HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by penetrations in the walls, the ceilings and unfinished constuction of a wall. This affected 2 of 2 floors in the Main Hospital and the Outpatient Clinic - Family Practice at Hesperia Community Health Center, 17071 Main Street, Suite 100, Hesperia, CA. This could result in the migration of smoke to other compartments, resulting in potential harm to patients, staff and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Findings:

During a tour of the facility with Hospital Engineering Staff on 10/15/13 through 10/18/13, the facility wall and ceilings were observed.

Main Hospital - on 10/15/13:
1. At 2:11 p.m., there was a 1/4 inch penetration in the ceiling next to the smoke detector in patient room 249, located in the upper level four corners.

2. At 3:07 p.m., there were three 1/2 inch penetrations in the left side of the wall inside of housekeeping room 2-535, located in the upper level north med surg.


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3. At 1:45 P.M., in Biohazard Room 1-136 on the main level, there was a 2 inch round penetration along the top of the metal circle in the back wall.

Outpatient Clinics - Family Practice at Hesperia Community Health Center, Suite 100, Hesperia - on 10/17/13:
4. At 3:00 P.M., the storage room next to the waiting room measured approximately 40 feet by 14 feet and had two rooms connected at each end which measured approximately 6 feet by 8 feet and 7 feet by 9 feet. The room had an unfinished wall with exposed studs measuring 40 feet long down the left side.

Based on observation, the facility failed to maintain their doors to resist the passage of smoke and fire as evidenced by doors that failed to positive latch and were impeded from closing. This had the potential to allow the migration of smoke causing harm to patients and staff. This affected 2 of 2 floors at the main hospital and at the OP Services - Patient Assessment, 18144 Outer Highway 18, Suite 130, Apple Valley.

Findings:

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, the doors were observed.

Main Hospital - on 10/15/13:
1. At 2:50 P.M., the door to Room 1-205 on the main level was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

2. At 2:55 P.M., the door to Room 1-263 on the main level was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

3. At 3:09 P.M., the right door to EVS Storage on the lower level was held open with a rock.

Main Hospital - on 10/17/13:
4. At 9:15 A.M., in ICU-A on the upper level, the fire door by Room 9 had a chair placed in front of it.

5. At 9:53 A.M., in Labor and Delivery on the upper level, the fire door to Room 7 failed to close due to a rocking chair placed up against it.

Out Patient Services - Patient Assessment, Suite 130, Apple Valley - on 10/17/13:
6. At 3:47 P.M., the door to the office was blocked by a tray and 2 plastic tubs containing charts.

Out Patient Services - Perinatal Testing at Perinatal Testing, Suite 800 and 600.
On 10/17/13:
7. At 5:15 P.M., in Suite 800, the door to Room 3 failed to latch.

8. At 5:16 P.M., in Suite 800, the door to Room 4 failed to latch.

9. At 5:25 P.M., in Suite 600, the door to the electrical room in the downstairs training room had a disassembled self-closing device on the door.

Based on observation, the facility failed to maintain the fire rated doors to prevent the passage of fire and smoke into the corridor. This was evidenced by doors that failed positive latch upon closure and failed to release from their magnetic hold open devices during the testing of the fire alarm system. This could result in the spread of smoke and/or fire from one smoke compartment to another and affected 2 of 3 smoke compartments at the Out Patient Surgery Pavilion.

Findings:

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, the doors on magnetic devices were observed during fire alarm testing.

Out Patient Surgery Pavilion - on 10/17/13:
1. At 4:18 p.m., the fire rated smoke barrier door to the storage room that is located across from staff lounge failed to latch when closed during the testing of the manual pull stations and sprinkler system.

2. At 4:19 p.m., the fire rated smoke barrier door to the GI Lab failed to latch when closed during the testing of the manual pull stations and sprinkler system.

3. At 4:20 P.M., the fire rated smoke barrier door to the "Warming Cabinet Sterilizer" room failed to release from the magnet after activation of a manual pull station and sprinkler system.

4. At 4:21 P.M., the fire rated smoke barrier door to the surgery suite failed to release from the magnet after activation of a manual pull station and sprinkler system.

Based on observation and interview, the facility failed to maintain the integrity of the fire rated construction of its smoke barrier walls as evidenced by unsealed penetrations in the smoke barrier walls. This failure affected 2 of 2 floors in the Main Hospital and could result in the migration of smoke resulting in potential harm to patients, staff and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 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 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 the Hospital Engineering Staff on 10/15/13 through 10/18/13, the smoke barrier walls were observed.

Main Hospital - on 10/15/13:
1. At 10:15 a.m., there was a 1 inch unsealed penetration around a bunch of white wires in the right side of the smoke barrier wall in the upper level East Telemetry.

2. At 10:52 a.m., there were three unsealed penetrations in the wall located in the north corridor of the upper level West Telemetry. 1. A 1 inch penetration around a bunch of wires in the right side of the wall, 2. A 1/2 inch penetration in the center of the wall and 3. A conduit penetrating the wall and was not sealed with fire stop material.

3. At 11:58 a.m., there was a 1/2 inch unsealed penetration around red wires in the smoke barrier wall located above the upper level North ICU west exit door. During an interview staff stated the fire alarm system had been upgraded recently.

4. At 2:58 p.m., there was a 4 inch conduit penetrating the smoke barrier wall in the upper level North Med Surg unit with wires running through that was not sealed with a fire stop material in the center of the conduit.



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Main Hospital - on 10/15/13:
5. At 2:17 P.M., in the smoke barrier wall by Room 1-171, Nuclear Medicine, on the main level, there was an unsealed penetration approximately 2 inches round with a metal conduit pipe and 2 red wires running through it in the wall above the fire doors. When interviewed, Hospital Staff stated that a new fire alarm panel was installed and they must have forgotten to patch the holes.

6. At 2:35 P.M., in the smoke barrier wall by the sign labeled "Entrance to Main Hospital", on the main level, there was an unsealed penetration approximately 1 inch in diameter around the metal conduit pipe in the wall above the fire doors.

7. At 2:47 P.M., in the smoke barrier wall by by Surgical Services Director office 1-205 on the main level, there were 2 penetrations approximately 1 ½ round in diameter in the wall above the fire doors. When interviewed, Hospital Staff stated that new censors had been put in above the doors and they forgot to seal the holes.

Based on observation, the facility failed to maintain their fire rated smoke barrier doors on magnetic hold open devices to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by smoke barrier doors that failed to latch upon activation of the fire alarm system. This could result in the spread of smoke and/or fire from one smoke compartment to another and affected 1 of 2 floors at the main hospital.

NFPA 101®, Life Safety Code®, 2000 Edition
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

Findings:

During fire alarm testing with Hospital Engineering Staff on 10/17/13, the smoke barrier doors were observed and tested.

Main Hospital - on 10/17/13:
At 9:47 A.M., the smoke barrier door to the Lab 2-234 on the upper level failed to latch during the activation of the fire alarm system.

Based on observation, the facility failed to maintain the fire rated wall construction of a hazardous area. This was evidenced by an unsealed penetration in the wall of a hazardous room. This failure affected 1 of 2 floors in the Main Hospital and could result in the migration of smoke resulting in potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with Hospital Engineering Staff on 10/15/13 through 10/18/13, the hazardous areas were observed.

Main Hospital - on 10/15/13:
At 4:01 p.m., there was a 5 inch by 2 inch penetration in the wall behind a large trash bin located in the upper level labor and delivery, trash collection room 2-178. This was acknowledged by the Facilities Manager.

Out Patient Services - Wound Care - on 10/17/13:
4. At 5:05 p.m., the emergency light in the dressing room failed to illuminate when tested.



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Based on observation and interview, the facility failed to provide battery-powered emergency lighting in the GI Lab Operating Room 1-202. This was evidenced by no battery powered emergency lighting in the GI Lab Operating Room 1-202, and the facility failed to maintain their emergency lighting as evidenced by emergency lighting units that failed to illuminate when tested and no record of monthly or annual maintenance and testing for the facility's emergency lighting system in the Main Hospital, Outpatient Clinics (OP) - Family Practice at Healthy Beginnings Apple Valley Family Resource Center, OP Clinics - Family Practice at Health Beginnings, suites 8 & 9, Adelanto, OP Clinics - Family Practice at Hesperia Community Health Center, Suite 100, OP Services - Perinatal Testing, Suite 600-A and 800, OP Services - Surgery Out Patient Surgery Pavilion, OP Services - Would Care, Suite A, and OP Services - Patient Assessment, Suite 130. This failure affected patients in the main hospital and all offsite locations listed above.

NFPA 101®, Life Safety Code®, 2000 Edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, the emergency lighting and exit signs with battery back up power were observed and tested, and the Hospital Staff was interviewed.

Main Hospital - on 10/15/13:
1. At 10:00 A.M., documentation of monthly and annual emergency/exit light testing for the main hospital and all offsite locations was requested.
At 2:55 P.M., the Facility Manager stated that they did test the emergency/exit lights but did not document the monthly testing or annual testing for any of the emergency/exit lighting units for the main hospital or all offsite locations.

2.. At 3:00 P.M., in the GI Lab area on the main level, 2 of 2 GI procedure rooms failed to have battery powered emergency lighting.

3. At 4:00 P.M., in the MRI Building, the emergency lighting in the main entrance failed to illuminate when tested. The exit sign with battery back up power in the adjacent room failed to illuminate due to bulbs that were burnt out.

Based on observation and interview, the facility failed to ensure an evacuation map was posted as evidenced by no evacuation map posted in the Out Patient Services, Patient Assessment, Suite 130. This failure could delay patients, staff and visitors from utilizing the correct escape path in an emergency evacuation. This affected the OP Services, Patient Assessment, Suite 130 building.

Findings:

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, the OP Services, Patient Assessment, Suite 130 building was observed.

Out Patient Services, Patient Assessment, Suite 130 -On 10/17/13:
At 3:45 P.M., Out Patient Services, Patient Assessment, Suite 130 failed to have an evacuation map posted.

Based on document review and interview, the facility failed to conduct fire drills at least quarterly for each shift of personnel as evidenced by the Outpatient Clinics (OP) - Family Practice at Healthy Beginnings Apple Valley Family Resource Center, OP Clinics - Family Practice at Health Beginnings, suites 8 & 9, Adelanto, and OP Services - Patient Assessment, Suite 130 failing to conduct fire drills every quarter. This failure could result in the staff's inability to respond to fire and/or disaster according to the facilities fire protection plan.

Findings:

During document review and interview with Hospital Engineering Staff on 10/15/13 through 10/18/13, the facility's fire drill records were reviewed.

Outpatient Clinics - Family Practice at Healthy Beginnings Apple Valley Family Resource Center- On 10/16/13:
1. At 1:00 P.M., the fire drill records indicate that the facility failed to have a fire drill for the 4th quarter, October, November and/or December 2012 quarter.

Out Patient Clinics - Family Practice at Health Beginnings, Suites 8 & 9, Adelanto.
On 10/16/13:
2. At 1:10 P.M., the fire drill records indicated that the facility failed to have a fire drill for the 4th quarter, October, November and/or December 2012 quarter.

Out Patient Services - Patient Assessment, Suite 130 - On 10/16/13:
3. At 1:15 P.M., the fire drill records indicate that the facility failed to have a fire drill for the 1st quarter January, February and/or March 2013 quarter and for 4th quarter, October, November and/or December 2012 quarter.

Main Hospital - on 10/17/13:
4. At approximately 5:35 p.m., facility staff stated there was no additional fire drill records for review.

Based on observation, the facility failed to maintain their fire alarm system as evidenced by the batteries in the Fire Alarm Control Panels (FACP) not tested, batteriers that had no dates and by no annual certification of the fire alarm control panel and components according to NFPA 72 specifications, . This could result in the fire alarm system not functioning as designed and could result in potential harm to patients and staff in the event of a fire. This affected the main hospital, the Out Patient Services, Patient Assessment, Suite 130 and Family Practice at Hesperia Community Health Center.

NFPA 72, 1999 Edition. Table 7-3.2 Testing Frequencies.
6. Batteries -- Fire Alarm Systems
d. Sealed Lead-Acid Type,
1. Charger Test (Replace battery every 4 years.)

Findings:

During the testing of the fire alarm system with Hospital Engineering Staff on 10/15/13 through 10/18/13, the fire alarms system was observed.

Out Patient Clinic - Family Practice at Hesperia Community Health Center- on 10/17/13:
1. At 2:57 p.m., the facility failed to provide annual testing and certification of the fire alarm system and for the maintenance and testing of 20 heat detectors and 2 manual pull alarms in the facility.


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Main Hospital - on 10/15/13:
2. At 3:37 P.M., in the EVS Storage building, there were 2 batteries in the FACP, Room 1-309, that were dated 7/7/09, which exceeded the expiration date.

Out Patient Services, Patient Assessment, Suite 130 - on 10/17/13:
3. At 3:45 P.M., Suite 130 failed to have any notification devices such as a smoke or heat detector. The building was not sprinklered.

Based on observation, the facility failed to maintain their smoke detectors as evidenced by a battery operated smoke detector failing to activate an audible alarm when tested. This failure could result in potential harm to patients and staff in the event of fire alarm system failures. This affected the MRI and NICU at the Main Hospital and the OP Surgery Pavilion.

Findings:

During fire alarm testing with Hospital Engineering Staff on 10/17/13, the smoke detectors were observed and tested.

Main Hospital - on 10/15/13:
1. At 4:22 p.m., during a tour of the NICU Isolation room the smoke detector in the room was observed to be covered with plastic.

Out Patient Surgery Pavilion- on 10/17/13:
2. During document review with Hospital Staff on 9/16/13 through 10/18/13, the facility failed to provide documentation for the sensitivity testing of 4 smoke detectors that are connected to the fire alarm panel.

Out Patient Clinic - Healthy Beginnings, Adlanto - on 10/17/13:
3. At 1:50 p.m., the facility failed to provide documentation for the maintenance and testing of 15 battery powered smoke detectors.

4. At 1:55 p.m., the facility failed to provide a smoke detector in treatment room 2. The facility is not sprinklered and the smoke detectors are the only notification devices in the facility.


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Main Hospital MRI Building - on 10/17/13:
5. At 11:40 P.M., the battery operated smoke detector failed to activate an alarm when tested with canned smoke.

Out Patient Surgery Pavilion - on 10/17/13:
6. At 4:24 P.M., the smoke detector labeled Zone 4-1 was tested with canned smoke and activated the smoke alarm. The panel stated "Zone 5". When interviewed, the Vendor stated that the smoke detector might be labeled incorrectly.

Based on observation, document review and interview, the facility failed to maintain their automatic sprinkler system as evidenced by a missing sprinkler escutcheon ring, and by incomplete documentation for the quarterly inspection and testing of the fire sprinkler system. This affected 1 of 2 floors in the Main Hospital, Out Patient Surgery Pavilion and Out Patient Wound Care. This failure could result in the fire sprinkler system not functioning as designed in the event of a fire and could result in potential harm to patients, staff and visitors.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water- Base Fire Protection Systems, 1998 Edition
Chapter 2 Sprinkler Systems 2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, paint, and physical damage and shall be installed in the proper orientation (e.g. upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2.2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are fee of physical damage.
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.

Findings:

During a tour of the facility with Hospital Engineering Staff on 10/15/13 through 10/18/13, the automatic sprinkler system was observed.

Main Hospital - on 10/15/13:
1. At 3:26 p.m., there was a missing sprinkler escutcheon ring in the upper floor Respiratory Equipment room 2-212.

2. During document review on 10/16/13 and 10/17/13, the facility failed to provide a second quarter sprinkler test and inspection report for the Out Patient Surgery Pavilion and for the Out Patient Wound Care Center. During interview facility staff stated there were no additional records for review.

Based on observation, the facility failed to ensure that the portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by a fire extinguisher that was mounted over 5ft from the floor to the top of the pin, and by a fire extinguisher that was on the floor. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire. This affected 2 of 2 Floors and the OP Services - Perinatal Testing at Perinatal Testing, Suite 800 and 600.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.

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).

Findings:

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, the fire extinguishers were observed.

Main Hospital - on 10/15/13:
1. At 2:12 P.M., in the Chapel on the main level, there was a fire extinguisher on the floor under the clamp mounted on the wall. The clamp was missing a screw and could not hold the fire extinguisher so it had been placed on the floor.

2. At 4:10 P.M., in the File Room on the lower level, there was a fire extinguisher mounted 6 feet 1 inch from the ground to the top of the pin.

OP Services - Perinatal Testing at Perinatal Testing, Suite 800 and 600 - on 10/17/13:
3. At 5:19 P.M., in Suite 600, the fire extinguisher was blocked by a chair, 3 wood boxes with a stereo and speakers sitting on top.

Based on observation and interview, the facility failed to ensure that cigarette butts were disposed in appropriate receptacles to prevent accidental fire. This was evidenced by cigarette butts disposed on the ground with piles of dried leaves. This could result in accidental fire and increase risk of injury to patients. This affected the main hospital and the OP Services - Surgery at Out Patient Surgery Pavilion.

Findings:

During a tour of the facility with the Hospital Staff on 10/15/13 through 10/18/13, the facility's property and designated smoking areas were observed and staff was interviewed.

Main Hospital - on 10/15/13:
At 3:15 P.M., in an area next to the designated smoking area across from the EVS Storage building, there were over 100 plus cigarette butts in the dirt and piles of dried leaves.

Based on observation and interview, the facility failed to ensure that portable space heating device were not used. This was evidenced by the use of portable space heater. This could potentially cause harm to patients, visitors and staff due to accidental fire from the space heaters. This affected 1 of 2 floors at the main hospital.

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, a portable space heater was observed and staff was interviewed.

Main Hospital - on 10/15/13:
At 1:58 P.M., the Doctors Relaxation Room 1-131 in the Emergency Department on the main level had a portable space heater labeled "Lakewood 1500W" on the floor next to the desk. The portable space heater was not on. When interviewed, hospital staff was asked if patients came into the room and stated that they did not, but due to the temperature rating, they would remove the heater.

Based on observation and interview, the facility failed to ensure the means of egress were free from obstructions as evidenced by large push cart stored in a corridor obstructing the path of egress. This affected 1 of 2 floors in the Main Hospital and could result in delayed egress in the event of a fire or other emergency.

Findings:

During a tour of the facility with Hospital Engineering Staff on 10/15/13 through 10/18/13, the exit corridors were observed.

Main Hospital - on 10/15/13:
1. At 3:58 p.m., there was a large push cart filled with card board boxes in the upper floor Labor and Delivery corridor across from room 8.

Main Hospital - on 10/17/13:
2. At 9:58 a.m., during fire alarm testing there was a large push cart with a box in the upper floor Labor and Delivery corridor across from room 8. During an interview, staff stated the cart is left there for pick ups and deliveries.

Based on observation, the facility failed to ensure that the full and empty oxygen cylinders were separated, not stored next to electrical outlets and had the proper precautionary signs displayed. This could result in potential harm to patient from fire and if the wrong culinder is pulled from the storage room. This affected the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
21-1.2.6 CGA Publications. Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.

Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a) 11e with respect to temperature limitations. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a) 11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b) 13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b) 27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b) 14.

4-3.5.2.1 (b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

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 Hospital Engineering Staff on 10/15/13 through 10/18/13, the facility's oxygen cylinder storage rooms were observed.

Main Hospital - on 10/15/13:
At 3:30 P.M., in the EVS Building, Room 1-300, there were 12 E-Tank oxygen cylinders stored next to a two plug electrical outlet with no precautionary sign to indicate the room was used for oxygen cylinder storage. The room failed to have a sign indicating which tanks were full or empty.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 edition. This was evidenced by electrical appliances plugged into extension cords and multi-plug power strips and not directly into electrical outlets and an electrical outlet missing a cover plate. This could result in an increased risk of electrical fire and potential injury to patients and staff in the event of a fire. This affected 2 of 2 floors.

NFPA 70 Section 400-8 1999 Ed. 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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Hospital Engineering Staff on 10/15/13 through 10/18/13, the electrical system was observed.

Main Hospital - on 10/15/13:
1. At 3:35 P.M., in the EVS Storage building, gift shop storage, room 1-306, there was a two plug electrical outlet missing a cover plate on the left wall.

2. At 4:12 p.m., in the upper level Anesthesia call room 2-135, there was a six outlet adapter in use that had no overcurrent protection.

Main Hospital, Histology Building
On 10/15/13:
3. At 3:50 P.M., in the "Clean Room" (employee break room), there was a microwave plugged into a multi-outlet adapter and not directly into an electrical outlet.

Main Hospital, Bio Med Shop
On 10/15/13:
4. At 4:10 P.M., in the Bio Med Shop there was a refrigerator and a microwave plugged into extension cords, plugged into a surge protector.

Based on document review and interview, the facility failed to provide a written fire watch procedure in the event the automatic sprinkler system was out of service for more than four hours. This failure could result in potential harm to patients, staff and visitors in the event the facility is unprotected due to sprinkler system failure. This affected the Main Hospital, Out Patient Surgery Pavilion, and the Out Patient Wound Care Center.

Findings:

During document review and interview with Hospital Engineering Staff on 10/15/13 through 10/18/13, Policy and Procedure manual was observed.

Main Hospital - on 10/16/13:
At 2:20 p.m., the facility provided a fire watch policy in the event of a power failure. There was no policy to protect their patients if the sprinkler system was out of service for more than four hours. During an interview, the facility staff stated they did not have a fire watch policy for the failure of the sprinkler system.