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Based on observation, the facility failed to maintain corridor doors free from obstructions to closing. This was evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors close and latch to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients in one of four smoke compartments on the first floor and one of five smoke compartments on the second floor at the main hospital.

Findings:

Main Hospital
During a tour of the facility with Engineering Staff 2 on 4/9/13, doors were observed.

1. At 12:25 p.m., the one hour fire-rated door to Electrical Room 693, located in the Sterile Core of the Surgery Suite, did not positive latch when tested by releasing the door from an open position.

2. At 12:45 p.m. the door to Environmental Service Room 248 did not positive latch when tested by releasing the door from an open position.

Based on observation, the facility failed to maintain all exit directional signs, as evidenced by an exit sign which was not illuminated. It is essential that all exit signs be properly illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected all staff and patients in one of one offsite location and could potentially result in a delayed evacuation in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition
38.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

Findings:

Rehabilitation Services
During a tour of the facility with Engineering Staff 1 on 4/9/13, exit signs were observed.

At 2:25 p.m., the exit directional sign located at the end of the corridor near the Lobby was not illuminated.

Based on document review, observation, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by documentation for the five year sprinkler report that did not pass the inspection due to noted deficiencies in the report, no current five year sprinkler certification, by an escutcheon ring that was not flush to the ceiling, and by an alarm bell that contained debris. These findings affected all staff and patients on two of two floors at the main hospital and one of one outpatient location. This could potentially result the automatic sprinkler system failing to function as designed, resulting in the spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
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.
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
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
Chapter 7 Water Spray Fixed Systems
7-6 Records. See Section 1-8 for recordkeeping and reporting procedures.
1-8* Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

During a tour of the facility with Engineering Staff 1 and 2, automatic sprinkler system components were observed and documents were reviewed.

1. On 4/8/13 at 2:00 p.m., documentation provided for the five year sprinkler inspection and testing report, dated 3/28/13, showed that the system failed the inspection due to following noted deficiencies in the report:

i. Level 1 Room - need to add one head in office. Head is more than seven feet six inches off of two walls.

ii. New Penthouse - need to add about six heads under duct work that is over 4 feet wide.

iii. E.D. Department Quiet Room 910 B - Relocate one head; it's four feet from another head.

iv. Booth 3 Registration - add one head ; 17 feet from the closest head.

v. Female Locker Room - lower one head needs model F957 Escutcheon. Relocate one head that is 9 feet 2 inches off of wall. Hard lid ceiling with fire walls on both sides.

vi. Room 629 - need 1 chrome 401 skirt.

vii Ambulatory Cr. Soiled holding next to Room 202 - change escutcheon to chrome model H

viii. Hydrant - need one four and one-half inch cap and four two and one-half inch caps Longbeach Hydrants.

On 4/9/13:
Between 9:15 a.m., and 9:35 a.m., the surveyor observed that there were no sprinkler heads under the duct work as mentioned in the five year sprinkler report. Engineering Staff 1 stated that the Penthouse was part of a recent OSHPD project and that it had passed inspection. The facility did not provide any evidence that showed the alternative protective measures provided as a substitute for the sprinkler protection.

2. At 9:15 a.m., the date of the last five year sprinkler inspection and certification tag on the main sprinkler riser was observed to be 3/11/08, more than 5 years.

3. At 10:40 a.m., the ceiling sprinkler escutcheon ring was not flush to the ceiling. This created and approximately one-half inch unsealed penetration around the sprinkler pipe. The ceiling in this room was a gypsum wall board.

Rehabilitation Services
4. At 2:30 p.m., fire alarm bell on the outside of the building had fiber-like debris in it that looked like an animal nest.

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

NFPA 99, Health Care Facilities, 1999 Edition
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

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

Findings:

Main Hospital
During a tour of the facility with Engineering Staff 1 and 2, electrical equipment was observed.

On 4/9/13, at 10:08 a.m., the Clinical Social Services Office had a portable electric heater on the floor. This heater had a high temperature label warning on it with a three feet clearance required in front of the heater. This heater did not have documentation indicating that it had been tested and approved by the facility to insure that the heating elements did not exceed 212 degrees Farenheit. The three feet clearance was not maintained in the front of the heater. Engineering Staff 1 removed the heater at that time and stated that it was not an approved heater.

Based on observation and interview, the facility failed to protect its medical compressed gas storage room. This was evidenced by cylinders that were stored and secured together instead of individually. This deficient practice affected one of one oxygen storage location at the main hospital and could potentially result in damage to the cylinders or surrounding equipment if they were to fall.

NFPA 99, Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 (3) Provisions shall be made for racks or fastenings to protect cylinders from damage or dislocation.

Findings:

Main Hospital
During a tour of the facility with Engineering Staff 1 and 2, the oxygen storage areas were observed.

On 4/9/13, at 9:05 a.m., the Bulk Oxygen Storage at the Central Plant had two locations where H size compressed gas cylinders were being stored. Both of these locations had H size compressed gas tanks that were chained together with two chains wrapped around the outside of the tank and that were not individually secured or in racks. One location had six nitrogen tanks chained together and the other location had three nitrogen, six oxygen, and four nitrous tanks chained together. When asked about the storage, Engineering Staff 1 Stated that the facility was in the process of installing two metal NFPA approved containers to store the compressed gas tanks. The surveyor observed one container that had been installed with racks inside and an area with a cement slab. The Staff stated that the cement slab area is going to be where the other container would be placed.

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

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.3 Anesthetizing Locations.
Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1.1 Ventilation in anesthetizing locations
The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During record review on 4/10/13, documentation was requested for monitoring humidity levels in areas where general anesthesia is used.

Main Hospital Building
At 7:45 a.m., humidity logs were reviewed for a twelve month period. During this time period, the following days showed that the humidity levels dropped below the required 35 percent relative humidity:

1. Point 5 Caesarian Section Room:
5/3/12 the humidity level was documented at 32.39 percent
6/28/12 the humidity level was documented at 34.26 percent
9/7/12 the humidity level was documented at 33.76 percent

2. Point 6 Recovery :
6/6/12 the humidity level was documented at 25.37 percent
6/7/12 the humidity level was documented at 27.91 percent

3. Point 4 Operating Room:
2/21/13 the humidity level was documented at 28.75 percent

At 10:50 a.m., Engineering Staff 2 was interviewed and stated that when the humidity is out of range, Engineering is called to make adjustments to the temperature which then changes the humidity level. Documentation for the time periods that were found to be below 35 percent did not indicate if the humidity was brought back into range after adjustments.

Engineering Staff 1 stated that they may request a waiver to lower the percent humidity level requirement to less than 35 percent.

Based on document review and interview, the facility failed to ensure that the Essential Electrical System was properly load tested. This was evidenced by documentation showing that the transfer times from normal power to emergency power exceeded the maximum time allowed during partial and full generator load testing. This finding affected two of two floors at the main hospital and could potentially result in devices and equipment tied to the emergency system to be without power for greater that 10 seconds.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.1.1.8 + Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 3-4.1]

3-4.2.1.4 + Automatic Transfer Switch Features. [110: 4-2.4]
(d) Time Delay on Starting of Alternate Power Source. A time delay device shall be provided to delay starting of the alternate source generator. The timer is intended to prevent nuisance starting of the alternate source generator with subsequent load transfer in the event of harmless momentary power dips and interruptions of the normal source. The time range shall be short enough so that the generator can start and be on the line within 10 seconds of the onset of failure.

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

During document Review with Engineering Staff 1 and 2 on 4/9/13, generator logs for load testing were reviewed,

Between 8:00 a.m. and 8:30 a.m., documentation indicated that the transfer times for automatic transfer switch number (ATS1) was greater that ten seconds for the following days:

1. 8/8/12 14 seconds
2. 9/12/12 15 seconds
3. 10/3/12 14 seconds

At 8:15 a.m., Engineering Staff 2 was interviewed and stated that when the engineers are load testing the generator, they are verbally counting the seconds and not using a stop watch to document the transfer times. Staff 1 and 2 stated that a stop watch should be used.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by high wattage devices which were plugged into power strips, the permanent use of extension cords, and a power strip that was plugged into another power strip. This deficient practice affected all staff and patients on one of two floors at the main hospital and could potentially result in the ignition of fire.

NFPA 70, National Electrical Code, 1999 Edition
210-23 Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.
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

Findings:

During a tour of the facility with Engineering Staff 1 and 2 on 4/9/13, electrical wiring and equipment were observed in the following locations:

1. At 9:55 a.m., there was a power strip plugged into another power strip in the X-Ray CT Storage Room 567.

2. At 10:25 a.m., the Intensive Care Unit Room 739 had a power strip with a microwave oven and a large toaster plugged into it. The microwave oven was rated at 1000 watts and the toaster was rated at 1440 watts.

3. At 10:41 a.m., Staff Break Room 762 had a power strip with a small refrigerator and a toaster plugged into it.

4. At 2:10 p.m., there was a power strip with a microwave oven plugged into it in Rehabilitation Services Room 1004.