HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by a penetration in the wall. This could result in the passage of smoke in the event of a fire, and affected one of three floors in the Park Pavilion.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/07/13, the walls and ceilings were observed.

Park Pavilion
1. On 8/7/13, at 12:20 p.m., in the Park Pavilion in the Basement, there was an approximately 2 1/2 inch penetration in the wall around a pipe, in the Telephone/Equipment Room.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the ceiling and walls. This could result in the passage of smoke in the event of a fire, and affected two of five floors in the New Main Building.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/8/13, the walls and ceilings were observed.

1. On 8/8/13, at 11:20 a.m., there was an approximately 1/8 inch penetration in the ceiling around a pipe, in Housekeeping across from Operating Room 5.



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During a tour of the facility with the Cheif Administrative Services Officer, on 8/07/13, the walls and ceilings in the facility were observed.

New Main Hospital Building
2. At 2:15 p.m., on the 1st floor, IC3 Low Voltage Room, there were four penetrations around four pipes. Each penetration measured approximately 1".

3. At 3:15 p.m., on the Ground Floor, in room #GA030 Low Voltage Room, the cover plate for a junction box near the door was missing.

Based on observation, the facility failed to maintain the integrity of the building's construction. This was evidenced by a penetration in the ceiling. This could result in the passage of smoke in the event of a fire, and affected 1 of 7 smoke compartments on the First Floor in the El Camino Hospital Los Gatos.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager 8/6/13, the walls and ceilings were observed.

El Camino Hospital Los Gatos
1. On 8/6/13, at 9:25 a.m., there was an approximately 1/4 inch penetration in the ceiling around a pipe, in the bathroom of Room 1014.

Based on observation and interview, the facility failed to maintain its corridor doors. This was evidenced by corridor doors that failed to close and positively latch. This could result in the passage of smoke in the event of a fire, and affected two of five floors in the New Main Building.

NFPA 101, Life Safety Code, 2000 Edition
18.3.6.3* Corridor Doors.
18.3.6.3.1* Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets,
and similar auxiliary spaces that do not contain flammable or
combustible materials.

Findings:

During a facility tour with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/8/13, the corridor doors were observed.

New Main Building
1. On 8/8/13, at 10:25 a.m., on the Ground Floor, the double door to the Kitchen entrance was equipped with a self-closing device. The left leaf of the door failed to close and positively latch when tested. Upon interview, the Chief Engineer stated that the closing sequence was off, and the door was not on automatic mode because of an incoming delivery.

2. On 8/8/13, at 11:01 a.m., on the 2nd floor, the door to the Operations Room Control Desk 2A308 was equipped with a self-closing device. The door failed to close and positively latch when tested.

Based on observation and interview, the facility failed to maintain the corridor doors, as evidenced by corridor doors that failed to close and positively latch, and by a door that was obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected 3 of 6 smoke compartments on the First Floor, two of eight floors in the El Camino - Old Main Building, one of three floors in the Women's Hospital, one of two floors in the Willow Pavilion, and one of two floors in the Park Pavilion.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager between 8/5/13, and 8/7/13, the corridor doors were observed.

El Camino Hospital - Old Main
1. On 8/5/13, at 1:43 p.m., on the 1st floor, the door to the Behavioral Health office failed to close and positively latch when tested.

2. On 8/5/13, at 1:46 p.m., on the 1st floor, the door to the Occupational Therapy Room failed to close and positively latch when tested.

3. On 8/5/13, at 2:05 p.m., on the 1st floor, the door to the Director of Security Office was equipped with a self-closing device. The door failed to close and positively latch when tested. Staff confirmed the door did not close and positively latch when tested.

4. On 8/5/13, at 2:43 p.m., on the Ground floor, the door to the receiving office was equipped with a self-closing device. The door failed to close and positively latch when tested.

Women's Hospital
5. On 8/7/13, at 9:35 a.m., in the Women's Hospital on the 1st floor Labor and Delivery Room 5, the door failed to latch.

6. On 8/7/13, at 9:37 a.m., in the Women's Hospital on the 1st floor, the door to Storage Room 4 located in Labor and Delivery was equipped with a self closing device. The self closing device hinge was disconnected.

7. On 8/7/13, at 9:39 a.m., in the Women's Hospital on the 1st floor Labor and Delivery Room 9, the door failed to close and positively latch when tested.

8. On 8/7/13, at 9:40 a.m., in the Women's Hospital on the 1st floor Laboratory and Delivery Room 11, the door failed to close and positively latch when tested.

9. On 8/7/13, at 9:43 a.m., in the Women's Hospital on the 1st floor Labor and Delivery Room 12, the door failed to close and positively latch when tested.

10. On 8/7/13, at 10:00 a.m., in the Women's Hospital on the 1st floor, the door to Storage Room by the Lactation Room failed to positively latch when tested.

Willow Pavilion
11. On 8/7/13, at 11:40 a.m., in the Willow Pavilion on the 2nd floor, the door to Consult/Exam Room 2 was equipped with a self closing device. The self closing device hinge was disconnected.

Park Pavilion
12. On 8/7/13, at 12:22 p.m., in the Park Pavilion in the Basement, the door to Meeting Room L failed to close and positively latch when tested.

13. On 8/7/13, at 12:40 p.m., in the Park Pavilion on the 2nd floor, the door to the Women's Public Restroom by the lobby was equipped with a self-closing device. The door failed to close and positively latch when tested.

14. On 8/7/13, at 12:41 p.m., in the Park Pavilion on the 2nd floor, the door to the Men's Public Restroom by the lobby was equipped with a self-closing device. The door failed to close and positively latch when tested.



27254

Old Main Building
15. On 8/05/13, at 1:53 p.m., on the 1st floor, in the Endoscopy Physician's work room, the self closing door to the room was held open with a door wedge.

Based on observation, the facility failed to maintain its corridor doors. This was evidenced by corridor doors that failed to close and positively latch. This could result in the passage of smoke in the event of a fire, and affected 4 of 7 smoke compartments on the First Floor in El Camino Hospital Los Gatos.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager 8/6/13, the corridor doors were observed.

El Camino Hospital Los Gatos
1. On 8/6/13, at 9:32 a.m., on the 1st floor, the door to Room 1015 failed to latch.

2. On 8/6/13, at 9:34 a.m., on the 1st floor, the door to Room 1017 failed to latch.

3. On 8/6/13, at 9:36 a.m., on the 1st floor, the door to Room 1019 failed to close and positively latch when tested.

4. On 8/6/13, at 10:05 a.m., on the first floor, the door to the Nutrition Female Staff Bathroom failed to close and positively latch when tested.

5. On 8/6/13, at 10:09 a.m., on the 1st floor, the door to Clean Linen was equipped with a self-closing device. The door failed to close and positively latch when tested.

6. On 8/6/13, at 10:15 a.m., on the 1st floor, the door to Room 1063 failed to latch.

7. On 8/6/13, at 10:30 a.m., on the 1st floor, the door to the Housekeeping Office by Medical Surge Overflow Station failed to close and positively latch when tested.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as evidenced by failure of the fire doors to release upon activation of the manual pull stations. This condition affected all smoke compartments on five of five floors in the New Main Hospital Building, and could result in the passage of smoke from one compartment to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
18.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.


Findings:

During fire alarm testing with the Chief Administrative Services Officer and Chief Engineer on 8/08/13, the fire doors were observed during fire alarm testing.

Between 9:00 a.m., and 12:30 p.m., upon activation of the manual pull station on the 4th floor, the fire doors in the designated zone failed to release and close. The Chief Administrative Services Officer, stated that the fire doors were not designed to release with the activation of the manual pull station. The fire doors did release with the activation of the smoke detectors and the water flow devices.

Based on observation and staff interview, the facility failed to maintain the doors that were held open by magnetic devices arranged to automatically close the doors upon activation of the fire alarm, smoke detection, and automatic sprinkler system. This was evidenced by the failure of the fire doors to automatically release from the magnetic hold open devices and close upon activation of the fire alarm system manual pull stations. This condition affected all smoke compartments on three of five floors in the Women's Hospital, and one floor in the Locked Psychiatric Unit, and could result in the passage of smoke from one compartment to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During fire alarm testing with the Chief Engineer and Facilities Services Manager on 8/07/13, between 10:30 a.m., and 12:00 p.m., the facility fire doors were observed.

1. Upon activation of the manual pull station on the 2nd floor, the fire doors in the designated zone failed to release and close. There were 9 fire doors on the 1st Floor, 1 fire door on the 2nd floor and 1 fire door on the 3rd floor that failed to release and close with the activation of the pull stations. The Chief Administrative Services Officer stated that the fire doors were not designed to release with the activation of the manual pull station. The fire doors did release with the activation of the smoke detectors and the water flow devices.



27254

During fire alarm testing with the Chief Administrative Services Officer, and the Chief Engineer on 8/07/13, the facility's fire doors were observed.

Old Main Building
1. At 12:13 p.m., on the 1st floor in the Locked Behavioral Unit, the double fire doors between room 110 and room 111 failed to release upon activation of the fire alarm system. The doors were not connected to the facility's fire alarm system, and only released upon activation of the door smoke detectors. The door smoke detectors did not activate the facility's fire alarm system.

Based on observation, the facility failed to maintain their smoke barrier walls free from penetrations. This was evidenced by penetrations in two smoke barrier walls. This affected four of seven smoke compartments on the first floor in El Camino Hospital - Los Gatos, and could result in the spread of fire and smoke to nearby smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
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

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/8/13, the smoke barrier walls were observed.

El Camino Hospital Los Gatos
1. On 8/8/13, at 2:37 p.m., in El Camino Hospital Los Gatos on the 1st floor, there was an approximately 1/8 inch penetration around a pipe in the smoke barrier wall by the Respiratory Therapy Office.



27254

During a tour of the facility with the Chief Administrative Services Officer on 8/08/13, the smoke barrier walls at El Camino Hospital - Los Gatos were observed.

2. At 2:40 p.m., the smoke barrier wall by Cafe El Gato had a one inch penetration around a pipe passing through the wall. The fire caulking had separated from the wall, and exposed the penetration.

Based on observation and interview, the facility failed to maintain fire doors, as evidenced by fire doors that did not fully close and latch, and by fire doors that were obstructed. These deficient conditions affected two of two occupied floors in the old Main Building, and could result in the spread of smoke in the event of a fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 80 Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.


Findings:
During a tour of the facility with the Chief Administrative Services Officer and the Chief Engineer, between 8/05/13 and 8/08/13, the facility fire doors were observed.

1. On 8/05/13, at 2:05 p.m., on the 1st floor, in Outpatient Lab lobby, the drop down fire door was obstructed by a plexi brochure holder.

2. On 8/07/13, at 11:47 a.m., by Pre-Procedure Endoscopy Recovery, the left hand fire door to the elevator lobby remained fully open.

3. On 8/07/13, at 12:20 p.m., on the Ground Floor, at the intersection at the North Elevators, the right hand door on to both sets of fire doors failed to release upon activation of the fire alarm system.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by one fire door that did not fully close and latch. This affected one of five floors in the New Main Building, and could result in the spread of smoke and/or fire from one compartment to another.

NFPA 101 Life Safety Code, 2000 edition
7.2.4.3.8* All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
Exception: Where approved by the authority having jurisdiction, existing cross-corridor doors in horizontal exits shall be permitted to be selfclosing.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

On 8/8/13, during fire alarm testing with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager, the fire doors were observed.

On 8/8/13, at 10:40 a.m., on the Ground Floor, the fire door left hand door leaf by the Laboratory Storage did not fully close and latch. The fire door had an approximately 3 inch gap.

Based on observation, the facility failed to maintain the emergency exit, as evidenced by one exit discharge that was obstructed by a shelf mounted on the corridor wall. This affected one of two occupied floors in the Old Main Building and could result in a delayed evacuation in the event of an emergency.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.

7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, on 8/05/13, the exit passages were observed.

At 1:55 p.m., on the 1st floor in the Endoscopy Suite outside of Procedure Room 4, there was a bookshelf mounted on the corridor wall. The shelf was mounted on the wall 5 feet off the ground, and protruded into the corridor approximately 12 inches. The shelf was mounted on the wall near the corridor fire door for the suite.

Based on interview, document review and observation, the facility failed to maintain their emergency lighting, as evidenced by no records found for the monthly, or annual testing of the emergency lighting in the facility operating rooms. This could lead to a malfunction of the emergency lighting in the event of an emergency, and affected ten of ten operating rooms in the Operating Suite located on the 2nd floor of New Main Hospital Building.

NFPA 101 Life Safety Code, 2000 edition
18.2.9 Emergency Lighting.
18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
18.2.9.2 Buildings equipped with or in which patients require the use of life-support systems (see 18.5.1.3) shall have emergency lighting equipment supplied by the life safety branch of the electrical system as described in NFPA 99, Standard for Health Care Facilities.
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 battery-powered emergency lighting system for not less than 1 ? 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.
NFPA 99 Health Care Facilities, 1999 edition
3-3.2.1.2 All Patient Care Areas.
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).


Findings:

During document review with the Chief Administrative Services Officer and the Chief Engineer on 8/05/13, the documentation for the testing of the emergency lights in the operating rooms was requested.

At 11:28 a.m., no documentation for the monthly, or annual testing of the emergency lights in the operating rooms was provided for review. Staff was unable to provide information for the testing of the emergency lights, and stated that the lights were not manually tested. Staff was unsure how the lights were tested.

Based on document review and staff interview, the facility failed to maintain fire drills at the Cancer Center as evidenced by three of four fire drills conducted in the Lab, that failed to include staff signatures from staff in the Cancer Center. This condition affected all staff and patients in the Cancer Center, and could result in the lack of staff knowledge in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
SECTION 4.7* FIRE DRILLS
4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.3 Competency. Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.
4.7.4 Orderly Evacuation. In the conduct of drills, emphasis shall be placed on orderly evacuation rather than on speed.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

During document review with the Chief Administrative Services Officer and the Chief Engineer, on 8/05/13, the fire drill records for the Cancer Center at Melchor Pavilion were requested.

At 11:45 a.m., the fire drill records were reviewed. The three of four fire drill conducted over the past year were conducted in the Lab with Lab staff. There were no signatures from staff in the Cancer Center. During an interview, staff stated that the fire drills were conducted in the Lab and in the Cancer Center and that staff from both Departments participated. No documentation was provided to show the staff from the Cancer Center participated in the Lab fire drills.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills with the activation of the fire alarm system. This condition affected two of two floors, and could result in the lack of staff knowledge in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.


Findings:

During document review with the Chief Engineer on 8/06/13, the fire drill records were reviewed.

At 10:00 a.m., the fire drill records for the El Camino Hospital - Los Gatos failed to indicate which device was activated during the fire drill, and if the fire doors closed. During an interview with Security, staff stated that the fire alarm was not activated during the Morning shift or the Evening shift. During the past year, records indicated that none of the fire drills were conducted with the activation of the fire alarm system.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as evidenced by failure of the fire alarm notification devices to activate on two floors of the building during fire alarm testing. This condition affected two of two floors of the El Camino Hospital - Los Gatos Building, and could result in the failure of occupant notification in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
Exception No. 1:* Elevator lobby, hoistway, and associated machine room smoke detectors used solely for elevator recall, and heat detectors used solely for elevator power shutdown, shall not be required to activate the building evacuation alarm if the power supply and installation wiring to these detectors are monitored by the building fire alarm system, and the activation of these detectors results in an audible and visible alarm signal at a constantly attended location.
Exception No. 2:* Smoke detectors used solely for closing dampers or heating, ventilating, and air conditioning system shutdown shall not be required to activate the building evacuation alarm.
Exception No. 3:* Detectors located at doors for the exclusive operation of automatic door release shall not be required to activate the building evacuation alarm.
Exception No. 4: Detectors in accordance with the exception to 22.3.4.3.1 and the exception to 23.3.4.3.1 shall not be required to activate the building evacuation alarm.
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are
hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
Exception No. 1:* Where total evacuation of occupants is impractical due to building configuration, only the occupants in the affected zones shall be initially notified. Provisions shall be made to selectively notify occupants in other zones to afford orderly evacuation of the entire building.
Exception No. 2: Where occupants are incapable of evacuating themselves
because of age, physical or mental disabilities, or physical restraint, the private operating mode as described in NFPA 72, National Fire Alarm Code, shall be permitted to be used. Only the attendants and other personnel required to evacuate occupants from a zone, area, floor, or building shall be required to be notified. This notification shall include means to readily identify the zone, area, floor, or building in need of evacuation.
Exception No. 3: Notification within the covered mall per 36.4.4.3.3
and 37.4.4.3.3.


Findings:

During fire alarm testing with the Chief Administrative Services Officer on 8/06/13, the fire alarm system at El Camino Hospital - Los Gatos was observed.

Between 1:20 p.m., and 3:00 p.m., when the smoke detector, pull station and water flow devices were tested, the occupant chimes and strobes notification devices on two floors of the building failed to function as designed. The fire alarm system could not be heard in all areas of the building. All of the fire doors released from the magnetic hold-open devices as required. The facility immediately implemented a fire watch, and contacted their vendor. The work order provided by the vendor indicated that a device failed, and caused the system to malfunction. The last annual inspection had been performed on 12/2012, and all devices had passed.

Based on observation, the facility failed to maintain their smoke detectors. This was evidenced by 2 of 5 smoke detectors that failed to initiate the fire alarm system when tested. This affected 1 of 7 smoke compartments at El Camino Hospital - Los Gatos, and could result in a delayed notification of a fire due to a malfunctioning smoke detector.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and
NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 National Fire Alarm Code, 1999 Edition
7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2
13. Initiating Devices (g) Smoke Detectors - The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager between 8/6/13, and 8/8/13, the smoke detectors were tested.

El Camino Hospital - Los Gatos
1. At 1:23 p.m., the smoke detector by Room 1029 located on the first floor failed to initiate the fire alarm system. The smoke detector was retested two times, and failed to initiate the fire alarm system.

2. At 1:28 p.m., the smoke detector by Room 1027 located on the first floor failed to initiate the fire alarm system. The smoke detector was retested two times,and failed to initiate the fire alarm system.

3. On 8/8/13, between 2:15 p.m., to 2:17 p.m., the smoke detectors located on the first floor by Room 1029 and Room 1027 were retested. The smoke detectors initiated the fire alarm system when tested.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system as evidenced by the wrong address for the Inspector's Test Valves provided by the system. This condition affected five of five floors in the New Main Hospital Building, and could result in dealy in notification in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

Findings:

During fire alarm testing with the Chief Administrative Services Officer and the Chief Engineer, on 8/08/13, the fire alarm system was observed.

Between 9:00 a.m., and 11:30 a.m., the fire alarm system in the New Main Building was tested. The Inspector's Test Valve (ITV) on each floor was tested for time and notification to the Fire Alarm Control Panel (FACP). The five ITV's tested all failed to report the correct address location to the fire alarm control panel. The ITV's reported the same address as the Tamper Valves on the floor. During an interview, staff stated that the ITV;s had a different address in the system, and were unsure as to why the address was reporting differently.

Based on observation, the facility failed to maintain the automatic sprinkler system. This was evidenced by paint and/or foreign material on sprinkler heads, by missing escutcheon rings, and by escutcheon rings that were not maintained flush with the ceiling. This could result in the automatic sprinkler system not functioning as designed in the event of a fire, and affected 4 of 7 smoke compartments, and 1 of 3 smoke compartments on the Second Floor in the El Camino Hospital Los Gatos.

NFPA 101 Life Safety Code, 2000 edition
4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
19.3.4.2 Initiation.
Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, Chief Engineer and Facilities Services Manager on 8/6/13, the automatic sprinkler system was observed.

El Camino Hospital Los Gatos
1. On 8/6/13, at 9:28 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was a missing escutcheon ring, in Room 1006.

2. On 8/6/13, at 9:29 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was a missing escutcheon ring, in Room 1003.

3. On 8/6/13, at 9:40 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was foreign material on two of four sprinkler heads, in the Nursery Work Room.

4. On 8/6/13, at 9:45 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/2 inch penetration in the ceiling, in Cardiologist Reading Room.

5. On 8/6/13, at 9:48 a.m., in El Camino Hospital Los Gatos on the 1st floor, there were two escutcheon rings that were not flush to the ceiling, and exposed an approximately 1/4 inch penetrations in the ceiling, in the Sterile Processing Room.

6. On 8/6/13, at 10:03 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in the Admitting restroom.

7. On 8/6/13, at 10:07 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/2 inch penetration in the ceiling, in the Nutrition Male Staff Bathroom.

8. On 8/6/13, at 10:10 a.m., in El Camino Hospital Los Gatos on the 1st floor, there were four of seven escutcheon rings that were not flush to the ceiling, and exposed approximately 1/2 inch penetrations in the ceiling, in the Outpatient Recovery Room.

9. On 8/6/13, at 10:20 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1 1/2 inch penetration in the ceiling, in the Therapy Gym.

10. On 8/6/13, at 10:35 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in the Meditation Room by Critical Care.

11. On 8/6/13, at 10:38 a.m., in El Camino Hospital Los Gatos on the 1st floor, one of four escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in the Emergency Waiting Room.

12. On 8/6/13, at 10:40 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, at the entrance to the Endoscopy area.

13. On 8/6/13, at 10:45 a.m., in El Camino Hospital Los Gatos on the 1st floor, two escutcheon rings were not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, at the ambulance entrance in the Emergency area.

14. On 8/6/13, at 10:47 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was a missing escutcheon ring, in Nuclear Medical Room/ Camera Equipment Room.

15. On 8/6/13, at 11:05 a.m., in El Camino Hospital Los Gatos on the 2nd floor, there was a missing escutcheon ring, in the Recovery Bed 1 area.

Based on observation, the facility failed to maintain the automatic sprinkler system. This was evidenced by paint and/or foreign material on sprinkler heads, by missing escutcheon rings, and by escutcheon rings that were not maintained flush with the ceiling. This could result in the automatic sprinkler system not functioning as designed in the event of a fire, and affected one of five floors in El Camino Hospital - Old Main, one compartment on the Second Floor in the Park Pavilion, one compartment on the First Floor in the Melchor Pavilion.

NFPA 101 Life Safety Code, 2000 edition
4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager between 8/5/13, and 8/7/13, the automatic sprinkler system was observed.

El Camino Hospital - Old Main
1. On 8/5/13, at 2:40 p.m., in the El Camino Hospital - Old Main on the Ground floor, the IT Office across from the old General Storage was missing an escutcheon ring.

Park Pavilion
2. On 8/7/13, at 12:39 p.m., in Park Pavilion on the 2nd floor, there was paint on the sprinkler head, in the Hydrotherapy Room.

Melchor Pavilion
3. On 8/7/13, at 2:05 p.m., in Melchor Pavilion on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in Consultation 4 Room.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable fire extinguisher that was stored unsecured. This affected one of five floors in El Camino Hospital - Old Main, and could result in damage to the portable fire extinguisher.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 10, 1998 Edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with the Chief Engineer and the Facilities Services Manager on 8/5/13, the portable fire extinguishers were observed.

At 1:53 p.m., in the Behavioral Health Clinic, there was an unmounted ABC-type portable fire extinguisher stored unsecured on top of a cabinet across from the Therapy A Room.

Based on observation, the facility failed maintain the relative humidity at equal to or greater than 35% as evidenced by several days in the past year that the humidity in 10 operating rooms dipped below 30%. This deficient practice affected all ten operating/procedure rooms in the Operating Suite.

Findings

During document review on 8/08/13, the Operating Room Humidity reports were reviewed.

At 4:00 p.m., the records provided indicated that the humidity dropped below 35%. Upon staff interview, the Chief Administrative Services Officer stated that the humidity range for the operating rooms was between 20% to 60%. The months of November, 2012; February, 2013; and July, 2013, were reviewed for compliance. Review of the records provided had humidity levels recorded as low at 11.22% in February of 2013. In July of 2013, the humidity dipped below 35% five times in operating rooms 1 and 4. In February 2013, the humidity dipped below 35% four times in operating room 1, and five times in operating room 5.

Based on observation, the facility failed maintain the relative humidity at equal to or greater than 35% as evidenced by several days in the past year that the humidity in 10 operating rooms was below 35%. This deficient practice affected ten of ten operating/procedure rooms in the Operating Suite, in the El Camino Hospital - Los Gatos Building, and could result in an increased risk of fire.

Findings:

During document review on 8/06/13, the Operating Room Humidity reports were reviewed.

At 4:00 p.m., the records provided indicated that the humidity dropped below 35%. Upon staff interview, the Chief Engineer stated that the humidity range for the operating rooms was between 20% to 60%.

In July of 2013, the humidity dipped below 35% five times in operating rooms 1 and 4. In the past year the humidity dropped below 35% 121 days in Operating Rooms 1 - 8. The humidity dropped below 35% on 187 days in the labor and delivery procedure rooms.

Based on interview and observation, the facility failed to maintain the electrical wiring and equipment. This was evidenced by an electrical panel that was obstructed by medical equipment, by the use of power strips as a substitute for fixed wiring, and by power strips that were fixed to the building surfaces. This could lead to a delay in working on the electrical equipment during an emergency, or in an increased risk of an electrical fire. This deficncy affected three of five floors in the New Main Hospital Building.

NFPA 101 Life Safety Code, 2000 edition
Chapter 9 BUILDING SERVICE AND FIRE PROTECTION EQUIPMENT
SECTION 9.1 UTILITIES
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 70, National Electrical Code, 1999 Edition
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space shall be suitably guarded.
800-5. Access to Electrical Equipment Behind Panels Designed to Allow Access. Access to equipment shall not be denied by an accumulation of wires and cables that prevents removal of panels, including suspended ceiling panels.
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with the Cheif Administrative Services Officer on 8/07/13, the electrical wiring in the facility was observed.

1. At 12:10 p.m., on the 3rd floor in Unit 3C across from Room 3322, a power strip was attached to the wall with screws.

2. At 2:46 p.m., on the 1st floor in Imaging ZRoom #1B211, a coffee maker was plugged into a power strip instead of directly into the wall outlet.

3. At 3:05 p.m., on the Ground floor, in Respiratory Therapy Room #GA001, four power strips were attached to the wall with screws. One power strip was attached to the wall, and one power strip was being used for a microwave and a fan.

4. At 3:15 p.m., on the Ground floor, in the Staff Lounge located in Central Supply, a toaster oven, a coffee maker and a water tower were all plugged into one power strip.

Based on interview and observation, the facility failed to maintain their electrical wiring and equipment, as evidenced by the use of power strips as a substitute for fixed wiring. This condition affected two of two occupied floors in the Old Main Building, one smoke compartment in the Basement in Park Pavilion, and could result in the ignition of an electrical fire.

NFPA 101 Life Safety Code, 2000 edition
Chapter 9 BUILDING SERVICE AND FIRE PROTECTION EQUIPMENT
SECTION 9.1 UTILITIES
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with the Chief Administrative Services Officer between 8/05/13, and 8/08/13, the electrical wiring in the facility was observed.

Old Main Building
1. On 8/05/13, at 1:51 p.m., on the 1st floor, in the Endoscopy Physician work room, a television was plugged into a power strip. The power strip was plugged into another power strip, instead of directly into the wall outlet.

2. On 8/05/13, at 1:51 p.m., on the 1st floor, in the Endoscopy Physician work room, a coffee maker was plugged into a power strip instead of directly into the wall outlet.

3. On 8/05/13, at 2:15 p.m., on the 1st floor, in the Endoscopy Admission Nurse's Office, a patient pressure machine was plugged into a power strip instead of directly into the wall outlet.

4. On 8/05/13, at 2:20 p.m., on the Ground Floor, in EKG Room 1, the treadmill was plugged into an extension cord instead of directly into the wall outlet.

5. On 8/05/13, at 2:22 p.m., on the Ground Floor, in EKG Room 5, a refrigerator was plugged into a power strip.

6. On 8/05/13, at 2:36 p.m., on the Ground Floor, in the IT Office, a microwave, a toaster oven, a refrigerator and a coffee machine were plugged into one power strip.



31201

Park Pavilion
1. On 8/7/13, at 12:35 p.m., in the Park Pavilion on the 2nd floor, in the Gym, there were two surge protectors in use. A treadmill, stair stepper and an Upper Cycle machine were plugged into Surge Protector 1, and a Biodex Bike was plugged into Surge Protector 2.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by a penetration in the wall. This could result in the passage of smoke in the event of a fire, and affected one of three floors in the Park Pavilion.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/07/13, the walls and ceilings were observed.

Park Pavilion
1. On 8/7/13, at 12:20 p.m., in the Park Pavilion in the Basement, there was an approximately 2 1/2 inch penetration in the wall around a pipe, in the Telephone/Equipment Room.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the ceiling and walls. This could result in the passage of smoke in the event of a fire, and affected two of five floors in the New Main Building.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/8/13, the walls and ceilings were observed.

1. On 8/8/13, at 11:20 a.m., there was an approximately 1/8 inch penetration in the ceiling around a pipe, in Housekeeping across from Operating Room 5.



27254

During a tour of the facility with the Cheif Administrative Services Officer, on 8/07/13, the walls and ceilings in the facility were observed.

New Main Hospital Building
2. At 2:15 p.m., on the 1st floor, IC3 Low Voltage Room, there were four penetrations around four pipes. Each penetration measured approximately 1".

3. At 3:15 p.m., on the Ground Floor, in room #GA030 Low Voltage Room, the cover plate for a junction box near the door was missing.

Based on observation, the facility failed to maintain the integrity of the building's construction. This was evidenced by a penetration in the ceiling. This could result in the passage of smoke in the event of a fire, and affected 1 of 7 smoke compartments on the First Floor in the El Camino Hospital Los Gatos.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager 8/6/13, the walls and ceilings were observed.

El Camino Hospital Los Gatos
1. On 8/6/13, at 9:25 a.m., there was an approximately 1/4 inch penetration in the ceiling around a pipe, in the bathroom of Room 1014.

Based on observation and interview, the facility failed to maintain its corridor doors. This was evidenced by corridor doors that failed to close and positively latch. This could result in the passage of smoke in the event of a fire, and affected two of five floors in the New Main Building.

NFPA 101, Life Safety Code, 2000 Edition
18.3.6.3* Corridor Doors.
18.3.6.3.1* Doors protecting corridor openings shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closets,
and similar auxiliary spaces that do not contain flammable or
combustible materials.

Findings:

During a facility tour with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/8/13, the corridor doors were observed.

New Main Building
1. On 8/8/13, at 10:25 a.m., on the Ground Floor, the double door to the Kitchen entrance was equipped with a self-closing device. The left leaf of the door failed to close and positively latch when tested. Upon interview, the Chief Engineer stated that the closing sequence was off, and the door was not on automatic mode because of an incoming delivery.

2. On 8/8/13, at 11:01 a.m., on the 2nd floor, the door to the Operations Room Control Desk 2A308 was equipped with a self-closing device. The door failed to close and positively latch when tested.

Based on observation and interview, the facility failed to maintain the corridor doors, as evidenced by corridor doors that failed to close and positively latch, and by a door that was obstructed from closing. This could result in the passage of smoke in the event of a fire, and affected 3 of 6 smoke compartments on the First Floor, two of eight floors in the El Camino - Old Main Building, one of three floors in the Women's Hospital, one of two floors in the Willow Pavilion, and one of two floors in the Park Pavilion.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager between 8/5/13, and 8/7/13, the corridor doors were observed.

El Camino Hospital - Old Main
1. On 8/5/13, at 1:43 p.m., on the 1st floor, the door to the Behavioral Health office failed to close and positively latch when tested.

2. On 8/5/13, at 1:46 p.m., on the 1st floor, the door to the Occupational Therapy Room failed to close and positively latch when tested.

3. On 8/5/13, at 2:05 p.m., on the 1st floor, the door to the Director of Security Office was equipped with a self-closing device. The door failed to close and positively latch when tested. Staff confirmed the door did not close and positively latch when tested.

4. On 8/5/13, at 2:43 p.m., on the Ground floor, the door to the receiving office was equipped with a self-closing device. The door failed to close and positively latch when tested.

Women's Hospital
5. On 8/7/13, at 9:35 a.m., in the Women's Hospital on the 1st floor Labor and Delivery Room 5, the door failed to latch.

6. On 8/7/13, at 9:37 a.m., in the Women's Hospital on the 1st floor, the door to Storage Room 4 located in Labor and Delivery was equipped with a self closing device. The self closing device hinge was disconnected.

7. On 8/7/13, at 9:39 a.m., in the Women's Hospital on the 1st floor Labor and Delivery Room 9, the door failed to close and positively latch when tested.

8. On 8/7/13, at 9:40 a.m., in the Women's Hospital on the 1st floor Laboratory and Delivery Room 11, the door failed to close and positively latch when tested.

9. On 8/7/13, at 9:43 a.m., in the Women's Hospital on the 1st floor Labor and Delivery Room 12, the door failed to close and positively latch when tested.

10. On 8/7/13, at 10:00 a.m., in the Women's Hospital on the 1st floor, the door to Storage Room by the Lactation Room failed to positively latch when tested.

Willow Pavilion
11. On 8/7/13, at 11:40 a.m., in the Willow Pavilion on the 2nd floor, the door to Consult/Exam Room 2 was equipped with a self closing device. The self closing device hinge was disconnected.

Park Pavilion
12. On 8/7/13, at 12:22 p.m., in the Park Pavilion in the Basement, the door to Meeting Room L failed to close and positively latch when tested.

13. On 8/7/13, at 12:40 p.m., in the Park Pavilion on the 2nd floor, the door to the Women's Public Restroom by the lobby was equipped with a self-closing device. The door failed to close and positively latch when tested.

14. On 8/7/13, at 12:41 p.m., in the Park Pavilion on the 2nd floor, the door to the Men's Public Restroom by the lobby was equipped with a self-closing device. The door failed to close and positively latch when tested.



27254

Old Main Building
15. On 8/05/13, at 1:53 p.m., on the 1st floor, in the Endoscopy Physician's work room, the self closing door to the room was held open with a door wedge.

Based on observation, the facility failed to maintain its corridor doors. This was evidenced by corridor doors that failed to close and positively latch. This could result in the passage of smoke in the event of a fire, and affected 4 of 7 smoke compartments on the First Floor in El Camino Hospital Los Gatos.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager 8/6/13, the corridor doors were observed.

El Camino Hospital Los Gatos
1. On 8/6/13, at 9:32 a.m., on the 1st floor, the door to Room 1015 failed to latch.

2. On 8/6/13, at 9:34 a.m., on the 1st floor, the door to Room 1017 failed to latch.

3. On 8/6/13, at 9:36 a.m., on the 1st floor, the door to Room 1019 failed to close and positively latch when tested.

4. On 8/6/13, at 10:05 a.m., on the first floor, the door to the Nutrition Female Staff Bathroom failed to close and positively latch when tested.

5. On 8/6/13, at 10:09 a.m., on the 1st floor, the door to Clean Linen was equipped with a self-closing device. The door failed to close and positively latch when tested.

6. On 8/6/13, at 10:15 a.m., on the 1st floor, the door to Room 1063 failed to latch.

7. On 8/6/13, at 10:30 a.m., on the 1st floor, the door to the Housekeeping Office by Medical Surge Overflow Station failed to close and positively latch when tested.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as evidenced by failure of the fire doors to release upon activation of the manual pull stations. This condition affected all smoke compartments on five of five floors in the New Main Hospital Building, and could result in the passage of smoke from one compartment to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
18.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.


Findings:

During fire alarm testing with the Chief Administrative Services Officer and Chief Engineer on 8/08/13, the fire doors were observed during fire alarm testing.

Between 9:00 a.m., and 12:30 p.m., upon activation of the manual pull station on the 4th floor, the fire doors in the designated zone failed to release and close. The Chief Administrative Services Officer, stated that the fire doors were not designed to release with the activation of the manual pull station. The fire doors did release with the activation of the smoke detectors and the water flow devices.

Based on observation and staff interview, the facility failed to maintain the doors that were held open by magnetic devices arranged to automatically close the doors upon activation of the fire alarm, smoke detection, and automatic sprinkler system. This was evidenced by the failure of the fire doors to automatically release from the magnetic hold open devices and close upon activation of the fire alarm system manual pull stations. This condition affected all smoke compartments on three of five floors in the Women's Hospital, and one floor in the Locked Psychiatric Unit, and could result in the passage of smoke from one compartment to another in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure (except boiler rooms, heater rooms, and mechanical equipment rooms) shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During fire alarm testing with the Chief Engineer and Facilities Services Manager on 8/07/13, between 10:30 a.m., and 12:00 p.m., the facility fire doors were observed.

1. Upon activation of the manual pull station on the 2nd floor, the fire doors in the designated zone failed to release and close. There were 9 fire doors on the 1st Floor, 1 fire door on the 2nd floor and 1 fire door on the 3rd floor that failed to release and close with the activation of the pull stations. The Chief Administrative Services Officer stated that the fire doors were not designed to release with the activation of the manual pull station. The fire doors did release with the activation of the smoke detectors and the water flow devices.



27254

During fire alarm testing with the Chief Administrative Services Officer, and the Chief Engineer on 8/07/13, the facility's fire doors were observed.

Old Main Building
1. At 12:13 p.m., on the 1st floor in the Locked Behavioral Unit, the double fire doors between room 110 and room 111 failed to release upon activation of the fire alarm system. The doors were not connected to the facility's fire alarm system, and only released upon activation of the door smoke detectors. The door smoke detectors did not activate the facility's fire alarm system.

Based on observation, the facility failed to maintain their smoke barrier walls free from penetrations. This was evidenced by penetrations in two smoke barrier walls. This affected four of seven smoke compartments on the first floor in El Camino Hospital - Los Gatos, and could result in the spread of fire and smoke to nearby smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
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

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager on 8/8/13, the smoke barrier walls were observed.

El Camino Hospital Los Gatos
1. On 8/8/13, at 2:37 p.m., in El Camino Hospital Los Gatos on the 1st floor, there was an approximately 1/8 inch penetration around a pipe in the smoke barrier wall by the Respiratory Therapy Office.



27254

During a tour of the facility with the Chief Administrative Services Officer on 8/08/13, the smoke barrier walls at El Camino Hospital - Los Gatos were observed.

2. At 2:40 p.m., the smoke barrier wall by Cafe El Gato had a one inch penetration around a pipe passing through the wall. The fire caulking had separated from the wall, and exposed the penetration.

Based on observation and interview, the facility failed to maintain fire doors, as evidenced by fire doors that did not fully close and latch, and by fire doors that were obstructed. These deficient conditions affected two of two occupied floors in the old Main Building, and could result in the spread of smoke in the event of a fire.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 80 Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.


Findings:
During a tour of the facility with the Chief Administrative Services Officer and the Chief Engineer, between 8/05/13 and 8/08/13, the facility fire doors were observed.

1. On 8/05/13, at 2:05 p.m., on the 1st floor, in Outpatient Lab lobby, the drop down fire door was obstructed by a plexi brochure holder.

2. On 8/07/13, at 11:47 a.m., by Pre-Procedure Endoscopy Recovery, the left hand fire door to the elevator lobby remained fully open.

3. On 8/07/13, at 12:20 p.m., on the Ground Floor, at the intersection at the North Elevators, the right hand door on to both sets of fire doors failed to release upon activation of the fire alarm system.

Based on observation, the facility failed to maintain its fire doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by one fire door that did not fully close and latch. This affected one of five floors in the New Main Building, and could result in the spread of smoke and/or fire from one compartment to another.

NFPA 101 Life Safety Code, 2000 edition
7.2.4.3.8* All fire doors in horizontal exits shall be self-closing or automatic-closing in accordance with 7.2.1.8. Horizontal exit doors located across a corridor shall be automatic-closing in accordance with 7.2.1.8.
Exception: Where approved by the authority having jurisdiction, existing cross-corridor doors in horizontal exits shall be permitted to be selfclosing.

NFPA 80
Standard for Fire Doors and Fire Windows
2-4.1.2* A closing device shall be installed on every fire door. Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.
2-4.1.3 All components of closing devices used shall be attached securely to doors and frames by steel screws or through-bolts.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

Findings:

On 8/8/13, during fire alarm testing with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager, the fire doors were observed.

On 8/8/13, at 10:40 a.m., on the Ground Floor, the fire door left hand door leaf by the Laboratory Storage did not fully close and latch. The fire door had an approximately 3 inch gap.

Based on observation, the facility failed to maintain the emergency exit, as evidenced by one exit discharge that was obstructed by a shelf mounted on the corridor wall. This affected one of two occupied floors in the Old Main Building and could result in a delayed evacuation in the event of an emergency.

NFPA 101 Life Safety Code, 2000 edition
4.5.3 Means of Egress.
4.5.3.2 Unobstructed Egress. In every occupied building or structure, means of egress from all parts of the building shall be maintained free and unobstructed. No lock or fastening shall be permitted that prevents free escape from the inside of any building other than in health care occupancies and detention and correctional occupancies where staff are continually on duty and effective provisions are made to remove occupants in case of fire or other emergency. Means of egress shall be accessible to the extent necessary to ensure reasonable safety for occupants having impaired mobility.

7.1.3.2.3* An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge. (See also 7.2.2.5.3.)

7.1.10 Means of Egress Reliability.
7.1.10.1* Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, on 8/05/13, the exit passages were observed.

At 1:55 p.m., on the 1st floor in the Endoscopy Suite outside of Procedure Room 4, there was a bookshelf mounted on the corridor wall. The shelf was mounted on the wall 5 feet off the ground, and protruded into the corridor approximately 12 inches. The shelf was mounted on the wall near the corridor fire door for the suite.

Based on interview, document review and observation, the facility failed to maintain their emergency lighting, as evidenced by no records found for the monthly, or annual testing of the emergency lighting in the facility operating rooms. This could lead to a malfunction of the emergency lighting in the event of an emergency, and affected ten of ten operating rooms in the Operating Suite located on the 2nd floor of New Main Hospital Building.

NFPA 101 Life Safety Code, 2000 edition
18.2.9 Emergency Lighting.
18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
18.2.9.2 Buildings equipped with or in which patients require the use of life-support systems (see 18.5.1.3) shall have emergency lighting equipment supplied by the life safety branch of the electrical system as described in NFPA 99, Standard for Health Care Facilities.
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 battery-powered emergency lighting system for not less than 1 ? 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.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.
NFPA 99 Health Care Facilities, 1999 edition
3-3.2.1.2 All Patient Care Areas.
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).


Findings:

During document review with the Chief Administrative Services Officer and the Chief Engineer on 8/05/13, the documentation for the testing of the emergency lights in the operating rooms was requested.

At 11:28 a.m., no documentation for the monthly, or annual testing of the emergency lights in the operating rooms was provided for review. Staff was unable to provide information for the testing of the emergency lights, and stated that the lights were not manually tested. Staff was unsure how the lights were tested.

Based on document review and staff interview, the facility failed to maintain fire drills at the Cancer Center as evidenced by three of four fire drills conducted in the Lab, that failed to include staff signatures from staff in the Cancer Center. This condition affected all staff and patients in the Cancer Center, and could result in the lack of staff knowledge in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
SECTION 4.7* FIRE DRILLS
4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.
4.7.2* Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.3 Competency. Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.
4.7.4 Orderly Evacuation. In the conduct of drills, emphasis shall be placed on orderly evacuation rather than on speed.
4.7.5* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

During document review with the Chief Administrative Services Officer and the Chief Engineer, on 8/05/13, the fire drill records for the Cancer Center at Melchor Pavilion were requested.

At 11:45 a.m., the fire drill records were reviewed. The three of four fire drill conducted over the past year were conducted in the Lab with Lab staff. There were no signatures from staff in the Cancer Center. During an interview, staff stated that the fire drills were conducted in the Lab and in the Cancer Center and that staff from both Departments participated. No documentation was provided to show the staff from the Cancer Center participated in the Lab fire drills.

Based on record review and staff interview, the facility failed to conduct quarterly fire drills with the activation of the fire alarm system. This condition affected two of two floors, and could result in the lack of staff knowledge in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.2* Fire drills in health care occupancies shall include the transmission of fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals
and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours)and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.


Findings:

During document review with the Chief Engineer on 8/06/13, the fire drill records were reviewed.

At 10:00 a.m., the fire drill records for the El Camino Hospital - Los Gatos failed to indicate which device was activated during the fire drill, and if the fire doors closed. During an interview with Security, staff stated that the fire alarm was not activated during the Morning shift or the Evening shift. During the past year, records indicated that none of the fire drills were conducted with the activation of the fire alarm system.

Based on observation and staff interview, the facility failed to maintain the fire alarm system as evidenced by failure of the fire alarm notification devices to activate on two floors of the building during fire alarm testing. This condition affected two of two floors of the El Camino Hospital - Los Gatos Building, and could result in the failure of occupant notification in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.3* The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
Exception No. 1:* Elevator lobby, hoistway, and associated machine room smoke detectors used solely for elevator recall, and heat detectors used solely for elevator power shutdown, shall not be required to activate the building evacuation alarm if the power supply and installation wiring to these detectors are monitored by the building fire alarm system, and the activation of these detectors results in an audible and visible alarm signal at a constantly attended location.
Exception No. 2:* Smoke detectors used solely for closing dampers or heating, ventilating, and air conditioning system shutdown shall not be required to activate the building evacuation alarm.
Exception No. 3:* Detectors located at doors for the exclusive operation of automatic door release shall not be required to activate the building evacuation alarm.
Exception No. 4: Detectors in accordance with the exception to 22.3.4.3.1 and the exception to 23.3.4.3.1 shall not be required to activate the building evacuation alarm.
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are
hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
Exception No. 1:* Where total evacuation of occupants is impractical due to building configuration, only the occupants in the affected zones shall be initially notified. Provisions shall be made to selectively notify occupants in other zones to afford orderly evacuation of the entire building.
Exception No. 2: Where occupants are incapable of evacuating themselves
because of age, physical or mental disabilities, or physical restraint, the private operating mode as described in NFPA 72, National Fire Alarm Code, shall be permitted to be used. Only the attendants and other personnel required to evacuate occupants from a zone, area, floor, or building shall be required to be notified. This notification shall include means to readily identify the zone, area, floor, or building in need of evacuation.
Exception No. 3: Notification within the covered mall per 36.4.4.3.3
and 37.4.4.3.3.


Findings:

During fire alarm testing with the Chief Administrative Services Officer on 8/06/13, the fire alarm system at El Camino Hospital - Los Gatos was observed.

Between 1:20 p.m., and 3:00 p.m., when the smoke detector, pull station and water flow devices were tested, the occupant chimes and strobes notification devices on two floors of the building failed to function as designed. The fire alarm system could not be heard in all areas of the building. All of the fire doors released from the magnetic hold-open devices as required. The facility immediately implemented a fire watch, and contacted their vendor. The work order provided by the vendor indicated that a device failed, and caused the system to malfunction. The last annual inspection had been performed on 12/2012, and all devices had passed.

Based on observation, the facility failed to maintain their smoke detectors. This was evidenced by 2 of 5 smoke detectors that failed to initiate the fire alarm system when tested. This affected 1 of 7 smoke compartments at El Camino Hospital - Los Gatos, and could result in a delayed notification of a fire due to a malfunctioning smoke detector.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and
NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 National Fire Alarm Code, 1999 Edition
7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2
13. Initiating Devices (g) Smoke Detectors - The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager between 8/6/13, and 8/8/13, the smoke detectors were tested.

El Camino Hospital - Los Gatos
1. At 1:23 p.m., the smoke detector by Room 1029 located on the first floor failed to initiate the fire alarm system. The smoke detector was retested two times, and failed to initiate the fire alarm system.

2. At 1:28 p.m., the smoke detector by Room 1027 located on the first floor failed to initiate the fire alarm system. The smoke detector was retested two times,and failed to initiate the fire alarm system.

3. On 8/8/13, between 2:15 p.m., to 2:17 p.m., the smoke detectors located on the first floor by Room 1029 and Room 1027 were retested. The smoke detectors initiated the fire alarm system when tested.

Based on observation and staff interview, the facility failed to maintain the automatic sprinkler system as evidenced by the wrong address for the Inspector's Test Valves provided by the system. This condition affected five of five floors in the New Main Hospital Building, and could result in dealy in notification in the event of a fire.

NFPA 101 Life Safety Code, 2000 edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

Findings:

During fire alarm testing with the Chief Administrative Services Officer and the Chief Engineer, on 8/08/13, the fire alarm system was observed.

Between 9:00 a.m., and 11:30 a.m., the fire alarm system in the New Main Building was tested. The Inspector's Test Valve (ITV) on each floor was tested for time and notification to the Fire Alarm Control Panel (FACP). The five ITV's tested all failed to report the correct address location to the fire alarm control panel. The ITV's reported the same address as the Tamper Valves on the floor. During an interview, staff stated that the ITV;s had a different address in the system, and were unsure as to why the address was reporting differently.

Based on observation, the facility failed to maintain the automatic sprinkler system. This was evidenced by paint and/or foreign material on sprinkler heads, by missing escutcheon rings, and by escutcheon rings that were not maintained flush with the ceiling. This could result in the automatic sprinkler system not functioning as designed in the event of a fire, and affected 4 of 7 smoke compartments, and 1 of 3 smoke compartments on the Second Floor in the El Camino Hospital Los Gatos.

NFPA 101 Life Safety Code, 2000 edition
4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
19.3.4.2 Initiation.
Initiation of the required fire alarm system shall be by manual means in accordance with 9.6.2 and by means of any required sprinkler system waterflow alarms, detection devices, or detection systems.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, Chief Engineer and Facilities Services Manager on 8/6/13, the automatic sprinkler system was observed.

El Camino Hospital Los Gatos
1. On 8/6/13, at 9:28 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was a missing escutcheon ring, in Room 1006.

2. On 8/6/13, at 9:29 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was a missing escutcheon ring, in Room 1003.

3. On 8/6/13, at 9:40 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was foreign material on two of four sprinkler heads, in the Nursery Work Room.

4. On 8/6/13, at 9:45 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/2 inch penetration in the ceiling, in Cardiologist Reading Room.

5. On 8/6/13, at 9:48 a.m., in El Camino Hospital Los Gatos on the 1st floor, there were two escutcheon rings that were not flush to the ceiling, and exposed an approximately 1/4 inch penetrations in the ceiling, in the Sterile Processing Room.

6. On 8/6/13, at 10:03 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in the Admitting restroom.

7. On 8/6/13, at 10:07 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/2 inch penetration in the ceiling, in the Nutrition Male Staff Bathroom.

8. On 8/6/13, at 10:10 a.m., in El Camino Hospital Los Gatos on the 1st floor, there were four of seven escutcheon rings that were not flush to the ceiling, and exposed approximately 1/2 inch penetrations in the ceiling, in the Outpatient Recovery Room.

9. On 8/6/13, at 10:20 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1 1/2 inch penetration in the ceiling, in the Therapy Gym.

10. On 8/6/13, at 10:35 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in the Meditation Room by Critical Care.

11. On 8/6/13, at 10:38 a.m., in El Camino Hospital Los Gatos on the 1st floor, one of four escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in the Emergency Waiting Room.

12. On 8/6/13, at 10:40 a.m., in El Camino Hospital Los Gatos on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, at the entrance to the Endoscopy area.

13. On 8/6/13, at 10:45 a.m., in El Camino Hospital Los Gatos on the 1st floor, two escutcheon rings were not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, at the ambulance entrance in the Emergency area.

14. On 8/6/13, at 10:47 a.m., in El Camino Hospital Los Gatos on the 1st floor, there was a missing escutcheon ring, in Nuclear Medical Room/ Camera Equipment Room.

15. On 8/6/13, at 11:05 a.m., in El Camino Hospital Los Gatos on the 2nd floor, there was a missing escutcheon ring, in the Recovery Bed 1 area.

Based on observation, the facility failed to maintain the automatic sprinkler system. This was evidenced by paint and/or foreign material on sprinkler heads, by missing escutcheon rings, and by escutcheon rings that were not maintained flush with the ceiling. This could result in the automatic sprinkler system not functioning as designed in the event of a fire, and affected one of five floors in El Camino Hospital - Old Main, one compartment on the Second Floor in the Park Pavilion, one compartment on the First Floor in the Melchor Pavilion.

NFPA 101 Life Safety Code, 2000 edition
4.6.12 Maintenance and Testing
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition
1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.
2-2.1 Sprinklers.
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.
Exception No. 1:* Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with the Chief Administrative Services Officer, the Chief Engineer and the Facilities Services Manager between 8/5/13, and 8/7/13, the automatic sprinkler system was observed.

El Camino Hospital - Old Main
1. On 8/5/13, at 2:40 p.m., in the El Camino Hospital - Old Main on the Ground floor, the IT Office across from the old General Storage was missing an escutcheon ring.

Park Pavilion
2. On 8/7/13, at 12:39 p.m., in Park Pavilion on the 2nd floor, there was paint on the sprinkler head, in the Hydrotherapy Room.

Melchor Pavilion
3. On 8/7/13, at 2:05 p.m., in Melchor Pavilion on the 1st floor, an escutcheon ring was not flush to the ceiling, and exposed an approximately 1/4 inch penetration in the ceiling, in Consultation 4 Room.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable fire extinguisher that was stored unsecured. This affected one of five floors in El Camino Hospital - Old Main, and could result in damage to the portable fire extinguisher.

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 10, 1998 Edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

Findings:

During a tour of the facility with the Chief Engineer and the Facilities Services Manager on 8/5/13, the portable fire extinguishers were observed.

At 1:53 p.m., in the Behavioral Health Clinic, there was an unmounted ABC-type portable fire extinguisher stored unsecured on top of a cabinet across from the Therapy A Room.

Based on observation, the facility failed maintain the relative humidity at equal to or greater than 35% as evidenced by several days in the past year that the humidity in 10 operating rooms dipped below 30%. This deficient practice affected all ten operating/procedure rooms in the Operating Suite.

Findings

During document review on 8/08/13, the Operating Room Humidity reports were reviewed.

At 4:00 p.m., the records provided indicated that the humidity dropped below 35%. Upon staff interview, the Chief Administrative Services Officer stated that the humidity range for the operating rooms was between 20% to 60%. The months of November, 2012; February, 2013; and July, 2013, were reviewed for compliance. Review of the records provided had humidity levels recorded as low at 11.22% in February of 2013. In July of 2013, the humidity dipped below 35% five times in operating rooms 1 and 4. In February 2013, the humidity dipped below 35% four times in operating room 1, and five times in operating room 5.

Based on observation, the facility failed maintain the relative humidity at equal to or greater than 35% as evidenced by several days in the past year that the humidity in 10 operating rooms was below 35%. This deficient practice affected ten of ten operating/procedure rooms in the Operating Suite, in the El Camino Hospital - Los Gatos Building, and could result in an increased risk of fire.

Findings:

During document review on 8/06/13, the Operating Room Humidity reports were reviewed.

At 4:00 p.m., the records provided indicated that the humidity dropped below 35%. Upon staff interview, the Chief Engineer stated that the humidity range for the operating rooms was between 20% to 60%.

In July of 2013, the humidity dipped below 35% five times in operating rooms 1 and 4. In the past year the humidity dropped below 35% 121 days in Operating Rooms 1 - 8. The humidity dropped below 35% on 187 days in the labor and delivery procedure rooms.

Based on interview and observation, the facility failed to maintain the electrical wiring and equipment. This was evidenced by an electrical panel that was obstructed by medical equipment, by the use of power strips as a substitute for fixed wiring, and by power strips that were fixed to the building surfaces. This could lead to a delay in working on the electrical equipment during an emergency, or in an increased risk of an electrical fire. This deficncy affected three of five floors in the New Main Hospital Building.

NFPA 101 Life Safety Code, 2000 edition
Chapter 9 BUILDING SERVICE AND FIRE PROTECTION EQUIPMENT
SECTION 9.1 UTILITIES
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 70, National Electrical Code, 1999 Edition
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space shall be suitably guarded.
800-5. Access to Electrical Equipment Behind Panels Designed to Allow Access. Access to equipment shall not be denied by an accumulation of wires and cables that prevents removal of panels, including suspended ceiling panels.
400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with the Cheif Administrative Services Officer on 8/07/13, the electrical wiring in the facility was observed.

1. At 12:10 p.m., on the 3rd floor in Unit 3C across from Room 3322, a power strip was attached to the wall with screws.

2. At 2:46 p.m., on the 1st floor in Imaging ZRoom #1B211, a coffee maker was plugged into a power strip instead of directly into the wall outlet.

3. At 3:05 p.m., on the Ground floor, in Respiratory Therapy Room #GA001, four power strips were attached to the wall with screws. One power strip was attached to the wall, and one power strip was being used for a microwave and a fan.

4. At 3:15 p.m., on the Ground floor, in the Staff Lounge located in Central Supply, a toaster oven, a coffee maker and a water tower were all plugged into one power strip.

Based on interview and observation, the facility failed to maintain their electrical wiring and equipment, as evidenced by the use of power strips as a substitute for fixed wiring. This condition affected two of two occupied floors in the Old Main Building, one smoke compartment in the Basement in Park Pavilion, and could result in the ignition of an electrical fire.

NFPA 101 Life Safety Code, 2000 edition
Chapter 9 BUILDING SERVICE AND FIRE PROTECTION EQUIPMENT
SECTION 9.1 UTILITIES
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

400-8. Uses not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.

Findings:

During a tour of the facility with the Chief Administrative Services Officer between 8/05/13, and 8/08/13, the electrical wiring in the facility was observed.

Old Main Building
1. On 8/05/13, at 1:51 p.m., on the 1st floor, in the Endoscopy Physician work room, a television was plugged into a power strip. The power strip was plugged into another power strip, instead of directly into the wall outlet.

2. On 8/05/13, at 1:51 p.m., on the 1st floor, in the Endoscopy Physician work room, a coffee maker was plugged into a power strip instead of directly into the wall outlet.

3. On 8/05/13, at 2:15 p.m., on the 1st floor, in the Endoscopy Admission Nurse's Office, a patient pressure machine was plugged into a power strip instead of directly into the wall outlet.

4. On 8/05/13, at 2:20 p.m., on the Ground Floor, in EKG Room 1, the treadmill was plugged into an extension cord instead of directly into the wall outlet.

5. On 8/05/13, at 2:22 p.m., on the Ground Floor, in EKG Room 5, a refrigerator was plugged into a power strip.

6. On 8/05/13, at 2:36 p.m., on the Ground Floor, in the IT Office, a microwave, a toaster oven, a refrigerator and a coffee machine were plugged into one power strip.



31201

Park Pavilion
1. On 8/7/13, at 12:35 p.m., in the Park Pavilion on the 2nd floor, in the Gym, there were two surge protectors in use. A treadmill, stair stepper and an Upper Cycle machine were plugged into Surge Protector 1, and a Biodex Bike was plugged into Surge Protector 2.