HospitalInspections.org

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire. This was evidenced by unsealed penetrations observed in the fire-rated sheeting. This affected all staff and patients in two of five smoke compartments at the main hospital building and two of five outpatient buildings. This could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

Findings:

During a tour of the facility with the Engineering Staff, penetrations were observed in the wall sheeting which could potentially result in the spread of smoke and/or fire.

Main Hospital Building
1. On 6/19/12, at 4:25 p.m., the Med. Surg. Lounge had a one inch unsealed pentration in the northeast corner of the wall near the ceiling caused by a cable traveling through the wall.

Healsburg Primary Care 1312 Prentice Drive
2. On 6/19/12, at 10:25 a.m., the I.T. Room had a three inch unsealed penetration in the ceiling caused by data cables traveling through the wall.

3. On 6/19/12, at 11:10 a.m., the outside Electrical Room had a one and one-half inch unsealed penetration in the upper right hand corner near the ceiling.

Blood Draw/Physical Therapy Cloverdale
4. On 6/20/12, at 11:03 a.m., there were two unsealed penetrations in a closet in the south west room of the building. One penetration was in the ceiling and was twelve inches by twelve inches in size. The other penetration was eight inches by twelve inches in size and was in the same closet near the floor. Engineering Staff stated that repairs were being made by the owner of the building.


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Main Hospital Building
5. On 6/19/12, at 10:25 a.m. in the Telephone Room, there were 2 pipes with 4 telephone cable wires running through the orifice of each pipe. The orifice of Pipe #1 measured 2 inches in diameter. The orifice was unsealed. The orifice of Pipe #2 measured 1 ½ inches in diameter. The orifice was unsealed.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in one of five outpatient service buildings and could potentially result in the spread of smoke and/or fire to other areas of the facility.

Findings:

Healdsburg Primary Care 1312 Prentice Drive
During a tour of the facility with Engineering Staff on 6/19/12, doors were inspected throughout the facility.

1. At 10:25 a.m., the door to the I.T. Room did not positive latch when tested.

2. At 10:30 a.m., the door from the Laboratory to Medical Records did not positive latch when tested.

3. At 10:35 a.m., the corridor door to the Laboratory was being held open by a door wedge.

4. At 10:40 a.m.., the corridor door to the Laboratory on the Family Practice side of the Primary Care Building was missing.

5. At 10:43 a.m. the Assistant Manager's Office door did not positive latch when tested.

6. At 10:52 a.m., the Staff Break Room had both corridor doors propped open with door wedges.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls in accordance with 2000 NFPA 101. This was evidenced by observed unsealed penetrations. This affected four of five smoke compartments at the main hospital building and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Engineering Staff on 6/20/12, smoke/fire barrier walls were inspected throughout the facility.

Main Hospital Building
1. At 1:41 p.m., the fire barrier wall in the attic located near Materials Management had two unsealed penetrations in the wall. One penetration was an approximately one inch hole that was drilled through the wall near a red four inch junction box. The other penetration was an approximately one-half inch wide space around grey, yellow, and orange data cables traveling through the wall.

2. At 1:55 p.m., the fire barrier wall in the attic near the Conference Room had three half inch round unsealed penetration above the ceiling joists in the middle of the wall.

3. At 2:06 p.m., the fire barrier wall in the attic near X-Ray had an approximately three inch sleeve to the right of the attic access door that was open on the end.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and were not equipped with self-closing mechanisms on the doors. This affected two of five smoke compartments at the main hospital building and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Engineering Staff, hazardous area enclosures were inspected.

Main Hospital Building
1. On 6/19/12, at 4:11 p.m., the Medical Records/Copy Room did not have a self-closing door. When asked, Engineering Staff stated that the closure had just been removed the day before.


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2. On 6/19/12, at 10:55 a.m., there was no self-closing mechanism on the door to the Dietary Dry Storage. The storage room measured approximately 14 ' by 14 ' , and contained items stored in cardboard boxes.

Based on observation and interview, the facility failed to ensure that exits are readily accessible at all times in accordance with 2000 NFPA 101. This was evidenced by patient room doors that were equipped with a double-action latching devices and no key readily available to unlock the doors in an emergency. This was also evidenced by two exit doors that were equipped with dead bolt locks. This affected all staff and patients in one of five outpatient buildings and could potentially result in a delayed egress in the event of an emergency.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

Findings:

Lab Draw and Physical Therapy at 106 East First Street Cloverdale
During a tour of the facility with Engineering Staff on 6/20/12, egress from the building to the public way was observed.

1. At 10:55 a.m., the north exit door leading from the reception area through the first floor stair landing to the exit door to the outside had a deadbolt lock on each door. The exit door from the reception area to the stairwell was equipped with a doorknob with no latching hardware. Above the doorknob was a deadbolt lock. The door leading from the stairwell to the outside was equipped with a double-action locking mechanism as well as a deadbolt lock. This door leading directly to the outside from the landing had a sign above the door stating that the door was to remain unlocked during business hours. The door leading from the reception area to the landing did not have a sign stating that it was to remain unlocked during business hours. Engineering staff stated that the upstairs was occupied by another tenant.

These doors required special knowledge to unlock the doors from the egress side, if the doors were locked.

2. At 11:03 a.m., the northeast Patient Room and the south Blood Draw Room had double- action locking hardware that was keyed on the nonegress side of the doors. When Staff was asked to provide a key to unlock the doors in an emergency, staff was unable to find a key. Later, at the end of the survey at 11:15 a.m., Staff stated to this surveyor that the key had been found to unlock the doors.

Based on observation, document review, and interview, the facility failed to test and maintain all exit signs in accordance with 2000 NFPA 101. This was evidenced by the lack of documentation of monthly and annual testing of the exit signs and exit signs that were not continuously illuminated tested. This could result in exit signs failing to guide the occupants of the building to safety during a fire emergency or power outage. This affected one of five smoke compartments at the main hospital building and one of five outpatient service buildings.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During Document Review, records of exit sign testing were requested.

Wound Center
1. On 6/18/12, at 2:00 p.m., the facility failed to provide documentation for monthly and annual testing of exit signs and the battery-powered task light for the Wound Center. Staff said they thought that the signs and back-up light were being tested, but that documentation was not available.

During a tour of the facility with Engineering Staff, the exit signs were inspected.

2. On 6/19/12, at 1:20 p.m., the exit sign located near the Physicians Copy Machine did not stay illuminated when the exit sign was tested by pushing the test button.

3. On 6/19/12, at 1:30 p.m., the exit sign located near the Fire Alarm Control Panel Closet did not stay illuminated when tested by pushing the test button.

During a tour of the facility with Engineering Staff, exit signs were inspected.

Main Hospital Building
4. On 6/19/12, at 4:45 p.m., the exit sign located in the X-Ray Reception Room was not illuminated.

Based on record review and interview, the facility failed to train all staff in the use of, and response to, fire alarms in accordance with 2000 NFPA 101. This was evidenced by a lack of documentation provided for two of four required fire drills at five of five offsite buildings in a twelve month period. This affected all staff and patients at five of five outpatient services buildings and could potentially result in staff not being trained and familiar with emergency procedures.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

Findings:

1. During document review on 6/18/12, at 2:00 p.m., the facility failed to provide documentation of fire drills for the third and fourth quarter of 2011 at all of its offsite outpatient locations. Engineering Staff stated that engineering personnel had started doing the fire drill trainings at the offsite locations as of in January of 2012. Staff stated that there were no documented training in 2011.

Based on document review and interview, the facility failed to maintain its fire alarm system in in accordance with NFPA 72 of the National Fire Alarm Code. This was evidenced by a lack of current documentation for the Annual Alarm Certification. This affected all staff and patients at one of five outpatient buildings and could potentially result in the alarm system not functioning properly in the event of a fire.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During record review on 6/18/12, at 2:00 p.m., documentation was requested for the most recent Annual Alarm Certification by a certified vendor.

Healdsburg Primary Care 1312 Prentice Drive, Healdsburg
1. At 2:00 p.m., the facility failed to provide a current Annual Alarm Certification.
During a tour of the facility on 6/19/12, the inspection sticker located on the Fire Alarm Control Panel had an inspection date of 4/2008. Staff stated that an inspection would be scheduled.

Based on observation, record review, and staff interview, the facility failed to periodically test its automatic sprinkler system in accordance with 2000 NFPA 101 and 1998 NFPA 25. This was evidenced by the failure to provide current documentation for the annual and quarterly sprinkler inspections of its automatic sprinkler system. This was evidenced by sprinklers that were loaded, corroded, or painted, or lacked proper clearance. This was also evidenced by the failure to provide a sprinkler wrench in the spare sprinkler box. This affected one of five smoke compartments at the main hospital building and two of two sprinklered outpatient buildings and could cause the sprinkler system to fail to function as designed resulting in the spread of smoke and/or fire.

4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2

2-4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.

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

NFPA 13, 1999 edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During record review on 6/18/12, documentation was requested for testing and maintenance of the automatic sprinkler system.

Healdsburg Primary Care 1312 Prentice Drive, Healdsburg
1. At 2:00 p.m., the facility failed to provide the current documentation for the annual or quarterly sprinkler inspections.
During a tour of the facility on 6/19/12, at 11:15 a.m., the date on the riser indicated that the last annual inspection was performed on 4/2008.

Wound Care and Physical Therapy 1540 Healdsburg Ave
2. At 2:00 p.m., the facility failed to provide the current documentation for the annual or quarterly sprinkler inspections.

During a tour of the facility with Engineering Staff on 6/19/12, the date on the riser indicated that the last annual inspection was performed during the five year sprinkler certification on 12/2/08.

Maintenance Staff stated that they would contact the vendor and if the testing had been done, the documentation would be provided to this surveyor.

Main Hospital Building


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3. At 10:30 a.m., 2 boxes of " Disaster Phones " were stored approximately 9 inches below the deflector in the Disaster Supply Room.

4. At 10:45 a.m., remnants of plastic were observed on 1 of 2 deflectors in the Soiled Linen Room near the Loading Dock.

5. At 10:58 a.m., the sprinkler wrench was missing from the spare sprinkler box.

6. At 10:58 a.m., there was only 1 spare sidewall sprinkler in the spare sprinkler box.

7. At 11:04 a.m., the sprinkler in the kitchen ' s walk-in freezer was corroded, loaded with debris, and missing an escutcheon ring.

8. At 11:05 a.m., 2 of 2 sprinklers in the kitchen ' s prep area were loaded with grease and debris.

9. At 11:08 a.m., 2 of 2 sprinklers in the ceiling above the stove were loaded with grease and debris.

10. At 11:09 a.m., 2 of 2 sprinklers in the kitchen ' s dishwashing area were loaded with grease and debris.

11. At 11:14 a.m. in the Cafeteria above the food line area, there was paint on the sprinkler ' s deflector.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by eleven portable fire extinguishers that were stored unsecured. This could result in an increased risk of fire.


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.

Findings:

During a tour of the facility on 6/19/12, fire extinguishers were observed.

Main Hospital Building
1. At 11:35 a.m., there were eleven unmounted fire extinguishers on the floor of the New Electrical Room. The Director of Plant Operations stated that the fire extinguishers were spares.

Based on record review, observation, and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A. This was evidenced by a lack of documentation provided for damper inspections. This finding affected one of five smoke compartments at the Main Hospital Building and could potentially result in the spread of smoke and/or fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 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 a review of the facility's documentation on 6/18/12, at 10:45 a.m., the facility failed to provide documentation indicating that dampers had been inspected within the last six years.
Engineering Staff stated that the fire alarm vendor does inspects the electric powered dampers. No documentation, however, was provided that identified damper location, which dampers were inspected, if the damper opened and closed fully during the inspection or if any had been replaced.

1. During an inspection of the fire barrier walls on 6/20/12, between 1:44 and 2:06 p.m., dampers were observed in the ceiling registers in the corridor near the Kitchen. One damper was identified as a "Fire Marshall 30 ASR".

Based on record review and interview, the facility failed to maintain its cooking facilities in accordance with 1998 NFPA 96. This was evidenced by a lack of documentation for inspection and cleaning of its kitchen hood by a professional company. This affected one of five smoke compartments at the main hospital building and could potentially result in the spread of smoke and/or fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

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

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

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

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

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

Findings:

During record review on 6/18/12, documentation of hood inspection and cleaning was requested. When asked, Engineering Staff stated that the Kitchen hood system was cleaned in-house, and that a professional cleaning company was not used

1. Documentation provided for the annual and semi-annual hood fire suppression system inspection and maintenance dated 11/10/11 and 6/14/12 was reviewed. Documentation did not state if the Kitchen hood ventilation system was being inspected throughout for grease build-up. The report dated 11/10/11 did state "need to clean filters".

Based on observation, the facility failed to protect its medical gas storage areas in accordance with 1999 NFPA 99. This was evidenced by cylinders which were not secured individually in a storage locations and by electrical fixtures that were lower than five feet from floor level. This affected two of two oxygen storage locations at the Main Hospital and could potentially result in injury or damage to cylinders, manifolds, or piping if cylinders were to fall. This could also result damage to electrical fixtures if cylinders were to fall.

NFPA 99, 1999 edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4-3.5.2 Gas System Policies-Level 1.

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers-Level 1.
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage.
8-3.1.11 Storage Requirements.
8-3.1.11.1 Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2. 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(h) Cylinder or container restraint shall meet 4-3.5.2.1 (b) 27.

Findings:

During a tour of the facility with Engineering Staff, oxygen storage locations were inspected.

Main Hospital Building
1. On 6/19/12, at 10:21 a.m., the Bulk Oxygen Storage located south the Main Hospital Entrance had twelve H size oxygen cylinders that were secured together to a metal fence with one rope. Staff confirmed the observation and said that they could be individually secured.


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2. On 6/19/12, at 10:58 a.m., oxygen storage was located in the facility ' s Riser Room. The light switch was mounted 48 inches from its operable part to the floor.

Based on record review, observation, and interview, the facility failed to maintain all parts of its piped-in medical gas system in accordance with 1999 NFPA 99. This was evidenced by a written deficiency in the medical gas certification report that had not been repaired. This finding affected staff and patients in three of five smoke compartments at the Main Hospital Building and could potentially result in the medical gas system not functioning as designed.

Findings:

During document review on 6/18/12, documentation provided for the 2011 medical gas certification report was reviewed.

1. At 2:00 p.m., documentation titled "Medical Gas PM Inspection 10/11/2011 Punch List", listed the following components as being in need of maintenance:

A. OR 1 Hose A Vacuum Reduced Flow.
B. OR 2 Hose A Vacuum leaks without adapter, reduced flow.
C. Warning Alarm Rooms 103,104, 105, and Billing Department Oxygen and Vacuum Area Labelling.
D. Warning Alarm Same Day Surgery Vacuum Indicator light out.

When asked about the discrepancies, Staff stated that the medical gas vendor had been contacted and would be at the facility on Wednesday.
On 6/20/12, the med gas vendor was observed at the facility and documentation was later provided indicating that the discrepancies had been been repaired.

Based on document review and interview, the facility failed to protect it anesthetizing locations in accordance with 1999 NFPA 99.
This was evidenced by the failure to monitor its relative humidity to insure that it is maintained equal to or greater than 35 percent.
This was also evidenced by the failure to provide battery-powered emergency lighting units in anesthetizing locations. This affected one of five smoke compartments within the facility and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment. This could also potentially result in a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer, if the generator fails to start).

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

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

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During record review with Engineering Staff on 6/20/12, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
1. At 8:30 a.m., Engineering Staff stated that the relative humidity in the Operating Rooms had not been documented in the past. Staff also stated that the facility had developed a form to use to monitor the humidity in the Operating Rooms and provided that form to this surveyor.
During a tour of Operating Room 1 at 10:00 a.m., a humidity gauge was observed on the wall which indicated that the humidity was 68 percent. Observation of another gauge in an adjacent room indicated 67 percent humidity.

2. At 10:05 a.m., this surveyor observed that there were no battery-operated task lights in Operating Room 1 on the wall. Operating Room Staff stated that the anesthesia machine, has a battery back-up light and there is also a flash light attached to the machine. Both Engineering Staff and OR Staff agreed that there were no battery-operated task lights mounted to the walls or in the ceiling fixtures of the Operating Rooms.

Based on document review and interview, the facility failed to maintain its emergency generator in accordance with 1999 NFPA 99. This was evidenced by the generator failing to transfer power within the required 10 seconds. This affected all staff and patients within the main hospital building and could potentially result in a delay in power to areas of critical need.

3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source. The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

Findings:

During record review, on 6/18/12, generator monthly full load tests logs were reviewed.

1. At 2:00 p.m., generator logs indicated that the time that it took for the generator to start and transfer the building load to the generator was greater than 10 seconds.

Log readings were as follows:
December 2011 transfer time was 12.09 seconds
January 2012 transfer time was 11.0 seconds
February 2012 transfer time was 12.81 seconds
March 2012 transfer time was 12.43 seconds
April 2012 transfer time was 11.27 seconds
May 2012 transfer time was 11.65 seconds

When asked, Engineering Staff stated that after the generator annunciator was installed the transfer times were recorded automatically by the instrumentation. Staff also stated that the generator vendor had been called and would be at the facility by 5:30 p.m..

Documentation from the vendor in the form of a scanned document was e-mailed to this surveyor on 6/21/12 at 10:29 a.m.. This documentation indicated that the time delay had been adjusted and the generator was transferring power in less than 10 seconds.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, and improper clearance in front of an electrical panel. This affected all staff and patients in three of five smoke compartments at the main hospital building and one of five outpatients service Buildings and could potentially result in the ignition of fire.

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

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less

Findings:

During a tour of the facility with Engineering Staff on 6/19/12, electrical wiring and equipment were observed.

Healdsburg Primary Care 1312 Prentice Drive
1. At 10:52 a.m., there was a microwave oven plugged into a power strip in the Staff Lounge.

2. At 10:57 a.m., the Family Practice Office had a power strip suspended above the floor applying tension to the joint and terminals.

3. At 11:12 a.m., there were cardboard boxes, a scale, and two E size oxygen tanks that were stored in front of the building's main electrical panels.

Main Hospital Building
4. At 4:07 p.m., Office 105 had a power strip plugged into another power strip.

5. At 4:17 p.m., the Business Office had a power strip plugged into another power strip.


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6. At 10:50 a.m., there were 2 power strips in the Dietary Manager ' s office. Power Strip # 1 with computer equipment plugged into it, was connected to Power Strip #2, also with computer equipment plugged into it.

7. At 11:25 a.m., there were 2 power strips in the Occupational Medicine RN ' s office. Power Strip #1, with a task light and computer equipment plugged into it, was connected to Power Strip #2. No devices were plugged into Power Strip #2.

8. At 1:08 p.m., there were 2 power strips in the Human Resource Assistant I ' s office. Power Strip #1, with computer equipment plugged into it, was connected to Power Strip #2, which had a pencil sharpener and an adding machine plugged into it.

9. At 1:58 p.m., the power strip in the IT Closet (Closet 4) across the hall from the OR Nurses ' Lounge was suspended approximately 34 inches above the floor. A UPS and 2 routers were plugged into the power strip.

10. At 2:01 p.m., a coffee maker, coffee bean grinder, and a microwave oven were plugged into a power strip in the OR Nurses ' Lounge.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the automatic sprinkler system is out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation provided for the notification of the AHJ. This affected all staff and patients in five of five smoke compartments at the main hospital building. This could potentially result in the AHJ (both the Department of Public Health and Local Fire Authority) being unable to exercise oversight and first responders being unaware that the building is unprotected by the shut down.

Findings:

During record review on 6/18/12, at 2:00 p.m., documentation for an approved fire watch did not provide guidance to notify the AHJ during a shut down of the sprinkler system lasting four or more hours in a 24 hour period. Documentation from the Policy and Procedure Safety 5.01 Fire Control Plan titled "Fire Watch" stated that in the event that the fire alarm system fails, a Fire Watch will be initiated until such time that the alarm system is operational. Engineering Staff confirmed that the policy provided did not include notification.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the fire alarm system is out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation provided for the notification of the AHJ. This affected all staff and patients in five of five smoke compartments at the main hospital building. This could potentially result in the AHJ (both the Department of Public Health and Local Fire Authority) being unable to exercise oversight and first responders being unaware that the building is unprotected by the shut down.

Findings:

During record review on 6/18/12, at 2:00 p.m., documentation for an approved fire watch did not provide guidance to notify the AHJ during a shut down of ther fire alarm system lasting four or more hours in a 24 hour period. Documentation from the Policy and Procedure Safety 5.01 Fire Control Plan titled "Fire Watch" stated that in the event that the fire alarm system fails, a Fire Watch will be initiated until such time that the alarm system is operational. Engineering Staff confirmed that the policy provided did not include notification.

Based on observation, the facility failed to install alcohol-based hand rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition. This was evidenced by ABHR dispensers located near an electrical box. This finding affected one of five smoke compartments at the main hospital building and one of five outpatient buildings. This could potentially result in the ignition of fire.

Where Alcohol Based Hand Rub (ABHR) dispensers are installed:
The corridor is at least 6 feet wide
The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)
The dispensers shall have a minimum spacing of 4 ft from each other
Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.
Dispensers are not installed over or adjacent to an ignition source.
If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

Findings:

During a tour of the facility with Engineering Staff on, ABHR dispensers were observed.

Main Hospital
1. On 6/19/12, at 4:36 p.m., the Radiology Reading Room had an ABHR dispenser located approximately three inches adjacent to and five inches above a light switch. Staff confirmed the location of the dispenser.

Specialty Office 1310 Prentice Drive Suite D
2. On 6/20/12 there was an ABHR dispenser located approximately 30 inches above a plug receptacle in the Reception Entry area of the Office.

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire. This was evidenced by unsealed penetrations observed in the fire-rated sheeting. This affected all staff and patients in two of five smoke compartments at the main hospital building and two of five outpatient buildings. This could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

Findings:

During a tour of the facility with the Engineering Staff, penetrations were observed in the wall sheeting which could potentially result in the spread of smoke and/or fire.

Main Hospital Building
1. On 6/19/12, at 4:25 p.m., the Med. Surg. Lounge had a one inch unsealed pentration in the northeast corner of the wall near the ceiling caused by a cable traveling through the wall.

Healsburg Primary Care 1312 Prentice Drive
2. On 6/19/12, at 10:25 a.m., the I.T. Room had a three inch unsealed penetration in the ceiling caused by data cables traveling through the wall.

3. On 6/19/12, at 11:10 a.m., the outside Electrical Room had a one and one-half inch unsealed penetration in the upper right hand corner near the ceiling.

Blood Draw/Physical Therapy Cloverdale
4. On 6/20/12, at 11:03 a.m., there were two unsealed penetrations in a closet in the south west room of the building. One penetration was in the ceiling and was twelve inches by twelve inches in size. The other penetration was eight inches by twelve inches in size and was in the same closet near the floor. Engineering Staff stated that repairs were being made by the owner of the building.


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Main Hospital Building
5. On 6/19/12, at 10:25 a.m. in the Telephone Room, there were 2 pipes with 4 telephone cable wires running through the orifice of each pipe. The orifice of Pipe #1 measured 2 inches in diameter. The orifice was unsealed. The orifice of Pipe #2 measured 1 ½ inches in diameter. The orifice was unsealed.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in one of five outpatient service buildings and could potentially result in the spread of smoke and/or fire to other areas of the facility.

Findings:

Healdsburg Primary Care 1312 Prentice Drive
During a tour of the facility with Engineering Staff on 6/19/12, doors were inspected throughout the facility.

1. At 10:25 a.m., the door to the I.T. Room did not positive latch when tested.

2. At 10:30 a.m., the door from the Laboratory to Medical Records did not positive latch when tested.

3. At 10:35 a.m., the corridor door to the Laboratory was being held open by a door wedge.

4. At 10:40 a.m.., the corridor door to the Laboratory on the Family Practice side of the Primary Care Building was missing.

5. At 10:43 a.m. the Assistant Manager's Office door did not positive latch when tested.

6. At 10:52 a.m., the Staff Break Room had both corridor doors propped open with door wedges.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of its smoke/fire barrier walls in accordance with 2000 NFPA 101. This was evidenced by observed unsealed penetrations. This affected four of five smoke compartments at the main hospital building and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Engineering Staff on 6/20/12, smoke/fire barrier walls were inspected throughout the facility.

Main Hospital Building
1. At 1:41 p.m., the fire barrier wall in the attic located near Materials Management had two unsealed penetrations in the wall. One penetration was an approximately one inch hole that was drilled through the wall near a red four inch junction box. The other penetration was an approximately one-half inch wide space around grey, yellow, and orange data cables traveling through the wall.

2. At 1:55 p.m., the fire barrier wall in the attic near the Conference Room had three half inch round unsealed penetration above the ceiling joists in the middle of the wall.

3. At 2:06 p.m., the fire barrier wall in the attic near X-Ray had an approximately three inch sleeve to the right of the attic access door that was open on the end.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and were not equipped with self-closing mechanisms on the doors. This affected two of five smoke compartments at the main hospital building and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Engineering Staff, hazardous area enclosures were inspected.

Main Hospital Building
1. On 6/19/12, at 4:11 p.m., the Medical Records/Copy Room did not have a self-closing door. When asked, Engineering Staff stated that the closure had just been removed the day before.


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2. On 6/19/12, at 10:55 a.m., there was no self-closing mechanism on the door to the Dietary Dry Storage. The storage room measured approximately 14 ' by 14 ' , and contained items stored in cardboard boxes.

Based on observation and interview, the facility failed to ensure that exits are readily accessible at all times in accordance with 2000 NFPA 101. This was evidenced by patient room doors that were equipped with a double-action latching devices and no key readily available to unlock the doors in an emergency. This was also evidenced by two exit doors that were equipped with dead bolt locks. This affected all staff and patients in one of five outpatient buildings and could potentially result in a delayed egress in the event of an emergency.

7.2.1.5 Locks and Latches.
7.2.1.5.1 Doors shall be arranged to be opened readily from the egress side whenever the building is occupied. Locks, if provided, shall not require the use of a key, a tool, or special knowledge or effort for operation from the egress side.

7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

39.2.2.2.2* Locks complying with Exception No. 2 to 7.2.1.5.1 shall be permitted only on principal entrance/exit doors.

Exception No. 2: Exterior doors shall be permitted to have key-operated locks from the egress side, provided that the following criteria are met:
(a) Permission to use this exception is provided in Chapters 12 through 42 for the specific occupancy.
(b) On or adjacent to the door, there is a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high on a contrasting background that reads as follows:

THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED

(c) The locking device is of a type that is readily distinguishable as locked.
(d) A key is immediately available to any occupant inside the building when it is locked.
Exception No. 2 shall be permitted to be revoked by the authority having jurisdiction for cause.

3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.

Findings:

Lab Draw and Physical Therapy at 106 East First Street Cloverdale
During a tour of the facility with Engineering Staff on 6/20/12, egress from the building to the public way was observed.

1. At 10:55 a.m., the north exit door leading from the reception area through the first floor stair landing to the exit door to the outside had a deadbolt lock on each door. The exit door from the reception area to the stairwell was equipped with a doorknob with no latching hardware. Above the doorknob was a deadbolt lock. The door leading from the stairwell to the outside was equipped with a double-action locking mechanism as well as a deadbolt lock. This door leading directly to the outside from the landing had a sign above the door stating that the door was to remain unlocked during business hours. The door leading from the reception area to the landing did not have a sign stating that it was to remain unlocked during business hours. Engineering staff stated that the upstairs was occupied by another tenant.

These doors required special knowledge to unlock the doors from the egress side, if the doors were locked.

2. At 11:03 a.m., the northeast Patient Room and the south Blood Draw Room had double- action locking hardware that was keyed on the nonegress side of the doors. When Staff was asked to provide a key to unlock the doors in an emergency, staff was unable to find a key. Later, at the end of the survey at 11:15 a.m., Staff stated to this surveyor that the key had been found to unlock the doors.

Based on observation, document review, and interview, the facility failed to test and maintain all exit signs in accordance with 2000 NFPA 101. This was evidenced by the lack of documentation of monthly and annual testing of the exit signs and exit signs that were not continuously illuminated tested. This could result in exit signs failing to guide the occupants of the building to safety during a fire emergency or power outage. This affected one of five smoke compartments at the main hospital building and one of five outpatient service buildings.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During Document Review, records of exit sign testing were requested.

Wound Center
1. On 6/18/12, at 2:00 p.m., the facility failed to provide documentation for monthly and annual testing of exit signs and the battery-powered task light for the Wound Center. Staff said they thought that the signs and back-up light were being tested, but that documentation was not available.

During a tour of the facility with Engineering Staff, the exit signs were inspected.

2. On 6/19/12, at 1:20 p.m., the exit sign located near the Physicians Copy Machine did not stay illuminated when the exit sign was tested by pushing the test button.

3. On 6/19/12, at 1:30 p.m., the exit sign located near the Fire Alarm Control Panel Closet did not stay illuminated when tested by pushing the test button.

During a tour of the facility with Engineering Staff, exit signs were inspected.

Main Hospital Building
4. On 6/19/12, at 4:45 p.m., the exit sign located in the X-Ray Reception Room was not illuminated.

Based on record review and interview, the facility failed to train all staff in the use of, and response to, fire alarms in accordance with 2000 NFPA 101. This was evidenced by a lack of documentation provided for two of four required fire drills at five of five offsite buildings in a twelve month period. This affected all staff and patients at five of five outpatient services buildings and could potentially result in staff not being trained and familiar with emergency procedures.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

Findings:

1. During document review on 6/18/12, at 2:00 p.m., the facility failed to provide documentation of fire drills for the third and fourth quarter of 2011 at all of its offsite outpatient locations. Engineering Staff stated that engineering personnel had started doing the fire drill trainings at the offsite locations as of in January of 2012. Staff stated that there were no documented training in 2011.

Based on document review and interview, the facility failed to maintain its fire alarm system in in accordance with NFPA 72 of the National Fire Alarm Code. This was evidenced by a lack of current documentation for the Annual Alarm Certification. This affected all staff and patients at one of five outpatient buildings and could potentially result in the alarm system not functioning properly in the event of a fire.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer ' s recommendations, and shall verify correct operation of the fire alarm system.

7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner ' s designated representative shall be informed of the impairment in writing within 24 hours.

Findings:

During record review on 6/18/12, at 2:00 p.m., documentation was requested for the most recent Annual Alarm Certification by a certified vendor.

Healdsburg Primary Care 1312 Prentice Drive, Healdsburg
1. At 2:00 p.m., the facility failed to provide a current Annual Alarm Certification.
During a tour of the facility on 6/19/12, the inspection sticker located on the Fire Alarm Control Panel had an inspection date of 4/2008. Staff stated that an inspection would be scheduled.

Based on observation, record review, and staff interview, the facility failed to periodically test its automatic sprinkler system in accordance with 2000 NFPA 101 and 1998 NFPA 25. This was evidenced by the failure to provide current documentation for the annual and quarterly sprinkler inspections of its automatic sprinkler system. This was evidenced by sprinklers that were loaded, corroded, or painted, or lacked proper clearance. This was also evidenced by the failure to provide a sprinkler wrench in the spare sprinkler box. This affected one of five smoke compartments at the main hospital building and two of two sprinklered outpatient buildings and could cause the sprinkler system to fail to function as designed resulting in the spread of smoke and/or fire.

4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance Item Activity Frequency Reference
Gauges (dry, preaction deluge systems) Inspection Weekly/monthly 2-2.4.2
Control valves Inspection Weekly/monthly Table 9-1
Alarm devices Inspection Quarterly 2-2.6
Gauges (wet pipe systems) Inspection Monthly 2-2.4.1
Hydraulic nameplate Inspection Quarterly 2-2.7
Buildings Inspection Annually (prior to freezing weather) 2-2.5
Hanger/seismic bracing Inspection Annually 2-2.3
Pipe and fittings Inspection Annually 2-2.2
Sprinklers Inspection Annually 2-2.1.1
Spare sprinklers Inspection Annually 2-2.1.3
Fire department connections Inspection Table 9-1
Valves (all types) Inspection Table 9-1
Alarm devices Test Quarterly 2-3.3
Main drain Test Annually Table 9-1
Antifreeze solution Test Annually 2-3.4
Gauges Test 5 years 2-3.2

2-4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers. One sprinkler wrench shall be provided for each type of sprinkler installed.

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

NFPA 13, 1999 edition
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During record review on 6/18/12, documentation was requested for testing and maintenance of the automatic sprinkler system.

Healdsburg Primary Care 1312 Prentice Drive, Healdsburg
1. At 2:00 p.m., the facility failed to provide the current documentation for the annual or quarterly sprinkler inspections.
During a tour of the facility on 6/19/12, at 11:15 a.m., the date on the riser indicated that the last annual inspection was performed on 4/2008.

Wound Care and Physical Therapy 1540 Healdsburg Ave
2. At 2:00 p.m., the facility failed to provide the current documentation for the annual or quarterly sprinkler inspections.

During a tour of the facility with Engineering Staff on 6/19/12, the date on the riser indicated that the last annual inspection was performed during the five year sprinkler certification on 12/2/08.

Maintenance Staff stated that they would contact the vendor and if the testing had been done, the documentation would be provided to this surveyor.

Main Hospital Building


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3. At 10:30 a.m., 2 boxes of " Disaster Phones " were stored approximately 9 inches below the deflector in the Disaster Supply Room.

4. At 10:45 a.m., remnants of plastic were observed on 1 of 2 deflectors in the Soiled Linen Room near the Loading Dock.

5. At 10:58 a.m., the sprinkler wrench was missing from the spare sprinkler box.

6. At 10:58 a.m., there was only 1 spare sidewall sprinkler in the spare sprinkler box.

7. At 11:04 a.m., the sprinkler in the kitchen ' s walk-in freezer was corroded, loaded with debris, and missing an escutcheon ring.

8. At 11:05 a.m., 2 of 2 sprinklers in the kitchen ' s prep area were loaded with grease and debris.

9. At 11:08 a.m., 2 of 2 sprinklers in the ceiling above the stove were loaded with grease and debris.

10. At 11:09 a.m., 2 of 2 sprinklers in the kitchen ' s dishwashing area were loaded with grease and debris.

11. At 11:14 a.m. in the Cafeteria above the food line area, there was paint on the sprinkler ' s deflector.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by eleven portable fire extinguishers that were stored unsecured. This could result in an increased risk of fire.


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.

Findings:

During a tour of the facility on 6/19/12, fire extinguishers were observed.

Main Hospital Building
1. At 11:35 a.m., there were eleven unmounted fire extinguishers on the floor of the New Electrical Room. The Director of Plant Operations stated that the fire extinguishers were spares.

Based on record review, observation, and interview, the facility failed to maintain its heating, ventilation, and air conditioning system, in accordance with NFPA 90A. This was evidenced by a lack of documentation provided for damper inspections. This finding affected one of five smoke compartments at the Main Hospital Building and could potentially result in the spread of smoke and/or fire.

9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A 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 a review of the facility's documentation on 6/18/12, at 10:45 a.m., the facility failed to provide documentation indicating that dampers had been inspected within the last six years.
Engineering Staff stated that the fire alarm vendor does inspects the electric powered dampers. No documentation, however, was provided that identified damper location, which dampers were inspected, if the damper opened and closed fully during the inspection or if any had been replaced.

1. During an inspection of the fire barrier walls on 6/20/12, between 1:44 and 2:06 p.m., dampers were observed in the ceiling registers in the corridor near the Kitchen. One damper was identified as a "Fire Marshall 30 ASR".

Based on record review and interview, the facility failed to maintain its cooking facilities in accordance with 1998 NFPA 96. This was evidenced by a lack of documentation for inspection and cleaning of its kitchen hood by a professional company. This affected one of five smoke compartments at the main hospital building and could potentially result in the spread of smoke and/or fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations

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

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

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

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

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

Findings:

During record review on 6/18/12, documentation of hood inspection and cleaning was requested. When asked, Engineering Staff stated that the Kitchen hood system was cleaned in-house, and that a professional cleaning company was not used

1. Documentation provided for the annual and semi-annual hood fire suppression system inspection and maintenance dated 11/10/11 and 6/14/12 was reviewed. Documentation did not state if the Kitchen hood ventilation system was being inspected throughout for grease build-up. The report dated 11/10/11 did state "need to clean filters".

Based on observation, the facility failed to protect its medical gas storage areas in accordance with 1999 NFPA 99. This was evidenced by cylinders which were not secured individually in a storage locations and by electrical fixtures that were lower than five feet from floor level. This affected two of two oxygen storage locations at the Main Hospital and could potentially result in injury or damage to cylinders, manifolds, or piping if cylinders were to fall. This could also result damage to electrical fixtures if cylinders were to fall.

NFPA 99, 1999 edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4-3.5.2 Gas System Policies-Level 1.

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers-Level 1.
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage.
8-3.1.11 Storage Requirements.
8-3.1.11.1 Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2. 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(h) Cylinder or container restraint shall meet 4-3.5.2.1 (b) 27.

Findings:

During a tour of the facility with Engineering Staff, oxygen storage locations were inspected.

Main Hospital Building
1. On 6/19/12, at 10:21 a.m., the Bulk Oxygen Storage located south the Main Hospital Entrance had twelve H size oxygen cylinders that were secured together to a metal fence with one rope. Staff confirmed the observation and said that they could be individually secured.


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2. On 6/19/12, at 10:58 a.m., oxygen storage was located in the facility ' s Riser Room. The light switch was mounted 48 inches from its operable part to the floor.

Based on record review, observation, and interview, the facility failed to maintain all parts of its piped-in medical gas system in accordance with 1999 NFPA 99. This was evidenced by a written deficiency in the medical gas certification report that had not been repaired. This finding affected staff and patients in three of five smoke compartments at the Main Hospital Building and could potentially result in the medical gas system not functioning as designed.

Findings:

During document review on 6/18/12, documentation provided for the 2011 medical gas certification report was reviewed.

1. At 2:00 p.m., documentation titled "Medical Gas PM Inspection 10/11/2011 Punch List", listed the following components as being in need of maintenance:

A. OR 1 Hose A Vacuum Reduced Flow.
B. OR 2 Hose A Vacuum leaks without adapter, reduced flow.
C. Warning Alarm Rooms 103,104, 105, and Billing Department Oxygen and Vacuum Area Labelling.
D. Warning Alarm Same Day Surgery Vacuum Indicator light out.

When asked about the discrepancies, Staff stated that the medical gas vendor had been contacted and would be at the facility on Wednesday.
On 6/20/12, the med gas vendor was observed at the facility and documentation was later provided indicating that the discrepancies had been been repaired.

Based on document review and interview, the facility failed to protect it anesthetizing locations in accordance with 1999 NFPA 99.
This was evidenced by the failure to monitor its relative humidity to insure that it is maintained equal to or greater than 35 percent.
This was also evidenced by the failure to provide battery-powered emergency lighting units in anesthetizing locations. This affected one of five smoke compartments within the facility and could potentially result in the ignition of fire due to electrostatic charges or other heat generating equipment in an oxygen-rich environment. This could also potentially result in a loss of lighting in the Operating Room during surgical procedures within the ten seconds of time that is allowed for the back-up generator to transfer power during power outages (or longer, if the generator fails to start).

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

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

NFPA 99 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:

During record review with Engineering Staff on 6/20/12, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
1. At 8:30 a.m., Engineering Staff stated that the relative humidity in the Operating Rooms had not been documented in the past. Staff also stated that the facility had developed a form to use to monitor the humidity in the Operating Rooms and provided that form to this surveyor.
During a tour of Operating Room 1 at 10:00 a.m., a humidity gauge was observed on the wall which indicated that the humidity was 68 percent. Observation of another gauge in an adjacent room indicated 67 percent humidity.

2. At 10:05 a.m., this surveyor observed that there were no battery-operated task lights in Operating Room 1 on the wall. Operating Room Staff stated that the anesthesia machine, has a battery back-up light and there is also a flash light attached to the machine. Both Engineering Staff and OR Staff agreed that there were no battery-operated task lights mounted to the walls or in the ceiling fixtures of the Operating Rooms.

Based on document review and interview, the facility failed to maintain its emergency generator in accordance with 1999 NFPA 99. This was evidenced by the generator failing to transfer power within the required 10 seconds. This affected all staff and patients within the main hospital building and could potentially result in a delay in power to areas of critical need.

3-4.3 Performance Criteria and Testing (Type 1 EES).
3-4.3.1 Source. The branches of the emergency system shall be installed and connected to the alternate power source specified in 3-4.1.1.2 and 3-4.1.1.3 so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source.

Findings:

During record review, on 6/18/12, generator monthly full load tests logs were reviewed.

1. At 2:00 p.m., generator logs indicated that the time that it took for the generator to start and transfer the building load to the generator was greater than 10 seconds.

Log readings were as follows:
December 2011 transfer time was 12.09 seconds
January 2012 transfer time was 11.0 seconds
February 2012 transfer time was 12.81 seconds
March 2012 transfer time was 12.43 seconds
April 2012 transfer time was 11.27 seconds
May 2012 transfer time was 11.65 seconds

When asked, Engineering Staff stated that after the generator annunciator was installed the transfer times were recorded automatically by the instrumentation. Staff also stated that the generator vendor had been called and would be at the facility by 5:30 p.m..

Documentation from the vendor in the form of a scanned document was e-mailed to this surveyor on 6/21/12 at 10:29 a.m.. This documentation indicated that the time delay had been adjusted and the generator was transferring power in less than 10 seconds.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70 and 1999 NFPA 99. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, and improper clearance in front of an electrical panel. This affected all staff and patients in three of five smoke compartments at the main hospital building and one of five outpatients service Buildings and could potentially result in the ignition of fire.

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

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

110-26 (a) A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less

Findings:

During a tour of the facility with Engineering Staff on 6/19/12, electrical wiring and equipment were observed.

Healdsburg Primary Care 1312 Prentice Drive
1. At 10:52 a.m., there was a microwave oven plugged into a power strip in the Staff Lounge.

2. At 10:57 a.m., the Family Practice Office had a power strip suspended above the floor applying tension to the joint and terminals.

3. At 11:12 a.m., there were cardboard boxes, a scale, and two E size oxygen tanks that were stored in front of the building's main electrical panels.

Main Hospital Building
4. At 4:07 p.m., Office 105 had a power strip plugged into another power strip.

5. At 4:17 p.m., the Business Office had a power strip plugged into another power strip.


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6. At 10:50 a.m., there were 2 power strips in the Dietary Manager ' s office. Power Strip # 1 with computer equipment plugged into it, was connected to Power Strip #2, also with computer equipment plugged into it.

7. At 11:25 a.m., there were 2 power strips in the Occupational Medicine RN ' s office. Power Strip #1, with a task light and computer equipment plugged into it, was connected to Power Strip #2. No devices were plugged into Power Strip #2.

8. At 1:08 p.m., there were 2 power strips in the Human Resource Assistant I ' s office. Power Strip #1, with computer equipment plugged into it, was connected to Power Strip #2, which had a pencil sharpener and an adding machine plugged into it.

9. At 1:58 p.m., the power strip in the IT Closet (Closet 4) across the hall from the OR Nurses ' Lounge was suspended approximately 34 inches above the floor. A UPS and 2 routers were plugged into the power strip.

10. At 2:01 p.m., a coffee maker, coffee bean grinder, and a microwave oven were plugged into a power strip in the OR Nurses ' Lounge.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the automatic sprinkler system is out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation provided for the notification of the AHJ. This affected all staff and patients in five of five smoke compartments at the main hospital building. This could potentially result in the AHJ (both the Department of Public Health and Local Fire Authority) being unable to exercise oversight and first responders being unaware that the building is unprotected by the shut down.

Findings:

During record review on 6/18/12, at 2:00 p.m., documentation for an approved fire watch did not provide guidance to notify the AHJ during a shut down of the sprinkler system lasting four or more hours in a 24 hour period. Documentation from the Policy and Procedure Safety 5.01 Fire Control Plan titled "Fire Watch" stated that in the event that the fire alarm system fails, a Fire Watch will be initiated until such time that the alarm system is operational. Engineering Staff confirmed that the policy provided did not include notification.

Based on document review and interview, the facility failed to provide a written protocol to insure that if the fire alarm system is out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified. This was evidenced by a lack of documentation provided for the notification of the AHJ. This affected all staff and patients in five of five smoke compartments at the main hospital building. This could potentially result in the AHJ (both the Department of Public Health and Local Fire Authority) being unable to exercise oversight and first responders being unaware that the building is unprotected by the shut down.

Findings:

During record review on 6/18/12, at 2:00 p.m., documentation for an approved fire watch did not provide guidance to notify the AHJ during a shut down of ther fire alarm system lasting four or more hours in a 24 hour period. Documentation from the Policy and Procedure Safety 5.01 Fire Control Plan titled "Fire Watch" stated that in the event that the fire alarm system fails, a Fire Watch will be initiated until such time that the alarm system is operational. Engineering Staff confirmed that the policy provided did not include notification.