HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This affected 4 of 8 floors in the Pacific Building, 2 of 7 floors on the California West Campus, 5 of 6 floors on the California East Campus and 1 of 1 Floor in the Clay Street Facility. This could result in the spread of fire and smoke causing potential harm to patients and staff, in the event of a fire.

Findings:

During the facility tour with staff, from 3/15/10 - 3/18/10, the walls and ceilings were observed.

Pacific Campus
1. On 03/15/10, at 10:40 a.m., there was an approximately 5 inch conduit that was not sealed in the fourth floor locker room, near the conference room.


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2. On 03/15/10, at 11:20 a.m., there was an approximately 1/2 inch circular penetration in the center of the right wall in Room 6821, 6th Floor.

3. On 03/15/10, at 12:08 p.m., there was an approximately 13 by 6 inch penetration in the bottom center of the back wall in the Utility Room P2136, 2nd Floor. There were two approximately 2 inch circular penetrations in the ceiling.

4. On 03/15/10, at 12:30 p.m., there were two approximately 1 and 1/2 inch penetrations in the bottom corner outside of the processing area, in the Laboratory, 2nd Floor.

5. On 03/15/10, at 2:30 p.m., there were two approximately 2 inch oval penetrations in the upper right corner of the 2M Phone Room, on the 2nd Floor Mezzanine.


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6. On 03/15/10, at 12:20 p.m., there were 15 approximately 1/4 to 1/8 inch penetrations on the wall, in exam room 8, A level.

Clay Street Rehab
On 03/17/10, at 1:42 p.m., there were three approximately 1/4 to 1/8 inch penetrations on the wall and ceiling, in the 2nd floor loft.

California East Campus
1. On 03/17/10, at 9:16 a.m., there was an approximately 1/2 inch penetration behind the door, where the door knob hit the wall, in the ASC Storage Room, 3rd Floor.

2. On 03/17/10, at 10:10 a.m., there were three approximately 1/2 inch penetrations and one 1/4 inch penetration in the center of the back wall, in the Bio-Hazard Room, on the outside of the building.
At 10:15 a.m., there was a approximately 4 inch by 6 inch cutout penetration in the center of the ceiling.





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California East Campus
3. On 3/17/10 at 9:30 a.m., there was an approximately 2 inch x 3 inch penetration in the left wall by the phone table, in room 2730, "Post Acute Services, Medical Staff Office," on the 2nd floor. The electrical cover plate was missing.

4. On 3/17/10 at 10:00 a.m., there was an approximately 2 x 3 inch penetration in the wall behind the X-Ray machine in room 287, BHC, on the 2nd floor. The electrical cover plate was missing.




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California East Campus
5. On 03/17/10, at 9:20 a.m., there was an approximately 1 inch penetration around a sprinkler pipe, in the 7th floor stairwell storage room.
6. At 9:29 a.m., there were two approximately 1/4 inch penetrations on the wall, near a gray cabinet, in the new born connection office, first floor.

California West Campus
1. On 03/16/10, at 11:18 a.m., the cover plate for the junction box was missing in Storage G450.
2. On 03/16/10, at 2:00 p.m., the plate for the emergency receptacle outlet was missing in the security office. An approximately 1 inch penetration was exposed around the receptacle.
3. On 03/16/10, at 2:14 p.m., the cover plate for the junction box in the dirty linen room was missing.

Based on observation, the facility failed to maintain doors protecting corridor openings, as evidenced by doors that were held open, by doors that did not positively latch and by door closures that were obstructed. This affected 3 of 8 floors on the Pacific Campus, 1 of 2 Floors in the Stanford Building, and 1 of 6 floors in the California East Campus. This could result in the potential spread of smoke and fire in the event of a fire.

Findings:

During a tour of the facility with staff, from 3/15/10 through 3/18/10, the corridor doors were observed.

Pacific Campus - fourth floor
1. On 03/15/10, at 10:51 a.m., a clean linen cart was obstructing the fire rated self-closing door to unit 4-2 TCCU.
2. On 03/15/10, at 10:55 a.m., the self-closing door to the negative pressure room was held open by a chair.
3. On 03/15/10, at 10:58 a.m., the door to the charting room was blocked by a linen cart.
4. On 03/15/10, at 11:45 a.m., the door to the ice machine room was blocked by a trash can.

Stanford Building - fourth floor
On 03/15/10, at 1:54 p.m., the roll down fire door, at the reception area, was obstructed from fully closing by a plant, lotion, pen holder, and a tray that were stored on the counter.


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Pacific Campus
5. On 03/15/10, at 11:40 a.m., the corridor door was impeded from closing by an electrical cord plugged into an an electrical outlet in the corridor, in Patient Room 623, 6th Floor.
6. On 03/15/10, at 11:55 a.m., the corridor door failed to positive latch in the Radiology Room 2122, 2nd Floor.


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5th floor -
7. On 03/15/10, at 9:55 a.m., the door in Room 515B, was obstructed by a striker bed.
8. On 03/15/10, at 9:56 a.m., the door in Room 532, was obstructed by a walker.
9. On 03/15/10, at 9:59 a.m., the door in Room 535, was obstructed by a trash can.

California East Campus
On 03/17/10, at 9:20 a.m., the corridor door closed but failed to positive latch for ASC Patient Recovery Room 392, 3rd Floor.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls, as evidenced by penetrations in the smoke barrier walls in one building. This affected 3 of 7 floors on the California West Campus. These penetrations could result in the spread of smoke and fire from one smoke compartment to another and could increase the risk of injury to patients.

Findings:

During observations with facility staff on March 16, 2010, the smoke barrier wall at California West Campus were observed.

California West Campus
1. On 03/16/10, at 11:00 a.m., there was an approximately 1 inch circular penetration in the left corner of the wall, in the smoke barrier wall by the MD Lounge 2328, above smoke barrier door H2-2, 2 North, Labor and Delivery.
2. On 03/16/10, at 2:45 p.m., there was an approximately 1 by 2 inch crescent shaped penetration in the center of the right wall, in the smoke barrier in the Radiology corridor, above smoke barrier door AG2, Lobby.
3. On 03/16/10, at 2:55 p.m., there was an approximately 1/2 by 1/2 inch penetration on the right side of a cables bundle, in the smoke barrier wall by Security G461, Basement.

Based on observation the facility failed to maintain the doors in smoke barriers, as evidenced by smoke and fire barrier doors that did not close and latch and by fire doors that were held open by door wedges. This affected 1 of 8 floors on the Pacific Campus, 1 of 2 floors on the Stanford Building, 1 of 6 floors on the California East Campus, 1 of 7 floors on the California West Campus and 1 of 1 floor in the Child Development Center. This could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During a tour of the facility from 3/15/10 through 3/18/10, with staff, the smoke barrier doors were observed.

Pacific Campus - Stanford Building
1. On 03/15/10, at 2:10 p.m., in the Stanford Building, the fire door to room 5414, was held open by a door wedge.
2. On 03/18/10, at 1:06 p.m., the door to Nuclear Medicine did not close and latch, on the second floor of the Pacific Campus.
3. On 03/18/10, at 3:00 p.m., the fire door at the elevator lobby, on the fourth floor of the Stanford Building, had a metal plate covering the fire rating.


Child Development Center
On 03/18/10, at 9:19 a.m., during fire alarm testing, the double fire doors near Room 342 did not positive latch when closed. Both doors were pushed open after closing.

California East Campus
On 03/17/10, at 11:15 a.m., the fire exit door to the fourth floor, West end stairwell, did not positive latch when closed. The door to the stairwell stuck on the door frame.

During the facility tour with staff on 03/18/10, the smoke barrier doors were observed at the California West Campus, during fire alarm testing.

At 9:57 a.m., the smoke barrier door to the Lobby failed to positive latch after closing. The right side door closed but failed to latch after activation of a pull station.

Based on observation, the facility failed to ensure the hazardous areas were maintained to resist the passage of smoke. This was evidenced by hazardous areas without self closing doors. This affected 1 of 8 floors on the Pacific Campus. This could result in the spread of smoke and fire within the facility and increase the risk of injury to patients, due to fire.

Findings:

During observations with facility staff, on March 15, 2010, hazardous areas on the Pacific Campus were observed.

Pacific Campus
1. On 03/15/10, at 12:32 p.m., the corridor door to the 2nd Floor Pathology Office, P2431, was not equipped with a self closing device. The room was greater than 50 square feet in size and contained quantities of combustible material such as books, binders and paper material.

2. On 03/15/10, at 12:35 p.m., the corridor door to the 2nd Floor Pathology Office, P2433,was not equipped with a self closing device. The room was greater than 50 square feet in size and contained quantities of combustible material such as books, binders and paper material.

3. On 03/15/10, at 12:40 p.m., the corridor door to the 2nd Floor purchasing and materials lab services storage room, P2440, was not equipped with a self closing device. The room was greater than 50 square feet in size and contained quantities of combustible material such as supplies, plastics, boxes and paper material.

Based on observation and interview, the facility failed to maintain the exit path from the fire rated stair tower, as evidenced by one door that failed to open on the right side. This affected 6 of 6 floors on the California East campus and could delay evacuation and increase the risk of harm to patients and staff in the event of a fire.

Findings:

During a tour of the facility with staff, on 03/17/10, the stairway exit doors were observed on the California East Campus.

On 03/17/10, at 9:55 a.m., the door exiting to Maple street, from the fire rated stair tower on the 1st floor (Stair 4), failed to open on the right side.

During an interview on 03/17/10 at 9:55 a.m., Staff 2 stated that the door was old and probably dated around 1930. He stated the hardware had failed and fused shut.

Based on observation and interview, the facility failed to ensure that exits are readily accessible at all times, as evidenced by carts on both sides of the exit path and by wheel chairs that blocked the path to an emergency exit stairwell. These conditions affected 1 of 8 floors on the Pacific Campus and 1 of 6 floors on the California East Campus. This could result in a delayed evacuation in the event of fire or emergency, and increase the risk of injury to patients and staff.

Findings:

During observations with facility staff from 3/15/10 through 3/18/10, the exit doors and corridors were observed.

Pacific Campus
On 03/15/10, at 1:42 p.m., there were four cart style wheel chairs stored in front of the reception desk in the Ambulatory Care Unit. The wheel chairs obstructed the exit and narrowed the passageway to the exit stairwell by half.

During an interview, Staff stated that the chairs are stored in that location during the day and put away at night.

California East Campus
On 03/17/10, at 10:00 a.m., the 1st Floor OR Exit Door was obstructed. There were two suture four-rack carts on the right side of the exit door and three carts on the left side of the door. There was a latex cart, pedi-med cart and allergy cart on the left side of the door.

Based on observation and staff interview, the facility failed to maintain two required exits from any room larger than 2500 ft?. This was evidenced by no available second exit door in the dialysis Room 2, in the Stanford Building. This affects one of three smoke compartments on the fourth floor of the Stanford Building and could result in the potential delay of egress in the event of an emergency.

NFPA 101 Life Safety Code, 2000 Edition
19.2.5.3 Any room or any suite of rooms, other than patient sleeping rooms, of more than 2500 ft? (230 m?) shall have not less than two exit access doors remotely located from each other.

Findings:

Pacific Campus - Stanford Building
During a tour of the facility with staff on 03/15/10, at 1:45 p.m., the side emergency exit was blocked by a linen cart, in Dialysis Room 2.
During an interview, Staff stated that the door was not used as an emergency exit because it led to a shaky fire escape. There was no sign posted to indicate that the door was not an emergency exit. There was no other exit in Dialysis Room 2.
When asked what the size of the room was, staff stated the room was 2,788.11 ft?.

Based on document review and interview, the facility failed to ensure that all staff members were trained with respect to their duties and the use of equipment, under the fire emergency plan, that all staff participate in fire drills, and that fire alarms are activated and heard during the drill. This could result in a delay in response and possible confusion in the event of a fire or other emergency, and increase the risk of injury to patients. This affected all buildings and off-site facilities.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns,maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm.

Findings:

During document review and staff interviews from 3/15/10 to 3/18/10, fire drills and fire procedures were reviewed.

Pacific Campus
On 03/16/10, at 2:45 p.m., during document review, fire drills were provided by the facility. Documents showed that in the 2nd quarter of 2009, 27 of 2700 staff participated in the the fire drills. In the 4th quarter of 2009, 18 of 2700 staff participated in the fire drills. In the third quarter, 2009, 225 staff participated.



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Pacific Campus
During an interview, on 3/18/10, at 12:40 p.m., 1 of 3 staff did not know how to respond when asked, "Can you find your nearest pull station?" Staff 10 stated his English is not good and he did not know what is a pull station and how to activate a pull station.


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Child Development Center
On 03/18/10, at 9:30 a.m., the documentation for the the quarterly fire drills and disaster drills were reviewed. One annual fire drill was conducted on 08/05/09. No disaster drill information was provided to indicate that the center had participated in a disaster drill.

California West Campus
1. On 03/17/10, at 11:45 a.m., Staff 5 was interviewed and asked to locate the nearest alarm activation device. Staff 5 did not know where the closest pull station was located.
2. On 03/18/10, at 12:12 p.m., Staff 6 was interviewed and asked to locate the nearest alarm activation device. Staff 6 did not know where the closest pull station was located.
3. On 03/18/10, at 12:20 p.m., Staff 7 was interviewed and asked to locate the nearest alarm activation device. Staff 7 did not know where the closest pull station was located.
4. On 03/18/10, at 12:39 p.m., Staff 8 was interviewed and asked to locate the nearest alarm activation device. Staff 8 did not know where the closest pull station was located.
Four of four staff interviewed could not locate an alarm activation device.


During record review on 03/18/10, at 3:15 p.m., Staff 9 was interviewed and asked if there were any more sign in sheets for staff training for fire drills. Staff 9 stated that he was aware of the low staff response to fire drills and would make sure more staff were trained in the future.



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During document review with facility Staff 2 on 03/16/10, the fire drill records were reviewed.
California West Campus
1. On 3/16/10 at 2:00 p.m., the fire drill records indicated that the facility failed to ensure all staff participate in fire drills and that fire alarms are activated and heard during the drill.

According to facility staff, there are approximately 1520 staff at the California East and West Campuses and 2754 staff at the Pacific Campus. All fire drill records had between 1 and 15 staff in attendance.

All fire drill forms failed to state what alarm device was activated.

2. When reviewing the facility fire drill form dated 2/25/10 at 2:30 p.m., the 1st floor Breast Health Center, scheduling department wrote "No audio" and "No" to question #1 - "Fire alarm & strobe lights work in your area."
When interviewed on 03/16/10, at 2:00 p.m., Staff 2 explained that the East Campus was set up a bit different because only the floor above and below the floor initiating the alarm device would hear the alarm. All other floors receive an overhead page. When Staff 2 was asked what, according to the fire drill forms, was not heard, Staff 2 stated that he did not know if it was the alarms and chimes or the overhead speaker that was not heard.

When reviewing the facility fire drill form dated 2/28/10 at 4:00 a.m., the Ped ER stated "nothing heard overhead."
When interviewed on 03/16/10, at 2:00 p.m., Staff 2 stated that they had been remodeling to install more speakers. Staff 2 said he would speak to the staff on that floor to find out exactly what was not heard.

Based on observation and interview, the facility failed to maintain the fire alarm system on 5 of 24 floors, as evidenced by devices that failed to activate, devices that were not labeled with the correct address and failure to sound an audible alarm. These conditions affected 3 of 8 floors in the Pacific Campus, 1 of 2 floors in the Stanford Building, and 1 of 6 floors in the California East Campus. This could delay staff response to a fire and increase the risk of injury to patients.

Findings:

During observations and interview with facility staff, from 03/16/10 through 03/19/10, the fire alarm system was tested in all buildings. After activation of the alarm, interviews with the staff at PBX confirmed the location of the alarm activation.

Pacific Campus
1. On 03/18/10, at 3:00 p.m., the smoke detector 20-28-81, in the corridor of the Stanford building, was labeled with the wrong address when confirmed by PBX during fire alarm testing.
2. On 03/18/10, at 3:10 p.m., the smoke detector 20-02-48, in the corridor of the Stanford building, was labeled with the wrong address when confirmed by PBX during fire alarm testing.
3. On 03/19/10, at 9:20 a.m., the fire alarm was not audible during fire alarm testing in the ground floor Gift Shop. During an interview, Staff 10 reported the alarm was not audible.
4. On 03/19/10, at 9:28 a.m., the chime/strobe device failed to activate during fire alarm testing, in the Radiology corridor by Restroom B262, in Basement B.


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5. On 03/18/10, at 1:05 p.m., the fire alarm chime/strobe failed to emit an audible sound in the pathology Room P2431, on the 2nd floor.

California East Campus
On 03/17/10, at 11:07 a.m., the fire curtain for Elevator 1 failed to drop during fire alarm testing, in the 7th Floor Elevator Lobby.

Based on record review and interview, the facility failed to ensure the maintenance, inspection and testing of smoke detectors as evidenced by no documentation for smoke detector sensitivity testing. This affected the Child Development Center and could result in an increased potential for smoke detector malfunction, resulting in the spread of fire and/or smoke.

NFPA 72, 7-3.2.1, Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Findings:

During record review on 03/18/10, at 10:00 a.m., no documents were provided to show the Child Development Center had conducted the bi-annual sensitivity testing of the smoke detectors. There was no report for bi-annual testing, to include a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. There was no documentation indicating that the smoke detectors were tested as required.

During an interview, staff stated that the smoke detectors had not been tested.

Based on observation, the facility failed to ensure that the automatic sprinkler system is maintained in accordance with NFPA 25 and NFPA 13. This was evidenced by escutcheon rings that were missing or not flush to the ceiling, by sprinkler heads coated with paint and debris, by incomplete records for quarterly flow inspections, and by one Inspector's Test Valve that was blocked. Escutcheon rings are used to cover the penetration around the sprinkler pipe. This could result in a potential sprinkler system malfunction or the spread of smoke and fire, during a fire.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition)

2-2 Inspection.
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.

3-3.3 Alarm Devices. Where provided, waterflow alarm and
supervisory devices shall be tested on a quarterly basis.
Exception: Where freezing conditions necessitate a delay in testing,
tests shall be performed as soon as weather allows.
3-4 Maintenance. Maintenance/repairs shall be in accordance
with 3-2.3 and Table 3-2.3.
3-5 Records. Records shall be maintained in accordance with
Section 1-8
8.2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

Findings:

During a tour of the facility with facility staff from 03/15/10 through 03/18/10, the sprinkler system and testing records were observed.

Pacific Campus
1. On 03/15/10, at 11:00 a.m., 1 of 1 sprinkler was coated with a build up of dust and dirt, in the 6th Floor Housekeeping Closet by Room 6824.
2. On 03/15/10, at 12:09 p.m., 1 of 1 sprinkler was missing an escutcheon ring, in the 6th Floor Utility Room 2136.
3. On 03/15/10, at 2:50 p.m., 3 of 4 sprinklers had a build up of dust and dirt, in the corridor by IT, 2 Mezzanine.


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4. On 3/18/10 at 1:21 p.m., the escutcheon ring was missing on the sprinkler head by Room 1-206, on the 1st floor.


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5. On 03/15/10, at 11:15 a.m., 1 of 1 escutcheon ring was missing in the first floor women's locker room. There was an approximately 1 inch penetration exposed on the ceiling.
6. On 03/15/10, at 11:24 a.m., 1 of 13 escutcheon rings was missing in the Enright Conference room, on the first floor. There was an approximately 1/4 inch penetration exposed on the ceiling.
7. On 03/15/10, at 11:25 a.m., 1 of 1 escutcheon ring was missing in the EVS closet Room 1-110-1, on the first floor. There was an approximately 1/4 inch penetration exposed on the ceiling.
8. On 03/15/10, at 11:27 a.m., 1 of 4 escutcheon rings was shifted to one side in the cath lab Room 1-410, on the first floor. There was an approximately 1/8 inch penetration exposed on the ceiling.
9. On 03/15/10, at 11:40 a.m., 1 of 1 escutcheon ring was shifted to one side in the first floor cafe storage room. There was an approximately 1/8 inch penetration exposed on the ceiling.
10. On 03/15/10, at 12:14 p.m.. 1 of 3 escutcheon rings was shifted to one side in treatment Room 9, A level. There was an approximately 1/8 inch penetration exposed on the ceiling.
11. On 03/15/10, at 1:35 p.m., 1 of 6 escutcheon rings was missing in the unit dose area, B level. There was an approximately 1/4 inch penetration exposed on the ceiling.
12. On 03/15/10, at 1:51 p.m., 1 of 1 escutcheon ring was shifted to one side in the radiation oncology Room 230F, B level. There was an approximately 1/4 inch penetration exposed on the ceiling.
13. On 03/15/10, at 1:53 p.m., 1 of 1 escutcheon ring was missing between elevator 1 and elevator 2, on the B level. There was approximately 1/4 inch penetration exposed on the ceiling.
14. On 03/15/10, at 1:56 p.m., 1 of 1 escutcheon ring was missing in the radioactive material Room 0269, B level. There was an approximately 1/4 inch penetration exposed on the ceiling.


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15. On 03/15/10, at 11:55 a.m., on the fourth floor, in Room 4818, one of three escutcheon rings was not flush with the ceiling surface exposing an approximately two inch penetration in the ceiling, around the sprinkler pipe.


Child Development Center
On 03/18/10, during record review, no documentation was provided for the quarterly flow test of the sprinkler system for the past 12 months.
During an interview, Staff stated that the sprinkler system was not tested quarterly.

California East Campus
1. On 03/17/10, at 10:09 a.m., in the Bio Hazard Room on the outside of the building, 1 of 2 sprinklers was missing an escutcheon ring.
2. On 03/18/10, at 10:15 a.m. the Inspector Test Valve located on the outside of the East Building, had a trash bag with trash in it tied to the Valve.

California West Campus - 2nd floor
1. On 03/16/10, at 10:50 a.m., in the corridor by Room 250, there was a sprinkler with a build up of debris.
2. On 03/16/10, at 11:10 a.m., in the Labor and Delivery (L and D) corridor, 3 of 3 sprinklers had a build up of debris.
3. On 03/16/10, at 11:15 a.m., in the L and D corridor, by Room 203, 2 of 6 sprinklers had a build up of debris.
4. On 03/16/10, at 11:20 a.m., in the corridor, 4 of 9 sprinklers had a build up of debris.
5. On 03/16/10, at 11:55 a.m., in the L and D Housekeeping Closet, by Room 236, 1 of 1 sprinkler had a build up of debris.
6. On 03/16/10, at 12:01 p.m., in the L and D corridor across from Room 232, 1 of 6 sprinklers had a build up of debris.
7. On 03/16/10, at 12:05 p.m., in the TCN corridor, 2 of 7 sprinklers had a build up of debris.
8. On 03/16/10, at 12:16 p.m., in the Bio-Waste Storage, 1 of 1 sprinkler had a build up of debris.
9. On 03/16/10, at 12:20 p.m., in Patient Room 265, 2 of 2 sprinklers had a build up of debris.
10. On 03/16/10, at 12:22 p.m., in Patient Room 263, 1 of 2 sprinklers had a build up of debris.
11. On 03/16/10, at 12:25 p.m., in Storage Room 2526, 2 of 3 sprinklers had a build up of debris.
12. On 03/16/10, at 12:26 p.m., in Patient Room 2525, 1 of 1 sprinkler had an approximately 1/2 inch gap from the ceiling to the escutcheon ring.
13. On 03/16/10, at 12:28 p.m., in the H2-5 Pantry, 1 of 1 sprinkler had a build up of debris.
14. On 03/16/10, at 12:30 p.m., in Patient Room 250, 2 of 2 sprinklers had a build up of debris.


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15. On 03/16/10. at 10:08 a.m., 1 of 1 escutcheon ring was shifted to one side in the PACU, on the 3rd floor. There was an approximately 1/2 inch penetration exposed on the ceiling.

California West Campus
1. On 03/16/10, at 2:22 p.m., the fire extinguisher was not securely mounted in a bracket in the Bio Med Basement. The fire extinguisher was left standing on the counter top.


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2. On 03/17/10, at 10:30 a.m., at the Oxygen Storage Room, on the outside of the West building, the fire extinguisher was impeded by an empty storage cart.

Based on observation, the facility failed to maintain portable fire extinguishers as evidenced by fire extinguishers that were not mounted, by fire extinguishers that were blocked and by fire extinguishers that were mounted more than 60 inches above the floor. This affected 1 of 8 floors on the Pacific Campus, 2 of 7 floors on the California West Campus, 3 of 6 floors on the California East Campus, and 1 of 1 floor in the Clay Street Facility. This could result in a delay to access the portable fire extinguishers in the event of a fire or damage to the cylinders if they were displaced.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6 General Requirements.
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6* Fire extinguishers shall not be obstructed or obscured
from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate
the location.
1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
1-6.10 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. Fire extinguishers having a gross weight greater than 40 lb(18.14 kg)(except wheeled types)shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).

Findings:

During a tour of the facility from 3/15/10 through 3/18/10, with staff, the fire extinguishers were observed.

Pacific Campus - 6th floor
1. On 03/15/10, at 11:15 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 647.
2. On 03/15/10, at 11:17 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 644.
3. On 03/15/10, at 11:25 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 637.
4. On 03/15/10, at 11:30 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 631.
5. On 03/15/10, at 11:45 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 617.
6. On 03/15/10, at 12:20 p.m., the fire extinguisher was impeded by a trash can, in the corridor by Patient Room 631.


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Pacific Campus
7. On 03/15/10, at 11:05 a.m., a portable ABC fire extinguisher, in the GI Lab on the 5th floor, was mounted with the handle at approximately 64 inches from the floor.
8. On 03/15/10, at 12 p.m., a portable ABC fire extinguisher in the kitchen, by the electrical panel, was mounted with the handle at approximately 67 inches from the floor.
9. On 03/15/10, at 12:05 p.m., a portable K class fire extinguisher in the kitchen, by the ansul equipment, was mounted with the handle at approximately 53 inches from the floor.


Clay Street
On 03/17/10, at 1:44 p.m., a portable ABC fire extinguisher was mounted at approximately 65 inches from the floor, in the cardiac rehab/PT area, on the 2nd floor loft.

California East Campus
1. On 0317/10, at 9:20 a.m., the fire extinguisher was impeded by a trash can in the Surgery Work Room, 1st Floor.
2. On 03/17/10, at 10:05 a.m., the fire extinguisher was impeded by a cart, at the entrance to OR, 1st Floor.
3. On 03/17/10, at 10:07 a.m., in the Women's Locker Room, 1st Floor, the fire extinguisher was blocked from view behind the entrance door.
4. On 03/17/10, at 10:25 a.m., the fire extinguisher was impeded by an oil can in the East Generator Room, on the outside of the building.



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5. On 03/17/10, at 10:10 a.m., a portable ABC fire extinguisher in the first floor Biohazard room, was mounted at approximately 62 inches from the floor.

Based on observation, the facility failed to provide containers with self closing devices to dispose of cigarette butts, as evidenced by cigarette butts on the top of the ashtray and on the ground in the smoking structure, in the designated smoking area. This affected 1 of 6 floors on the California East Campus, and could result in an increased risk of fire in the smoking area.

Findings:

During a tour of the facility with facility Staff 1, Staff 2 and Staff 4 on 03/17/10, the facilities smoking areas were observed.

California East Campus
On 3/17/10 at 10:15 a.m., the designated staff smoking area had 2 cigarette butts on the ground in the smoking structure and approximately 15 cigarette butts at the top of the combination ashtray/trash container. There was no metal self closing container, provided by the facility, for emptying ashtrays.

Based on document review and staff interview, the facility failed to maintain the heating, ventilating and air conditioning system, as evidenced by no documentation for the inspection of the smoke dampers in one off site building. This affected the Child Development Center and could result in the potential failure of fire/smoke dampers in the event of a fire.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 Edition
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review for the Child Development Center with staff, on 03/18/10, at 10:00 a.m., no documents were provided to indicate that the dampers had been inspected as required.
During an interview, Staff stated that they did not have the documentation for the inspection of the smoke dampers.

Based on observation and interview, the facility failed to maintain the corridor free from obstructions, as evidenced by two E cylinders that were stored in the corridor. This condition affected 1 of 8 floors in the Pacific Campus and could result in a delay in evacuation and the potential acceleration of a fire in the event of a fire.

Findings:

During a tour of the facility with staff on 03/15/10, at 11:55 a.m., the corridors were observed on the 3rd Floor. There were two oxygen E-cylinders stored in the corridor by room 333. When asked if the oxygen cylinders are always in that location, staff stated "Yes, they are used during physical therapy."

Based on observation, the facility failed to prohibit the use of loosely hanging furnishing and decorations. This was evidenced by the use of loosely hanging privacy curtains that were not fire rated, in the New Born Connection Room. This affected 1 of 6 floors in the California East Campus and could result in an increased potential for ignition of a fire.

Findings:

During a tour of the California East Campus with staff, on 3/17/10, the rooms were observed.

California East Campus
1. At 9:30 a.m., a purple privacy curtain was used for separating the new born office and the store room, in the new born connection on the first floor. The curtain did not contain a flame resistant tag. There was no documentation indicating the privacy curtain had been treated with flame retardant solution.
2. At 9:33 a.m., a white privacy curtain was used for separating the laxation room and the library, in the new born connection on the first floor. The curtain did not contain a flame resistant tag. There was no documentation indicating the privacy curtain had been treated with flame retardant solution.

Based on observation, the facility failed to comply with regulations regarding electrical wiring and utilities, as evidenced by the use of surge protectors for medical equipment and for motorized items, by surge protectors plugged into other surge protectors and by the use of unapproved extension cords. This affected 4 of 8 floors in the Pacific campus, 3 of 7 floors in the California West Campus, 2 of 6 floors in the California East Campus and 1 of 1 floor in the Clay Street Facility. This could result in the increased risk of electric shock or an electrical fire.

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

3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces).

NFPA 70 National Electrical Code
Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with staff, from 3/15/10 through 3/18/10, the electrical wiring and connections were observed.

Pacific Campus
1. On 03/15/10, at 11:05 a.m., seven IV pumps were plugged into surge protectors instead of directly into the wall outlets, in Rooms 4828 and 4114, on the fourth floor.


Child Development Center
At 8:40 a.m., a lamp was plugged into a power strip that was plugged into another power strip, in the Intake Room. The power strip should be connected directly to the wall outlet.

During document review, at 10:00 a.m., no documents were provided for the receptacle outlet continuity, polarity and tension testing. Staff stated that there was no documentation for outlet testing.


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Pacific Campus
2. On 03/15/10, at 11:06 a.m., a microwave was plugged into an extension cord, in the GI Lab on the 5th floor. At 11:07 a.m., a surge protector was plugged into another surge protector in the GI Lab.
3. On 03/15/10, at 11:36 a.m., a cover plate was missing on the 4 inch junction box, in the PBS operator area on the 1st floor.
4. On 03/15/10, at 11:38 a.m., a salt lamp was plugged into an extension cord, in the gift shop on the 1st floor.
5. On 03/15/10, at 11:43 a.m., a computer monitor was plugged into an extension cord, in the PBS operator area, on the 1st floor.
6. On 03/15/10, at 1:50 p.m., the light fixture was missing on the junction box, in the telephone/data room, B level.
7. On 03/15/10, at 1:55 p.m., a respiratory monitor was plugged into an orange extension cord, in the Treatment Room 0280, B level.


Clay Street Rehab
On 03/17/10, at 1:40 p.m., a surge protector was plugged into another surge protector in the cardio rehab/PT on the 2nd floor loft.

California West
1. On 03/16/10, at 10:51 a.m., in the Kitchen, a refrigerator was plugged into an orange extension cord instead of directly into the wall outlet.
2. On 03/16/10, at 10:55 a.m., in the Kitchen supervisor's office, a fax machine was plugged into an orange extension cord instead of directly into the wall outlet.
3. On 03/16/10, at 11:58 a.m., in the ground level patient registration area, a printer was plugged into a power strip that was plugged into another power strip.
4. On 03/16/10, at 10:00 a.m., an orange power strip was plugged into a power strip instead of directly into the wall outlet in the same area.
5. On 03/16/10, at 12:05 p.m., in the ground level Gift Shop, a jewelry cabinet was plugged into a power strip that was plugged into another power strip.
6. On 03/16/10, at 1:37 p.m., in the basement IT Training Room, there were three daisy chains (power strips plugged into other power strips) connected to the computers used in the training room.
7. On 03/16/10, at 2:12 p.m., in the basement EVS Women's Locker Room, a refrigerator and a microwave were plugged into a power strip instead of directly into the wall outlet.
8. On 03/16/10, at 2:54 p.m., in the basement, in room 412, a power strip was plugged into another power strip instead of directly into the wall outlet.
9. On 03/16/10, at 3:00 p.m., in the basement Lab, four Centrifuges were plugged into one power strip instead of directly into the wall outlet.


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10. On 3/18/10 at 10:45 a.m., in the 1st floor Business Office, there were four interconnected multi-plug power strips in the cubicle in the middle of the office area.

During observations with facility staff on 03/17/10, the electrical wiring and connections were observed at California East Campus.

California East Campus
1. On 03/17/10, at 9:15 a.m., in the 3rd floor ASC Electrical Room, there was a cable box missing a cover plate on the right wall in the upper corner. There was an electrical plate missing a cover on the left center of the wall.


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2nd Floor -
2. On 3/17/10 at 9:25 a.m., in Room 2730 the "Post Acute Services, Medical Staff Office," there was an orange extension cord plugged into a multi-plug power strip.
At 9:26 a.m., there was an orange extension cord plugged into a multi-plug power strip with office equipment plugged into it.
At 9:26 a.m., there were two interconnected multi-plug power strips connecting a fax machine to the wall outlet in the same office.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This affected 4 of 8 floors in the Pacific Building, 2 of 7 floors on the California West Campus, 5 of 6 floors on the California East Campus and 1 of 1 Floor in the Clay Street Facility. This could result in the spread of fire and smoke causing potential harm to patients and staff, in the event of a fire.

Findings:

During the facility tour with staff, from 3/15/10 - 3/18/10, the walls and ceilings were observed.

Pacific Campus
1. On 03/15/10, at 10:40 a.m., there was an approximately 5 inch conduit that was not sealed in the fourth floor locker room, near the conference room.


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2. On 03/15/10, at 11:20 a.m., there was an approximately 1/2 inch circular penetration in the center of the right wall in Room 6821, 6th Floor.

3. On 03/15/10, at 12:08 p.m., there was an approximately 13 by 6 inch penetration in the bottom center of the back wall in the Utility Room P2136, 2nd Floor. There were two approximately 2 inch circular penetrations in the ceiling.

4. On 03/15/10, at 12:30 p.m., there were two approximately 1 and 1/2 inch penetrations in the bottom corner outside of the processing area, in the Laboratory, 2nd Floor.

5. On 03/15/10, at 2:30 p.m., there were two approximately 2 inch oval penetrations in the upper right corner of the 2M Phone Room, on the 2nd Floor Mezzanine.


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6. On 03/15/10, at 12:20 p.m., there were 15 approximately 1/4 to 1/8 inch penetrations on the wall, in exam room 8, A level.

Clay Street Rehab
On 03/17/10, at 1:42 p.m., there were three approximately 1/4 to 1/8 inch penetrations on the wall and ceiling, in the 2nd floor loft.

California East Campus
1. On 03/17/10, at 9:16 a.m., there was an approximately 1/2 inch penetration behind the door, where the door knob hit the wall, in the ASC Storage Room, 3rd Floor.

2. On 03/17/10, at 10:10 a.m., there were three approximately 1/2 inch penetrations and one 1/4 inch penetration in the center of the back wall, in the Bio-Hazard Room, on the outside of the building.
At 10:15 a.m., there was a approximately 4 inch by 6 inch cutout penetration in the center of the ceiling.





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California East Campus
3. On 3/17/10 at 9:30 a.m., there was an approximately 2 inch x 3 inch penetration in the left wall by the phone table, in room 2730, "Post Acute Services, Medical Staff Office," on the 2nd floor. The electrical cover plate was missing.

4. On 3/17/10 at 10:00 a.m., there was an approximately 2 x 3 inch penetration in the wall behind the X-Ray machine in room 287, BHC, on the 2nd floor. The electrical cover plate was missing.




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California East Campus
5. On 03/17/10, at 9:20 a.m., there was an approximately 1 inch penetration around a sprinkler pipe, in the 7th floor stairwell storage room.
6. At 9:29 a.m., there were two approximately 1/4 inch penetrations on the wall, near a gray cabinet, in the new born connection office, first floor.

California West Campus
1. On 03/16/10, at 11:18 a.m., the cover plate for the junction box was missing in Storage G450.
2. On 03/16/10, at 2:00 p.m., the plate for the emergency receptacle outlet was missing in the security office. An approximately 1 inch penetration was exposed around the receptacle.
3. On 03/16/10, at 2:14 p.m., the cover plate for the junction box in the dirty linen room was missing.

Based on observation, the facility failed to maintain doors protecting corridor openings, as evidenced by doors that were held open, by doors that did not positively latch and by door closures that were obstructed. This affected 3 of 8 floors on the Pacific Campus, 1 of 2 Floors in the Stanford Building, and 1 of 6 floors in the California East Campus. This could result in the potential spread of smoke and fire in the event of a fire.

Findings:

During a tour of the facility with staff, from 3/15/10 through 3/18/10, the corridor doors were observed.

Pacific Campus - fourth floor
1. On 03/15/10, at 10:51 a.m., a clean linen cart was obstructing the fire rated self-closing door to unit 4-2 TCCU.
2. On 03/15/10, at 10:55 a.m., the self-closing door to the negative pressure room was held open by a chair.
3. On 03/15/10, at 10:58 a.m., the door to the charting room was blocked by a linen cart.
4. On 03/15/10, at 11:45 a.m., the door to the ice machine room was blocked by a trash can.

Stanford Building - fourth floor
On 03/15/10, at 1:54 p.m., the roll down fire door, at the reception area, was obstructed from fully closing by a plant, lotion, pen holder, and a tray that were stored on the counter.


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Pacific Campus
5. On 03/15/10, at 11:40 a.m., the corridor door was impeded from closing by an electrical cord plugged into an an electrical outlet in the corridor, in Patient Room 623, 6th Floor.
6. On 03/15/10, at 11:55 a.m., the corridor door failed to positive latch in the Radiology Room 2122, 2nd Floor.


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5th floor -
7. On 03/15/10, at 9:55 a.m., the door in Room 515B, was obstructed by a striker bed.
8. On 03/15/10, at 9:56 a.m., the door in Room 532, was obstructed by a walker.
9. On 03/15/10, at 9:59 a.m., the door in Room 535, was obstructed by a trash can.

California East Campus
On 03/17/10, at 9:20 a.m., the corridor door closed but failed to positive latch for ASC Patient Recovery Room 392, 3rd Floor.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls, as evidenced by penetrations in the smoke barrier walls in one building. This affected 3 of 7 floors on the California West Campus. These penetrations could result in the spread of smoke and fire from one smoke compartment to another and could increase the risk of injury to patients.

Findings:

During observations with facility staff on March 16, 2010, the smoke barrier wall at California West Campus were observed.

California West Campus
1. On 03/16/10, at 11:00 a.m., there was an approximately 1 inch circular penetration in the left corner of the wall, in the smoke barrier wall by the MD Lounge 2328, above smoke barrier door H2-2, 2 North, Labor and Delivery.
2. On 03/16/10, at 2:45 p.m., there was an approximately 1 by 2 inch crescent shaped penetration in the center of the right wall, in the smoke barrier in the Radiology corridor, above smoke barrier door AG2, Lobby.
3. On 03/16/10, at 2:55 p.m., there was an approximately 1/2 by 1/2 inch penetration on the right side of a cables bundle, in the smoke barrier wall by Security G461, Basement.

Based on observation the facility failed to maintain the doors in smoke barriers, as evidenced by smoke and fire barrier doors that did not close and latch and by fire doors that were held open by door wedges. This affected 1 of 8 floors on the Pacific Campus, 1 of 2 floors on the Stanford Building, 1 of 6 floors on the California East Campus, 1 of 7 floors on the California West Campus and 1 of 1 floor in the Child Development Center. This could result in the spread of smoke and fire from one smoke compartment to another.

Findings:

During a tour of the facility from 3/15/10 through 3/18/10, with staff, the smoke barrier doors were observed.

Pacific Campus - Stanford Building
1. On 03/15/10, at 2:10 p.m., in the Stanford Building, the fire door to room 5414, was held open by a door wedge.
2. On 03/18/10, at 1:06 p.m., the door to Nuclear Medicine did not close and latch, on the second floor of the Pacific Campus.
3. On 03/18/10, at 3:00 p.m., the fire door at the elevator lobby, on the fourth floor of the Stanford Building, had a metal plate covering the fire rating.


Child Development Center
On 03/18/10, at 9:19 a.m., during fire alarm testing, the double fire doors near Room 342 did not positive latch when closed. Both doors were pushed open after closing.

California East Campus
On 03/17/10, at 11:15 a.m., the fire exit door to the fourth floor, West end stairwell, did not positive latch when closed. The door to the stairwell stuck on the door frame.

During the facility tour with staff on 03/18/10, the smoke barrier doors were observed at the California West Campus, during fire alarm testing.

At 9:57 a.m., the smoke barrier door to the Lobby failed to positive latch after closing. The right side door closed but failed to latch after activation of a pull station.

Based on observation, the facility failed to ensure the hazardous areas were maintained to resist the passage of smoke. This was evidenced by hazardous areas without self closing doors. This affected 1 of 8 floors on the Pacific Campus. This could result in the spread of smoke and fire within the facility and increase the risk of injury to patients, due to fire.

Findings:

During observations with facility staff, on March 15, 2010, hazardous areas on the Pacific Campus were observed.

Pacific Campus
1. On 03/15/10, at 12:32 p.m., the corridor door to the 2nd Floor Pathology Office, P2431, was not equipped with a self closing device. The room was greater than 50 square feet in size and contained quantities of combustible material such as books, binders and paper material.

2. On 03/15/10, at 12:35 p.m., the corridor door to the 2nd Floor Pathology Office, P2433,was not equipped with a self closing device. The room was greater than 50 square feet in size and contained quantities of combustible material such as books, binders and paper material.

3. On 03/15/10, at 12:40 p.m., the corridor door to the 2nd Floor purchasing and materials lab services storage room, P2440, was not equipped with a self closing device. The room was greater than 50 square feet in size and contained quantities of combustible material such as supplies, plastics, boxes and paper material.

Based on observation and interview, the facility failed to maintain the exit path from the fire rated stair tower, as evidenced by one door that failed to open on the right side. This affected 6 of 6 floors on the California East campus and could delay evacuation and increase the risk of harm to patients and staff in the event of a fire.

Findings:

During a tour of the facility with staff, on 03/17/10, the stairway exit doors were observed on the California East Campus.

On 03/17/10, at 9:55 a.m., the door exiting to Maple street, from the fire rated stair tower on the 1st floor (Stair 4), failed to open on the right side.

During an interview on 03/17/10 at 9:55 a.m., Staff 2 stated that the door was old and probably dated around 1930. He stated the hardware had failed and fused shut.

Based on observation and interview, the facility failed to ensure that exits are readily accessible at all times, as evidenced by carts on both sides of the exit path and by wheel chairs that blocked the path to an emergency exit stairwell. These conditions affected 1 of 8 floors on the Pacific Campus and 1 of 6 floors on the California East Campus. This could result in a delayed evacuation in the event of fire or emergency, and increase the risk of injury to patients and staff.

Findings:

During observations with facility staff from 3/15/10 through 3/18/10, the exit doors and corridors were observed.

Pacific Campus
On 03/15/10, at 1:42 p.m., there were four cart style wheel chairs stored in front of the reception desk in the Ambulatory Care Unit. The wheel chairs obstructed the exit and narrowed the passageway to the exit stairwell by half.

During an interview, Staff stated that the chairs are stored in that location during the day and put away at night.

California East Campus
On 03/17/10, at 10:00 a.m., the 1st Floor OR Exit Door was obstructed. There were two suture four-rack carts on the right side of the exit door and three carts on the left side of the door. There was a latex cart, pedi-med cart and allergy cart on the left side of the door.

Based on observation and staff interview, the facility failed to maintain two required exits from any room larger than 2500 ft?. This was evidenced by no available second exit door in the dialysis Room 2, in the Stanford Building. This affects one of three smoke compartments on the fourth floor of the Stanford Building and could result in the potential delay of egress in the event of an emergency.

NFPA 101 Life Safety Code, 2000 Edition
19.2.5.3 Any room or any suite of rooms, other than patient sleeping rooms, of more than 2500 ft? (230 m?) shall have not less than two exit access doors remotely located from each other.

Findings:

Pacific Campus - Stanford Building
During a tour of the facility with staff on 03/15/10, at 1:45 p.m., the side emergency exit was blocked by a linen cart, in Dialysis Room 2.
During an interview, Staff stated that the door was not used as an emergency exit because it led to a shaky fire escape. There was no sign posted to indicate that the door was not an emergency exit. There was no other exit in Dialysis Room 2.
When asked what the size of the room was, staff stated the room was 2,788.11 ft?.

Based on document review and interview, the facility failed to ensure that all staff members were trained with respect to their duties and the use of equipment, under the fire emergency plan, that all staff participate in fire drills, and that fire alarms are activated and heard during the drill. This could result in a delay in response and possible confusion in the event of a fire or other emergency, and increase the risk of injury to patients. This affected all buildings and off-site facilities.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns,maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.
19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm.

Findings:

During document review and staff interviews from 3/15/10 to 3/18/10, fire drills and fire procedures were reviewed.

Pacific Campus
On 03/16/10, at 2:45 p.m., during document review, fire drills were provided by the facility. Documents showed that in the 2nd quarter of 2009, 27 of 2700 staff participated in the the fire drills. In the 4th quarter of 2009, 18 of 2700 staff participated in the fire drills. In the third quarter, 2009, 225 staff participated.



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Pacific Campus
During an interview, on 3/18/10, at 12:40 p.m., 1 of 3 staff did not know how to respond when asked, "Can you find your nearest pull station?" Staff 10 stated his English is not good and he did not know what is a pull station and how to activate a pull station.


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Child Development Center
On 03/18/10, at 9:30 a.m., the documentation for the the quarterly fire drills and disaster drills were reviewed. One annual fire drill was conducted on 08/05/09. No disaster drill information was provided to indicate that the center had participated in a disaster drill.

California West Campus
1. On 03/17/10, at 11:45 a.m., Staff 5 was interviewed and asked to locate the nearest alarm activation device. Staff 5 did not know where the closest pull station was located.
2. On 03/18/10, at 12:12 p.m., Staff 6 was interviewed and asked to locate the nearest alarm activation device. Staff 6 did not know where the closest pull station was located.
3. On 03/18/10, at 12:20 p.m., Staff 7 was interviewed and asked to locate the nearest alarm activation device. Staff 7 did not know where the closest pull station was located.
4. On 03/18/10, at 12:39 p.m., Staff 8 was interviewed and asked to locate the nearest alarm activation device. Staff 8 did not know where the closest pull station was located.
Four of four staff interviewed could not locate an alarm activation device.


During record review on 03/18/10, at 3:15 p.m., Staff 9 was interviewed and asked if there were any more sign in sheets for staff training for fire drills. Staff 9 stated that he was aware of the low staff response to fire drills and would make sure more staff were trained in the future.



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During document review with facility Staff 2 on 03/16/10, the fire drill records were reviewed.
California West Campus
1. On 3/16/10 at 2:00 p.m., the fire drill records indicated that the facility failed to ensure all staff participate in fire drills and that fire alarms are activated and heard during the drill.

According to facility staff, there are approximately 1520 staff at the California East and West Campuses and 2754 staff at the Pacific Campus. All fire drill records had between 1 and 15 staff in attendance.

All fire drill forms failed to state what alarm device was activated.

2. When reviewing the facility fire drill form dated 2/25/10 at 2:30 p.m., the 1st floor Breast Health Center, scheduling department wrote "No audio" and "No" to question #1 - "Fire alarm & strobe lights work in your area."
When interviewed on 03/16/10, at 2:00 p.m., Staff 2 explained that the East Campus was set up a bit different because only the floor above and below the floor initiating the alarm device would hear the alarm. All other floors receive an overhead page. When Staff 2 was asked what, according to the fire drill forms, was not heard, Staff 2 stated that he did not know if it was the alarms and chimes or the overhead speaker that was not heard.

When reviewing the facility fire drill form dated 2/28/10 at 4:00 a.m., the Ped ER stated "nothing heard overhead."
When interviewed on 03/16/10, at 2:00 p.m., Staff 2 stated that they had been remodeling to install more speakers. Staff 2 said he would speak to the staff on that floor to find out exactly what was not heard.

Based on observation and interview, the facility failed to maintain the fire alarm system on 5 of 24 floors, as evidenced by devices that failed to activate, devices that were not labeled with the correct address and failure to sound an audible alarm. These conditions affected 3 of 8 floors in the Pacific Campus, 1 of 2 floors in the Stanford Building, and 1 of 6 floors in the California East Campus. This could delay staff response to a fire and increase the risk of injury to patients.

Findings:

During observations and interview with facility staff, from 03/16/10 through 03/19/10, the fire alarm system was tested in all buildings. After activation of the alarm, interviews with the staff at PBX confirmed the location of the alarm activation.

Pacific Campus
1. On 03/18/10, at 3:00 p.m., the smoke detector 20-28-81, in the corridor of the Stanford building, was labeled with the wrong address when confirmed by PBX during fire alarm testing.
2. On 03/18/10, at 3:10 p.m., the smoke detector 20-02-48, in the corridor of the Stanford building, was labeled with the wrong address when confirmed by PBX during fire alarm testing.
3. On 03/19/10, at 9:20 a.m., the fire alarm was not audible during fire alarm testing in the ground floor Gift Shop. During an interview, Staff 10 reported the alarm was not audible.
4. On 03/19/10, at 9:28 a.m., the chime/strobe device failed to activate during fire alarm testing, in the Radiology corridor by Restroom B262, in Basement B.


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5. On 03/18/10, at 1:05 p.m., the fire alarm chime/strobe failed to emit an audible sound in the pathology Room P2431, on the 2nd floor.

California East Campus
On 03/17/10, at 11:07 a.m., the fire curtain for Elevator 1 failed to drop during fire alarm testing, in the 7th Floor Elevator Lobby.

Based on record review and interview, the facility failed to ensure the maintenance, inspection and testing of smoke detectors as evidenced by no documentation for smoke detector sensitivity testing. This affected the Child Development Center and could result in an increased potential for smoke detector malfunction, resulting in the spread of fire and/or smoke.

NFPA 72, 7-3.2.1, Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method.
(2) Manufacturer's calibrated sensitivity test instrument.
(3) Listed control equipment arranged for the purpose.
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range.
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction. Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Findings:

During record review on 03/18/10, at 10:00 a.m., no documents were provided to show the Child Development Center had conducted the bi-annual sensitivity testing of the smoke detectors. There was no report for bi-annual testing, to include a complete list of smoke detectors, results of the sensitivity testing, or the name of the person conducting the tests. There was no documentation indicating that the smoke detectors were tested as required.

During an interview, staff stated that the smoke detectors had not been tested.

Based on observation, the facility failed to ensure that the automatic sprinkler system is maintained in accordance with NFPA 25 and NFPA 13. This was evidenced by escutcheon rings that were missing or not flush to the ceiling, by sprinkler heads coated with paint and debris, by incomplete records for quarterly flow inspections, and by one Inspector's Test Valve that was blocked. Escutcheon rings are used to cover the penetration around the sprinkler pipe. This could result in a potential sprinkler system malfunction or the spread of smoke and fire, during a fire.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems (1998 Edition)

2-2 Inspection.
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.

3-3.3 Alarm Devices. Where provided, waterflow alarm and
supervisory devices shall be tested on a quarterly basis.
Exception: Where freezing conditions necessitate a delay in testing,
tests shall be performed as soon as weather allows.
3-4 Maintenance. Maintenance/repairs shall be in accordance
with 3-2.3 and Table 3-2.3.
3-5 Records. Records shall be maintained in accordance with
Section 1-8
8.2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

Findings:

During a tour of the facility with facility staff from 03/15/10 through 03/18/10, the sprinkler system and testing records were observed.

Pacific Campus
1. On 03/15/10, at 11:00 a.m., 1 of 1 sprinkler was coated with a build up of dust and dirt, in the 6th Floor Housekeeping Closet by Room 6824.
2. On 03/15/10, at 12:09 p.m., 1 of 1 sprinkler was missing an escutcheon ring, in the 6th Floor Utility Room 2136.
3. On 03/15/10, at 2:50 p.m., 3 of 4 sprinklers had a build up of dust and dirt, in the corridor by IT, 2 Mezzanine.


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4. On 3/18/10 at 1:21 p.m., the escutcheon ring was missing on the sprinkler head by Room 1-206, on the 1st floor.


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5. On 03/15/10, at 11:15 a.m., 1 of 1 escutcheon ring was missing in the first floor women's locker room. There was an approximately 1 inch penetration exposed on the ceiling.
6. On 03/15/10, at 11:24 a.m., 1 of 13 escutcheon rings was missing in the Enright Conference room, on the first floor. There was an approximately 1/4 inch penetration exposed on the ceiling.
7. On 03/15/10, at 11:25 a.m., 1 of 1 escutcheon ring was missing in the EVS closet Room 1-110-1, on the first floor. There was an approximately 1/4 inch penetration exposed on the ceiling.
8. On 03/15/10, at 11:27 a.m., 1 of 4 escutcheon rings was shifted to one side in the cath lab Room 1-410, on the first floor. There was an approximately 1/8 inch penetration exposed on the ceiling.
9. On 03/15/10, at 11:40 a.m., 1 of 1 escutcheon ring was shifted to one side in the first floor cafe storage room. There was an approximately 1/8 inch penetration exposed on the ceiling.
10. On 03/15/10, at 12:14 p.m.. 1 of 3 escutcheon rings was shifted to one side in treatment Room 9, A level. There was an approximately 1/8 inch penetration exposed on the ceiling.
11. On 03/15/10, at 1:35 p.m., 1 of 6 escutcheon rings was missing in the unit dose area, B level. There was an approximately 1/4 inch penetration exposed on the ceiling.
12. On 03/15/10, at 1:51 p.m., 1 of 1 escutcheon ring was shifted to one side in the radiation oncology Room 230F, B level. There was an approximately 1/4 inch penetration exposed on the ceiling.
13. On 03/15/10, at 1:53 p.m., 1 of 1 escutcheon ring was missing between elevator 1 and elevator 2, on the B level. There was approximately 1/4 inch penetration exposed on the ceiling.
14. On 03/15/10, at 1:56 p.m., 1 of 1 escutcheon ring was missing in the radioactive material Room 0269, B level. There was an approximately 1/4 inch penetration exposed on the ceiling.


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15. On 03/15/10, at 11:55 a.m., on the fourth floor, in Room 4818, one of three escutcheon rings was not flush with the ceiling surface exposing an approximately two inch penetration in the ceiling, around the sprinkler pipe.


Child Development Center
On 03/18/10, during record review, no documentation was provided for the quarterly flow test of the sprinkler system for the past 12 months.
During an interview, Staff stated that the sprinkler system was not tested quarterly.

California East Campus
1. On 03/17/10, at 10:09 a.m., in the Bio Hazard Room on the outside of the building, 1 of 2 sprinklers was missing an escutcheon ring.
2. On 03/18/10, at 10:15 a.m. the Inspector Test Valve located on the outside of the East Building, had a trash bag with trash in it tied to the Valve.

California West Campus - 2nd floor
1. On 03/16/10, at 10:50 a.m., in the corridor by Room 250, there was a sprinkler with a build up of debris.
2. On 03/16/10, at 11:10 a.m., in the Labor and Delivery (L and D) corridor, 3 of 3 sprinklers had a build up of debris.
3. On 03/16/10, at 11:15 a.m., in the L and D corridor, by Room 203, 2 of 6 sprinklers had a build up of debris.
4. On 03/16/10, at 11:20 a.m., in the corridor, 4 of 9 sprinklers had a build up of debris.
5. On 03/16/10, at 11:55 a.m., in the L and D Housekeeping Closet, by Room 236, 1 of 1 sprinkler had a build up of debris.
6. On 03/16/10, at 12:01 p.m., in the L and D corridor across from Room 232, 1 of 6 sprinklers had a build up of debris.
7. On 03/16/10, at 12:05 p.m., in the TCN corridor, 2 of 7 sprinklers had a build up of debris.
8. On 03/16/10, at 12:16 p.m., in the Bio-Waste Storage, 1 of 1 sprinkler had a build up of debris.
9. On 03/16/10, at 12:20 p.m., in Patient Room 265, 2 of 2 sprinklers had a build up of debris.
10. On 03/16/10, at 12:22 p.m., in Patient Room 263, 1 of 2 sprinklers had a build up of debris.
11. On 03/16/10, at 12:25 p.m., in Storage Room 2526, 2 of 3 sprinklers had a build up of debris.
12. On 03/16/10, at 12:26 p.m., in Patient Room 2525, 1 of 1 sprinkler had an approximately 1/2 inch gap from the ceiling to the escutcheon ring.
13. On 03/16/10, at 12:28 p.m., in the H2-5 Pantry, 1 of 1 sprinkler had a build up of debris.
14. On 03/16/10, at 12:30 p.m., in Patient Room 250, 2 of 2 sprinklers had a build up of debris.


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15. On 03/16/10. at 10:08 a.m., 1 of 1 escutcheon ring was shifted to one side in the PACU, on the 3rd floor. There was an approximately 1/2 inch penetration exposed on the ceiling.

California West Campus
1. On 03/16/10, at 2:22 p.m., the fire extinguisher was not securely mounted in a bracket in the Bio Med Basement. The fire extinguisher was left standing on the counter top.


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2. On 03/17/10, at 10:30 a.m., at the Oxygen Storage Room, on the outside of the West building, the fire extinguisher was impeded by an empty storage cart.

Based on observation, the facility failed to maintain portable fire extinguishers as evidenced by fire extinguishers that were not mounted, by fire extinguishers that were blocked and by fire extinguishers that were mounted more than 60 inches above the floor. This affected 1 of 8 floors on the Pacific Campus, 2 of 7 floors on the California West Campus, 3 of 6 floors on the California East Campus, and 1 of 1 floor in the Clay Street Facility. This could result in a delay to access the portable fire extinguishers in the event of a fire or damage to the cylinders if they were displaced.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1-6 General Requirements.
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6* Fire extinguishers shall not be obstructed or obscured
from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate
the location.
1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
1-6.10 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. Fire extinguishers having a gross weight greater than 40 lb(18.14 kg)(except wheeled types)shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).

Findings:

During a tour of the facility from 3/15/10 through 3/18/10, with staff, the fire extinguishers were observed.

Pacific Campus - 6th floor
1. On 03/15/10, at 11:15 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 647.
2. On 03/15/10, at 11:17 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 644.
3. On 03/15/10, at 11:25 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 637.
4. On 03/15/10, at 11:30 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 631.
5. On 03/15/10, at 11:45 a.m., the fire extinguisher was impeded by an over-bed table, in the corridor by Patient Room 617.
6. On 03/15/10, at 12:20 p.m., the fire extinguisher was impeded by a trash can, in the corridor by Patient Room 631.


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Pacific Campus
7. On 03/15/10, at 11:05 a.m., a portable ABC fire extinguisher, in the GI Lab on the 5th floor, was mounted with the handle at approximately 64 inches from the floor.
8. On 03/15/10, at 12 p.m., a portable ABC fire extinguisher in the kitchen, by the electrical panel, was mounted with the handle at approximately 67 inches from the floor.
9. On 03/15/10, at 12:05 p.m., a portable K class fire extinguisher in the kitchen, by the ansul equipment, was mounted with the handle at approximately 53 inches from the floor.


Clay Street
On 03/17/10, at 1:44 p.m., a portable ABC fire extinguisher was mounted at approximately 65 inches from the floor, in the cardiac rehab/PT area, on the 2nd floor loft.

California East Campus
1. On 0317/10, at 9:20 a.m., the fire extinguisher was impeded by a trash can in the Surgery Work Room, 1st Floor.
2. On 03/17/10, at 10:05 a.m., the fire extinguisher was impeded by a cart, at the entrance to OR, 1st Floor.
3. On 03/17/10, at 10:07 a.m., in the Women's Locker Room, 1st Floor, the fire extinguisher was blocked from view behind the entrance door.
4. On 03/17/10, at 10:25 a.m., the fire extinguisher was impeded by an oil can in the East Generator Room, on the outside of the building.



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5. On 03/17/10, at 10:10 a.m., a portable ABC fire extinguisher in the first floor Biohazard room, was mounted at approximately 62 inches from the floor.

Based on observation, the facility failed to provide containers with self closing devices to dispose of cigarette butts, as evidenced by cigarette butts on the top of the ashtray and on the ground in the smoking structure, in the designated smoking area. This affected 1 of 6 floors on the California East Campus, and could result in an increased risk of fire in the smoking area.

Findings:

During a tour of the facility with facility Staff 1, Staff 2 and Staff 4 on 03/17/10, the facilities smoking areas were observed.

California East Campus
On 3/17/10 at 10:15 a.m., the designated staff smoking area had 2 cigarette butts on the ground in the smoking structure and approximately 15 cigarette butts at the top of the combination ashtray/trash container. There was no metal self closing container, provided by the facility, for emptying ashtrays.

Based on document review and staff interview, the facility failed to maintain the heating, ventilating and air conditioning system, as evidenced by no documentation for the inspection of the smoke dampers in one off site building. This affected the Child Development Center and could result in the potential failure of fire/smoke dampers in the event of a fire.

NFPA 90A Standard for the Installation of Air-Conditioning and Ventilating Systems 1999 Edition
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review for the Child Development Center with staff, on 03/18/10, at 10:00 a.m., no documents were provided to indicate that the dampers had been inspected as required.
During an interview, Staff stated that they did not have the documentation for the inspection of the smoke dampers.

Based on observation and interview, the facility failed to maintain the corridor free from obstructions, as evidenced by two E cylinders that were stored in the corridor. This condition affected 1 of 8 floors in the Pacific Campus and could result in a delay in evacuation and the potential acceleration of a fire in the event of a fire.

Findings:

During a tour of the facility with staff on 03/15/10, at 11:55 a.m., the corridors were observed on the 3rd Floor. There were two oxygen E-cylinders stored in the corridor by room 333. When asked if the oxygen cylinders are always in that location, staff stated "Yes, they are used during physical therapy."

Based on observation, the facility failed to prohibit the use of loosely hanging furnishing and decorations. This was evidenced by the use of loosely hanging privacy curtains that were not fire rated, in the New Born Connection Room. This affected 1 of 6 floors in the California East Campus and could result in an increased potential for ignition of a fire.

Findings:

During a tour of the California East Campus with staff, on 3/17/10, the rooms were observed.

California East Campus
1. At 9:30 a.m., a purple privacy curtain was used for separating the new born office and the store room, in the new born connection on the first floor. The curtain did not contain a flame resistant tag. There was no documentation indicating the privacy curtain had been treated with flame retardant solution.
2. At 9:33 a.m., a white privacy curtain was used for separating the laxation room and the library, in the new born connection on the first floor. The curtain did not contain a flame resistant tag. There was no documentation indicating the privacy curtain had been treated with flame retardant solution.

Based on observation, the facility failed to comply with regulations regarding electrical wiring and utilities, as evidenced by the use of surge protectors for medical equipment and for motorized items, by surge protectors plugged into other surge protectors and by the use of unapproved extension cords. This affected 4 of 8 floors in the Pacific campus, 3 of 7 floors in the California West Campus, 2 of 6 floors in the California East Campus and 1 of 1 floor in the Clay Street Facility. This could result in the increased risk of electric shock or an electrical fire.

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

3-3.3.3 Receptacle Testing in Patient Care Areas
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 grams (4 ounces).

NFPA 70 National Electrical Code
Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with staff, from 3/15/10 through 3/18/10, the electrical wiring and connections were observed.

Pacific Campus
1. On 03/15/10, at 11:05 a.m., seven IV pumps were plugged into surge protectors instead of directly into the wall outlets, in Rooms 4828 and 4114, on the fourth floor.


Child Development Center
At 8:40 a.m., a lamp was plugged into a power strip that was plugged into another power strip, in the Intake Room. The power strip should be connected directly to the wall outlet.

During document review, at 10:00 a.m., no documents were provided for the receptacle outlet continuity, polarity and tension testing. Staff stated that there was no documentation for outlet testing.


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Pacific Campus
2. On 03/15/10, at 11:06 a.m., a microwave was plugged into an extension cord, in the GI Lab on the 5th floor. At 11:07 a.m., a surge protector was plugged into another surge protector in the GI Lab.
3. On 03/15/10, at 11:36 a.m., a cover plate was missing on the 4 inch junction box, in the PBS operator area on the 1st floor.
4. On 03/15/10, at 11:38 a.m., a salt lamp was plugged into an extension cord, in the gift shop on the 1st floor.
5. On 03/15/10, at 11:43 a.m., a computer monitor was plugged into an extension cord, in the PBS operator area, on the 1st floor.
6. On 03/15/10, at 1:50 p.m., the light fixture was missing on the junction box, in the telephone/data room, B level.
7. On 03/15/10, at 1:55 p.m., a respiratory monitor was plugged into an orange extension cord, in the Treatment Room 0280, B level.


Clay Street Rehab
On 03/17/10, at 1:40 p.m., a surge protector was plugged into another surge protector in the cardio rehab/PT on the 2nd floor loft.

California West
1. On 03/16/10, at 10:51 a.m., in the Kitchen, a refrigerator was plugged into an orange extension cord instead of directly into the wall outlet.
2. On 03/16/10, at 10:55 a.m., in the Kitchen supervisor's office, a fax machine was plugged into an orange extension cord instead of directly into the wall outlet.
3. On 03/16/10, at 11:58 a.m., in the ground level patient registration area, a printer was plugged into a power strip that was plugged into another power strip.
4. On 03/16/10, at 10:00 a.m., an orange power strip was plugged into a power strip instead of directly into the wall outlet in the same area.
5. On 03/16/10, at 12:05 p.m., in the ground level Gift Shop, a jewelry cabinet was plugged into a power strip that was plugged into another power strip.
6. On 03/16/10, at 1:37 p.m., in the basement IT Training Room, there were three daisy chains (power strips plugged into other power strips) connected to the computers used in the training room.
7. On 03/16/10, at 2:12 p.m., in the basement EVS Women's Locker Room, a refrigerator and a microwave were plugged into a power strip instead of directly into the wall outlet.
8. On 03/16/10, at 2:54 p.m., in the basement, in room 412, a power strip was plugged into another power strip instead of directly into the wall outlet.
9. On 03/16/10, at 3:00 p.m., in the basement Lab, four Centrifuges were plugged into one power strip instead of directly into the wall outlet.


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10. On 3/18/10 at 10:45 a.m., in the 1st floor Business Office, there were four interconnected multi-plug power strips in the cubicle in the middle of the office area.

During observations with facility staff on 03/17/10, the electrical wiring and connections were observed at California East Campus.

California East Campus
1. On 03/17/10, at 9:15 a.m., in the 3rd floor ASC Electrical Room, there was a cable box missing a cover plate on the right wall in the upper corner. There was an electrical plate missing a cover on the left center of the wall.


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2nd Floor -
2. On 3/17/10 at 9:25 a.m., in Room 2730 the "Post Acute Services, Medical Staff Office," there was an orange extension cord plugged into a multi-plug power strip.
At 9:26 a.m., there was an orange extension cord plugged into a multi-plug power strip with office equipment plugged into it.
At 9:26 a.m., there were two interconnected multi-plug power strips connecting a fax machine to the wall outlet in the same office.