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Based on document review and interview, the facility failed to maintain an emergency preparedness policies and procedures. This was evidenced by the failure to provide a completed system to track on-duty staff at the Main Hospital, and by the failure to provide a system to track patients and on-duty staff at the De Anza Surgery Center. This could result in failure to provide the location of the patients and staff during an emergency evacuation. This affected 389 residents, staff, and visitors at the Main Hospital, and affected three cases at the De Anza Surgery Center.

Findings:

During document review and interview with the Hospital Staff from 5/20/19 through 5/23/19, the emergency preparedness plans were reviewed.

Main Hospital, 5/21/19:

1. At 8:42 a.m., the facility did not provide a system to track the on-duty staff at the Main Hospital. The policy and procedure provided by ES2 only included a plan to track the patients but there was no written evidence of a plan to track the staff.

De Anza Surgery Center, 5/23/19:

2. At 2:43 p.m., the facility did not provide a completed system to tracking patients and on-duty staff at the De Anza Surgery Center. During a concurrent interview, the ES2 stated they will use the Hospital Incident Command System (HICS) forms during an emergency. The ES2 also stated that they had not reviewed the HICS forms in the past year to familiarize themselves with the items on the form and procedures.

Based on document review and interview, the facility failed to maintain the emergency preparedness policies and procedures. This was evidenced by the failure to provide prearranged transfer agreements with other facilities to receive or transfer patients. This could result in ineffective hospital evacuation during an emergency or disaster. This affected 389 residents, staff, and visitors at the Main Hospital.

Findings:

During document review and interview with the Hospital Staff from 5/20/19 through 5/23/19, the policies and procedures were reviewed, and the prearranged agreements with facilities were requested.

Main Hospital, 5/21/19:

At 9:49 a.m., the facility did not provide the prearranged transfer agreements with other facilities. The emergency preparedness provided by the ES2 showed several alternative care sites. This included a location at a church, an urgent care, and three outpatient services located on campus. During an interview at 10:06 a.m., the ES2 confirmed the finding and stated he will look for the county hospital transfer agreement.

During document review and interview, the facility failed to maintain the emergency preparedness communication plan. This was evidenced by the failure to establish a primary and alternate means for communicating with the facility staff and emergency officials at the De Anza Surgery Center. This could result in a communication delay with the facility staff and the emergency responders during an emergency or disaster. This affected three cases at the De Anza Surgery Center.

Findings:

During document review and interview with the Hospital Staff from 5/20/19 through 5/23/19, the emergency preparedness communication plan was reviewed.

De Anza Surgery Center, 5/23/19:

At approximately 2 p.m., the emergency preparedness for the De Anza Surgery Center was provided by the ES2. The plan did not identify the primary and alternate means for communicating with the facility staff and emergency officials. During an interview at 2:43 p.m., the ES2 confirmed the finding and stated it was not in the emergency plan but the information will be added.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the ceiling and wall. This affected one of six floors in C Tower at the Main Hospital and the De Anza Surgery Center. This could result in the expedited spread of smoke or fire to other areas of the facility.

Findings:

During a tour of the facility and interview with the Hospital Staff on 5/23/19, the ceiling and wall was observed.

C Tower - Main Hospital, 5/23/19:

1. At 9:47, on the 2nd floor, there was an approximately 3 inch by 3 inch penetration observed in the ceiling located in the Janitor's closet, Room C224.1. When interviewed, the ES1 and MM3 confirmed the finding and stated that the junction box cover in the ceiling was missing.

De Anza Surgery Center, 5/23/19:

2. At 11:32 a.m., there was an approximately 2 inch by 3 inch penetration in the wall between the Fire Alarm Control Panel room and the Mechanical room. When interviewed, the ES3 and MM3 confirmed the finding.

Based on observation and interview, the facility failed to maintain a safe path of egress. This was evidenced by medical beds that were stored in the corridor. During a fire or other emergency, this could delay evacuation and harm patients, visitors, and staff. This affected one of six floors in the B Tower at the Main Hospital.

NFPA 101, Life Safety Code, 2012 Edition
19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm),except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses ' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.

Findings:

During a facility tour and interview with the Hospital Staff from 5/20/19 through 5/23/19, the means of egress in the emergency department was observed.

B Tower - Main Hospital, 5/22/19:

At 11:59 a.m., there were three medical beds that were in use and were stationed along the path of egress. The beds reduced nearly the entire width of the 6-feet corridor in Emergency Department 1. During an interview at 12:04 p.m., the EM1 confirmed the finding and stated they have an overflow of patients and they used the hallway to temporarily store the beds for two days until the patients are medically cleared. At 2:23 p.m., the Riverside District Office confirmed there was no program flex to allow the overflow of patient beds.

Based on observation and interview, the facility failed to maintain the self-closing doors. This was evidenced by a door that failed to close when tested, and by a self-closing device that was detached from a door leaf. This affected one of six floors in the C Tower and one of six floors in the B Tower at the Main Hospital. This could result in the spread of smoke and fire, increasing the risk of injury to patients.

NFPA 101, Life Safety Code, 2012 Edition
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
7.1.10.1* General. Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

Findings:

During a tour of the facility with the Hospital Staff from 5/20/19 through 5/23/19, the fire doors equipped with self-closing/automatic-closing mechanisms were observed.

C Tower - Main Hospital, 5/23/19:

1. At 10:01 a.m., on the 2nd floor, the exit door to the level 2 stairwell was equipped with a self-closing device. The door was opened to the fullest extent and released. The self-closing door failed to fully close and positively latch. The ES1 confirmed the door failed to latch.


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B Tower - Main Hospital, 5/22/19:

2. At 11:38 a.m., the door to the fast track area was equipped with a self-closing device. The device was broken and detached from the door leaf. The room was located in the first floor in the B Tower. During a concurrent interview, the PO1 confirmed the finding and he did not know the self closing device was broken.

Based on interview and document review, the facility failed to maintain the battery-powered emergency exit signs. This was evidenced by the failure to complete an annual functional test of the battery-powered emergency exit sign. This could result in a failure to provide back-up lighting in the event of evacuation. This affected the Main Hospital, De Anza Surgery Center and Orthopedic Institute.

NFPA 101, Life Safety Code, 2012 Edition
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days or shall be periodically monitored in accordance with 7.9.3.1.3.

7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During document review, and interview with Hospital Staff on 5/20/19, the battery-powered emergency exit sign testing document was requested.

Main Hospital, De Anza Surgery Center and Orthopedic Institute, 5/20/19:

At 3:10 p.m., there was no documentation that indicated the facility had completed an annual 90 minutes functional test. The last annual inspection was unknown. The ES1 confirmed that the annual 90 minutes functional test was not conducted.

Based on observation and interview, the facility failed to maintain the hazardous areas. This was evidenced by a door to a hazardous area enclosure that was not equipped with self closing device. This could result in the faster spread of smoke and fire to other areas in the event of a fire. This affected the entire facility at the De Anza Surgery Center.

Findings:

During a tour of the facility and interview with the Hospital Staff from 5/20/19 through 5/23/19, the hazardous areas were observed.

De Anza Surgery Center, 5/23/19:

At 12:15 p.m., there was a storage room that was not equipped with a self closing device and the room was used to store a large amount of medical equipment. The room was larger than 50 square feet. During a concurrent interview, the ES1 and SM1 confirmed the storage room was larger than 50 square feet.

Based on observation and interview, the facility failed to maintain the fire alarm system (FAS) in a reliable operating condition. This was evidenced by the failure of the FAS to provide the correct signals during a fire alarm functional test. This could result in a delay for the staff and emergency officials to respond to a fire disaster. This affected the entire facility at the De Anza Surgery Center.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm and Signal Code, 2010 Edition
26.6.3.1.7 End-to-End Communication Time for an Alarm.
The maximum duration between the initiation of an alarm signal at the protected premises, transmission of the signal, and subsequent display and recording of the alarm signal at the supervising station shall not exceed 90 seconds.

26.6.3.1.10 Signal Error Detection and Correction.
26.6.3.1.10.1 Communication of alarm, supervisory, and trouble signals shall be in accordance with this section to prevent degradation of the signal in transit, which in turn would result in either of the following:
(1) Failure of the signal to be displayed and recorded at the supervising station
(2) An incorrect corrupted signal displayed and recorded at the supervising station

26.6.3.1.10.2 Reliability of the signal shall be achieved by any of the following:
(1) Signal repetition - multiple transmissions repeating the same signal
(2) Parity check - a mathematically check sum algorithm of a digital message that verifies correlation between transmitted and received message
(3) An equivalent means to 26.6.3.1.10.2(1) or 26.6.3.1.10.2(2) that provides a certainty of 99.99 percent that the received message is identical to the transmitted message

Findings:

During a tour of the facility and interview with the Hospital Staff from 5/20/19 through 5/23/19, the FAS was tested, and the monitoring report was requested.

De Anza Surgery Center, 5/23/19:

At 1:07 p.m., the monitoring report was provided by the JC1. The report showed that a manual pull station was activated at 12:23 p.m., when the correct signal should have been a smoke detector. During a concurrent interview, the JC1 acknowledged there was a signal error on the report and stated the fire panel reports a signal on a per point system, which is different from an addressable system.

Based on observation, document review, and interview, the facility failed to maintain their Fire Alarm System (FAS). This was evidenced by a trouble signal noted on the Fire Alarm Control Panel (FACP), by failure to conduct the required smoke detector sensitivity test of all installed smoke detectors, and by the failure to correct deficiencies identified on the sensitivity testing. This could result in the lack of protection/notification in the event of a fire. This affected the entire De Anza Surgery Center.

NFPA 101, Life Safety Code, 2012 Edition
21.3.4.1 General. Ambulatory health care facilities shall be provided with fire alarm systems in accordance with Section 9.6, except as modified by 21.3.4.2 through 21.3.4.4.
9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1* General.
9.6.1.1 The provisions of Section 9.6 shall apply only where specifically required by another section of this Code.
9.6.1.2 Fire detection, alarm, and communications systems installed to make use of an alternative permitted by this Code shall be considered required systems and shall meet the provisions
of this Code applicable to required systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.4 All systems and components shall be approved for the purpose for which they are installed.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.

NFPA 72, National Fire Alarm Code, 2010 Edition
10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

10.12 Trouble Signals.
10.12.1 Trouble signals and their restoration to normal shall be indicated within 200 seconds at the locations identified in 10.12.6 or 10.12.7.
10.12.2 Indication of primary power failure trouble signals transmitted to a supervising station shall be delayed in accordance with 10.17.3.3.
10.12.3 If an intermittent signal is used, it shall sound at least once every 10 seconds, with a minimum duration of 1?2 second.
10.12.4 A single audible trouble signal shall be permitted to annunciate multiple fault conditions.
10.12.5 The trouble signal(s) shall be located in an area where it is likely to be heard.
10.12.6 Visible and audible trouble signals and visible indication of their restoration to normal shall be indicated at the following locations:
(1) Fire alarm control unit for protected premises alarm systems
(2) Building fire command center for in-building fire emergency voice/alarm communications systems
(3) Central station or remote station location for systems installed in compliance with Chapter 26.

14.2.1.1.2 Inspection, testing, and maintenance program shall verify correct operation of the system.
14.2.1.2.2 System defects and malfunctions shall be corrected.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.
14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.
14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
14.4.5.3.4 To ensure that each smoke detector or smoke alarm is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.

Finding:

During a tour of the facility, document review, and interview with Hospital Staff on 5/23/19, the Fire Alarm System (FAS) was observed and documentation requested.

De Anza Surgery Center, 5/23/19:

1. At 11:27 a.m., a trouble signal was observed on the FACP. The ES1 was interviewed. He stated that the trouble was due to a ground fault and their vendor was aware of the problem. The ES1 stated that they are currently getting the roof replaced. He stated that it will not compromise the system. At 12:09 p.m., ES1 stated that he contacted their vendor and a technician is scheduled to be at the facility between 2 p.m. to 5 p.m. Between 12:11 p.m. to 12:48 p.m., devices were tested, FAS activated. JC1 and MM3 were able to reset the system.

2. At 1:30 p.m., the smoke detector sensitivity testing was requested. The document, "Biennial Smoke Detector Sensitivity Testing" dated 9/5/18 indicated that 54 of 55 smoke detectors failed. Under Comments: The smoke type - Silent Knight SD505 - APS sensitivity ranges are 0.88% - 3.57%. The ranges for the 54 smoke detector was above 4.0%. All 54 smokes located on the surgery side of the building failed the sensitivity test far above the max of 3.57%. All will need to be replaced.

3. At 1:38 p.m., the document showed that one of 55 smoke detectors was not tested. The document, titled "Biennial Smoke Detector Sensitivity Testing" and dated 9/5/18, indicated that the vendor had no access to the server room that had the old fire panel. At 3:30 p.m., the ES1 stated that their vendor was onsite and was informed that the issue with their FACP was that a smoke detector was cut at the construction location.

Based on observation, document review, and interview, the facility failed to maintain the automatic fire sprinkler system and components. This was evidenced by the absence of twelve of twelve monthly visual inspections and foreign material on sprinkler heads. This affected the Main Hospital, De Anza Surgery Center, Cancer Center and Orthopedic Institute. This could result in the malfunction of the sprinkler system in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 Edition.
4.3 Records
4.3.1* Records shall be made inspections, tests, and maintenance of the system and its components and shall be made available to the authority having jurisdiction upon request.
5.2 * Inspection.
5.2.1 Sprinklers.
5.2.1.1 * Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1 * Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.4 Gauges
5.2.4.1* Gauges on a wet pipe sprinkler shall be inspected monthly to ensure that they are in good condition and the normal water supply pressure is being maintained.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.
13.6.1.1.1 Valves secured with locks or electrically supervised in accordance with applicable NFPA standards shall be inspected monthly.

Findings:

During a tour of the facility, document review, and interview with Hospital Staff from 5/20/19 through 5/23/19, the components to the automatic sprinkler system were observed and records where requested.

Main Hospital, De Anza Surgery Center, Cancer Center and Orthopedic Institute:

1. On 5/20/19, at 3:10 p.m., the facility failed to provide records of twelve of twelve monthly visual inspections for the automatic fire sprinkler gauge and control valves for the past 12 months. On 5/22/19, at 8:21 a.m., the ES1 was interviewed. He confirmed the finding and stated that he was not aware of the monthly visual inspection. He recently was informed of the inspection and stated that they will start the inspection in May 2019.

C Tower - Main Hospital, 5/21/19:

2. At 3:16 p.m., on the 4th floor, there was foreign material on the sprinkler head, in the Soiled Linen and Utility, Room 400.6. The finding was confirmed by ES3.

G Tower - Main Hospital, 5/22/19:

3. At 10:25 a.m., on the 6th floor, there was a blue plastic stuck to the sprinkler, in the Soiled Workroom, Room 6MS101. The finding was confirmed by ES1.


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B Tower - Main Hospital, 5/21/19:

4. At 1:10 p.m., there was a sprinkler head with dust accumulation in Room B652 by bed A. The PO1 confirmed the finding and stated they use a high-efficiency particulate arrestance (HEPA) vacuum to clean the debris from the sprinkler heads every quarter.

5. At 1:36 p.m., there were sprinkler heads with heavy dust accumulation in Room B674 by bed A and bed D. The PO1 confirmed the finding and stated he will use the HEPA vacuum to clean off the debris.

6. At 2:13 p.m., there was a sprinkler head with dust accumulation in Room B561 by bed A. The PO1 confirmed the finding.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by an unsecured fire extinguisher and by a fire extinguisher that was obstructed from immediate access. This could result in damage to or malfunction of the fire extinguisher, and affected two of six floors in the C Tower at the Main Hospital.

NFPA 101, Life Safety Code, 2012 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses
6.1.3.5 Wheeled fire extinguishers shall be located in designated locations.
6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.
6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

Findings:

During a tour of the facility with Hospital Staff from 5/20/19 through 5/23/19, the portable fire extinguishers were observed.

C Tower - Main Hospital:

1. On 5/21/19, at 3:34 p.m., on the 3rd floor, a fire extinguisher in the hallway to the Mechanical room was observed. The fire extinguisher was on the floor unsecured. The finding was confirmed by MM3.

2. On 5/23/19, at 10:14 a.m., on the 1st floor, in the Emergency Department, a fire extinguisher was obstructed from immediate access by a EKG machine placed in front of the fire extinguisher. The finding was confirmed by ES3.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to close and latch, and a corridor door that was obstructed for closing. This could result in the spread of smoke into the corridor in the event of fire. This affected two of six floors in the B Tower, three of three floors plus the basement in the D Tower, two of six floors in the C Tower, two of seven floors in the G Tower at the Main Hospital, and the entire facility at the De Anza Surgery Center.

Findings:

During a tour and interview with the Hospital Staff from 5/20/19 and 5/23/19, the corridor doors were observed.

B Tower - Main Hospital, 5/21/19:

1. At 2:46 p.m., the clean linen door located in the fourth floor of the B Tower did not latch because the top of the door rubbed against door frame. During a concurrent interview, the MM1 confirmed the finding and stated he was not aware of the door not latching. He stated the nurses will inform the maintenance department and a work order will be submitted to correct the door.

2. At 2:58 p.m., the shower room door located in the third floor of the B Tower did not latch because the latching hardware rubbed against the striker plate. Two attempts were made. The MM1 confirmed the finding.

D Tower - Main Hospital, 5/21/19:

3. At 3:26 p.m., a patient room door D325 located in the third floor of the D Tower did not latch because the latching device was stuck and did not allow to latch. Two attempts were made. The MM1 confirmed the finding.


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D Tower - Main Hospital, 5/21/19:

4. At 1:05 p.m., on the 4th floor, a computer table obstructed the door to the Social Services office. The ES3 confirmed the finding.

5. At 1:54 p.m., on the 2nd floor, the door to Room 221, Nursing Support Space was equipped with a self-closing device that failed to latch when fully opened and released. The ES3 confirmed the finding and stated that he will submit a work order.

6. At 2:06 p.m., on the 2nd floor, the door to the Janitor's closet, Room 205.1 was equipped with a self-closing device that failed to latch when fully opened and released. The ES3 confirmed the finding and stated that he will submit a work order.

7. At 2:08 p.m., on the 2nd floor, the door to the Linen room near Room 201 was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested three times and failed. The ES3 confirmed the finding and stated that he will submit a work order.

8. At 2:36 p.m., in the Basement, the door to the Laundry Chute room failed to close and latch. There was a tape on the striker plate. The finding was confirmed by the ES3.

9. At 2:39 p.m., the door knob to the Maintenance Lounge was missing. This finding was confirmed by the PLS1.

C Tower, Main Hospital - 5/21/19:

10. At 3:23 p.m., on the 4th floor, the door to Room 400.3 failed to latch when manually tested. When interviewed, the MM3 stated that the latching device was stuck.

G Tower, Main Hospital - 5/22/19:

11. At 10:17 a.m., on the 6th floor, the door to Room 6203 failed to latch when manually tested. When interviewed, the MM3 stated that the latching device was stuck.

12. At 10:19 a.m., on the 6th floor, the door to Room 6234 failed to latch when manually tested. When interviewed, the MM3 stated that the latching device was stuck.

13. At 10:30 a.m., on the 5th floor, the door to Room 5217 failed to latch.

14. At 10:43 a.m., on the 5th floor, the door to the Soiled Workroom, MS083 was equipped with a self-closing device that failed to latch when fully opened and released. When interviewed, the MM3 confirmed the finding and stated that the self-closure needed adjusting and the hinges needed to be lubricated.

C Tower, Main Hospital - 5/23/19:

15. At 9:56 a.m., on the 2nd floor, the door to the staff lounge was equipped with a self-closing device that failed to latch when fully opened and released. The door was tested three times and failed. When interviewed, ES3 confirmed the finding and stated that the self-closure device needed adjusting.

16. At 10:03 a.m., on the 2nd floor, the door to Operating Room 6 was equipped with a self-closing device that failed to latch when fully opened and released. When interviewed, the ES3 confirmed the finding, and stated that the hinges need adjusting.

Based on document review and interview, the facility failed to ensure quarterly fire drills were held on all shifts. This was evidenced by the failure to conduct 11 of 12 fire drills in one year. This could result in staff not familiar with their responsibilities in the event of a fire. This affected the entire building at the De Anza Surgery Center.

NFPA 101, Life Safety Code, 2012 Edition
21.7* Operating Features.
21.7.1 Evacuation and Relocation Plan and Fire Drills.
21.7.1.1 The administration of every ambulatory health care facility shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary.
21.7.1.2 All employees shall be periodically instructed and kept informed with respect to their duties under the plan required by 21.7.1.1.
21.7.1.3 A copy of the plan required by 21.7.1.1 shall be readily available at all times in the telephone operator's location or at the security center.
21.7.1.4* Fire drills in ambulatory health care facilities shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.
21.7.1.5 Patients shall not be required to be moved during drills to safe areas or to the exterior of the building.
21.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.
21.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
21.7.1.8 Employees of ambulatory health care facilities shall be instructed in life safety procedures and devices.

Findings:

During document review and interview with the Hospital Staff from 5/20/19 through 5/23/19, the fire drill records were reviewed.

De Anza Surgery Center:

On 5/20/19, at 1 p.m., the fire drill records were provided by the ES2. The facility did not conduct the fire drills on all shifts for each quarter at the De Anza Surgery Center. On 5/21/19 at 10:28 a.m., the facility conducted two fire drills in the last 12 months. The drills were conducted during the first shift on 12/26/18 and 3/15/19. During a concurrent interview, the ES2 stated the drills were not being done quarterly on each shift at the De Anza building.

Based on observation, document review, and interview, the facility failed to maintain the piped Gas and Vacuum Systems. This was evidenced by discrepancies on the Annual Inspection. This affected one of six floors at the B Tower at the Main Hospital, and could result in a system malfunction.

NFPA 99, Health Care Facilities Code, 2012 Edition.
Chapter 4 Fundamentals
4.1* Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.
4.1.1* Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

5.1 Category 1 Piped Gas and Vacuum Systems.
5.1.1* Applicability.
5.1.1.1 These requirements shall apply to health care facilities that require Category 1 systems as referenced in Chapter 4.
5.1.1.4 An existing system that is not in strict compliance with the provisions of this code shall be permitted to be continued in use as long as the authority having jurisdiction has determined
that such use does not constitute a distinct hazard to life.
5.1.1.6 Paragraph 5.1.14.4.3 through 5.1.14.4.9 and 5.1.13 through 5.1.15 shall apply to existing health care facilities.
5.1.1.7 Paragraph 5.1.14.3 and 5.1.14.4.1 shall apply to new and existing health care facilities.
5.1.2 Nature of Hazards of Gas and Vacuum Systems. Potential fire and explosion hazards associated with positive pressure gas central piping systems and medical-surgical vacuum
systems shall be considered in the design, installation, testing, operation, and maintenance of these systems.

Findings:

During observation, document review, and interview with Staff from 5/20/19 through 5/23/19, the piped Gas and Vacuum Systems were observed, and maintenance records were requested.

B Tower - Main Hospital:

1. On 5/20/19, at 2:20 p.m., the annual medical gas certification conducted on 10/8/18 was reviewed. The documentation, titled "2018 Annual Inspection Repair Report" and dated 10/19/18, indicated the following: OR 3B - VAC A, VAC B and WAGD - reduced flow, needs new and shorter hose and Bulk Enclosure - 02 - Leak at isolation valve on upstream side of bottom final line regulator, Leak at bonnet of bottom final line regulator, and Leak at isolation valve downstream side of bottom final line regulator.

On 5/23/19, at 8:59 a.m., the ES1 was interviewed. He stated that they are currently working with their vendor for the repairs.

Based on document review and interview, the facility failed to maintain emergency power supply (EPS) in a reliable operating condition. This was evidenced by the failure to inspect the generator weekly. This could result in failure to supply emergency power to the facility in the event of a normal power loss. This affected the Main Hospital, De Anza Surgery Center, Cancer Center, and Orthopedic Institute.

NFPA 101, Life Safety Code, 2012 Edition
7.9.2.4 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition
8.3 Maintenance and Operational Testing.
8.3.1* The EPSS shall be maintained to ensure to a reasonable degree that the system is capable of supplying service within the time specified for the type and for the time duration specified for the class.
8.3.4 A permanent record of the EPSS inspections, test, exercising, operation, and repairs shall be maintained and readily available.
8.4 Operational Inspection and Testing.
8.4.1* EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Findings:

During document review and interview with the Hospital Staff from 5/20/19 through 5/23/19, the diesel generator records were reviewed, and documentation was requested.

Main Hospital, De Anza Surgery Center, Cancer Center and Orthopedic Institute:

On 5/20/19 at approximately 11:30 a.m., the diesel generator maintenance records for the Main Hospital and the De Anza Surgery Center were requested. At 1 p.m., the generator records from 2018 and 2019 were provided by the ES2 and ES3.

On 5/21/19 at 9:50 a.m., the weekly inspections were incomplete. There were 12 of 52 week inspections in the 2019 binder and no records in the 2018 binder. At 12:43 p.m., the ES3 stated the generator records have been provided. The 2019 binder weekly inspection included the following dates:
1/25/19
1/18/19
1/11/19
1/03/19
2/01/19
3/08/19
3/01/19
4/05/19
5/10/19

Based on observation and interview, the facility failed to maintain the electrical safety. This was evidenced by the non-compliant use of extension cord and surge protectors. This could result in an electrical fire. This affected one of three floors in the D Tower and one of six floors in the C Tower at the Main Hospital, and the De Anza Surgery Center.

NFPA 101, Life Safety Code, 2012 edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 edition
400.8 Uses Not Permitted. Unless specifically permitted in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
590.3 Time Constraints.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

Findings:

During a tour of the facility with the Hospital Staff from 5/20/19 through 5/23/19, the facility's electrical equipment was observed.

D Tower - Main Hospital, 5/21/19:

1. At 2:27 p.m., on the 1st floor in the Rehabilitation office, a microwave, coffee maker and a toaster were plugged into a surge protected power strip instead of directly to the wall outlet.

C Tower - Main Hospital, 5/23/19:

2. At 9:50 a.m., on the 2nd floor in the hallway near the Business office, a stapler, camera, and walkie-talkie chargers were plugged into a surge protected power strip. The power strip was plugged into another power strip instead of directly into a wall outlet.

De Anza Surgery Center, 5/23/19:

3. At 11:32 a.m., a portable air condition was plugged into an extension cord, in the Mechanical Pump room. The ES3 confirmed that the portable air condition was plugged into an extension cord.


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B Tower - Main Hospital, 5/21/19:

4. At 2:43 p.m., there was a white extension cord in patient Room B476. The patient's cell phone charger was plugged directly into the extension cord. During a concurrent interview, the MM1 and CO1 confirmed the finding and stated it belonged to the patient.

Based on observation and interview, the facility failed to properly secure the medical gas cylinders. This was evidenced by cylinders that were not supported in a proper cylinder stand or cart, and by a cylinder stored improperly under a medical bed. This could result in damage to the medical gas equipment during a disaster. This affected two of seven floors in the G Tower at the Main Hospital, and one of six floors in the B Tower at the Main Hospital.

NFPA 101, Life Safety Code, 2012 Edition

19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99, Standard for Healthcare Facilities, 2012 Edition
11.6 Operation and Management of Cylinders

11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:
(1) Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device.
(2) Oxygen cylinders shall not be stored near elevators or gangways or in locations where heavy moving objects will strike them or fall on them.
(3) Cylinders shall be protected from tampering by unauthorized individuals.
(4) Cylinders or cylinder valves shall not be repaired, painted, or altered.
(5) Safety relief devices in valves or cylinders shall not be tampered with.
(6) Valve outlets clogged with ice shall be thawed with warm- not boiling - water.
(7) A torch flame shall not be permitted, under any circumstances, to come in contact with a cylinder, cylinder valve, or safety device.
(8) Sparks and flame shall be kept away from cylinders.
(9) Even if they are considered to be empty, cylinders shall not be used as rollers, supports, or for any purpose other than that for which the supplier intended them.
(10) Large cylinders (exceeding size E) and containers larger than 45 kg (100 lb.) weight shall be transported on a proper hand truck or cart complying with 11.4.3.1.
(11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
(12) Cylinders shall not be supported by radiators, steam pipes, or heat ducts.

Findings:

During a tour of the facility and interview with the Hospital Staff from 5/20/19 and 5/23/19, the oxygen cylinders were observed.

G Tower - Main Hospital, 5/22/19:

1. At 10:54 a.m., on the 4th floor, there was an empty oxygen cylinder that was on the floor and unsecured. The cylinder was not properly chained or supported in a proper cylinder stand or cart. The cylinder was observed in the Equipment Storage room across Room 4207. This finding was confirmed by ES1.

2. At 11:19 a.m., on the 2nd floor, there was a full oxygen cylinder that was on the floor and unsecured. The cylinder was not properly chained or supported in a proper cylinder stand or cart. The cylinder was observed in the Post-Anesthesia Care Unit across from the nurse station. This finding was confirmed by ES1.


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B Tower - Main Hospital, 5/21/19:

3. At 2:25 p.m., there was an oxygen "E" type cylinder stored under an empty patient bed in the corridor of the fourth floor between the B Tower and Social Services office. The cylinder was laying flat on the plastic frame approximately 2 feet under the mattress. During a concurrent interview, the PO1 and CO1 confirmed the finding and PO1 stated the cylinder was possibly placed there by a staff.