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Based on observation and interview, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the fire-rated sheeting of the walls and ceiling. This deficient practice affected five of eleven floors at the Main Hospital and one of one smoke compartment at the Mary Philippa Health Clinic, which could potentially result in the spread of smoke and/or fire from one compartment to another.

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, unsealed penetrations were observed in the fire-rated sheeting in the following locations:

Main Hospital Building
1. On 11/16/10, between 4:00 and 4:30 p.m., the fire-rated wall on B Level, between the Medical Air Room and the Chiller Room, had a three by six inch unsealed penetration in the wall approximately 36 inches up from the floor.


Findings:

During a tour of the facility with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the facility walls and ceilings were observed.

Main Hospital Building
On 11/16/10:

2. At 10:18 a.m., in the Sitz bath room on the 6th floor there were five 1/4 inch round penetrations in the back wall.

3. At 10:20 a.m., in Room 646 on the 6th floor there were eight ? inch round penetrations in the wall.

4. At 10:45 a.m., in the Locker room with the abandoned tray system on the 6th floor there were four ? in round penetrations in the left wall.

5. At 10:53 a.m., in Room T6-25 on the 6th floor there were two 1 inch round penetrations in the right wall.

6. At 11:00 a.m., in Room 481A on the 4th floor, there were two 1 inch round penetrations in the back wall.

7. At 11:28 p.m., in Room B on the 2nd floor, there was one penetration approximately 2 inches x 2 inches round in the ceiling above the television.

8. At 11:40 a.m., in the Waiting room for the USF College Clinic on the 2nd floor there were three ? round penetrations in the wall over the chairs.

9. At 1:35 p.m., in the Conference Room in ICU on the 2nd floor there were 5 ? inch round penetrations in the back wall.

10. At 2:45 p.m., in Room A-6 on A Level, the second room containing the AC for the CT scan did not have sheet rock from floor to ceiling on the wall where the door is located exposing pipes.

OP Services - Sister Mary Philippa Health Center
On 11/17/10:

11. At 2:45 p.m., in the corridor wall above the door across from the " J Specialty Clinics on the 5th floor there were two penetrations approximately ? inch round each.

Based on observation, the facility failed to maintain its corridor doors as evidenced by doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected two of eleven floors at the Main Hospital and one of two smoke compartments at the McAuley Behavior Health Institute building.

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, corridor doors were observed in the following locations:

Main Hospital
1. On 11/16/10, at 3:15 p.m., the corridor door leading to the Pathology Work Room in the OR Unit on Level B did not positive latch when tested by releasing it from an open position.

McAuley Behavior Health Institute
2. On 11/17/10, at 2:50 p.m., the corridor door to Room 588 did not positive latch when tested.

Findings:

During a tour of the facility the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the corridor doors were observed.

Main Hospital
On 11/16/10:
3. At 10:23 a.m., the door to Room 643 on the 6th floor had a self closing device but, failed to positive latch upon closure.

Based on observation, the facility failed to maintain all cross-corridor doors to continuously serve as a smoke barrier, as evidenced by cross-corridor doors which were equipped with latching hardware but failed to latch when tested. This deficient practice affected eight of 36 smoke compartments within the Main Hospital and two of two smoke compartments at the McAuley Behavior Health Institute buildings, and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, cross corridor doors were tested in the following locations:

Main Hospital
1. On 11/16/10, at 10:20 a.m., the cross corridor doors near Patient Room 764 did not positive latch.
2. On 11/17/10, at 9:08 a.m., the cross corridor doors near Patient Room 833 did not positive latch.
3. On 11/17/10, at 10:55 a.m., during fire alarm testing on the Fourth Floor, the left leaf of the cross corridor doors near Room T4-85 did not positive latch.

McAuley Behavior Health Institute
4. On 11/17/10, at 3:09 p.m., during fire system testing, the south leaf facing south of the cross corridor doors near Room P5-20 did not positive latch when tested.

Based on observation and interview, the facility failed to protect its hazardous area enclosures, as evidenced by:
1. 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.
2. A mechanical room door that did not positive latch when tested.
This deficient practice affected two of eleven floors 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 Chief Engineer and the Environmental Care Manager between 11/16/10, hazardous area enclosures were observed in the following locations:

Main Hospital Building
1. At 3:10 p.m., the area identified as the Pathology Work Room on the B Level did not have a self closure on the door. This room contained approximately four gallons of flammable liquid identified as one gallon each of methanol, alcohol, 95 percent dehydrated alcohol, and xylene, which were stored under a counter top cabinet. This door was also observed to be in the open position. This room was approximately 100 square feet in size.

2. Between 4:00 and 4:30 p.m., the door between the Boiler Room and the Chiller Room on the C Level did not positive latch when released from an open position.

Based on observation and staff interview, the facility failed to maintain an acceptable amount of flammable liquids in its laboratory in accordance with 1999 NFPA 99, which was evidenced by stored flammable liquids in excess of 1 gallon per 100 sq. ft. This deficient practice affected one of eleven floors at the Main Hospital and could potentially result in the ignition of fire.

NFPA 99, 1999 edition, 10-7.2.2 Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of an approved storage cabinets and safety cans shall not exceed 1 gallon per 100 sq. ft. The total volume of Class I, II, and IIIA liquids including those contained in an approved storage cabinet and safety cans shall not exceed 2 gallons per 100 sq. ft. No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit....

Findings:

Main Hospital Building
During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, at 3:10 p.m., the room identified as the Pathology Work Room contained approximately four gallons of flammable liquid identified as one gallon each of methanol, alcohol, 95 percent dehydrated alcohol, and xylene, which were stored under a counter top cabinet. This room was approximately 100 square feet in size. Staff 1 confirmed that the room had four gallons of combustible liquid and that it would be moved.

Based on observation, the facility failed to clearly mark all exits, in accordance with 2000 NFPA 101, as evidenced by an exit sign that was not illuminated. This finding affected one of two smoke compartments within the SFO Airport Clinic and could potentially result in injury and/or a delayed evacuation in the event of an emergency.

Findings:

SFO Airport Clinic
During a tour of the facility on 11/18/10, the exit sign located at the Rear Clinic Exit exiting into the airport was not illuminated.

Based on record review and interview, the facility failed to document that all staff are being trained in the use of, and response to, fire alarms in accordance with 2000 NFPA 101. This was evidenced by incomplete documentation for fire drills. This deficient practice affected all staff and four of four patients within the McAuley Behavior Health Institute building and could potentially result in some staff not being trained and familiar with emergency procedures.

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

Findings:

McAuley Behavior Health Institute
During document review on 11/18/10, at 1:45 p.m., the facility failed to provide documentation for fire drills for the first quarter a.m. or NOC shift, the second quarter a.m. or NOC shift, the third quarter a.m. or p.m. shift of 2010, and the fourth quarter a.m. or NOC shift of 2009. Staff 1 confirmed that the drills had not been done for those time periods.

Based on observation and interview, the facility failed to maintain all fire alarm system devices in accordance with 1999 NFPA 72 to provide effective warning in any part of the building. This was evidenced by fire alarm system devices which failed to function or be heard during testing. This deficient practice potentially affected all staff and patients on five of eleven floors at the Main Hospital, one of two smoke compartments at the McAuley Behavior Health Institute, and one of one smoke compartment at the Mary Philippa Health Clinic. This could potentially result in the facility ' s occupants in some locations not being warned if a fire or other emergency occurred.

4-3.2.2* To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.

Findings:

Main Hospital Building
During fire alarm testing on 11/17/10, fire alarm system devices were observed that failed to function or were not installed in the following locations:

1. On 11/17/10, at 11:50 a.m., the room identified as Micro Biology did not have an audible alarm or strobe that could be heard or seen during activation of the fire alarm system.
2. On 11/17/10, at 11:56 a.m., the room identified as Nuclear Medicine did not have an audible alarm or strobe that could be heard or seen during activation of the fire alarm system.

McAuley Behavior Health Institute
3. On 11/17/10, at 3:00 p.m., the alarm device located near the Copy Room P5-13 did not produce an audible alarm during testing

Findings:

During a tour of the facility the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the facilities fire alarm system was observed.

Main Hospital Building
On 11/17/10:

5. At 10:25 a.m., in the Break room on 5 East on the 5th floor, the pull station was activated in the smoke compartment and the alarm could not be heard in the Break Room. When interviewed on November 17, 2010 at 10:25 a.m., Staff 1 stated that they could not hear the alarm or the over head page in the break room. The room contained no strobe, chime/bell.

6. At 9:10 a.m., the chime by the elevators across from Room 883 on the 8th floor failed to activate during testing of the fire alarm system.

7. At 11:04 a.m., the chime by Room T3-76 failed to activate during testing of the fire alarm system.

8. At 11:55 a.m., in the Radiology core area on Level A the pull station was activated and the alarm could not be heard. When interviewed on November 17, 2010 at 11:55 a.m., Staff 2 stated that they could not hear the alarm or an overhead page in that area.

During facility testing with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the smoke detectors were tested.

OP Services - Sister Mary Philippa Health Center
On 11/17/10

9. At 3:06 p.m., the smoke detector in the waiting area of the Specialty Clinic on the 5th floor failed to activate.

10. At 3:08 p.m., the smoke detector in the Specialty Clinic Office failed to activate.

Based on ...

During facility testing with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the smoke detectors were tested.

OP Services - SR Mary Phillippa @ 2235 Hayes Street, 5th floor

On 11/17/10

1. At 3:06 p.m., the smoke detector in the waiting area of the Specialty Clinic on the 5th floor failed to activate.

2. At 3:08 p.m., the smoke detector in the Specialty Clinic Office failed to activate.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system in accordance with 1998 NFPA 25, as evidenced by
1. The automatic sprinkler system fire hose connections missing their protective caps.
This deficient practice affected all staff and patients on four of eleven floors in the Main Hospital Building. This could potentially result in obstructions and/or damage to the interior of the connection and the spread of smoke and/or fire if fire hose connections can not be used.

9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.

9-7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.
9-7.3 Components shall be repaired or replaced as necessary in accordance with the manufacturer ' s instructions. Any obstructions that are present shall be removed.

Findings:

Main Hospital Building
1. During a tour of the facility on 11/15/10, at 3:20 p.m., the fire hose connection caps located on the fourth, fifth, sixth, seventh, and eighth floor east stairwells were missing. Staff 1 stated that the caps were all missing, that they are frequently stolen, and called staff to have new caps installed.

Based on observation and interview, the facility failed to maintain their portable fire extinguisher as evidenced by fire extinguisher ' s that were blocked from access. This deficient practice potentially affected all staff, patients, and visitors on two of eleven floor at the Main Hospital Building and one of one smoke compartments at the Sister Mary Philippa Health Center and has the potential for inaccessibility to the fire extinguisher, which could cause potential harm to staff and patients in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 2002 Edition
1.5.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal path of travel, including exits from area.

Findings:

During a tour of the facility with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the fire extinguishers were observed.

Main Hospital Building
On 11/16/10:

1. At 11:10 a.m., the fire extinguisher in the Physical Therapy/Gym area on the 4th floor was blocked from access by a treatment matt bed.

2. At 11:40 a.m., the fire extinguisher in the waiting room for USF College Clinic on the 2nd floor was blocked from access by three chairs.

OP Services - Sister Mary Philippa Health Center
On 11/17/10:

3. At 2:30 p.m., 3 of 7 fire extinguishers in the Fire Hose cabinet on the 5th floor did not have a tool to break the glass or a key for the staff to be able to open the door. When interviewed on 11/17/10 at 2:30 p.m., the Director was asked how they would get to the fire extinguisher in an emergency. The Director stated that they would wrap a sheet or blanket around their hand a brake the glass.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items that were stored in the path of egress in an exit corridor. This deficient practice had the potetial to affected all staff and patients on one of eleven floors at the Main Hospital and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

Main Hospital
During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, between 4:00 and 4:30 p.m., the corridor near the Cafeteria Room TB-80 had approximately 30 chairs and ten tables from the Cafeteria stored against the wall. The clear corridor width was approximately four feet throughout the corridor which was approximately 50 feet long. Staff 1 stated that the chairs were going to be used for an award dinner on Friday, but that they would move them out of the corridor right away.

Based on document review and staff interview, the facility failed to provide complete documentation of generator maintenance in accordance with 1999 NFPA 110, as evidenced by incomplete documentation for generator weekly inspections for 12 of 52 weeks in a twelve month period. This finding affected all staff and residents within the facility and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

Findings:

During a review of the facility's documentation on 11/18/10 at 3:05 p.m., documentation provided indicated that the generator was being tested under load at least once per month as required; documentation did not indicate, however, that weekly inspections were done for approximately 12 out of 52 weeks. Staff 1 stated that the weekly inspections were done but a not recorded for that time period.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 99 and 1999 NFPA 70. This was evidenced by power strips which were suspended above the floor, high wattage electrical appliances which were not plugged directly into fixed electrical outlets, storage in front of the electrical panels, electrical outlets missing covers, and incomplete documentation for receptacle testing. This deficient practice had the potential to affected all staff, patients, and visitors on nine of eleven floors at the Main Hospital and two of two smoke compartments at the McAuley Behavior Health Institute, and could potentially result in the ignition of fire and/or a delay in access to electrical panels during an emergency.

NFPA 99
3-3.4.2.3 Maintenance and Testing of Electrical System.
(a) Testing Interval for Receptacles in Patient Care Areas.
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.

3.3.3.3 Receptacle Testing in Patient Care Areas.
a) The physical integrity of each receptacle shall be confirmed by visual inspection.
b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 70 Table 110-26 (a)
A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less

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

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

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

NFPA 70 1999 edition
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.



Findings:

During Record Review on 11/15/10, at 10:00 a.m., documentation provided for receptacle testing was in the form of a work order which was titled Electrical Area Sweep. These work orders were for each floor for the hospital main building as well as the outpatient facilities. This documentation did not provide any information on the rooms that were checked or if any of the receptacles had been replaced.

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, electrical wiring and equipment were observed in the following locations:

Main Hospital
1. On 11/15/10, at 3:30 p.m., the East Eighth Floor Nurses Station had a power strip under a desk that was suspended above the floor.

During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, electrical wiring and equipment were observed:

2. At 10:55 p.m., the Fifth Floor Staff Locker Room Tray Room had an electrical panel access that was blocked by two ladders in front of the panel. These panels had warnings in red letter stating, " Do not block " .
3. At 1:25 p.m., the First Floor Cardiac Rehabilitation had a power strip suspended above the floor in office T3-68.
4. At 1:35 p.m., the First Floor HIM Office area had an extension cord suspended above the floor.
5. Between 1:45 and 2:05 p.m., the First Floor Nursing Station Staffing Office had a microwave oven and coffee pot plugged into a power strip. The Nursing Administration Office had a power strip plugged into another power strip.
6. At 2:12 p.m., the First Floor Fire Alarm Control Panel Room had cardboard boxes stored in front of an electrical panel. This panel had warnings in red letter stating, " Do not block " .
7. At 2:50 p.m., the B Level PACU Nurses ' Station had two power strip plugged into each other.
8. At 3:05 p.m., the B Level Nurse Manager ' s Office N21-31 had a power strip plugged into another power strip.
9. At 3:05 p.m., the B Level Male Locker Room had a microwave oven plugged into a power strip.
10. At 3:20 p.m., the B Level Doctors ' Lounge had a coffee pot and a refrigerator plugged into a power strip.
11. Between 3:30 and 4:00 p.m., the A Level Store Room Office in Receiving had a microwave oven plugged into a power strip. The Linen Re-Packing break Room area had a microwave oven plugged into a power strip.

McAuley Behavior Health Institute
During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/17/10, electrical wiring and equipment were observed:
12. At 2:54 p.m., the Staff Room had a power strip suspended above the floor with a microwave oven plugged into it.
13. At 3:00 p.m., the Medications Room had three power strips that were plugged into each other.


Findings:

During a tour of the facility with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the electrical system was observed.

Main Hospital Building
On 11/16/10:

14. At 10:30 a.m., in Room 636 on the 6th floor, there was a nurse call box missing the cover exposing a 2 inch x 2 inch square penetration in the wall.
15. At 11:38 a.m., in Room 400 on the 4th floor there was a cable box hanging out of the wall exposing a 3 inch x 3 inch penetration in the wall.

16. At 12:00 p.m., in the Infusion Center Conference Room by Room 225 on the 2nd floor there was a microwave plugged into a multi-plug power strip.

17. At 2:00 p.m., in Room TA-193 on Level A there was a refrigerator plugged into a multi-plug power strip.

Based on observation and interview, 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 ABHR dispensers located near or above electrical devices. This deficient practice had the potential to affected three of eleven floors at the Main Hospital and one of two smoke compartments at the SFO Airport Clinic, and could potentially result in the ignition of fire.

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

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, ABHR dispensers were observed in the following locations:

Main Hospital Tower
1. At 10:10 a.m., Patient Rooms 827, 826, and 732 had ABHR dispensers located above recessed wall lights which were approximately 12 inches above the finished floor.
2. At 11:30 a.m., Room T3-61 in Therapy had an ABHR dispenser located above a light switch.

SFO Airport Clinic
3. During a tour of the SFO Clinic with the Chief Engineer and the Materials Management Manager on 11/18/10, between 9:15 and 9:20 a.m., the Break Room and Billing Office each had an ABHR dispenser located near light switches.

Based on observation and interview, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the fire-rated sheeting of the walls and ceiling. This deficient practice affected five of eleven floors at the Main Hospital and one of one smoke compartment at the Mary Philippa Health Clinic, which could potentially result in the spread of smoke and/or fire from one compartment to another.

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, unsealed penetrations were observed in the fire-rated sheeting in the following locations:

Main Hospital Building
1. On 11/16/10, between 4:00 and 4:30 p.m., the fire-rated wall on B Level, between the Medical Air Room and the Chiller Room, had a three by six inch unsealed penetration in the wall approximately 36 inches up from the floor.


Findings:

During a tour of the facility with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the facility walls and ceilings were observed.

Main Hospital Building
On 11/16/10:

2. At 10:18 a.m., in the Sitz bath room on the 6th floor there were five 1/4 inch round penetrations in the back wall.

3. At 10:20 a.m., in Room 646 on the 6th floor there were eight ? inch round penetrations in the wall.

4. At 10:45 a.m., in the Locker room with the abandoned tray system on the 6th floor there were four ? in round penetrations in the left wall.

5. At 10:53 a.m., in Room T6-25 on the 6th floor there were two 1 inch round penetrations in the right wall.

6. At 11:00 a.m., in Room 481A on the 4th floor, there were two 1 inch round penetrations in the back wall.

7. At 11:28 p.m., in Room B on the 2nd floor, there was one penetration approximately 2 inches x 2 inches round in the ceiling above the television.

8. At 11:40 a.m., in the Waiting room for the USF College Clinic on the 2nd floor there were three ? round penetrations in the wall over the chairs.

9. At 1:35 p.m., in the Conference Room in ICU on the 2nd floor there were 5 ? inch round penetrations in the back wall.

10. At 2:45 p.m., in Room A-6 on A Level, the second room containing the AC for the CT scan did not have sheet rock from floor to ceiling on the wall where the door is located exposing pipes.

OP Services - Sister Mary Philippa Health Center
On 11/17/10:

11. At 2:45 p.m., in the corridor wall above the door across from the " J Specialty Clinics on the 5th floor there were two penetrations approximately ? inch round each.

Based on observation, the facility failed to maintain its corridor doors as evidenced by doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected two of eleven floors at the Main Hospital and one of two smoke compartments at the McAuley Behavior Health Institute building.

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, corridor doors were observed in the following locations:

Main Hospital
1. On 11/16/10, at 3:15 p.m., the corridor door leading to the Pathology Work Room in the OR Unit on Level B did not positive latch when tested by releasing it from an open position.

McAuley Behavior Health Institute
2. On 11/17/10, at 2:50 p.m., the corridor door to Room 588 did not positive latch when tested.

Findings:

During a tour of the facility the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the corridor doors were observed.

Main Hospital
On 11/16/10:
3. At 10:23 a.m., the door to Room 643 on the 6th floor had a self closing device but, failed to positive latch upon closure.

Based on observation, the facility failed to maintain all cross-corridor doors to continuously serve as a smoke barrier, as evidenced by cross-corridor doors which were equipped with latching hardware but failed to latch when tested. This deficient practice affected eight of 36 smoke compartments within the Main Hospital and two of two smoke compartments at the McAuley Behavior Health Institute buildings, and could potentially result in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, cross corridor doors were tested in the following locations:

Main Hospital
1. On 11/16/10, at 10:20 a.m., the cross corridor doors near Patient Room 764 did not positive latch.
2. On 11/17/10, at 9:08 a.m., the cross corridor doors near Patient Room 833 did not positive latch.
3. On 11/17/10, at 10:55 a.m., during fire alarm testing on the Fourth Floor, the left leaf of the cross corridor doors near Room T4-85 did not positive latch.

McAuley Behavior Health Institute
4. On 11/17/10, at 3:09 p.m., during fire system testing, the south leaf facing south of the cross corridor doors near Room P5-20 did not positive latch when tested.

Based on observation and interview, the facility failed to protect its hazardous area enclosures, as evidenced by:
1. 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.
2. A mechanical room door that did not positive latch when tested.
This deficient practice affected two of eleven floors 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 Chief Engineer and the Environmental Care Manager between 11/16/10, hazardous area enclosures were observed in the following locations:

Main Hospital Building
1. At 3:10 p.m., the area identified as the Pathology Work Room on the B Level did not have a self closure on the door. This room contained approximately four gallons of flammable liquid identified as one gallon each of methanol, alcohol, 95 percent dehydrated alcohol, and xylene, which were stored under a counter top cabinet. This door was also observed to be in the open position. This room was approximately 100 square feet in size.

2. Between 4:00 and 4:30 p.m., the door between the Boiler Room and the Chiller Room on the C Level did not positive latch when released from an open position.

Based on observation and staff interview, the facility failed to maintain an acceptable amount of flammable liquids in its laboratory in accordance with 1999 NFPA 99, which was evidenced by stored flammable liquids in excess of 1 gallon per 100 sq. ft. This deficient practice affected one of eleven floors at the Main Hospital and could potentially result in the ignition of fire.

NFPA 99, 1999 edition, 10-7.2.2 Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of an approved storage cabinets and safety cans shall not exceed 1 gallon per 100 sq. ft. The total volume of Class I, II, and IIIA liquids including those contained in an approved storage cabinet and safety cans shall not exceed 2 gallons per 100 sq. ft. No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit....

Findings:

Main Hospital Building
During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, at 3:10 p.m., the room identified as the Pathology Work Room contained approximately four gallons of flammable liquid identified as one gallon each of methanol, alcohol, 95 percent dehydrated alcohol, and xylene, which were stored under a counter top cabinet. This room was approximately 100 square feet in size. Staff 1 confirmed that the room had four gallons of combustible liquid and that it would be moved.

Based on observation, the facility failed to clearly mark all exits, in accordance with 2000 NFPA 101, as evidenced by an exit sign that was not illuminated. This finding affected one of two smoke compartments within the SFO Airport Clinic and could potentially result in injury and/or a delayed evacuation in the event of an emergency.

Findings:

SFO Airport Clinic
During a tour of the facility on 11/18/10, the exit sign located at the Rear Clinic Exit exiting into the airport was not illuminated.

Based on record review and interview, the facility failed to document that all staff are being trained in the use of, and response to, fire alarms in accordance with 2000 NFPA 101. This was evidenced by incomplete documentation for fire drills. This deficient practice affected all staff and four of four patients within the McAuley Behavior Health Institute building and could potentially result in some staff not being trained and familiar with emergency procedures.

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

Findings:

McAuley Behavior Health Institute
During document review on 11/18/10, at 1:45 p.m., the facility failed to provide documentation for fire drills for the first quarter a.m. or NOC shift, the second quarter a.m. or NOC shift, the third quarter a.m. or p.m. shift of 2010, and the fourth quarter a.m. or NOC shift of 2009. Staff 1 confirmed that the drills had not been done for those time periods.

Based on observation and interview, the facility failed to maintain all fire alarm system devices in accordance with 1999 NFPA 72 to provide effective warning in any part of the building. This was evidenced by fire alarm system devices which failed to function or be heard during testing. This deficient practice potentially affected all staff and patients on five of eleven floors at the Main Hospital, one of two smoke compartments at the McAuley Behavior Health Institute, and one of one smoke compartment at the Mary Philippa Health Clinic. This could potentially result in the facility ' s occupants in some locations not being warned if a fire or other emergency occurred.

4-3.2.2* To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.

Findings:

Main Hospital Building
During fire alarm testing on 11/17/10, fire alarm system devices were observed that failed to function or were not installed in the following locations:

1. On 11/17/10, at 11:50 a.m., the room identified as Micro Biology did not have an audible alarm or strobe that could be heard or seen during activation of the fire alarm system.
2. On 11/17/10, at 11:56 a.m., the room identified as Nuclear Medicine did not have an audible alarm or strobe that could be heard or seen during activation of the fire alarm system.

McAuley Behavior Health Institute
3. On 11/17/10, at 3:00 p.m., the alarm device located near the Copy Room P5-13 did not produce an audible alarm during testing

Findings:

During a tour of the facility the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the facilities fire alarm system was observed.

Main Hospital Building
On 11/17/10:

5. At 10:25 a.m., in the Break room on 5 East on the 5th floor, the pull station was activated in the smoke compartment and the alarm could not be heard in the Break Room. When interviewed on November 17, 2010 at 10:25 a.m., Staff 1 stated that they could not hear the alarm or the over head page in the break room. The room contained no strobe, chime/bell.

6. At 9:10 a.m., the chime by the elevators across from Room 883 on the 8th floor failed to activate during testing of the fire alarm system.

7. At 11:04 a.m., the chime by Room T3-76 failed to activate during testing of the fire alarm system.

8. At 11:55 a.m., in the Radiology core area on Level A the pull station was activated and the alarm could not be heard. When interviewed on November 17, 2010 at 11:55 a.m., Staff 2 stated that they could not hear the alarm or an overhead page in that area.

During facility testing with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the smoke detectors were tested.

OP Services - Sister Mary Philippa Health Center
On 11/17/10

9. At 3:06 p.m., the smoke detector in the waiting area of the Specialty Clinic on the 5th floor failed to activate.

10. At 3:08 p.m., the smoke detector in the Specialty Clinic Office failed to activate.

Based on ...

During facility testing with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the smoke detectors were tested.

OP Services - SR Mary Phillippa @ 2235 Hayes Street, 5th floor

On 11/17/10

1. At 3:06 p.m., the smoke detector in the waiting area of the Specialty Clinic on the 5th floor failed to activate.

2. At 3:08 p.m., the smoke detector in the Specialty Clinic Office failed to activate.

Based on observation and interview, the facility failed to maintain its automatic sprinkler system in accordance with 1998 NFPA 25, as evidenced by
1. The automatic sprinkler system fire hose connections missing their protective caps.
This deficient practice affected all staff and patients on four of eleven floors in the Main Hospital Building. This could potentially result in obstructions and/or damage to the interior of the connection and the spread of smoke and/or fire if fire hose connections can not be used.

9-7.1 Fire department connections shall be inspected quarterly.
The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.

9-7.2 If fire department connection plugs or caps are not in place, the interior of the connection shall be inspected for obstructions, and it shall be verified that the valve clapper is operational over its full range.
9-7.3 Components shall be repaired or replaced as necessary in accordance with the manufacturer ' s instructions. Any obstructions that are present shall be removed.

Findings:

Main Hospital Building
1. During a tour of the facility on 11/15/10, at 3:20 p.m., the fire hose connection caps located on the fourth, fifth, sixth, seventh, and eighth floor east stairwells were missing. Staff 1 stated that the caps were all missing, that they are frequently stolen, and called staff to have new caps installed.

Based on observation and interview, the facility failed to maintain their portable fire extinguisher as evidenced by fire extinguisher ' s that were blocked from access. This deficient practice potentially affected all staff, patients, and visitors on two of eleven floor at the Main Hospital Building and one of one smoke compartments at the Sister Mary Philippa Health Center and has the potential for inaccessibility to the fire extinguisher, which could cause potential harm to staff and patients in the event of a fire.

NFPA 10 Standard for Portable Fire Extinguishers, 2002 Edition
1.5.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal path of travel, including exits from area.

Findings:

During a tour of the facility with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the fire extinguishers were observed.

Main Hospital Building
On 11/16/10:

1. At 11:10 a.m., the fire extinguisher in the Physical Therapy/Gym area on the 4th floor was blocked from access by a treatment matt bed.

2. At 11:40 a.m., the fire extinguisher in the waiting room for USF College Clinic on the 2nd floor was blocked from access by three chairs.

OP Services - Sister Mary Philippa Health Center
On 11/17/10:

3. At 2:30 p.m., 3 of 7 fire extinguishers in the Fire Hose cabinet on the 5th floor did not have a tool to break the glass or a key for the staff to be able to open the door. When interviewed on 11/17/10 at 2:30 p.m., the Director was asked how they would get to the fire extinguisher in an emergency. The Director stated that they would wrap a sheet or blanket around their hand a brake the glass.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items that were stored in the path of egress in an exit corridor. This deficient practice had the potetial to affected all staff and patients on one of eleven floors at the Main Hospital and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

Main Hospital
During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, between 4:00 and 4:30 p.m., the corridor near the Cafeteria Room TB-80 had approximately 30 chairs and ten tables from the Cafeteria stored against the wall. The clear corridor width was approximately four feet throughout the corridor which was approximately 50 feet long. Staff 1 stated that the chairs were going to be used for an award dinner on Friday, but that they would move them out of the corridor right away.

Based on document review and staff interview, the facility failed to provide complete documentation of generator maintenance in accordance with 1999 NFPA 110, as evidenced by incomplete documentation for generator weekly inspections for 12 of 52 weeks in a twelve month period. This finding affected all staff and residents within the facility and could potentially result in deficiencies with the generator going unnoticed and the generator not functioning properly during a loss of normal power.

Findings:

During a review of the facility's documentation on 11/18/10 at 3:05 p.m., documentation provided indicated that the generator was being tested under load at least once per month as required; documentation did not indicate, however, that weekly inspections were done for approximately 12 out of 52 weeks. Staff 1 stated that the weekly inspections were done but a not recorded for that time period.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 99 and 1999 NFPA 70. This was evidenced by power strips which were suspended above the floor, high wattage electrical appliances which were not plugged directly into fixed electrical outlets, storage in front of the electrical panels, electrical outlets missing covers, and incomplete documentation for receptacle testing. This deficient practice had the potential to affected all staff, patients, and visitors on nine of eleven floors at the Main Hospital and two of two smoke compartments at the McAuley Behavior Health Institute, and could potentially result in the ignition of fire and/or a delay in access to electrical panels during an emergency.

NFPA 99
3-3.4.2.3 Maintenance and Testing of Electrical System.
(a) Testing Interval for Receptacles in Patient Care Areas.
1. Testing shall be performed after initial installation, replacement, or servicing of the device.
2. Additional testing shall be performed at intervals defined by documented performance data.
Exception: Receptacles not listed as hospital-grade shall be tested at intervals not exceeding 12 months.

3.3.3.3 Receptacle Testing in Patient Care Areas.
a) The physical integrity of each receptacle shall be confirmed by visual inspection.
b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

NFPA 70 Table 110-26 (a)
A minimum clearance of 3 feet shall be maintained in front of electrical panels and equipment operating at 600 volts or less

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

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

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

NFPA 70 1999 edition
370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.



Findings:

During Record Review on 11/15/10, at 10:00 a.m., documentation provided for receptacle testing was in the form of a work order which was titled Electrical Area Sweep. These work orders were for each floor for the hospital main building as well as the outpatient facilities. This documentation did not provide any information on the rooms that were checked or if any of the receptacles had been replaced.

During a tour of the facility with the Chief Engineer and the Environmental Care Manager between 11/15/10 and 11/18/10, electrical wiring and equipment were observed in the following locations:

Main Hospital
1. On 11/15/10, at 3:30 p.m., the East Eighth Floor Nurses Station had a power strip under a desk that was suspended above the floor.

During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/16/10, electrical wiring and equipment were observed:

2. At 10:55 p.m., the Fifth Floor Staff Locker Room Tray Room had an electrical panel access that was blocked by two ladders in front of the panel. These panels had warnings in red letter stating, " Do not block " .
3. At 1:25 p.m., the First Floor Cardiac Rehabilitation had a power strip suspended above the floor in office T3-68.
4. At 1:35 p.m., the First Floor HIM Office area had an extension cord suspended above the floor.
5. Between 1:45 and 2:05 p.m., the First Floor Nursing Station Staffing Office had a microwave oven and coffee pot plugged into a power strip. The Nursing Administration Office had a power strip plugged into another power strip.
6. At 2:12 p.m., the First Floor Fire Alarm Control Panel Room had cardboard boxes stored in front of an electrical panel. This panel had warnings in red letter stating, " Do not block " .
7. At 2:50 p.m., the B Level PACU Nurses ' Station had two power strip plugged into each other.
8. At 3:05 p.m., the B Level Nurse Manager ' s Office N21-31 had a power strip plugged into another power strip.
9. At 3:05 p.m., the B Level Male Locker Room had a microwave oven plugged into a power strip.
10. At 3:20 p.m., the B Level Doctors ' Lounge had a coffee pot and a refrigerator plugged into a power strip.
11. Between 3:30 and 4:00 p.m., the A Level Store Room Office in Receiving had a microwave oven plugged into a power strip. The Linen Re-Packing break Room area had a microwave oven plugged into a power strip.

McAuley Behavior Health Institute
During a tour of the facility with the Chief Engineer and the Environmental Care Manager on 11/17/10, electrical wiring and equipment were observed:
12. At 2:54 p.m., the Staff Room had a power strip suspended above the floor with a microwave oven plugged into it.
13. At 3:00 p.m., the Medications Room had three power strips that were plugged into each other.


Findings:

During a tour of the facility with the Assistant Chief Engineer and the Director of Materials Management on November 15, 2010 through November 18, 2010, the electrical system was observed.

Main Hospital Building
On 11/16/10:

14. At 10:30 a.m., in Room 636 on the 6th floor, there was a nurse call box missing the cover exposing a 2 inch x 2 inch square penetration in the wall.
15. At 11:38 a.m., in Room 400 on the 4th floor there was a cable box hanging out of the wall exposing a 3 inch x 3 inch penetration in the wall.

16. At 12:00 p.m., in the Infusion Center Conference Room by Room 225 on the 2nd floor there was a microwave plugged into a multi-plug power strip.

17. At 2:00 p.m., in Room TA-193 on Level A there was a refrigerator plugged into a multi-plug power strip.