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Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations. This affected staff and patients in two of 26 smoke compartments within the facility and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

During a tour of the facility with the the Director and Assistant Director of Plant Operations penetrations were observed in the walls.

Main Hospital
1. On 9/6/12, at 10:17 a.m., there was a two inch unsealed penetration under a desk in the Emergency Room Registration area.

2. On 9/6/12, at 10:25 a.m., the ceiling sprinkler escutcheon in the room identified as the Laundry/Electrical Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the sprinkler pipe.

3. On 9/6/12, at 2:50 p.m., the ceiling sprinkler escutcheon in Medical Records in Administration was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the sprinkler pipe.

4. On 9/7/12, at 10:15 a.m., there was an approximately two by four inch unsealed penetration through both sides of the wall between the Elevator Mechanical Room and the Medical Equipment Storage Room.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in four of 26 smoke compartments at the Main Hospital.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations doors were observed.

Main Hospital
1. On 9/6/12, at 10:14 a.m., the Emergency Room Doctors' Lounge door did not positive latch when tested.

2. On 9/6/12, at 10:20 a.m., the door to the Quiet Room in the Emergency Room Core did not positive latch when tested by releasing the door from an open position.

3. On 9/6/12, at 10:40 a.m., the door to the Equipment Storage in the Lounge Area of the Cardiology Unit was impeded from closing by three BiPAP Breathing Machines placed in the swing area of the door.

4. On 9/6/12, at 11:08 a.m., the door to the Bath/Storage Room in Same Day Surgery was impeded from closing by two hampers that were placed in the swing area of the door.

5. On 9/6/12, at 11:11 a.m., the door to Office 307 in Same Day Surgery could not be closed when pulled shut because of a desk that was placed in the swing area of the door.

6. On 9/6/12, at 11:21 a.m., the door to the Nutrition Room at the Same Day Surgery Nurses' Station had a trash can placed within the swing area of the door. This door did not latch when tested.

7. On 9/6/12, at 2:17 p.m., during fire alarm testing, the door to Labor Room 2 did not positive latch when tested.

8. On 9/6/12, at 3:18 p.m., the door between the Micro Biology Room and the Blood Bank was being held open by a door wedge and ten boxes placed within the swing area of the door.

9. On 9/6/12, at 3:20 p.m., the door between the Blood Bank and the Lab was being held open by three boxes placed within the swing area of the door.

10. On 9/6/12, between 4:00 p.m. and 4:15 p.m., the door to the Laboratory Breakroom did not positive latch when tested.

11. On 9/7/12, at 9:43 a.m., the door to Discharge Planning had a door wedge impeding the door from closing.

12. On 9/7/12, at 9:45 a.m., the door to the Soiled Linen Room in Unit 1 did not positive latch when tested by releasing the door from an open position.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms that posed a degree of hazard greater than that normal to the general occupancy of the building whose doors were being held open by devices not designed to automatically close upon activation of the fire alarm system.
This affected all staff and patients in three of 26 smoke compartments at the main hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations, hazardous area enclosures were observed.

Main Hospital
1. On 9/6/12, at 3:28 p.m., the corridor door to the Micro Biology Room was being held open by a door wedge placed at the bottom of the door. Engineering Staff removed the wedge at that time.

2. On 9/7/12, at 8:55 a.m., this surveyor observed that the same corridor door was propped open by another door wedge. Engineering Staff removed the wedge a second time.

Based on observation, the facility failed to maintain the fire-rated construction of it's smoke/fire barrier walls. This was evidenced by observed unsealed penetrations. This affected two of 26 smoke compartments at the Main Hospital and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

2000 NFPA 101
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Engineering Staff on 9/10/12, smoke/fire barriers were observed.

Main Hospital
1. At 7:15 a.m., the two hour fire-rated wall separating the Skilled Nursing Unit from the General Acute Care portion of the building had a one-half inch unsealed penetration caused by a black data cable traveling through the wall. This penetration was sealed on one side of the wall only.

2. At 7:17 a.m., the two hour fire separation wall near the Phlebotomy Supervisor's Office had a two inch pipe sleeve penetrating the wall. This sleeve had blue data cables traveling in it that did not completely fill the pipe creating an approximately one-half inch by one and one- half inch unsealed area in the sleeve.

3. At 7:26 a.m., the three hour fire-rated separation wall located near Surgery near Unit 2 Medical/Surgical had a penetration that was filled with a non fire-rated foam caulking. This penetration was around the outside of an approximately four inch pipe passing through the wall.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by a room which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and was not equipped with a self-closing mechanism on the door.
This affected all staff and residents in two of 26 smoke compartments and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Maintenance Staff, hazardous area enclosures were observed.

Main Hospital
1. On 9/7/12, at 9:16 a.m., the Paper Storage Room located in the Obstetrics Unit had the door closure removed. This room was approximately eight feet by eight feet (64ft) in size and was in a non sprinklered portion of the building.

2. On 9/7/12, at 9:31 a.m., the Storage Room located outside of the Obstetrics Unit near Janitors' Closet 1 had the door closure removed. This room was approximately 6 by 14 feet (84ft) in size and contained combustible paper products.

Based on observation, the facility failed to identify hazards leading into its laboratory. This was evidenced by the failure to provide signs on doors leading into the laboratory that would identify flammable liquids exceeding ten gallons. This affected one of 26 smoke compartments within the facility and could potentially result in first responders being unaware of the potential hazards within the laboratory in the event of a fire.

1999 NFPA 99
10-8.2 Identification of Hazards.
10-8.2.1* All doors leading to laboratories in health-related facilities shall be marked with signage indicating the fire hazards of materials when significant quantities, as defined below, are intended to be used within the area. For signage purposes ' ' significant quantities ' ' in an area shall include any of the following:
(a) Hazardous materials in glass containers that are 1 gal (4.4 L) in size or larger
(b) Compressed gases or cryogenic liquids in containers that are greater than 5 in. (12.7 cm) in diameter and 15 in. (48 cm) in length.
(c) Dry hazardous chemicals in containers in excess of 5 lb (2.2.7 kg)
(d) Aggregate quantities of hazardous materials exceeding 200 lb (91 kg), or flammable liquids exceeding 10 gal (44.4 L)

10-8.2.2* All doors leading to laboratories, laboratory work areas, and laboratory storage areas, shall be identified with signs to warn emergency response personnel of unusual or severe hazards that are not directly related to the fire hazards of contents.
10-8.2.3 It shall be the responsibility of the laboratory safety officer to ensure periodically that the signage properly indicates the nature of the materials being used within the identified space.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, the Laboratory was observed.

Main Hospital
1. At 8:55 a.m., the doors to the Laboratory did not have signs on the two corridor doors and the door leading from the Laboratory to the outside that would identify any hazards within the area

During observation of the of the flammable/combustible liquids storage cabinet inside of the laboratory at 9:00 a.m., there were approximately five gallons of reagent strength ethyl alcohol, three gallons of alcohol, two gallons of propanol, one gallon of xylene, two gallons of acetone, one gallon of isopropanol, and two gallons of 100 percent ethanol. On the floor near the flammable/combustible liquids cabinet was a cardboard box with three gallons of 100 percent ethanol.

Based on observation, the facility failed to ensure that exits are readily accessible at all times. This was evidenced by exit access that was partially blocked, a corridor door that was equipped with both a deadbolt and a latching device, and a barrel bolt type latch/lock device installed on the door This affected all staff and patients in four of 26 smoke compartments within the facility and could potentially result in a delayed egress in the event of an emergency.

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

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

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

Findings:

a) During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/6/12, exit access was observed.

Main Hospital
1. At 10:20 a.m., the room identified as the Quiet Room had three chairs that were partially blocking two doors.

2. At 10:31 a.m., the door to the Lounge/Cardiology area had a barrel bolt attached to the door approximately 55 inches above the floor.

3. At 11:12 a.m., the door to the Shower Room in Same Day Surgery had a double-action latch/locking hardware requiring two distinct motions to open the door from the egress side.

4. At 11:26 a.m., the doors to the three Endoscopy Rooms were equipped with a standard latch as well deadbolt latching mechanism. These deadbolts were above 48 inch from the floor.

b) During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, exit access was observed.

5. At 9:04 a.m., there was a full size refrigerator placed near the door to the Obstetrics Breakroom that reduced the clear width of the door from 35 inches to 26 inches.

6. At 10:10 a.m., there were two filing cabinets placed in front of an exit door in the Clean Linen/Conference Room that reduced the clear width of the doorway to 23 inches. This door was marked as an exit.

Based on observation and interview, the facility failed to maintain thier back up emergency illumination lights. This was evidenced by a battery-powered emergency lighting unit that did not function when tested and areas that did not have emergency illumination. This affected one of 26 smoke compartments at the main hospital and two of seven suites at the Offsite Outpatient Services at 2809 Olive Highway and could potentially result in a delay in egress in the event of an emergency.

Findings:

Main Hospital
During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, battery-powered emergency lighting was observed.

1. Between 10:50 a.m. and 11:15 a.m., the battery-powered lighting unit in Sterile Central supply did not come on when tested. In an interview with staff, Engineering Staff stated that the plug looked damaged.

Building 2

Suite 120 Valley Women's Imaging
2. On 9/7/12, at 4:04 p.m., the combination emergency light/exit light did not function on battery power when tested. This light was located above the exit door near Suite 140.

Suite 130 Valley Medical Imaging
3. On 9/7/12, between 3:45 p.m. and 4:20 p.m., this surveyor did not observe an emergency light in the Valley Medical Imaging Suite. The CT Scanning area and the Main Corridor were located in a windowless area. When Staff was asked if they had experienced a power outage in that location, Staff 1 stated that they had and it was very dark. Staff 2 stated that they thought that there was some lighting that came on in the corridor during power outages, but was not sure where. No documentation was provided indicating if there was, in fact, battery-powered lights in the above mentioned areas.

Based on observation, the facility failed to mark access to exits with readily visible signs. This was evidenced by the failure to provide exit signs where the direction to exit was not obvious, an exit sign that did not function when tested, and exit signs that were not illuminated. This affected one of 26 smoke compartments at the Main Hospital and three of seven suites at the Offsite Outpatient Services at 2809 Olive Highway and could result in a delay evacuation during an emergency.

Findings:

During a tour of the facility with the Director of Plant Operations, exits and exit access were observed.

Main Hospital
1. On 9/6/12 at 9:42 a.m., the direction of egress near the elevators and Nutritional Services was not obvious. With the two sets of cross-corridor doors closed, exit signs were not visible in that location.

Building 2

During a tour of the facility with the the Director of Plant Operations on 9/7/12, exit signs were observed.

Suite 220 Surgical Practices
1. At 3:27 p.m., did not have an exit sign at the end of the hall directing patients to the exit.

Suite 260 Oroville Women's Health
2. At 3:45 p.m., the exit signs in the Woman's Health Clinic the exit signs were not illuminated.

Suite 130 Valley Medical Imaging Services
3. Between 3:50 p.m. and 4:20 p.m., the exit signs in the Valley Medical Imaging Services Suite did not have a battery back-up in its exit signs.

Based on record review and interview, the facility failed to ensure that all staff participate in the use of, and response to, fire alarms. This was evidenced by a lack of documentation provided which would show that all hospital department staff are participating in fire drills. This affected all staff and patients in 11 of 22 departments within the facility and could potentially result in some staff not being trained and familiar with emergency procedures.

NFPA 101, 2000 Edition,
19.7.2.3, All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

Findings:

During document review on 9/7/12, at 2:35 p.m. fire drill documentation was reviewed.

Main Hospital
The facility failed to provide monthly documentation verifying that the following departments participated in fire drills in 2012:
January - Unit 2
March - Surgery
April - Physical Therapy
May - Nursing Administration
June - Unit 1
July - Unit 1

In 2011:
September - Medical Records and Surgery
October - ICU and Administration
November - Dietary and Unit 2
December - Cardio Pulmonary, Emergency Services and Unit 2

Based on observation and interview, the facility failed to maintain their fire alarm devices as evidenced by one audible device and one detection device that failed to function during fire alarm testing. This affected two of 26 smoke compartments at the main hospital and could potentially result in the spread of smoke and fire.

Findings:

During fire alarm testing with the Director and Assistant Director of Plant Operations, on 9/6/12, the following devices did not function when tested:

Main Hospital
1. At 1:33 p.m., the smoke detector numbered 26-13 in the Same Day Surgery Unit did not function when tested with canned smoke. This device was part of the door closure hardware to the east smoke barrier door in same day surgery and was one of two smoke detectors in that unit. This unit was Type I construction and was non sprinklered.
During a review on 9/7/12, at 2:35 p.m., of the Annual Alarm Certification dated 10/20/11, the report did not indicate that the device was included in the testing. On 9/7/12, At 2:45 p.m., the smoke detector numbered 26-13 was again tested with canned smoke and failed to function.

2. At 2:22 p.m., the water flow alarm at the Inspector's Test Valve (ITV) in Mechanical Room 3 was tested. The audible alarm device on the wall in the Mechanical Room did not make any sound.

Based on record review and staff interview, the facility failed to periodically test its automatic sprinkler system. This was evidenced by a lack of documentation for quarterly sprinkler inspections at one of five inspector's test valves for one quarter in a twelve month period. This could potentially result in the spread of smoke and/or fire and a delayed response by first responders if the alarm failed to activate within 90 seconds or failed to alarm at all.

NFPA 101, 2000 Edition, 4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 25, 2998 Edition,
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Findings:

Main Hospital
1. During record review with the Assistant Director of Plant Operations on 9/7/12, at 2:35 p.m., the facility failed to provide documentation for one quarterly flow test at the inspector's test valve located in the Number 3 Mechanical Room. Documentation was not available for the second quarter of 2012.
Engineering Staff confirmed that the documentation was missing for that date.

Based on observation and interview, the facility failed to provide a portable fire extinguisher at its heliport in accordance with NFPA 10 and 1995 NFPA 418. This was evidenced by a portable fire extinguisher that was not quickly accessible from the landing pad or potential ignition source, and was not located and marked conspicuously. This could potentially result in a delay in access to the fire extinguisher resulting in the spread of fire.

NFPA 10 Standard for Portable Fire Extinguishers
1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

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

1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.

1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately protected.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

1-6.13* Where fire extinguishers are installed in closed cabinets that are exposed to elevated temperatures, the cabinets shall be provided with screened openings and drains.

2-4 Application for Specific Locations. Where portable fire extinguishers are required to be installed, the following documents shall be reviewed for the occupancies outlined in their respective scopes. However, in no case shall the requirements be less than those specified in this standard.

NFPA 418, Standard for Heliports

3-3* Fire Extinguisher Size and Placement for Class B Fires Other Than for Fires in Flammable Liquids of Appreciable Depth.

3-3.1 Minimal sizes of fire extinguishers for the listed grades of hazard shall be provided on the basis of Table 3-3.1. Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in the table used. (See Appendix E.)
Exception: Fire extinguishers of lesser rating, desired for small specific hazards within the general hazard area, can be used, but shall not be considered as fulfilling any part of the requirements of Table 3-3.1.

3-3.2 Two or more fire extinguishers of lower rating shall not be used to fulfill the protection requirements of Table 3-3.1.
Exception No. 1: Up to three AFFF or FFFP fire extinguishers of at least 2 1/2 -gal (9.46-L) capacity shall be permitted to be used to fulfill extra (high) hazard requirements.
Exception No. 2: Two AFFF or FFFP fire extinguishers of at least 1 1/2 -gal (6-L) capacity shall be permitted to be used to fulfill ordinary (moderate) hazard requirements.

3-3.3 The protection requirements shall be permitted to be fulfilled with fire extinguishers of higher ratings, provided the travel distance to such larger fire extinguishers does not exceed 50 ft (15.25 m).

NFPA 418 Standard From Heliports
Chapter 5 Portable Fire Extinguishers
5-1 Quantity and Rating. At least one portable fire extinguisher as specified in Table 5-1 shall be provided for each takeoff and landing area, parking area, and fuel storage area.
Exception: This requirement shall not apply to unattended ground level heliports.

Table 5-1 Minimum Ratings of Portable Fire Extinguishers for Heliport Categories Helicopter
Category H-1

Overall Length H-1 Up to but not including 50 ft (15.2)

Minimum Rating 4-A:80-B

Helicopter length, including the tail boom and the rotors


Findings:

During a tour of the facility with the the Director and Assistant Director of Plant Operations on 9/7/12, at 10:40 a.m., the Helicopter Landing Area was observed. This Helicopter Landing Pad was located north of the facility across the Parking Lot at ground level.

Main Hospital
1. The closest fire extinguisher located at the Heliport was located inside of a chain link fence This fire extinguisher was also not conspicuously located and did not have identifying signage that was visible from the landing pad.

Fire extinguishers for Class B flammable liquids are required to be within 50 feet of the potential hazard.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system. This was evidenced by incomplete documentation for damper inspections. This finding affected all staff and patients on two of two floors at the main hospital and could potentially result in the spread of smoke and/or fire.

NFPA 101, 2000 Edition,
9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

Findings:

Main Hospital
1. During a review of the facility's documentation on 9/7/12, at 2:35 p.m., the facility failed to provide documentation indicating that all dampers had been inspected within the past six years. Documentation provided for damper inspections showed that only 6 of 20 dampers listed on one page of a spread sheet had been inspected on 2/13/07. When asked, Engineering Staff 1 stated that they could not find any other documentation for damper inspections. Hospitals are granted a categorical waiver to extend Damper testing to 6 years. The documentation provided was not complete.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by unapproved portable heaters observed in non-sleeping staff areas. This affected all staff and patients in two of 26 smoke compartments at the main hospital and could potentially result in the ignition of fire.

1999 NFPA 99
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

1999 NFPA 70
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:

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/6/12, portable electric heaters were observed.

Main Hospital
1. At 3:02 p.m., there was a portable electric heater plugged in under a desk in the Laboratory Administration Office. This heater was 1500 watts and had a label warning, "high temperature three feet of clearance required".

2. At 3:57 p.m., Nursing Administration Office 1 had a portable electric heater plugged in sitting in on the floor under a desk. This heater was plugged into a multiple outlet extension cord with no over-current protection. The heater had a label warning, "high temperature three feet of clearance required" and was within 12 inches of paper products.

3. At 3:58 p.m., Nursing Administration Office 2 had a portable electric heater plugged in sitting on the floor under a desk. This heater was plugged into a power strip. The heater had a label warning, "high temperature three feet of clearance required".

In an interview with staff, Engineering Staff stated he would remove all heaters during the survey

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full and instant use. This was evidenced by items stored in the exit corridor. This affected all staff and patients in two of 26 fire compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, exit corridors were observed.

Main Hospital
1. At 9:24 a.m., there were two rocking chairs and two scales stored for more than 30 minutes in the corridor of Unit 4 Obstetrics. These items were stored near the cross-corridor doors near the Delivery Room Nurses' Station. The opening width of the cross-corridor doors was approximately 70 inches and the clear width with the items stored near the doors was reduced to 60 inches.

Based on observation, the facility failed to protect its medical compressed gas cylinders. This was evidenced by cylinders which were stored secured together instead of individually, cylinders that were free standing, and a room used as oxygen storage that was not identified as an oxygen storage room. This affected three of 26 smoke compartments within the facility and could potentially result in damage to the cylinders if they were to fall.

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

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations compressed gas cylinders were observed.

Main Hospital
1. On 9/6/12, at 10:05 a.m., there were 23 E size oxygen cylinders stored in the Emergency Department in a room identified as the clean utility room. The door to this room did not have a sign on the door indicating that it was being used as an oxygen storage room.

2. On 9/6/12, at 3:35 p.m., the room identified as the Processing Work Room had three E size oxygen tanks secured with one chain. There was another E size tank that was sitting free standing on the floor outside of the chain.

3. On 9/7/12, at 10:10 a.m., the Medical Gas Source Room located near the Elevator Mechanical Room had six H size compressed gas tanks chained together with one chain instead of individually secured.

Based on interview, the facility failed to insure that the relative humidity is maintained above 35 percent in its anesthetizing locations. This was evidenced by the failure to monitor and document relative humidity levels and track any actions or corrections taken in areas where general anesthesia is used. This affected five of five operating room within the facility and could potentially result in the ignition of fire due to electrostatic charges or other heat- generating equipment in an oxygen-rich environment.

Findings:

Main Hospital
1. During a tour of the facility on 9/7/12, between 10:45 and 11:15 a.m., Operating Room Charge Staff 1 was asked if the facility documented the relative humidity levels in the Operating Rooms. Staff stated that the humidity levels were checked each day, but that it was not documented.

During an interview with Engineering Staff 1, when asked, Staff 1 stated that the facility is in the process of getting new humidity gauges and may be interested in requesting a waiver to lower the humidity level requirements to 20 percent.

Based on observation and interview, the facility failed to provide emergency illumination in all required areas. This was evidenced by the failure to provide a battery-powered emergency lighting unit in all anesthetizing locations. This affected one of five operating rooms and could potentially result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start), that is allowed for the back-up generator to transfer power during power outages.

NFPA 99, 1999 Edition, 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 70, 1999 Edition, 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:.

During a tour of the facility with the Assistant Director of Plant Operations on 9/7/12, operating rooms were observed.

Main Hospital
1. Between 10:50 a.m. and 11:15 a.m., there was no battery-powered emergency lighting unit in Operating Room 5. When asked, Operating Room Charge Staff 1 stated that the room is used mostly for eye procedures without general anesthesia. Charge Staff 1 stated that it was maybe used once or twice per year for procedures using general anesthesia.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities as evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, and the permanent use of extension cords and fixtures without covers. This affected all staff and patients in six of 26 smoke compartments and could potentially result in the ignition of fire.

NFPA 70, 1999 Edition,
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

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

370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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

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

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations electrical wiring and equipment was observed.

Main Hospital
1. On 9/6/12, at 10:14 a.m., the light fixture in the Doctors' Lounge was missing a canopy cover.

2. On 9/6/12, at 10:17 a.m., there was a power strip suspended above the floor under a desk in the Emergency Room Registration area.

3. On 9/6/12, at 10:20 a.m., the plug receptacle in the Quiet Room was missing a cover plate.

4. On 9/6/12, at 10:39 a.m., in the Cardiology Lounge there were two microwave ovens, a toaster, and a coffee pot plugged into a power strip. The coffee pot was also plugged into an extension cord.

5. On 9/6/12, at 3:18 p.m., there were two extension cords in use in the Laboratory Office. One extension cord was supplying power to a computer and the other was supplying power to a server.

6. On 9/6/12, at 3:31 p.m., the Client Services Office had three power strips chained together under a desk.

7. On 9/6/12, at 3:57 p.m., the Nursing Administration Office 1 had a portable electric heater plugged into an unprotected extension cord that was plugged into a power strip.

8. On 9/6/12, at 3:58 p.m., the Nursing Administration Office 2 had a portable electric heater plugged into a power strip.

9. On 9/7/12, at 9:04 a.m., there was a cord to a refrigerator in the breakroom in the Obstetrics Unit that was traveling through a doorway to a plug outlet.

10. On 9/7/12, at 9:30 a.m., there was a microwave oven, a coffee pot, a toaster, and two blenders plugged into a power strip in the Obstetrics Unit Pantry.

11. On 9/7/12, at 10:23 a.m., there was a power strip and extension cord attached to a chain link fence outside of the Bio Med Room.

12. On 9/7/12, at 10:30 a.m., there were three power strips chained together in the Pharmacy Office.

Based on observation, the facility failed to install Alcohol Based Hand Rub (ABHR) dispensers in locations not adjacent to or above sources of potential ignition, as evidenced by an ABHR dispenser located above light switches. This finding affected two of 26 smoke compartments at the main hospital and one of seven suites at the Offsite Outpatient Services at 2809 Olive Highway and could potentially result in the ignition of fire.

Findings:

Main Hospital
During a tour of the facility with the Director and Assistant Director of Plant Operations, ABHR dispensers were observed.

1. On 9/6/12, at 10:31 a.m., there was an ABHR dispenser eight inches above a light switch in Cardiology Room 1.

2. On 9/6/12, at 2:17 p.m., there was an ABHR dispenser located above a light switch in Labor Room 2.

Building 2

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, at the Offsite Outpatient Services at 2809 Olive Highway ABHR dispensers were observed.

Suite 270 Pediatric Service Clinic
3. At 3:28 p.m., there was an ABHR dispenser eight inches above a light switch in the Lobby.

4. At 3:31 p.m., there was an ABHR dispenser eight inches above a light switch in Patient Room 5.

Suite 120 Valley Women's Imaging
5. At 4:07 p.m., there was an ABHR dispenser six inches above a light switch in the Corner Patient Room.

Based on observation, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations. This affected staff and patients in two of 26 smoke compartments within the facility and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

During a tour of the facility with the the Director and Assistant Director of Plant Operations penetrations were observed in the walls.

Main Hospital
1. On 9/6/12, at 10:17 a.m., there was a two inch unsealed penetration under a desk in the Emergency Room Registration area.

2. On 9/6/12, at 10:25 a.m., the ceiling sprinkler escutcheon in the room identified as the Laundry/Electrical Room was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the sprinkler pipe.

3. On 9/6/12, at 2:50 p.m., the ceiling sprinkler escutcheon in Medical Records in Administration was not flush to the ceiling creating an approximately one-half inch unsealed penetration around the sprinkler pipe.

4. On 9/7/12, at 10:15 a.m., there was an approximately two by four inch unsealed penetration through both sides of the wall between the Elevator Mechanical Room and the Medical Equipment Storage Room.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched quickly to prevent the spread of smoke and/or fire into other areas of the facility. This affected staff and patients in four of 26 smoke compartments at the Main Hospital.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations doors were observed.

Main Hospital
1. On 9/6/12, at 10:14 a.m., the Emergency Room Doctors' Lounge door did not positive latch when tested.

2. On 9/6/12, at 10:20 a.m., the door to the Quiet Room in the Emergency Room Core did not positive latch when tested by releasing the door from an open position.

3. On 9/6/12, at 10:40 a.m., the door to the Equipment Storage in the Lounge Area of the Cardiology Unit was impeded from closing by three BiPAP Breathing Machines placed in the swing area of the door.

4. On 9/6/12, at 11:08 a.m., the door to the Bath/Storage Room in Same Day Surgery was impeded from closing by two hampers that were placed in the swing area of the door.

5. On 9/6/12, at 11:11 a.m., the door to Office 307 in Same Day Surgery could not be closed when pulled shut because of a desk that was placed in the swing area of the door.

6. On 9/6/12, at 11:21 a.m., the door to the Nutrition Room at the Same Day Surgery Nurses' Station had a trash can placed within the swing area of the door. This door did not latch when tested.

7. On 9/6/12, at 2:17 p.m., during fire alarm testing, the door to Labor Room 2 did not positive latch when tested.

8. On 9/6/12, at 3:18 p.m., the door between the Micro Biology Room and the Blood Bank was being held open by a door wedge and ten boxes placed within the swing area of the door.

9. On 9/6/12, at 3:20 p.m., the door between the Blood Bank and the Lab was being held open by three boxes placed within the swing area of the door.

10. On 9/6/12, between 4:00 p.m. and 4:15 p.m., the door to the Laboratory Breakroom did not positive latch when tested.

11. On 9/7/12, at 9:43 a.m., the door to Discharge Planning had a door wedge impeding the door from closing.

12. On 9/7/12, at 9:45 a.m., the door to the Soiled Linen Room in Unit 1 did not positive latch when tested by releasing the door from an open position.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms that posed a degree of hazard greater than that normal to the general occupancy of the building whose doors were being held open by devices not designed to automatically close upon activation of the fire alarm system.
This affected all staff and patients in three of 26 smoke compartments at the main hospital and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations, hazardous area enclosures were observed.

Main Hospital
1. On 9/6/12, at 3:28 p.m., the corridor door to the Micro Biology Room was being held open by a door wedge placed at the bottom of the door. Engineering Staff removed the wedge at that time.

2. On 9/7/12, at 8:55 a.m., this surveyor observed that the same corridor door was propped open by another door wedge. Engineering Staff removed the wedge a second time.

Based on observation, the facility failed to maintain the fire-rated construction of it's smoke/fire barrier walls. This was evidenced by observed unsealed penetrations. This affected two of 26 smoke compartments at the Main Hospital and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

2000 NFPA 101
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Engineering Staff on 9/10/12, smoke/fire barriers were observed.

Main Hospital
1. At 7:15 a.m., the two hour fire-rated wall separating the Skilled Nursing Unit from the General Acute Care portion of the building had a one-half inch unsealed penetration caused by a black data cable traveling through the wall. This penetration was sealed on one side of the wall only.

2. At 7:17 a.m., the two hour fire separation wall near the Phlebotomy Supervisor's Office had a two inch pipe sleeve penetrating the wall. This sleeve had blue data cables traveling in it that did not completely fill the pipe creating an approximately one-half inch by one and one- half inch unsealed area in the sleeve.

3. At 7:26 a.m., the three hour fire-rated separation wall located near Surgery near Unit 2 Medical/Surgical had a penetration that was filled with a non fire-rated foam caulking. This penetration was around the outside of an approximately four inch pipe passing through the wall.

Based on observation, the facility failed to protect its hazardous area enclosures. This was evidenced by a room which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building and was not equipped with a self-closing mechanism on the door.
This affected all staff and residents in two of 26 smoke compartments and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Maintenance Staff, hazardous area enclosures were observed.

Main Hospital
1. On 9/7/12, at 9:16 a.m., the Paper Storage Room located in the Obstetrics Unit had the door closure removed. This room was approximately eight feet by eight feet (64ft) in size and was in a non sprinklered portion of the building.

2. On 9/7/12, at 9:31 a.m., the Storage Room located outside of the Obstetrics Unit near Janitors' Closet 1 had the door closure removed. This room was approximately 6 by 14 feet (84ft) in size and contained combustible paper products.

Based on observation, the facility failed to identify hazards leading into its laboratory. This was evidenced by the failure to provide signs on doors leading into the laboratory that would identify flammable liquids exceeding ten gallons. This affected one of 26 smoke compartments within the facility and could potentially result in first responders being unaware of the potential hazards within the laboratory in the event of a fire.

1999 NFPA 99
10-8.2 Identification of Hazards.
10-8.2.1* All doors leading to laboratories in health-related facilities shall be marked with signage indicating the fire hazards of materials when significant quantities, as defined below, are intended to be used within the area. For signage purposes ' ' significant quantities ' ' in an area shall include any of the following:
(a) Hazardous materials in glass containers that are 1 gal (4.4 L) in size or larger
(b) Compressed gases or cryogenic liquids in containers that are greater than 5 in. (12.7 cm) in diameter and 15 in. (48 cm) in length.
(c) Dry hazardous chemicals in containers in excess of 5 lb (2.2.7 kg)
(d) Aggregate quantities of hazardous materials exceeding 200 lb (91 kg), or flammable liquids exceeding 10 gal (44.4 L)

10-8.2.2* All doors leading to laboratories, laboratory work areas, and laboratory storage areas, shall be identified with signs to warn emergency response personnel of unusual or severe hazards that are not directly related to the fire hazards of contents.
10-8.2.3 It shall be the responsibility of the laboratory safety officer to ensure periodically that the signage properly indicates the nature of the materials being used within the identified space.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, the Laboratory was observed.

Main Hospital
1. At 8:55 a.m., the doors to the Laboratory did not have signs on the two corridor doors and the door leading from the Laboratory to the outside that would identify any hazards within the area

During observation of the of the flammable/combustible liquids storage cabinet inside of the laboratory at 9:00 a.m., there were approximately five gallons of reagent strength ethyl alcohol, three gallons of alcohol, two gallons of propanol, one gallon of xylene, two gallons of acetone, one gallon of isopropanol, and two gallons of 100 percent ethanol. On the floor near the flammable/combustible liquids cabinet was a cardboard box with three gallons of 100 percent ethanol.

Based on observation, the facility failed to ensure that exits are readily accessible at all times. This was evidenced by exit access that was partially blocked, a corridor door that was equipped with both a deadbolt and a latching device, and a barrel bolt type latch/lock device installed on the door This affected all staff and patients in four of 26 smoke compartments within the facility and could potentially result in a delayed egress in the event of an emergency.

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

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

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

Findings:

a) During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/6/12, exit access was observed.

Main Hospital
1. At 10:20 a.m., the room identified as the Quiet Room had three chairs that were partially blocking two doors.

2. At 10:31 a.m., the door to the Lounge/Cardiology area had a barrel bolt attached to the door approximately 55 inches above the floor.

3. At 11:12 a.m., the door to the Shower Room in Same Day Surgery had a double-action latch/locking hardware requiring two distinct motions to open the door from the egress side.

4. At 11:26 a.m., the doors to the three Endoscopy Rooms were equipped with a standard latch as well deadbolt latching mechanism. These deadbolts were above 48 inch from the floor.

b) During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, exit access was observed.

5. At 9:04 a.m., there was a full size refrigerator placed near the door to the Obstetrics Breakroom that reduced the clear width of the door from 35 inches to 26 inches.

6. At 10:10 a.m., there were two filing cabinets placed in front of an exit door in the Clean Linen/Conference Room that reduced the clear width of the doorway to 23 inches. This door was marked as an exit.

Based on observation and interview, the facility failed to maintain thier back up emergency illumination lights. This was evidenced by a battery-powered emergency lighting unit that did not function when tested and areas that did not have emergency illumination. This affected one of 26 smoke compartments at the main hospital and two of seven suites at the Offsite Outpatient Services at 2809 Olive Highway and could potentially result in a delay in egress in the event of an emergency.

Findings:

Main Hospital
During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, battery-powered emergency lighting was observed.

1. Between 10:50 a.m. and 11:15 a.m., the battery-powered lighting unit in Sterile Central supply did not come on when tested. In an interview with staff, Engineering Staff stated that the plug looked damaged.

Building 2

Suite 120 Valley Women's Imaging
2. On 9/7/12, at 4:04 p.m., the combination emergency light/exit light did not function on battery power when tested. This light was located above the exit door near Suite 140.

Suite 130 Valley Medical Imaging
3. On 9/7/12, between 3:45 p.m. and 4:20 p.m., this surveyor did not observe an emergency light in the Valley Medical Imaging Suite. The CT Scanning area and the Main Corridor were located in a windowless area. When Staff was asked if they had experienced a power outage in that location, Staff 1 stated that they had and it was very dark. Staff 2 stated that they thought that there was some lighting that came on in the corridor during power outages, but was not sure where. No documentation was provided indicating if there was, in fact, battery-powered lights in the above mentioned areas.

Based on observation, the facility failed to mark access to exits with readily visible signs. This was evidenced by the failure to provide exit signs where the direction to exit was not obvious, an exit sign that did not function when tested, and exit signs that were not illuminated. This affected one of 26 smoke compartments at the Main Hospital and three of seven suites at the Offsite Outpatient Services at 2809 Olive Highway and could result in a delay evacuation during an emergency.

Findings:

During a tour of the facility with the Director of Plant Operations, exits and exit access were observed.

Main Hospital
1. On 9/6/12 at 9:42 a.m., the direction of egress near the elevators and Nutritional Services was not obvious. With the two sets of cross-corridor doors closed, exit signs were not visible in that location.

Building 2

During a tour of the facility with the the Director of Plant Operations on 9/7/12, exit signs were observed.

Suite 220 Surgical Practices
1. At 3:27 p.m., did not have an exit sign at the end of the hall directing patients to the exit.

Suite 260 Oroville Women's Health
2. At 3:45 p.m., the exit signs in the Woman's Health Clinic the exit signs were not illuminated.

Suite 130 Valley Medical Imaging Services
3. Between 3:50 p.m. and 4:20 p.m., the exit signs in the Valley Medical Imaging Services Suite did not have a battery back-up in its exit signs.

Based on record review and interview, the facility failed to ensure that all staff participate in the use of, and response to, fire alarms. This was evidenced by a lack of documentation provided which would show that all hospital department staff are participating in fire drills. This affected all staff and patients in 11 of 22 departments within the facility and could potentially result in some staff not being trained and familiar with emergency procedures.

NFPA 101, 2000 Edition,
19.7.2.3, All health care occupancy personnel shall be instructed in the use of and response to fire alarms.

Findings:

During document review on 9/7/12, at 2:35 p.m. fire drill documentation was reviewed.

Main Hospital
The facility failed to provide monthly documentation verifying that the following departments participated in fire drills in 2012:
January - Unit 2
March - Surgery
April - Physical Therapy
May - Nursing Administration
June - Unit 1
July - Unit 1

In 2011:
September - Medical Records and Surgery
October - ICU and Administration
November - Dietary and Unit 2
December - Cardio Pulmonary, Emergency Services and Unit 2

Based on observation and interview, the facility failed to maintain their fire alarm devices as evidenced by one audible device and one detection device that failed to function during fire alarm testing. This affected two of 26 smoke compartments at the main hospital and could potentially result in the spread of smoke and fire.

Findings:

During fire alarm testing with the Director and Assistant Director of Plant Operations, on 9/6/12, the following devices did not function when tested:

Main Hospital
1. At 1:33 p.m., the smoke detector numbered 26-13 in the Same Day Surgery Unit did not function when tested with canned smoke. This device was part of the door closure hardware to the east smoke barrier door in same day surgery and was one of two smoke detectors in that unit. This unit was Type I construction and was non sprinklered.
During a review on 9/7/12, at 2:35 p.m., of the Annual Alarm Certification dated 10/20/11, the report did not indicate that the device was included in the testing. On 9/7/12, At 2:45 p.m., the smoke detector numbered 26-13 was again tested with canned smoke and failed to function.

2. At 2:22 p.m., the water flow alarm at the Inspector's Test Valve (ITV) in Mechanical Room 3 was tested. The audible alarm device on the wall in the Mechanical Room did not make any sound.

Based on record review and staff interview, the facility failed to periodically test its automatic sprinkler system. This was evidenced by a lack of documentation for quarterly sprinkler inspections at one of five inspector's test valves for one quarter in a twelve month period. This could potentially result in the spread of smoke and/or fire and a delayed response by first responders if the alarm failed to activate within 90 seconds or failed to alarm at all.

NFPA 101, 2000 Edition, 4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 25, 2998 Edition,
2-3.3* Alarm Devices.
Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-3.3.1* Testing the waterflow alarms on wet pipe systems shall be accomplished by opening the inspector ' s test connection. Fire pumps shall not be turned off during testing unless all impairment procedures contained in Chapter 11 are followed.
Exception: Where freezing weather conditions or other circumstances prohibit use of the inspector ' s test connection, the bypass connection shall be permitted to be used.

Findings:

Main Hospital
1. During record review with the Assistant Director of Plant Operations on 9/7/12, at 2:35 p.m., the facility failed to provide documentation for one quarterly flow test at the inspector's test valve located in the Number 3 Mechanical Room. Documentation was not available for the second quarter of 2012.
Engineering Staff confirmed that the documentation was missing for that date.

Based on observation and interview, the facility failed to provide a portable fire extinguisher at its heliport in accordance with NFPA 10 and 1995 NFPA 418. This was evidenced by a portable fire extinguisher that was not quickly accessible from the landing pad or potential ignition source, and was not located and marked conspicuously. This could potentially result in a delay in access to the fire extinguisher resulting in the spread of fire.

NFPA 10 Standard for Portable Fire Extinguishers
1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

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

1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.

1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage, (e.g., from impact, vibration, the environment) shall be adequately protected.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

1-6.13* Where fire extinguishers are installed in closed cabinets that are exposed to elevated temperatures, the cabinets shall be provided with screened openings and drains.

2-4 Application for Specific Locations. Where portable fire extinguishers are required to be installed, the following documents shall be reviewed for the occupancies outlined in their respective scopes. However, in no case shall the requirements be less than those specified in this standard.

NFPA 418, Standard for Heliports

3-3* Fire Extinguisher Size and Placement for Class B Fires Other Than for Fires in Flammable Liquids of Appreciable Depth.

3-3.1 Minimal sizes of fire extinguishers for the listed grades of hazard shall be provided on the basis of Table 3-3.1. Fire extinguishers shall be located so that the maximum travel distances do not exceed those specified in the table used. (See Appendix E.)
Exception: Fire extinguishers of lesser rating, desired for small specific hazards within the general hazard area, can be used, but shall not be considered as fulfilling any part of the requirements of Table 3-3.1.

3-3.2 Two or more fire extinguishers of lower rating shall not be used to fulfill the protection requirements of Table 3-3.1.
Exception No. 1: Up to three AFFF or FFFP fire extinguishers of at least 2 1/2 -gal (9.46-L) capacity shall be permitted to be used to fulfill extra (high) hazard requirements.
Exception No. 2: Two AFFF or FFFP fire extinguishers of at least 1 1/2 -gal (6-L) capacity shall be permitted to be used to fulfill ordinary (moderate) hazard requirements.

3-3.3 The protection requirements shall be permitted to be fulfilled with fire extinguishers of higher ratings, provided the travel distance to such larger fire extinguishers does not exceed 50 ft (15.25 m).

NFPA 418 Standard From Heliports
Chapter 5 Portable Fire Extinguishers
5-1 Quantity and Rating. At least one portable fire extinguisher as specified in Table 5-1 shall be provided for each takeoff and landing area, parking area, and fuel storage area.
Exception: This requirement shall not apply to unattended ground level heliports.

Table 5-1 Minimum Ratings of Portable Fire Extinguishers for Heliport Categories Helicopter
Category H-1

Overall Length H-1 Up to but not including 50 ft (15.2)

Minimum Rating 4-A:80-B

Helicopter length, including the tail boom and the rotors


Findings:

During a tour of the facility with the the Director and Assistant Director of Plant Operations on 9/7/12, at 10:40 a.m., the Helicopter Landing Area was observed. This Helicopter Landing Pad was located north of the facility across the Parking Lot at ground level.

Main Hospital
1. The closest fire extinguisher located at the Heliport was located inside of a chain link fence This fire extinguisher was also not conspicuously located and did not have identifying signage that was visible from the landing pad.

Fire extinguishers for Class B flammable liquids are required to be within 50 feet of the potential hazard.

Based on record review and interview, the facility failed to maintain its heating, ventilation, and air conditioning system. This was evidenced by incomplete documentation for damper inspections. This finding affected all staff and patients on two of two floors at the main hospital and could potentially result in the spread of smoke and/or fire.

NFPA 101, 2000 Edition,
9.2.1 Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

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

Findings:

Main Hospital
1. During a review of the facility's documentation on 9/7/12, at 2:35 p.m., the facility failed to provide documentation indicating that all dampers had been inspected within the past six years. Documentation provided for damper inspections showed that only 6 of 20 dampers listed on one page of a spread sheet had been inspected on 2/13/07. When asked, Engineering Staff 1 stated that they could not find any other documentation for damper inspections. Hospitals are granted a categorical waiver to extend Damper testing to 6 years. The documentation provided was not complete.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices. This was evidenced by unapproved portable heaters observed in non-sleeping staff areas. This affected all staff and patients in two of 26 smoke compartments at the main hospital and could potentially result in the ignition of fire.

1999 NFPA 99
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

1999 NFPA 70
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:

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/6/12, portable electric heaters were observed.

Main Hospital
1. At 3:02 p.m., there was a portable electric heater plugged in under a desk in the Laboratory Administration Office. This heater was 1500 watts and had a label warning, "high temperature three feet of clearance required".

2. At 3:57 p.m., Nursing Administration Office 1 had a portable electric heater plugged in sitting in on the floor under a desk. This heater was plugged into a multiple outlet extension cord with no over-current protection. The heater had a label warning, "high temperature three feet of clearance required" and was within 12 inches of paper products.

3. At 3:58 p.m., Nursing Administration Office 2 had a portable electric heater plugged in sitting on the floor under a desk. This heater was plugged into a power strip. The heater had a label warning, "high temperature three feet of clearance required".

In an interview with staff, Engineering Staff stated he would remove all heaters during the survey

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full and instant use. This was evidenced by items stored in the exit corridor. This affected all staff and patients in two of 26 fire compartments within the facility and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations on 9/7/12, exit corridors were observed.

Main Hospital
1. At 9:24 a.m., there were two rocking chairs and two scales stored for more than 30 minutes in the corridor of Unit 4 Obstetrics. These items were stored near the cross-corridor doors near the Delivery Room Nurses' Station. The opening width of the cross-corridor doors was approximately 70 inches and the clear width with the items stored near the doors was reduced to 60 inches.

Based on observation, the facility failed to protect its medical compressed gas cylinders. This was evidenced by cylinders which were stored secured together instead of individually, cylinders that were free standing, and a room used as oxygen storage that was not identified as an oxygen storage room. This affected three of 26 smoke compartments within the facility and could potentially result in damage to the cylinders if they were to fall.

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

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations compressed gas cylinders were observed.

Main Hospital
1. On 9/6/12, at 10:05 a.m., there were 23 E size oxygen cylinders stored in the Emergency Department in a room identified as the clean utility room. The door to this room did not have a sign on the door indicating that it was being used as an oxygen storage room.

2. On 9/6/12, at 3:35 p.m., the room identified as the Processing Work Room had three E size oxygen tanks secured with one chain. There was another E size tank that was sitting free standing on the floor outside of the chain.

3. On 9/7/12, at 10:10 a.m., the Medical Gas Source Room located near the Elevator Mechanical Room had six H size compressed gas tanks chained together with one chain instead of individually secured.

Based on interview, the facility failed to insure that the relative humidity is maintained above 35 percent in its anesthetizing locations. This was evidenced by the failure to monitor and document relative humidity levels and track any actions or corrections taken in areas where general anesthesia is used. This affected five of five operating room within the facility and could potentially result in the ignition of fire due to electrostatic charges or other heat- generating equipment in an oxygen-rich environment.

Findings:

Main Hospital
1. During a tour of the facility on 9/7/12, between 10:45 and 11:15 a.m., Operating Room Charge Staff 1 was asked if the facility documented the relative humidity levels in the Operating Rooms. Staff stated that the humidity levels were checked each day, but that it was not documented.

During an interview with Engineering Staff 1, when asked, Staff 1 stated that the facility is in the process of getting new humidity gauges and may be interested in requesting a waiver to lower the humidity level requirements to 20 percent.

Based on observation and interview, the facility failed to provide emergency illumination in all required areas. This was evidenced by the failure to provide a battery-powered emergency lighting unit in all anesthetizing locations. This affected one of five operating rooms and could potentially result in a loss of lighting in the operating room during the ten seconds of time (or longer if the generator fails to start), that is allowed for the back-up generator to transfer power during power outages.

NFPA 99, 1999 Edition, 3-3.2.1.2, 5 (e)
5. Wiring in Anesthetizing Locations
e. Battery-powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e)

NFPA 70, 1999 Edition, 700-12 (e)
(e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.

Findings:.

During a tour of the facility with the Assistant Director of Plant Operations on 9/7/12, operating rooms were observed.

Main Hospital
1. Between 10:50 a.m. and 11:15 a.m., there was no battery-powered emergency lighting unit in Operating Room 5. When asked, Operating Room Charge Staff 1 stated that the room is used mostly for eye procedures without general anesthesia. Charge Staff 1 stated that it was maybe used once or twice per year for procedures using general anesthesia.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities as evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, and the permanent use of extension cords and fixtures without covers. This affected all staff and patients in six of 26 smoke compartments and could potentially result in the ignition of fire.

NFPA 70, 1999 Edition,
400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

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

370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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

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

Findings:

During a tour of the facility with the Director and Assistant Director of Plant Operations electrical wiring and equipment was observed.

Main Hospital
1. On 9/6/12, at 10:14 a.m., the light fixture in the Doctors' Lounge was missing a canopy cover.

2. On 9/6/12, at 10:17 a.m., there was a power strip suspended above the floor under a desk in the Emergency Room Registration area.

3. On 9/6/12, at 10:20 a.m., the plug receptacle in the Quiet Room was missing a cover plate.

4. On 9/6/12, at 10:39 a.m., in the Cardiology Lounge there were two microwave ovens, a toaster, and a coffee pot plugged into a power strip. The coffee pot was also plugged into an extension cord.

5. On 9/6/12, at 3:18 p.m., there were two extension cords in use in the Laboratory Office. One extension cord was supplying power to a computer and the other was supplying power to a server.

6. On 9/6/12, at 3:31 p.m., the Client Services Office had three power strips chained together under a desk.

7. On 9/6/12, at 3:57 p.m., the Nursing Administration Office 1 had a portable electric heater plugged into an unprotected extension cord that was plugged into a power strip.

8. On 9/6/12, at 3:58 p.m., the Nursing Administration Office 2 had a portable electric heater plugged into a power strip.

9. On 9/7/12, at 9:04 a.m., there was a cord to a refrigerator in the breakroom in the Obstetrics Unit that was traveling through a doorway to a plug outlet.

10. On 9/7/12, at 9:30 a.m., there was a microwave oven, a coffee pot, a toaster, and two blenders plugged into a power strip in the Obstetrics Unit Pantry.

11. On 9/7/12, at 10:23 a.m., there was a power strip and extension cord attached to a chain link fence outside of the Bio Med Room.

12. On 9/7/12, at 10:30 a.m., there were three power strips chained together in the Pharmacy Office.