HospitalInspections.org

Based upon observations and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the patients, staff and/or visitors within the facility.

The findings include:

Penetrations were observed in the following locations:

Verbeck building physical therapy department behind the water cooler. Corrected during inspection.

Room HS004 - in the ceiling. Corrected during inspection.

Laboratory - in wall at ceiling height.

Room 226 - in ceiling.

NFPA 101 19.3.6.2.3, 8.3.5, 8.4.4.1, 8.5.6.2 2012

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

Verbeck Building:

Restroom by the tenant laundry - door did not have enough closing force to latch when closed. Corrected during inspection.

Room 303 - door did not have enough closing force to latch when closed. Corrected during inspection.

Restroom by Exam 1 - door did not have enough closing force to latch when closed. Corrected during inspection.

NFPA 101 19.3.7.8, 8.5.4.4

The above was discussed and acknowledged by facility staff.

Based upon observations and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain stairways and smoke-proof enclosures in a manner that will keep those inside safe from fire and smoke. This could potentially endanger patients, staff, and visitors inside these areas trying to evacuate or waiting for help.

The findings include:

HS020 cross corridor doors required excessive force to open.

NFPA 101 19.2.1, 7.2, 7.2.1.4.5.1 2012

The above was discussed and acknowledged by the facility staff.

Based upon observation, documentation review and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result delayed egress and in tripping and fall injuries to patient, staff, and/or visitors.

The findings include:

Oroville - the facility was usable to provide documentation of monthly 30 second and annual 90 minute testing of the emergency lighting and exit signs.

Oroville - the emergency light failed to illuminate when tested.

NFPA 101 19.2.8, 7.9.3.1.1 2012

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to conduct testing/maintenance of the hood and duct fire suppression equipment protecting the commercial cooking equipment. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of two semi annual service reports of the kitchen hood suppression system within the past twelve months.

NFPA 101 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1 2012, NFPA 96 11.2.1 2011

Contractor service reports must free of deficiencies.

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interview on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.

The findings include:

1) Oroville - The facility was unable to provide documentation of annual fire alarm service within the past twelve months.

NFPA 101 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1 2012, NFPA 72 1.1.1, 14.4.5, 14.6.2 2010

Contractor service reports must free of deficiencies.

2) Oroville - the smoke detector was detached from the ceiling mount in the storage closet.
Room 308 - the smoke detector had been removed. Corrected during inspection.
Room 401 - the smoke detector was detached from the ceiling mount. Corrected during inspection.

NFPA 101 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1 2012, NFPA 72 1.1.1, 10.3.2 2010

The above was discussed and acknowledged by the facility staff.

Based on documentation review, observation and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1) Quick response fire sprinkler heads greater than twenty years old must be tested or replaced.
2) Extreme condition sprinkler heads in the kitchen coolers greater than 10 years old must be tested or replaced.

NFPA 101 19.3.5.3, 9.7.5 2012, NFPA 25 5.3.1.1.1.3 2011

NFPA 101 19.3.5.3, 9.7.5 2012, NFPA 25 5.3.1.1.1.6 2011

Testing reports must free of deficiencies.

3) Fire sprinkler heads were loaded in the following locations:
Verbeck building patient charting room.
Kitchen
Kitchen coolers
Admitting by the printer
COVID room
Emergency department soiled utility room
Dictation room
Pharmacy restricted area
OB tub room
Respiratory therapist room
Room 203, 204, 227, OB111, OB112, A105

NFPA 101 19.3.5.3, 9.7.5 2012, NFPA 25 5.2.1.1.4 2011

4) Wood Shop - wires and zip ties were attached to the fire sprinkler pipes. Corrected during inspection.

NFPA 101 19.3.5.3, 9.7.5 2012, NFPA 25 5.2.2.2 2011

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.

The findings include:

Oroville - the light in the storage appears to have overheated creating burn marks around it on the ceiling.
Old generator room - open junction box. Corrected during inspection.

NFPA 101 19.5.1, 9.1.2 2012, NFPA 70 90.1(B), 110.12(B) 2011

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to perform monthly operation of the fire fighter emergency operations on the facility elevator(s). This could potentially result in the fire service personnel not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include:

Hospital and Verbeck buildings - The facility was unable to provide documentation of monthly operation of the fire fighter emergency operations.

NFPA 101 19.5.3, 9.4.6.2 2012

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.

The findings include:

The facility was unable to provide documentation of night shift fire drill during the last quarter of 2020.

The above was discussed and acknowledged by the facility staff.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.7.1.6

Based upon documentation review, observations and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff inside the building.

The findings include:

The facility was unable to provide documentation of repairs/corrections to doors found deficient during the annual fire door inspection on July 13, 2021.

NFPA 101 19.1.1.1.1, 19.2.1, 7.2.1.15.2 2012, NFPA 80 1.1, 5.2.4.1, 5.1.5.1 2010

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 27, 2021 between approximately 0815 to 1700 hours the facility has failed to maintain signage medical gas rooms, which could endanger patients, staff, visitors, and first responders in the event of an emergency.

The findings include:

The facility failed to provide required signage on the medical gas storage room. Signage shall state:

Positive Pressure Gases
NO Smoking or Open Flame
Room May Have Insufficient Oxygen
Open Door and Allow Room to
Ventilate Before Entering

NFPA 99 5.1.3.1.8 2012

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1) The facility was unable to provide documentation of generator fuel testing.

NFPA 99 6.4.4.1.1.3, 2.1 2012, NFPA 110 1.1, 8.3.8, 8.1.1 2010

Testing report must free of deficiencies.

2) The facility was unable to provide documentation of tri-annual load test.

NFPA 99 6.4.4.1.1.3, 2.1 2012, NFPA 110 1.1, 8.4.9 2010

Contractors service report must free of deficiencies.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on July 27, 2021 between approximately 0815 and 1700 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

Oroville - a power strip was plugged into another powerstrip in the office.

Room 406 - an unfused powerstrip was in use behind the television.

The above was discussed and acknowledged by the facility staff.

NFPA 99, 2012 10.2.4.2.1

Based on observation and staff interviews on July 27, 2021 between approximately 0815 and 1700 hours the facility has failed to maintain segregation of oxygen cylinders. This could allow for the tampering with or damage to of oxygen storage cylinders, which could endanger patients, staff, and/or visitors.

The findings include:

Empty cylinders were not segregated from full cylinders.

The above was discussed and acknowledged by the facility staff.

NFPA 99, 2012 11.6.2.4