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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by a penetration in a wall of the Main Hospital. This could result in faster spread of fire and smoke to other locations. This affected 1 of 13 smoke compartments.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the facility building construction was observed.

Main Hospital:

1. At 3:02 p.m., there was an approximately six inch by one inch unsealed penetration in the west wall of the Men's Dressing Room for the Operating Room Staff.

Based on observation and interview, the facility failed to maintain their corridor doors to resist the passage of smoke. This was evidenced by corridor doors that were impeded from closing or latching. This affected 4 of 13 smoke compartments in the Main Hospital and could result in the migration of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the corridor doors were observed.

Main Hospital:

1. At 8:46 a.m., the corridor door to the Triage Room in the Emergency Department was impeded from closing by a blood pressure machine. The room was unattended.

2. At 8:55 a.m., the self-closing corridor door to the Oxygen Room in the Emergency Department failed to latch when tested. There was white tape placed over the striker plate that prevented the door from latching. At 8:56 a.m., the Director of Facility Administration was interviewed. The Director of Facility Administration indicated that that the doors were recently checked and that somebody must have just put this tape on the door.

3. At 8:58 a.m., the self-closing corridor door to the Ultra Sound Room was impeded from closing by a brown rubber wedge placed under the door leaf.

4. At 9:01 a.m., the self-closing corridor door to the Radiologist Office was impeded from closing by a block positioned in the swing path of the door.

5. At 9:28 a.m., the self-closing corridor door to the Microbiology Room in the Lab was impeded from closing by a brown rubber wedge placed under the door leaf.

6. At 9:47 a.m., the self-closing corridor door to the Medi-Cal Office was not latching when tested.

Based on observation, the facility failed to maintain their emergency lighting units as evidenced by an emergency light that failed to illuminate when tested. This affected the main entrance to the Community Clinic and could result in limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the emergency lighting units were observed and tested.

Community Clinic:

1. At 10:31 a.m., the emergency lighting unit near the main entrance to the Community Clinic failed to illuminate when the test button was pressed.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by an exit sign equipped with battery back-up that failed to illuminate when tested. This affected 5 of 13 smoke compartments and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 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.

Findings:

Main Hospital

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the facility exit signs were observed and tested.

Main Hospital:

1. At 8:30 a.m., the east exit sign near the Admitting corridor failed to illuminate when the test button was pressed.

Based on interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by a staff member that was unable to locate a fire alarm activation device and a fire extinguisher. This affected 1 of 13 smoke compartments and could result in facility staff not being prepared to respond to a fire emergency.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, staff members were interviewed.

Main Hospital:

1. At 9:24 a.m., Staff Member 1 was interviewed. Staff Member 1 had two years experience in the Gift Shop. Staff Member 1 was asked to locate a fire extinguisher. Staff Member 1 did not know where a fire extinguisher was located. The nearest fire extinguisher was located approximately 20 feet away. Staff Member 1 was asked to locate a fire alarm manual pull station device. Staff Member 1 did not know where a fire alarm manual pull station was located. The nearest fire alarm manual pull station device was located approximately 25 feet away.

Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by obstructed manual fire alarm pull stations in the Main Hospital and Heavenly Mountain Clinic. This could result in a delayed activation of the fire alarm system in the event of a fire. This affected 1 of 13 smoke compartments.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the manual fire alarm pull stations were observed.

Main Hospital:

1. At 8:25 a.m., the manual fire alarm pull station near the east Acute Care exit was impeded from access and obstructed from view by an approximately 200 gallon capacity trash container.

Heavenly Mountain Clinic:

2. At 10:55 a.m., the manual fire alarm pull station alarm near the middle exit was impeded from access and obstructed from view by three snow shovels that were leaning over the device.

Based on observation, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by a sprinkler head that was missing an escutcheon ring. The failure to maintain the sprinkler heads could result in a malfunctioning automatic fire sprinkler system in the event of a fire. This affected 1 of 13 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the sprinkler system was observed.

Main Hospital:

1. At 10:10 a.m., the sprinkler in the Equipment Storage Room near Room 217 was missing an escutcheon ring.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by a portable fire extinguisher that was mounted greater than 60 inches from floor level in the Main Hospital and a fire extinguisher that was obstructed from access in the Pediatrics Clinic. This affected 1 of 13 smoke compartments in the Main Hospital and the entire Pediatrics Clinic. This could result in a delay in accessing a portable fire extinguisher.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1-6.3 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 paths of travel, including exits from areas.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the portable fire extinguishers were observed.

Main Hospital:

1. At 9:32 a.m., the portable fire extinguisher near the janitor closet in the Lab was mounted approximately 68 inches from the top of the extinguisher to the floor.

Community Clinic (Pediatrics):

2. At 10:40 a.m., the portable fire extinguisher near the east exit in the Pediatrics side of the Community Clinic was obstructed by a wooded shred file box that was directly in front of the device.

Based on observation, the facility failed to ensure that trash receptacles exceeding 32 gallons were not stored in the hallway. This could fuel a fire and cause potential harm to patients in the event of a fire emergency. This affected 1 of 13 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the trash receptacles were observed.

Main Hospital:

1. At 8:27 a.m., there was an approximately 200 gallon trash container near the east Acute Care exit corridor that was unattended.

Based on record review and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity equal to or greater than 35% in five of five operating rooms in the Main Hospital. This could result in the increased risk of a facility fire due to electrostatic charges in an oxygen rich environment.

Findings:

During document review with the Director of Facility Administration and Manager 1 on 12/27/12, the humidity logs for the operating rooms were observed.

Main Hospital:

1. At 3:45 p.m., the recorded relative humidity for Operating Room 1 on 12/17/12 was 31.5%. The recorded relative humidity for Operating Room 2 on 12/17/12 was 33.5%. The recorded relative humidity for Operating Room 3 on 12/17/12 was 29.5%. The recorded relative humidity for Operating Room 4 on 12/17/12 was 31%. The recorded relative humidity for Operating Room 5 on 12/17/12 was 34%.

At 3:46 p.m., Director of Facility Administration said during an interview that the facility maintains the humidity levels in their Operating Rooms according to Association of Perioperative Registered Nurses (AORN) standards.

Based on observation, the facility failed to maintain their electrical equipment and wiring. This was evidenced by a broken receptacle cover, the use of multi-plug power strips plugged into other multi-plug power strips, and impeded circuit breaker panels. This affected 3 of 13 smoke compartments and could result in an electrical shock or an electrical fire.

NFPA 70, 1999 edition
110-26(a)2 Width of Working Space.
The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
110-26(b) Clear Spaces.
Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
370-25 Covers and Canopies.
In completed installations, each box shall have a cover, faceplate, or fixture canopy.
400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the facility's electrical equipment and wiring was observed.

Main Hospital:

1. At 8:41 a.m., the electrical receptacle behind the aquarium in the Emergency Room was missing approximately 30 percent of the cover plate.

2. At 8:50 a.m., the electrical panels L1C, 1 section 21, and 1 (three electrical panels), located in the emergency room were impeded from access and view by a large linen cart positioned in front of them.

3. At 9:05 a.m., a multi-plug power strip in the Medical Imaging front office was plugged into another multi-plug power strip.

4. At 9:20 a.m., a multi-plug power strip in the Gift Shop was plugged into another multi-plug power strip near the holiday decorated tree.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by a penetration in a wall of the Main Hospital. This could result in faster spread of fire and smoke to other locations. This affected 1 of 13 smoke compartments.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the facility building construction was observed.

Main Hospital:

1. At 3:02 p.m., there was an approximately six inch by one inch unsealed penetration in the west wall of the Men's Dressing Room for the Operating Room Staff.

Based on observation and interview, the facility failed to maintain their corridor doors to resist the passage of smoke. This was evidenced by corridor doors that were impeded from closing or latching. This affected 4 of 13 smoke compartments in the Main Hospital and could result in the migration of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the corridor doors were observed.

Main Hospital:

1. At 8:46 a.m., the corridor door to the Triage Room in the Emergency Department was impeded from closing by a blood pressure machine. The room was unattended.

2. At 8:55 a.m., the self-closing corridor door to the Oxygen Room in the Emergency Department failed to latch when tested. There was white tape placed over the striker plate that prevented the door from latching. At 8:56 a.m., the Director of Facility Administration was interviewed. The Director of Facility Administration indicated that that the doors were recently checked and that somebody must have just put this tape on the door.

3. At 8:58 a.m., the self-closing corridor door to the Ultra Sound Room was impeded from closing by a brown rubber wedge placed under the door leaf.

4. At 9:01 a.m., the self-closing corridor door to the Radiologist Office was impeded from closing by a block positioned in the swing path of the door.

5. At 9:28 a.m., the self-closing corridor door to the Microbiology Room in the Lab was impeded from closing by a brown rubber wedge placed under the door leaf.

6. At 9:47 a.m., the self-closing corridor door to the Medi-Cal Office was not latching when tested.

Based on observation, the facility failed to maintain their emergency lighting units as evidenced by an emergency light that failed to illuminate when tested. This affected the main entrance to the Community Clinic and could result in limited visibility in the event of a power failure.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the emergency lighting units were observed and tested.

Community Clinic:

1. At 10:31 a.m., the emergency lighting unit near the main entrance to the Community Clinic failed to illuminate when the test button was pressed.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by an exit sign equipped with battery back-up that failed to illuminate when tested. This affected 5 of 13 smoke compartments and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 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.

Findings:

Main Hospital

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the facility exit signs were observed and tested.

Main Hospital:

1. At 8:30 a.m., the east exit sign near the Admitting corridor failed to illuminate when the test button was pressed.

Based on interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by a staff member that was unable to locate a fire alarm activation device and a fire extinguisher. This affected 1 of 13 smoke compartments and could result in facility staff not being prepared to respond to a fire emergency.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, staff members were interviewed.

Main Hospital:

1. At 9:24 a.m., Staff Member 1 was interviewed. Staff Member 1 had two years experience in the Gift Shop. Staff Member 1 was asked to locate a fire extinguisher. Staff Member 1 did not know where a fire extinguisher was located. The nearest fire extinguisher was located approximately 20 feet away. Staff Member 1 was asked to locate a fire alarm manual pull station device. Staff Member 1 did not know where a fire alarm manual pull station was located. The nearest fire alarm manual pull station device was located approximately 25 feet away.

Based on observation, the facility failed to maintain the fire alarm system. This was evidenced by obstructed manual fire alarm pull stations in the Main Hospital and Heavenly Mountain Clinic. This could result in a delayed activation of the fire alarm system in the event of a fire. This affected 1 of 13 smoke compartments.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the manual fire alarm pull stations were observed.

Main Hospital:

1. At 8:25 a.m., the manual fire alarm pull station near the east Acute Care exit was impeded from access and obstructed from view by an approximately 200 gallon capacity trash container.

Heavenly Mountain Clinic:

2. At 10:55 a.m., the manual fire alarm pull station alarm near the middle exit was impeded from access and obstructed from view by three snow shovels that were leaning over the device.

Based on observation, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by a sprinkler head that was missing an escutcheon ring. The failure to maintain the sprinkler heads could result in a malfunctioning automatic fire sprinkler system in the event of a fire. This affected 1 of 13 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the sprinkler system was observed.

Main Hospital:

1. At 10:10 a.m., the sprinkler in the Equipment Storage Room near Room 217 was missing an escutcheon ring.

Based on observation, the facility failed to maintain their portable fire extinguishers. This was evidenced by a portable fire extinguisher that was mounted greater than 60 inches from floor level in the Main Hospital and a fire extinguisher that was obstructed from access in the Pediatrics Clinic. This affected 1 of 13 smoke compartments in the Main Hospital and the entire Pediatrics Clinic. This could result in a delay in accessing a portable fire extinguisher.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 edition
1-6.3 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 paths of travel, including exits from areas.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the portable fire extinguishers were observed.

Main Hospital:

1. At 9:32 a.m., the portable fire extinguisher near the janitor closet in the Lab was mounted approximately 68 inches from the top of the extinguisher to the floor.

Community Clinic (Pediatrics):

2. At 10:40 a.m., the portable fire extinguisher near the east exit in the Pediatrics side of the Community Clinic was obstructed by a wooded shred file box that was directly in front of the device.

Based on observation, the facility failed to ensure that trash receptacles exceeding 32 gallons were not stored in the hallway. This could fuel a fire and cause potential harm to patients in the event of a fire emergency. This affected 1 of 13 smoke compartments in the Main Hospital.

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the trash receptacles were observed.

Main Hospital:

1. At 8:27 a.m., there was an approximately 200 gallon trash container near the east Acute Care exit corridor that was unattended.

Based on record review and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by the facility's failure to maintain the relative humidity equal to or greater than 35% in five of five operating rooms in the Main Hospital. This could result in the increased risk of a facility fire due to electrostatic charges in an oxygen rich environment.

Findings:

During document review with the Director of Facility Administration and Manager 1 on 12/27/12, the humidity logs for the operating rooms were observed.

Main Hospital:

1. At 3:45 p.m., the recorded relative humidity for Operating Room 1 on 12/17/12 was 31.5%. The recorded relative humidity for Operating Room 2 on 12/17/12 was 33.5%. The recorded relative humidity for Operating Room 3 on 12/17/12 was 29.5%. The recorded relative humidity for Operating Room 4 on 12/17/12 was 31%. The recorded relative humidity for Operating Room 5 on 12/17/12 was 34%.

At 3:46 p.m., Director of Facility Administration said during an interview that the facility maintains the humidity levels in their Operating Rooms according to Association of Perioperative Registered Nurses (AORN) standards.

Based on observation, the facility failed to maintain their electrical equipment and wiring. This was evidenced by a broken receptacle cover, the use of multi-plug power strips plugged into other multi-plug power strips, and impeded circuit breaker panels. This affected 3 of 13 smoke compartments and could result in an electrical shock or an electrical fire.

NFPA 70, 1999 edition
110-26(a)2 Width of Working Space.
The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
110-26(b) Clear Spaces.
Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
370-25 Covers and Canopies.
In completed installations, each box shall have a cover, faceplate, or fixture canopy.
400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:
(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a tour of the facility with the Director of Facility Administration and Manager 1 on 12/27/12, the facility's electrical equipment and wiring was observed.

Main Hospital:

1. At 8:41 a.m., the electrical receptacle behind the aquarium in the Emergency Room was missing approximately 30 percent of the cover plate.

2. At 8:50 a.m., the electrical panels L1C, 1 section 21, and 1 (three electrical panels), located in the emergency room were impeded from access and view by a large linen cart positioned in front of them.

3. At 9:05 a.m., a multi-plug power strip in the Medical Imaging front office was plugged into another multi-plug power strip.

4. At 9:20 a.m., a multi-plug power strip in the Gift Shop was plugged into another multi-plug power strip near the holiday decorated tree.