. This could result in the ignition of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.

6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.

6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.

6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months.

6.3.4.2 Record Keeping.
6.3.4.2.1* General.
6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modification.

6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter.


Findings:

During document review with staff on 8/8/17 and 8/9/17, the records for the testing of the electrical outlets were requested.

Coffee Road Surgery Center and Precision Health Imaging:
8/8/17

1. At 1 p.m., and 2:33 p.m., no documents for the annual testing of the receptacle outlets were provided. The findings were confirmed by the Director of Plant Operations 1.

Valley Hyperbaric Oxygen Center:
8/9/17

2. At 3:40 p.m., no documents for the annual testing of the receptacle outlets were provided. The findings were confirmed by the Director of Plant Operations 1.

Based on observation and interview, the facility failed to maintain their medical gas storage. This was evidenced by full and empty oxygen cylinders that were not segregated in storage. This affected one of two floors in the Stanislaus Surgical Hospital and could result in a delay in identifying a full oxygen cylinder, in the event of an emergency.

NFPA 99, Health Care Facilities Code, 2012 Edition.
11.6.5 Special Precautions - Storage of Cylinders and Containers.

11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.

11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

11.6.5.2.1 When the facility employs cylinders with integral pressure gauge, it shall establish the threshold pressure at which a cylinder is considered empty.

11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Findings:

During a tour of the facility with staff on 8/7/17, the oxygen storage room was observed.

Stanislaus Surgical Hospital:

1. At 11:08 a.m., the Medical Gas Storage located on the first floor was observed. There were four empty cylinders and eight full cylinders stored in the same rack designated for empties. When interviewed, Director Plant Operations 1 stated that there was not enough room for another rack. Empty and full cylinders were stored in the same location and not segregated.