HospitalInspections.org

Based on observation, the facility failed to maintain the building construction in a condition that would resist the passage of smoke and fire. This was evidenced by observed unsealed penetrations in the ceilings of the building. This affected staff and patients in two of two smoke compartments within the main hospital and could potentially result in the spread of smoke and/or fire from one area to another.


Findings:

During a tour of the facility with the Plant Operations Manager, penetrations were observed.

Main Hospital
1. On 3/27/13, at 3:50 p.m., the sprinkler located near the restrooms near Admitting was missing the escutcheon ring creating a one-half inch penetration around the sprinkler pipe.

2. On 3/27/13, at 3:57 p.m., the sprinkler escutcheon located in the Nutrition Room near the Acute Nurses' Station was not flush to the ceiling creating an approximately one-half inch penetration around the sprinkler pipe.

3. On 3/28/13, at 10:47 a.m., the sprinkler escutcheon ring located near the door to the Nursing Administration Office was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe

4. On 3/28/13, at 8:30 a.m., the sprinkler escutcheon in the Doctors' Dictation Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that were impeded from closing. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients in one of two smoke compartments at the main hospital.


Findings:

During a tour of the facility with the Plant Operations Manager on 3/27/13, doors were observed.

1. At 4:00 p.m., the door to Patient Room 202 was impeded from closing by a bed that was located in the swing area of the door.

2. At 4:12 p.m., the door to patient room 200 was impeded from closing by a serving table located in the swing area of the door.

Based on observation, the facility failed to protect its hazardous area enclosures.
This was evidenced by a room which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and was not equipped with a self-closing mechanism on the door or had the door propped open.
This was also evidenced by an unsealed penetration in the ceiling of a mechanical room.
This affected all staff and patients in one of two smoke compartments at the main hospital and one of two offsite clinic buildings and could potentially result in the spread of smoke and/or fire from one area to another.

NFPA 101 Life Safety Code, 2000 Edition
39.3.2 Protection from Hazards.
39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.
39.3.1 Protection of Vertical Openings.
39.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
39.3.1.2 Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.

8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
Findings:

During a tour of the facility with the Director of Plant Operations and Engineering Staff, hazardous area enclosures were observed.

Main Hospital
1. On 3/27/13, at 3:48 p.m., the corridor door to the Laboratory was propped open with a plastic tube placed between the bottom of the door and the floor.


Portola Medical Dental Clinic
2. On 3/28/13, between 1:45 and 2:00 p.m., the Mechanical Room in the Basement Medical Records Storage Room had approximately 20 percent of the five-eighths inch ceiling drywall sheeting removed. The south and north portion of the ceiling was missing the sheeting where the ceiling meets the walls in an approximately 18 inch by ten foot area of the wall. The west portion of the ceiling was missing the sheeting in an approximately 18 inch by five foot area of the wall. This room was being used as mechanical room for the compressor and vacuum pump for the Dental Office.

3. On 3/28/13, between 1:45 and 2:00 p.m., the door at the top of the stairs to the Medical/ Dental Clinic did not have a self-closing device on the door. At the bottom of the stairs was a partial basement being used as an Office, Medical Records Storage, and Mechanical Room for the compressor and vacuum pump for the dental office.

Based on observation and document review, the facility failed to maintain its emergency illumination. This was evidenced by a battery-powered emergency lighting unit that failed to function when tested. This finding affected one of two offsite locations and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility with the Clinic Administrative Staff on 3/28/13, the battery back-up light/exit sign at the south end of corridor did not function when tested. When the test button was pushed, the two lights did not come on, but the exit sign did remain illuminated.

Based on observation, document review, and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by noted deficiencies in the five year sprinkler certification that had not been repaired. This was also evidenced by one missing quarterly sprinkler flow test, by a lack of documentation provided for four of four quarterly sprinkler visual inspections and an obstructed sprinkler head. This affected all staff and patients in two of two smoke compartments at the main hospital and could potentially cause the automatic sprinkler system to fail to function as designed resulting in the spread of smoke and/or fire.

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

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

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.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

1999 NFPA 13
5-8.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

5-8.6 Clearance to Storage (Extended Coverage Upright and Pendent Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

During document review with the Plant Operations Manager on 3/27/13, sprinkler system inspecting and testing documentation was reviewed.

1. At 9:45 a.m., documentation titled "Sprinkler System Testing and Inspection" noted on the additional comments section that the following locations had sprinkler heads that were painted or should be changed.

X-Ray Tech Area
Ultra Sound Lab inside and outside of the room.
Laboratory Room with refrigerator.
Restroom next to Laboratory.
Food Storage Room
Kitchen Office painted and should be a 401 style
Kitchen has seven painted heads
Breaker above the microwave oven
Room 200 Bathroom painted
Office near Post Anesthesia Recovery Room

During a tour of the facility with the Plant Operations Manager between 8:50 and 9:10 a.m., this surveyor observed that these sprinkler heads did have paint on the deflector or usable links.

2. At 10:25 a.m., sprinkler system quarterly inspections did not document a flow for the fourth quarter of 2012. There was no flow test done between 9/12/12 and 2/16/13. Documentation also did not include the quarterly visual inspection of the sprinkler system which includes the visual inspection of the alarm devices (water flow switch), hydraulic nameplate, fire department connections and confirmation that valves are in the proper position.

3. At 3:32 p.m., the Housekeeping Closet near the Oxygen Storage Room had five inches of clearance between the sprinkler deflector and the top shelf storage items.

Based on observation, the facility failed to inspect its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by a fire extinguisher that was missing documentation for one monthly visual inspection. This deficient practice affected one of two offsite clinics and could potentially result in the fire extinguisher not functioning properly during a fire.

NFPA 10, 1998 edition
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.
4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30- day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a tour of the facility with Clinic Administrative Staff on 3/28/13, fire extinguishers were observed. At 4:50 p.m., the fire extinguisher located at the south end of the corridor was missing the February monthly inspection on the back of the HMIS label.

Based on observation, the facility failed to protect its smoking areas. This was evidenced by the failure to provide ashtrays of a safe design in areas where smoking is permitted. This deficient practice affected one of one smoking area outside of the facility and could potentially result in the ignition of fire.

Findings:

During a tour of the facility with the Plant Operations Manager on 3/27/13, the smoking area was observed.

At 3:41 p.m., the smoking area on the east side of the facility had a five gallon plastic bucket that was being used as an ashtray. This bucket was filled with sand to within approximately six inches from the top and had approximately 10 cigarette butts in it. Staff removed the bucket at that time.

Based on record review and interview, the facility failed to maintain its cooking facilities, in accordance with 1998 NFPA 96 8-3.1 table 8-3.1, as evidenced by a lack of documentation for one of two semi-annual kitchen hood fire suppression system inspection and cleaning reports. This deficient practice affected two of two smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.

8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

NFPA 96 (1998) 8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1
Systems serving moderate-volume cooking operations - Semiannually

Findings:

During record review on 3/27/13, at 9:45 a.m., documentation for the current and previous fire suppression system and cleaning reports were requested.

During a tour of the facility on 3/27/13, at 4:40 p.m., the inspection tag date for the current kitchen hood suppression system inspection was dated 3/14/13.
The hood cleaning sticker on the hood was dated 12/11/12. No other documentation was provided for the previous inspection and cleaning to verify if the facility is having the service done every six months.

Staff stated that they would contact the vendor and request the documentation, if it was available.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by unapproved portable heaters in a patient care area and a non-sleeping staff area. This affected all staff and patients in one of two smoke compartments within the facility and could potentially result in the ignition of fire.

1999 NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with the Plant Operations Manager, electrical equipment was observed.

1. On 3/28/13, at 3:45 p.m., the Mammography Patient Room had a portable electric heater that was plugged into the fixed wall outlet. This heater was partially behind the patient room door. The heater had a high temperature warning label on the top of it and was rated at 1500 watts. This heater also had a Bio-Med testing sticker on it indicating that it had been tested. During a later interview on 3/28/13 with the Bio-Medical Staff, when asked, Staff stated that the testing for the heater just tests for current leakage, not temperature.

2. On 3/28/13, at 8:30 a.m., there was a portable electric heater in the Doctors' Dictation Room that was plugged into a power strip. This heater had a high temperature warning, "three feet of clearance required" and was rated at 1500 watts.

Staff removed the heater in the patient care area. No documentation was provided indicating that the heating elements of the heaters did not exceed 212 degrees.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in case of a fire or other emergency. This was evidenced by items stored in the exit corridor. This deficient practice affected all staff and patients in two of two smoke compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility on 3/27/13, exit corridors were observed.

1. At 3:12 p.m., the area between the laboratory corridor door and the cross corridor had items stored in the corridor. There was bed, two wheelchairs, two folding chairs, two IV stands and another wheelchair on the north side of the wall. There were 55 inches of clearance between the bed and the opposite wall. On 3/28/13 at 8:30 a.m., these items were still in the same location.

2. At 4:35 p.m., the corridor leading to the Operating Room had items stored in the corridor. There were two computers on rolling stands and two gurneys stored in the corridor outside of the Operating Room near the exit door.

Based on observation, and interview, the facility failed to maintain its piped medical gas source location. This was evidenced by a ventilation fan that was not working. This affected all staff and patients in two of two smoke compartments at the main hospital and could potentially result in the acceleration of fire.

1999 NFPA 99 Standard for Health Facilities
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)*Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)

4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.


Findings:

Main Campus
During a tour of the facility with the Plant Operations Manager on 3/28/13, at 10:00 a.m., the medical gas source location was observed. This surveyor observed that the ventilation fan in the ceiling was not working. The door to the source room had a seven by fourteen inch vent in the door for natural ventilation. Engineering Staff confirmed that he fan was not working.

Based on document review and interview, the facility failed to protect its anesthetizing locations. This was evidenced by the failure to maintain the relative humidity in the operating room to insure it is equal to, or greater than, 35 percent.
This affected one of two smoke compartments at the main hospital and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment.

19.3.2.3 Anesthetizing Locations.
Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review with Operating Room Staff on 3/28/13, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
1. Between 11:15 and 11:45 a.m., Operating Room Staff provided a log of Operating Room 1 relative humidity. Documentation indicated that the humidity levels had been monitored for February and March only.

The February 26th humidity level was recorded at 23 percent.
The March 11th and 26th humidity levels were recorded at 21 percent.

Staff stated that surgeries are usually done two days per month.

The Plant Operations Manager stated that the facility might request a waiver to lower the humidity requirements to 20 percent.

Based on document review and staff interview, the facility failed to inspect its generator weekly. This was evidenced by incomplete documentation for weekly generator inspections. This finding affected all staff and patients in two of two smoke compartments and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

Findings:

During record review on 3/27/13, generator logs and maintenance reports were reviewed.

1. At 9:45 a.m., documentation indicated that the generator had not been inspected weekly for 18 of 52 weeks in a twelve month period. Staff confirmed the missing documentation

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities as evidenced by a high-wattage appliance that was plugged into a power strip instead of being plugged directly into a fixed wall outlet. This deficient practice affected staff and patients in one of two smoke compartments and could potentially result in the ignition of fire.

NFPA 70
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

Findings:

During a tour of the facility with the Plant Operations Manager on 3/27/13 at 3:45 p.m., the Doctors' Dictation Room had a portable electric heater that was plugged into a power strip. This heater was rated at 1500 watts.

Based on observation, the facility failed to maintain the building construction in a condition that would resist the passage of smoke and fire. This was evidenced by observed unsealed penetrations in the ceilings of the building. This affected staff and patients in two of two smoke compartments within the main hospital and could potentially result in the spread of smoke and/or fire from one area to another.


Findings:

During a tour of the facility with the Plant Operations Manager, penetrations were observed.

Main Hospital
1. On 3/27/13, at 3:50 p.m., the sprinkler located near the restrooms near Admitting was missing the escutcheon ring creating a one-half inch penetration around the sprinkler pipe.

2. On 3/27/13, at 3:57 p.m., the sprinkler escutcheon located in the Nutrition Room near the Acute Nurses' Station was not flush to the ceiling creating an approximately one-half inch penetration around the sprinkler pipe.

3. On 3/28/13, at 10:47 a.m., the sprinkler escutcheon ring located near the door to the Nursing Administration Office was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe

4. On 3/28/13, at 8:30 a.m., the sprinkler escutcheon in the Doctors' Dictation Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the pipe.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that were impeded from closing. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients in one of two smoke compartments at the main hospital.


Findings:

During a tour of the facility with the Plant Operations Manager on 3/27/13, doors were observed.

1. At 4:00 p.m., the door to Patient Room 202 was impeded from closing by a bed that was located in the swing area of the door.

2. At 4:12 p.m., the door to patient room 200 was impeded from closing by a serving table located in the swing area of the door.

Based on observation, the facility failed to protect its hazardous area enclosures.
This was evidenced by a room which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and was not equipped with a self-closing mechanism on the door or had the door propped open.
This was also evidenced by an unsealed penetration in the ceiling of a mechanical room.
This affected all staff and patients in one of two smoke compartments at the main hospital and one of two offsite clinic buildings and could potentially result in the spread of smoke and/or fire from one area to another.

NFPA 101 Life Safety Code, 2000 Edition
39.3.2 Protection from Hazards.
39.3.2.1* Hazardous areas including, but not limited to, areas used for general storage, boiler or furnace rooms, and maintenance shops that include woodworking and painting areas shall be protected in accordance with Section 8.4.
39.3.1 Protection of Vertical Openings.
39.3.1.1 Any vertical opening shall be enclosed or protected in accordance with 8.2.5.
39.3.1.2 Floors below the street floor used for storage or other than business occupancy shall have no unprotected openings to business occupancy floors.

8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the
building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.
8.4.1.3 Doors in barriers required to have a fire resistance rating shall have a 3/4-hour fire protection rating and shall be self-closing or automatic-closing in accordance with 7.2.1.8.
Findings:

During a tour of the facility with the Director of Plant Operations and Engineering Staff, hazardous area enclosures were observed.

Main Hospital
1. On 3/27/13, at 3:48 p.m., the corridor door to the Laboratory was propped open with a plastic tube placed between the bottom of the door and the floor.


Portola Medical Dental Clinic
2. On 3/28/13, between 1:45 and 2:00 p.m., the Mechanical Room in the Basement Medical Records Storage Room had approximately 20 percent of the five-eighths inch ceiling drywall sheeting removed. The south and north portion of the ceiling was missing the sheeting where the ceiling meets the walls in an approximately 18 inch by ten foot area of the wall. The west portion of the ceiling was missing the sheeting in an approximately 18 inch by five foot area of the wall. This room was being used as mechanical room for the compressor and vacuum pump for the Dental Office.

3. On 3/28/13, between 1:45 and 2:00 p.m., the door at the top of the stairs to the Medical/ Dental Clinic did not have a self-closing device on the door. At the bottom of the stairs was a partial basement being used as an Office, Medical Records Storage, and Mechanical Room for the compressor and vacuum pump for the dental office.

Based on observation and document review, the facility failed to maintain its emergency illumination. This was evidenced by a battery-powered emergency lighting unit that failed to function when tested. This finding affected one of two offsite locations and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility with the Clinic Administrative Staff on 3/28/13, the battery back-up light/exit sign at the south end of corridor did not function when tested. When the test button was pushed, the two lights did not come on, but the exit sign did remain illuminated.

Based on observation, document review, and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by noted deficiencies in the five year sprinkler certification that had not been repaired. This was also evidenced by one missing quarterly sprinkler flow test, by a lack of documentation provided for four of four quarterly sprinkler visual inspections and an obstructed sprinkler head. This affected all staff and patients in two of two smoke compartments at the main hospital and could potentially cause the automatic sprinkler system to fail to function as designed resulting in the spread of smoke and/or fire.

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

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.

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.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

1999 NFPA 13
5-8.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-8.5.2 and 5-8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard.

5-8.6 Clearance to Storage (Extended Coverage Upright and Pendent Spray Sprinklers). The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

During document review with the Plant Operations Manager on 3/27/13, sprinkler system inspecting and testing documentation was reviewed.

1. At 9:45 a.m., documentation titled "Sprinkler System Testing and Inspection" noted on the additional comments section that the following locations had sprinkler heads that were painted or should be changed.

X-Ray Tech Area
Ultra Sound Lab inside and outside of the room.
Laboratory Room with refrigerator.
Restroom next to Laboratory.
Food Storage Room
Kitchen Office painted and should be a 401 style
Kitchen has seven painted heads
Breaker above the microwave oven
Room 200 Bathroom painted
Office near Post Anesthesia Recovery Room

During a tour of the facility with the Plant Operations Manager between 8:50 and 9:10 a.m., this surveyor observed that these sprinkler heads did have paint on the deflector or usable links.

2. At 10:25 a.m., sprinkler system quarterly inspections did not document a flow for the fourth quarter of 2012. There was no flow test done between 9/12/12 and 2/16/13. Documentation also did not include the quarterly visual inspection of the sprinkler system which includes the visual inspection of the alarm devices (water flow switch), hydraulic nameplate, fire department connections and confirmation that valves are in the proper position.

3. At 3:32 p.m., the Housekeeping Closet near the Oxygen Storage Room had five inches of clearance between the sprinkler deflector and the top shelf storage items.

Based on observation, the facility failed to inspect its portable fire extinguishers in accordance with 1998 NFPA 10. This was evidenced by a fire extinguisher that was missing documentation for one monthly visual inspection. This deficient practice affected one of two offsite clinics and could potentially result in the fire extinguisher not functioning properly during a fire.

NFPA 10, 1998 edition
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.
4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30- day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.
4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a tour of the facility with Clinic Administrative Staff on 3/28/13, fire extinguishers were observed. At 4:50 p.m., the fire extinguisher located at the south end of the corridor was missing the February monthly inspection on the back of the HMIS label.

Based on observation, the facility failed to protect its smoking areas. This was evidenced by the failure to provide ashtrays of a safe design in areas where smoking is permitted. This deficient practice affected one of one smoking area outside of the facility and could potentially result in the ignition of fire.

Findings:

During a tour of the facility with the Plant Operations Manager on 3/27/13, the smoking area was observed.

At 3:41 p.m., the smoking area on the east side of the facility had a five gallon plastic bucket that was being used as an ashtray. This bucket was filled with sand to within approximately six inches from the top and had approximately 10 cigarette butts in it. Staff removed the bucket at that time.

Based on record review and interview, the facility failed to maintain its cooking facilities, in accordance with 1998 NFPA 96 8-3.1 table 8-3.1, as evidenced by a lack of documentation for one of two semi-annual kitchen hood fire suppression system inspection and cleaning reports. This deficient practice affected two of two smoke compartments within the facility and could potentially result in the spread of smoke and/or fire.

8-2* Inspection. An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also indicate areas not cleaned.

NFPA 96 (1998) 8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1
Systems serving moderate-volume cooking operations - Semiannually

Findings:

During record review on 3/27/13, at 9:45 a.m., documentation for the current and previous fire suppression system and cleaning reports were requested.

During a tour of the facility on 3/27/13, at 4:40 p.m., the inspection tag date for the current kitchen hood suppression system inspection was dated 3/14/13.
The hood cleaning sticker on the hood was dated 12/11/12. No other documentation was provided for the previous inspection and cleaning to verify if the facility is having the service done every six months.

Staff stated that they would contact the vendor and request the documentation, if it was available.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by unapproved portable heaters in a patient care area and a non-sleeping staff area. This affected all staff and patients in one of two smoke compartments within the facility and could potentially result in the ignition of fire.

1999 NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.

9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with the Plant Operations Manager, electrical equipment was observed.

1. On 3/28/13, at 3:45 p.m., the Mammography Patient Room had a portable electric heater that was plugged into the fixed wall outlet. This heater was partially behind the patient room door. The heater had a high temperature warning label on the top of it and was rated at 1500 watts. This heater also had a Bio-Med testing sticker on it indicating that it had been tested. During a later interview on 3/28/13 with the Bio-Medical Staff, when asked, Staff stated that the testing for the heater just tests for current leakage, not temperature.

2. On 3/28/13, at 8:30 a.m., there was a portable electric heater in the Doctors' Dictation Room that was plugged into a power strip. This heater had a high temperature warning, "three feet of clearance required" and was rated at 1500 watts.

Staff removed the heater in the patient care area. No documentation was provided indicating that the heating elements of the heaters did not exceed 212 degrees.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in case of a fire or other emergency. This was evidenced by items stored in the exit corridor. This deficient practice affected all staff and patients in two of two smoke compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.


Findings:

During a tour of the facility on 3/27/13, exit corridors were observed.

1. At 3:12 p.m., the area between the laboratory corridor door and the cross corridor had items stored in the corridor. There was bed, two wheelchairs, two folding chairs, two IV stands and another wheelchair on the north side of the wall. There were 55 inches of clearance between the bed and the opposite wall. On 3/28/13 at 8:30 a.m., these items were still in the same location.

2. At 4:35 p.m., the corridor leading to the Operating Room had items stored in the corridor. There were two computers on rolling stands and two gurneys stored in the corridor outside of the Operating Room near the exit door.

Based on observation, and interview, the facility failed to maintain its piped medical gas source location. This was evidenced by a ventilation fan that was not working. This affected all staff and patients in two of two smoke compartments at the main hospital and could potentially result in the acceleration of fire.

1999 NFPA 99 Standard for Health Facilities
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a)*Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)

4. Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.


Findings:

Main Campus
During a tour of the facility with the Plant Operations Manager on 3/28/13, at 10:00 a.m., the medical gas source location was observed. This surveyor observed that the ventilation fan in the ceiling was not working. The door to the source room had a seven by fourteen inch vent in the door for natural ventilation. Engineering Staff confirmed that he fan was not working.

Based on document review and interview, the facility failed to protect its anesthetizing locations. This was evidenced by the failure to maintain the relative humidity in the operating room to insure it is equal to, or greater than, 35 percent.
This affected one of two smoke compartments at the main hospital and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment.

19.3.2.3 Anesthetizing Locations.
Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review with Operating Room Staff on 3/28/13, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
1. Between 11:15 and 11:45 a.m., Operating Room Staff provided a log of Operating Room 1 relative humidity. Documentation indicated that the humidity levels had been monitored for February and March only.

The February 26th humidity level was recorded at 23 percent.
The March 11th and 26th humidity levels were recorded at 21 percent.

Staff stated that surgeries are usually done two days per month.

The Plant Operations Manager stated that the facility might request a waiver to lower the humidity requirements to 20 percent.

Based on document review and staff interview, the facility failed to inspect its generator weekly. This was evidenced by incomplete documentation for weekly generator inspections. This finding affected all staff and patients in two of two smoke compartments and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

Findings:

During record review on 3/27/13, generator logs and maintenance reports were reviewed.

1. At 9:45 a.m., documentation indicated that the generator had not been inspected weekly for 18 of 52 weeks in a twelve month period. Staff confirmed the missing documentation

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities as evidenced by a high-wattage appliance that was plugged into a power strip instead of being plugged directly into a fixed wall outlet. This deficient practice affected staff and patients in one of two smoke compartments and could potentially result in the ignition of fire.

NFPA 70
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

Findings:

During a tour of the facility with the Plant Operations Manager on 3/27/13 at 3:45 p.m., the Doctors' Dictation Room had a portable electric heater that was plugged into a power strip. This heater was rated at 1500 watts.