HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. These deficient practices affected one of two smoke compartments in the Willow Clinic, one of two smoke compartments in the Mike Nevin Clinic, one of two smoke compartments on the 1st floor Clinics Building, and one of one smoke compartments on the 3rd floor of the Administration Building. These conditions could result in the spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire.

Findings:

During the tour of the facility with facility staff the following observations were made:
Main Campus:
1. On 8/23/10, at 11:13 a.m., there was a one inch penetration around the escutcheon ring, in the storage file closet 2W-LC.
2. On 8/23/10, at 3:00 p.m., there were unsealed penetrations around a three inch pipe conduit, and a five inch pipe conduit, in the Edison Clinic electrical closet.
Mike Nevin Clinic:
1. On 8/24/10, at 9:15 a.m., there were two 5" pipe conduits, three 5" conduits with wires running through, and one 3" pipe conduit with wires running through that had not been sealed, in the electrical closet.
Willow Clinic:
1. On 8/26/10, at 9:32 a.m., the telephone junction box was hanging off the wall and exposed a 3" by 2" penetration in the wall, in the office area behind cubicle 7.
2. On 8/26/10, at 9:34 a.m., the telephone junction box on the left hand wall of the office was attached to the wall with clear packing tape, in the Charge Nurse office.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested, by doors that were obstructed, and by roll down doors that were blocked by items stored on the counter top. It is important 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 staff and residents in one of eight smoke compartments on the second floor in the main building, one of three smoke compartments in the Mike Nevin Clinic, one of one smoke compartments in the Administration Building, and one of three smoke compartments in the North Addition. These conditions could result in the increased potential to allow the spread of smoke and fire in the event of a fire.
.


Findings:

During a tour of the facility with Administrative Staff on 8/23/10, corridor doors were observed in the following locations:

San Mateo Medical Center Main Campus
1. At 11:21 a.m., the Soiled Utility Room near the Restroom on the Second Floor in the Intensive Care Unit did not positive latch when tested.
2. At 11:50 a.m., the door to Treatment Room Two on the Second Floor Endoscopy Unit was impeded from closing by a chair placed in the swing area of the door.

3. During a tour of the facility with Administrative Staff on 8/25/10, at 9:20 a.m., the corridor door to the Staff Breakroom on the Second Floor 2B Unit had the door strike plate hardware covered with tape, preventing the door from latching when tested.







27254

Main Campus:
1. On 8/23/10, at 11:16 a.m., the door to room 2W-RD was held open by a door wedge, on the 3rd floor of the Administration Building.
2. On 8/23/10, at 2:20 p.m., 2 of 3 roll down doors were blocked by items stored on the counter top in the Pharmacy, on the 1st floor of the North Addition Building.
Mike Nevin:
1. On 8/24/10, at 9:10 a.m., the 3 roll down doors at the reception area were blocked by items stored on the counter tops.

Based on observation and interview, the facility failed to maintain the smoke barrier doors. This was evidenced by smoke barrier doors that were held open by magnetic hold-open devices that did not release upon activation of the fire alarm system. This deficient practice affected staff and patients in two of two smoke compartments, and could result in the spread of smoke and/or fire.

Findings:

Out-patient Services Fair Oaks Adult Clinic
During fire alarm testing with Administrative Staff on 8/24/10, at 11:00 a.m., the cross corridor smoke barrier separating the Admission portion of the Clinic from the Examination/Diabetes area failed to release and close upon activation of the smoke detectors, or the automatic sprinkler system. Only one leaf of the cross corridor doors could be held open by the magnetic hold-open device. In an interview with staff, staff stated that these doors are normally kept closed.

Based on observation and staff interview, the facility failed to maintain the one-half hour fire- rated construction of the smoke barrier walls, in accordance with 2000 NFPA 101. This was evidenced by three unsealed penetrations observed in the exterior wall between the second and third floors. This deficient practice affected one of eight smoke compartments on the third floor, and could result in smoke and/or fire spreading from one floor to another.

8.2.3.2.4 Penetrations and Miscellaneous Openings in Fire
Barriers.
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.


Findings:

San Mateo Medical Center Main Campus
During an inspection of the facility's smoke barriers with Engineering Staff on 8/23/10, unsealed penetrations were observed in the wall between the third and second floor. Observation of the smoke barrier walls on the third floor above the drop down ceiling above the cross corridor doors near Stair 27 showed three unsealed two inch pipe conduits traveling from the third floor near the ceiling to the second floor above the drop down ceiling. The conduits were sealed on the second floor end with a fire-rated caulking but not on the third floor. In an interview with staff, staff confirmed that the ends of the conduit were not sealed on the third floor.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor doors which were equipped with latching hardware but failed to latch when tested, and by doors which were not equipped with self-closing devices, and by doors that required more than five pounds of force to open the doors. This deficient practice affected all staff and patients in three of fourteen smoke compartments on the Second Floor at the Main Campus, four smoke compartments on the 3rd floor, four smoke compartments on the 2nd floor and two smoke compartments on the 1st floor, and one of two smoke compartments at the Fair Oaks Adult Clinic.

Findings:

San Mateo Medical Center Main Campus
During a fire alarm testing with Administrative Staff on 8/23/10, cross corridor doors were tested in the following locations:
1. At 11:37 a.m., the right leaf facing south of the cross corridor doors separating the North Edition from the 2 A/B Unit did not positive latch when tested.
2. At 11:42 a.m., the cross corridor doors separating Administration from the North Edition near stairwell 28 did not positive latch when tested.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility with Administrative Staff on 8/24/10, between 10:25 and 10:40 a.m., the door to the Fire Alarm Control Panel Room which separated the Warehouse from the Clinic by a one hour fire separation wall, did not have a self-closing mechanism on the door.



27254

NFPA 101 Life Safety Code - 2000 edition
7.2.1.4 Swing and Force to Open.
7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging
doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.
Exception No. 2: The opening forces for horizontal sliding doors shall be as provided in Chapters 22 and 23.
Exception No. 3: The opening forces for power-operated doors shall be as provided in 7.2.1.9
7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.5 Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.
Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware. The unlatching of any leaf shall not require more than one operation.



During fire alarm testing at the Main Campus with staff members on 8/24/10, the following observations were made:
1. At 3:19 p.m., on the third floor, the fire door by patient Room 302, the right hand door did not positively latch when released from the door hold open device.
2. At 3:18 p.m., on the third floor, the fire door by patient Room 318, the left hand door did not positively latch when released from the door hold open device.
3. At 3:50 p.m., on the second floor of the North Addition Building, by the Specialty Clinics, the 3 hour fire door did not fully close and latch. Once closed, the door hardware did not release the doors from the egress side. Staff stated that the doors did not fully close due to the air ducts.
4. At 4:00 p.m., on the second floor of the Nursing Wing Bldg., by patient Room 215, the left hand and right hand doors did not positively latch when closed.
5. At 4:15 p.m., on the first floor of the North Addition Building, by the Edison Clinic, the 3 hour fire door did not fully close and latch. Staff stated that the doors did not fully close due to the air ducts.

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

San Mateo Medical Center Main Campus
During a tour of the facility with Engineering Staff on 8/23/10, at 12:10 p.m., the north door to the Short Stay Waiting Room in the Endoscopy Department was marked with an exit sign which was not illuminated. The door to this room was one of two exit doors exiting the Short Stay Waiting Room. It had a key-type door lock locking the door from the egress side, preventing occupants from exiting through that door. Keys to the door were kept in the locked Medication Room in the Recovery portion of the Endoscopy unit Staff stated that the key-type door lock had been added later to prevent patients from entering the treatment portion of the Department.









27254

Based on observation and interview, the facility failed to maintain exit access so that exits are readily accessible at all times as evidenced by an egress corridor in the receiving area that had packages stored along the corridor, and by an exit door that was locked from the egress side. This affected one of two smoke compartments in the Administration Building, and one of eight smoke compartments in the Short Stay Endoscopy Waiting Room. This could result in a delay of egress in the event of an emergency.

NFPA 101 Life Safety Code
7.1.3.2.3 - An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, an area of refuge.
7.1.10 Means of Egress Reliability.
7.1.10.1* 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.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility with a staff member on 8/25/10 at 1:30 p.m., in the Administration Building receiving area there were packages stored along the corridor and blocked approximately 40% of the corridor passageway.
Staff stated that the packages were exchange carts that had recently been received, and were to be moved in no more than two weeks.

Based on observation and interview, the facility failed to maintain and provide emergency illumination in accordance with 1999 NFPA 99 and 2000 NFPA 101. This was evidenced by a lack of battery-powered emergency lighting units in anesthetizing locations, and by a battery-operated emergency egress light which failed to function when tested. This deficient practice affected three of three operating rooms at the Main Campus, and one of two smoke compartments at the Outpatient Clinic. This could result in a loss of lighting in the Operating Room during surgical procedures in the ten seconds of time that is allowed for the back-up generator to transfer power during power outages.

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

NFPA 2000 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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

San Mateo Medical Center Main Campus
During a tour of the facility with Staff on 8/24/10, at 3:15 p.m., three of three Operating Rooms did not have battery back-up emergency lighting units. When asked about the emergency lighting, Staff stated in an interview that there were no battery back-up lighting units in the Operating Rooms, but there were flashlights that could be used in a emergency.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility on 8/24/10, at 1:10 p.m., the emergency egress lighting mounted on the Kitchen wall did not function under battery power when tested by pushing the test button. In an interview with staff, staff confirmed that the light was not functioning.

Based on observation, the facility failed to maintain all exit and directional signs, as evidenced by exit signs which were not illuminated. It is essential that all exit signs are illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected two of eight smoke compartments on the second floor of the Main Campus, and one of two smoke compartments at the Out-Patient Services Clinic. This could result in a delay in evacuation in the event of an emergency.

Findings:

San Mateo Medical Center Main Campus
During a tour of the facility with Administrative Staff on 8/23/10, exit signs were observed which were not illuminated in the following locations:

1. At 12:10 p.m., the north exit sign located in the Short Stay Waiting Room was not illuminated.
2. Between 2:00 and 2:30 p.m., the exit sign located in the exit discharge outside near Stair well 27 which led to the Physician's Parking Lot was not illuminated.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility with Administrative Staff on 8/24/10, at 10:39 a.m., the exit sign located at the West Exit was not illuminated on one side.

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 lack of, or incomplete documentation for, fire drills at one of the facility's Out-Patient Clinics, and the Clinics at the Main Campus. This deficient practice affected all staff and residents in six of six smoke compartments at the Main Campus Clinics, and two of two smoke compartments at an Out-patient Clinic, and could result in staff not being properly trained and familiar with emergency procedures.


NFPA 101, 19.7.1.2 "Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: infirm, or bedridden patients shall not be required to be moved during drills to safe areas, or to be exterior of the building. "

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

Findings:

San Mateo Medical Center Main Campus
During document review on 8/25/10, at 10:15 a.m., the facility failed to provide complete documentation for fire drills for the First, Second, and Third Floor Clinics for the first and second quarters of 2010. Documentation was provided for three fire drills for the campus's nine clinics. Two of the fire drills did not have sign-in sheets which corresponded with Clinic Staff.

Out-patient Services Fair Oaks Adult Clinic
During record review with Administrative Staff on 8/24/10, at 9:30 a.m., documentation for fire drills indicated that the last fire drill training was dated 4/30/08. In an interview with staff, Administrative Staff confirmed that it was the last documented fire drill.

Based on record review and interview, the facility failed to maintain its fire alarm system, in accordance with 1999 NFPA 72. This was evidenced by fire alarm initiating devices failing to activate the fire alarm control panel and produce audible alarms in all areas of the facility, and by the remote monitoring company failing to receive the fire alarm signal when alarm devices were activated. This deficient practice affected staff and patients in two of two smoke compartments at the Out-patient Fair Oaks Adult Clinic, and could result in a delay in response from firefighters and/or staff in the the event of a fire.

Findings:

During document review on 8/24/10, at 9:30 a.m., Administrative Staff stated that the fire alarm system was having problems and was not currently being monitored. Documentation provided for the quarterly sprinkler inspection and testing report dated 6/25/10 stated in the deficiencies and comments section that "Central station did not receive the supervisory and water flow signal during the alarm testing. Please have your alarm company troubleshoot why........". Additional documentation from the alarm vendor dated 7/15/10 stated that "the phone line are good need to return with programer to check program if program is good possible bad panel".

During a fire alarm testing with Administrative Staff on 8/24/10 alarm devices were tested with the following results:

1. At 11:00 a.m., smoke detectors in the diabetes clinic were activated with artifical canned smoke. These detectors were not interconnected with the detectors in the smoke compartment in the front admissions portion of the building, and could not be heard in that area.

2. At 11:10 a.m., the automatic sprinkler system was tested by opening the Inspector's Test Valve. The fire alarm activated within the required maximum time of 90 seconds, but could not be heard inside of the building. The audible alarm for the automatic sprinkler system was the water activated bell on the side of the Warehouse portion of the building, approximately 150 feet away.

Administrative Staff AS3 called the alarm monitoring company and confirmed in an interview that the signals had not been received during the alarm testing.

Based on observation, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by a fire extinguisher that was not securely mounted. This deficient practice affected one of two smoke compartments in the Administration Building, and could result in damage to the portable fire extinguisher.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition states:
1-6 General Requirements.
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.
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.
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate
the location.
1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb(18.14 kg)(except wheeled types)shall be so installed that the
top of the fire extinguisher is not more than 3 1/2 ft (1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).

Findings:

During a tour of the facility with a staff member on 8/23/10. at 2:33 p.m., there was a portable fire extinguisher that was not securely mounted on the bracket, and was stored on the floor next to a cart, in the Kitchen.

Based on observation, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in patient care and non-sleeping staff areas. This deficient practice affected all staff and patients in one of four smoke compartments within the facility, and could result in the ignition of fire.

Findings:

During a tour of the facility with Engineering Staff on 8/23/10, portable electric heaters were observed on the Second Floor without testing or facility inspection documentation in the following locations:

San Mateo Medical Center Main Campus
1. At 11:48 a.m., the EEG Room in Physical Therapy had a 1500 watt portable electric heater on the floor.
2. At 1:45 p.m., the Pediatrics Clinic Office 217 had a portable electric heater on the floor with a box located approximately 18 inches in front of and to the side of the heater.
3. At 2:45 p.m., the PBX Office had a portable electric heater on the floor.

These heaters had three foot clearance warnings, and did not have facility inspection and acceptance documentation.

Based on observation and staff interview, the facility failed to maintain the facility free of flammable furnishings and decorations as observed by privacy curtains that were hung in exam rooms with no fire rating. This deficient practice affected all patients in the Mike Nevin Clinic, and could result in the spread of fire and smoke in the event of a fire.

Findings:

During a tour of the facility with a staff member on 8/24/10, at 9:30 a.m., the twelve privacy curtains in the clinic had no tags to identify the fire rating. Staff stated that there were no records available to disclose the fire rating of the privacy curtains.

Based on document review and staff interview, the facility failed to maintain a relative humidity log to maintain the operating room humidity equal to or greater than 35%. This deficient practice was evidenced by no records for the operating rooms humidity and affected the entire operating area. This condition could result in the potential spread of smoke and fire in the event of a fire.

Findings:

During document review on 8/26/10, no humidity logs were provided for the humidity of the operating rooms.

In an interview with staff, staff stated that logs are not kept and that only 24 hour preview of the OR humidity could be provided. The OR humidity is set between 30% and 70%, and if it drops below or exceeds the limits, an alarm is activated.

Based on observation and interview, the facility failed to post no smoking signs in areas where oxygen was stored as evidenced by no sign posted in an oxygen storage area. This deficient practice affected one of two smoke compartments on the first floor of the Clinics Building, and could result in the acceleration of a fire.

Findings:

During a tour of the facility on 8/23/10, at 3:03 p.m., in the Senior Care Clinic in the Clinics Building, oxygen was stored in the conference room and there was no sign posted for no smoking in the area.

In an interview with staff, staff stated that they were unaware that a sign needed to be posted.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities, in accordance with 1999 NFPA 70. This was evidenced by the permanent use of extension cords, and by equipment stored in front of electrical panels. This deficient practice affected staff and residents in one of eight smoke compartments at the Main Campus, and one of two smoke compartments at the Out-patient Clinic. This could result in the ignition of fire, or a delay in access to electrical panels in an emergency.

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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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

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.

Findings:

San Mateo Medical Center Main Campus
During a tour of the facility with Engineering Staff on 8/23/10, at 11:45 a.m., the Storage Room in Physical Therapy had two electrical panels which had a patient lift and two boxes stored in front of the electrical panels.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility with Administrative Staff on 8/24/10 electrical wiring and utilities were observed in the following locations:

1. At 10:10 a.m., the copy machine was plugged into a multi-outlet extension cord.
2. At 10:25 a.m., the Storage Room had an extension cord that was attached to the wall, traveling up the wall through the ceiling tile around the door jamb, and down the other side of the wall. Staff stated that the cord is no longer in use, but had not been removed.
3. At 10:38 a.m., a coffee pot was plugged into an extension cord, instead of into a fixed electrical outlet, in the area near the Fire Alarm Control Panel Room.
4. At 10:39 a.m., the Electrical Room had a television and a shopping cart stored in front of the electrical panels.









27254

Based on observation and staff interview, the facility failed to comply with regulations regarding electrical wiring and utilities as evidenced by the use of surge protectors for motorized items, and by surge protectors that were plugged into other surge protectors instead of directly into wall outlets. These deficient practices affected one of two smoke compartments on the second floor of the Clinics Building, one of two smoke compartments in the Administration Building, and one of two smoke compartments in the Willow Clinic. These conditions could result in the potential to ignite an electrical fire.

NFPA 70 National Electrical Code
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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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 a staff member, the following observations were made:
Main Campus:
1. On 8/23/10, at 11:41 a.m., in the Clinics Building on the third floor, in room 3SS030, an extension cord was used for a telephone and a video monitor. Staff stated that the equipment is used for conference calls.
2. On 8/23/10, at 2:49 p.m., in the Coroners Division of the Administration Building on the first floor in the technicians office, a small refrigerator and microwave were plugged into a power strip instead of directly into the wall outlet.

Willow Clinic:
1. On 8/26/10, at 9:41 a.m., in the Staff Break room, computer equipment was plugged into a power strip, that was plugged into another power strip instead of directly into the wall outlet.
2. On 8/26/10, at 9:54 p.m., in the lunch room of the Dental Clinic, a microwave and two small refrigerators were plugged into a power strip, instead of directly into the wall outlet.

Based on document review and interview, the facility failed to follow its fire watch policy to insure that if the fire alarm system is out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified, and the facility would be evacuated, or an approved fire watch would be initiated. This was evidenced by the facility failing to provide documentation of a fire watch during malfunction of the fire alarm system. This could result in the facility's occupants being unprotected in the event of a fire.

Findings:

During a review of the facility's records with Administrative Staff on 8/24/10, at 10:50 a.m., Administrative Staff stated that the fire alarm system was not functioning properly because the monitoring company was not receiving signals during fire alarm testing. Documentation provided from the Sprinkler Vendor and Fire Alarm Vendor dated 6/25/10 and 7/15/10 confirmed that the monitoring company was not receiving signals from the Fire Alarm Control Panel during testing.

Documentation for the facility's fire watch policy was provided during record review on 8/25/10 at 10:15 a.m. The fire watch policy stated that the Fire Watch Protocol would be initiated when the fire alarm system and/or sprinkler system malfunctioned. This policy is applicable to medical and all health and hospital facilities, including off-site clinics.

No documentation for an initiated fire watch was provided for the time period prior to 8/25/10 at 9:00 a.m.

Based on observation, the facility failed to install alcohol-based hand rub dispensers (ABHR) in locations not adjacent to or above sources of ignition. This was evidenced by alcohol-based hand rub dispensers mounted on walls above light switches and potential ignition sources. This affected all staff and patients in two of eight smoke compartments at the Main Campus, and one of two smoke compartments at the Out-Patient Services Clinic, and could result in an increased risk of the ignition of fire.

Findings:

During a tour of the facility on 8/23/10, the following rooms had ABHR dispensers located above ignition sources:

San Mateo Medical Center Main Campus
1. At 12:15 p.m., the Copy Machine Room in Rehabilitation had an ABHR dispenser located above a copy machine.
2. At 2:00 p.m., Education Room Two had an ABHR dispenser located approximately eight inches above a light switch.

Out-patient Services Fair Oaks Adult Clinic
3. During a tour of the facility with Administrative Staff on 8/24/10, at 10:07 a.m., the CPSP Office had an ABHR dispenser located approximately four inches above a light switch.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. These deficient practices affected one of two smoke compartments in the Willow Clinic, one of two smoke compartments in the Mike Nevin Clinic, one of two smoke compartments on the 1st floor Clinics Building, and one of one smoke compartments on the 3rd floor of the Administration Building. These conditions could result in the spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire.

Findings:

During the tour of the facility with facility staff the following observations were made:
Main Campus:
1. On 8/23/10, at 11:13 a.m., there was a one inch penetration around the escutcheon ring, in the storage file closet 2W-LC.
2. On 8/23/10, at 3:00 p.m., there were unsealed penetrations around a three inch pipe conduit, and a five inch pipe conduit, in the Edison Clinic electrical closet.
Mike Nevin Clinic:
1. On 8/24/10, at 9:15 a.m., there were two 5" pipe conduits, three 5" conduits with wires running through, and one 3" pipe conduit with wires running through that had not been sealed, in the electrical closet.
Willow Clinic:
1. On 8/26/10, at 9:32 a.m., the telephone junction box was hanging off the wall and exposed a 3" by 2" penetration in the wall, in the office area behind cubicle 7.
2. On 8/26/10, at 9:34 a.m., the telephone junction box on the left hand wall of the office was attached to the wall with clear packing tape, in the Charge Nurse office.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested, by doors that were obstructed, and by roll down doors that were blocked by items stored on the counter top. It is important 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 staff and residents in one of eight smoke compartments on the second floor in the main building, one of three smoke compartments in the Mike Nevin Clinic, one of one smoke compartments in the Administration Building, and one of three smoke compartments in the North Addition. These conditions could result in the increased potential to allow the spread of smoke and fire in the event of a fire.
.


Findings:

During a tour of the facility with Administrative Staff on 8/23/10, corridor doors were observed in the following locations:

San Mateo Medical Center Main Campus
1. At 11:21 a.m., the Soiled Utility Room near the Restroom on the Second Floor in the Intensive Care Unit did not positive latch when tested.
2. At 11:50 a.m., the door to Treatment Room Two on the Second Floor Endoscopy Unit was impeded from closing by a chair placed in the swing area of the door.

3. During a tour of the facility with Administrative Staff on 8/25/10, at 9:20 a.m., the corridor door to the Staff Breakroom on the Second Floor 2B Unit had the door strike plate hardware covered with tape, preventing the door from latching when tested.







27254

Main Campus:
1. On 8/23/10, at 11:16 a.m., the door to room 2W-RD was held open by a door wedge, on the 3rd floor of the Administration Building.
2. On 8/23/10, at 2:20 p.m., 2 of 3 roll down doors were blocked by items stored on the counter top in the Pharmacy, on the 1st floor of the North Addition Building.
Mike Nevin:
1. On 8/24/10, at 9:10 a.m., the 3 roll down doors at the reception area were blocked by items stored on the counter tops.

Based on observation and interview, the facility failed to maintain the smoke barrier doors. This was evidenced by smoke barrier doors that were held open by magnetic hold-open devices that did not release upon activation of the fire alarm system. This deficient practice affected staff and patients in two of two smoke compartments, and could result in the spread of smoke and/or fire.

Findings:

Out-patient Services Fair Oaks Adult Clinic
During fire alarm testing with Administrative Staff on 8/24/10, at 11:00 a.m., the cross corridor smoke barrier separating the Admission portion of the Clinic from the Examination/Diabetes area failed to release and close upon activation of the smoke detectors, or the automatic sprinkler system. Only one leaf of the cross corridor doors could be held open by the magnetic hold-open device. In an interview with staff, staff stated that these doors are normally kept closed.

Based on observation and staff interview, the facility failed to maintain the one-half hour fire- rated construction of the smoke barrier walls, in accordance with 2000 NFPA 101. This was evidenced by three unsealed penetrations observed in the exterior wall between the second and third floors. This deficient practice affected one of eight smoke compartments on the third floor, and could result in smoke and/or fire spreading from one floor to another.

8.2.3.2.4 Penetrations and Miscellaneous Openings in Fire
Barriers.
8.2.3.2.4.2* Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through fire barriers shall be protected as follows:
(1) The space between the penetrating item and the fire barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the fire barrier, the sleeve shall be solidly set in the fire barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the fire resistance of the fire barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

8.3.6.2 Openings occurring at points where floors or smoke barriers meet the outside walls, other smoke barriers, or fire barriers of a building shall meet one of the following conditions:
(1) It shall be filled with a material that is capable of maintaining the smoke resistance of the floor or smoke barrier.
(2) It shall be protected by an approved device that is designed for the specific purpose.


Findings:

San Mateo Medical Center Main Campus
During an inspection of the facility's smoke barriers with Engineering Staff on 8/23/10, unsealed penetrations were observed in the wall between the third and second floor. Observation of the smoke barrier walls on the third floor above the drop down ceiling above the cross corridor doors near Stair 27 showed three unsealed two inch pipe conduits traveling from the third floor near the ceiling to the second floor above the drop down ceiling. The conduits were sealed on the second floor end with a fire-rated caulking but not on the third floor. In an interview with staff, staff confirmed that the ends of the conduit were not sealed on the third floor.

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a barrier to prevent the spread of smoke and/or fire. This was evidenced by cross-corridor doors which were equipped with latching hardware but failed to latch when tested, and by doors which were not equipped with self-closing devices, and by doors that required more than five pounds of force to open the doors. This deficient practice affected all staff and patients in three of fourteen smoke compartments on the Second Floor at the Main Campus, four smoke compartments on the 3rd floor, four smoke compartments on the 2nd floor and two smoke compartments on the 1st floor, and one of two smoke compartments at the Fair Oaks Adult Clinic.

Findings:

San Mateo Medical Center Main Campus
During a fire alarm testing with Administrative Staff on 8/23/10, cross corridor doors were tested in the following locations:
1. At 11:37 a.m., the right leaf facing south of the cross corridor doors separating the North Edition from the 2 A/B Unit did not positive latch when tested.
2. At 11:42 a.m., the cross corridor doors separating Administration from the North Edition near stairwell 28 did not positive latch when tested.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility with Administrative Staff on 8/24/10, between 10:25 and 10:40 a.m., the door to the Fire Alarm Control Panel Room which separated the Warehouse from the Clinic by a one hour fire separation wall, did not have a self-closing mechanism on the door.



27254

NFPA 101 Life Safety Code - 2000 edition
7.2.1.4 Swing and Force to Open.
7.2.1.4.5 The forces required to fully open any door manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the door in motion, and 15 lbf (67 N) to open the door to the minimum required width. Opening forces for interior side-hinged or pivoted-swinging
doors without closers shall not exceed 5 lbf (22 N). These forces shall be applied at the latch stile.
Exception No. 1: The opening force for existing doors in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.
Exception No. 2: The opening forces for horizontal sliding doors shall be as provided in Chapters 22 and 23.
Exception No. 3: The opening forces for power-operated doors shall be as provided in 7.2.1.9
7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.5 Where pairs of doors are required in a means of egress, each leaf of the pair shall be provided with its own releasing device. Devices that depend on the release of one door before the other shall not be used.
Exception: Where exit doors are used in pairs and approved automatic flush bolts are used, the door leaf equipped with the automatic flush bolts shall have no doorknob or surface-mounted hardware. The unlatching of any leaf shall not require more than one operation.



During fire alarm testing at the Main Campus with staff members on 8/24/10, the following observations were made:
1. At 3:19 p.m., on the third floor, the fire door by patient Room 302, the right hand door did not positively latch when released from the door hold open device.
2. At 3:18 p.m., on the third floor, the fire door by patient Room 318, the left hand door did not positively latch when released from the door hold open device.
3. At 3:50 p.m., on the second floor of the North Addition Building, by the Specialty Clinics, the 3 hour fire door did not fully close and latch. Once closed, the door hardware did not release the doors from the egress side. Staff stated that the doors did not fully close due to the air ducts.
4. At 4:00 p.m., on the second floor of the Nursing Wing Bldg., by patient Room 215, the left hand and right hand doors did not positively latch when closed.
5. At 4:15 p.m., on the first floor of the North Addition Building, by the Edison Clinic, the 3 hour fire door did not fully close and latch. Staff stated that the doors did not fully close due to the air ducts.

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

San Mateo Medical Center Main Campus
During a tour of the facility with Engineering Staff on 8/23/10, at 12:10 p.m., the north door to the Short Stay Waiting Room in the Endoscopy Department was marked with an exit sign which was not illuminated. The door to this room was one of two exit doors exiting the Short Stay Waiting Room. It had a key-type door lock locking the door from the egress side, preventing occupants from exiting through that door. Keys to the door were kept in the locked Medication Room in the Recovery portion of the Endoscopy unit Staff stated that the key-type door lock had been added later to prevent patients from entering the treatment portion of the Department.









27254

Based on observation and interview, the facility failed to maintain exit access so that exits are readily accessible at all times as evidenced by an egress corridor in the receiving area that had packages stored along the corridor, and by an exit door that was locked from the egress side. This affected one of two smoke compartments in the Administration Building, and one of eight smoke compartments in the Short Stay Endoscopy Waiting Room. This could result in a delay of egress in the event of an emergency.

NFPA 101 Life Safety Code
7.1.3.2.3 - An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, an area of refuge.
7.1.10 Means of Egress Reliability.
7.1.10.1* 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.
7.1.10.2 Furnishings and Decorations in Means of Egress.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility with a staff member on 8/25/10 at 1:30 p.m., in the Administration Building receiving area there were packages stored along the corridor and blocked approximately 40% of the corridor passageway.
Staff stated that the packages were exchange carts that had recently been received, and were to be moved in no more than two weeks.

Based on observation and interview, the facility failed to maintain and provide emergency illumination in accordance with 1999 NFPA 99 and 2000 NFPA 101. This was evidenced by a lack of battery-powered emergency lighting units in anesthetizing locations, and by a battery-operated emergency egress light which failed to function when tested. This deficient practice affected three of three operating rooms at the Main Campus, and one of two smoke compartments at the Outpatient Clinic. This could result in a loss of lighting in the Operating Room during surgical procedures in the ten seconds of time that is allowed for the back-up generator to transfer power during power outages.

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

NFPA 2000 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 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

San Mateo Medical Center Main Campus
During a tour of the facility with Staff on 8/24/10, at 3:15 p.m., three of three Operating Rooms did not have battery back-up emergency lighting units. When asked about the emergency lighting, Staff stated in an interview that there were no battery back-up lighting units in the Operating Rooms, but there were flashlights that could be used in a emergency.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility on 8/24/10, at 1:10 p.m., the emergency egress lighting mounted on the Kitchen wall did not function under battery power when tested by pushing the test button. In an interview with staff, staff confirmed that the light was not functioning.

Based on observation, the facility failed to maintain all exit and directional signs, as evidenced by exit signs which were not illuminated. It is essential that all exit signs are illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected two of eight smoke compartments on the second floor of the Main Campus, and one of two smoke compartments at the Out-Patient Services Clinic. This could result in a delay in evacuation in the event of an emergency.

Findings:

San Mateo Medical Center Main Campus
During a tour of the facility with Administrative Staff on 8/23/10, exit signs were observed which were not illuminated in the following locations:

1. At 12:10 p.m., the north exit sign located in the Short Stay Waiting Room was not illuminated.
2. Between 2:00 and 2:30 p.m., the exit sign located in the exit discharge outside near Stair well 27 which led to the Physician's Parking Lot was not illuminated.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility with Administrative Staff on 8/24/10, at 10:39 a.m., the exit sign located at the West Exit was not illuminated on one side.

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 lack of, or incomplete documentation for, fire drills at one of the facility's Out-Patient Clinics, and the Clinics at the Main Campus. This deficient practice affected all staff and residents in six of six smoke compartments at the Main Campus Clinics, and two of two smoke compartments at an Out-patient Clinic, and could result in staff not being properly trained and familiar with emergency procedures.


NFPA 101, 19.7.1.2 "Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. 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. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: infirm, or bedridden patients shall not be required to be moved during drills to safe areas, or to be exterior of the building. "

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

Findings:

San Mateo Medical Center Main Campus
During document review on 8/25/10, at 10:15 a.m., the facility failed to provide complete documentation for fire drills for the First, Second, and Third Floor Clinics for the first and second quarters of 2010. Documentation was provided for three fire drills for the campus's nine clinics. Two of the fire drills did not have sign-in sheets which corresponded with Clinic Staff.

Out-patient Services Fair Oaks Adult Clinic
During record review with Administrative Staff on 8/24/10, at 9:30 a.m., documentation for fire drills indicated that the last fire drill training was dated 4/30/08. In an interview with staff, Administrative Staff confirmed that it was the last documented fire drill.

Based on record review and interview, the facility failed to maintain its fire alarm system, in accordance with 1999 NFPA 72. This was evidenced by fire alarm initiating devices failing to activate the fire alarm control panel and produce audible alarms in all areas of the facility, and by the remote monitoring company failing to receive the fire alarm signal when alarm devices were activated. This deficient practice affected staff and patients in two of two smoke compartments at the Out-patient Fair Oaks Adult Clinic, and could result in a delay in response from firefighters and/or staff in the the event of a fire.

Findings:

During document review on 8/24/10, at 9:30 a.m., Administrative Staff stated that the fire alarm system was having problems and was not currently being monitored. Documentation provided for the quarterly sprinkler inspection and testing report dated 6/25/10 stated in the deficiencies and comments section that "Central station did not receive the supervisory and water flow signal during the alarm testing. Please have your alarm company troubleshoot why........". Additional documentation from the alarm vendor dated 7/15/10 stated that "the phone line are good need to return with programer to check program if program is good possible bad panel".

During a fire alarm testing with Administrative Staff on 8/24/10 alarm devices were tested with the following results:

1. At 11:00 a.m., smoke detectors in the diabetes clinic were activated with artifical canned smoke. These detectors were not interconnected with the detectors in the smoke compartment in the front admissions portion of the building, and could not be heard in that area.

2. At 11:10 a.m., the automatic sprinkler system was tested by opening the Inspector's Test Valve. The fire alarm activated within the required maximum time of 90 seconds, but could not be heard inside of the building. The audible alarm for the automatic sprinkler system was the water activated bell on the side of the Warehouse portion of the building, approximately 150 feet away.

Administrative Staff AS3 called the alarm monitoring company and confirmed in an interview that the signals had not been received during the alarm testing.

Based on observation, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by a fire extinguisher that was not securely mounted. This deficient practice affected one of two smoke compartments in the Administration Building, and could result in damage to the portable fire extinguisher.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition states:
1-6 General Requirements.
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.
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.
1-6.6* Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction
cannot be completely avoided, means shall be provided to indicate
the location.
1-6.7* Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb(18.14 kg)(except wheeled types)shall be so installed that the
top of the fire extinguisher is not more than 3 1/2 ft (1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).

Findings:

During a tour of the facility with a staff member on 8/23/10. at 2:33 p.m., there was a portable fire extinguisher that was not securely mounted on the bracket, and was stored on the floor next to a cart, in the Kitchen.

Based on observation, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in patient care and non-sleeping staff areas. This deficient practice affected all staff and patients in one of four smoke compartments within the facility, and could result in the ignition of fire.

Findings:

During a tour of the facility with Engineering Staff on 8/23/10, portable electric heaters were observed on the Second Floor without testing or facility inspection documentation in the following locations:

San Mateo Medical Center Main Campus
1. At 11:48 a.m., the EEG Room in Physical Therapy had a 1500 watt portable electric heater on the floor.
2. At 1:45 p.m., the Pediatrics Clinic Office 217 had a portable electric heater on the floor with a box located approximately 18 inches in front of and to the side of the heater.
3. At 2:45 p.m., the PBX Office had a portable electric heater on the floor.

These heaters had three foot clearance warnings, and did not have facility inspection and acceptance documentation.

Based on observation and staff interview, the facility failed to maintain the facility free of flammable furnishings and decorations as observed by privacy curtains that were hung in exam rooms with no fire rating. This deficient practice affected all patients in the Mike Nevin Clinic, and could result in the spread of fire and smoke in the event of a fire.

Findings:

During a tour of the facility with a staff member on 8/24/10, at 9:30 a.m., the twelve privacy curtains in the clinic had no tags to identify the fire rating. Staff stated that there were no records available to disclose the fire rating of the privacy curtains.

Based on document review and staff interview, the facility failed to maintain a relative humidity log to maintain the operating room humidity equal to or greater than 35%. This deficient practice was evidenced by no records for the operating rooms humidity and affected the entire operating area. This condition could result in the potential spread of smoke and fire in the event of a fire.

Findings:

During document review on 8/26/10, no humidity logs were provided for the humidity of the operating rooms.

In an interview with staff, staff stated that logs are not kept and that only 24 hour preview of the OR humidity could be provided. The OR humidity is set between 30% and 70%, and if it drops below or exceeds the limits, an alarm is activated.

Based on observation and interview, the facility failed to post no smoking signs in areas where oxygen was stored as evidenced by no sign posted in an oxygen storage area. This deficient practice affected one of two smoke compartments on the first floor of the Clinics Building, and could result in the acceleration of a fire.

Findings:

During a tour of the facility on 8/23/10, at 3:03 p.m., in the Senior Care Clinic in the Clinics Building, oxygen was stored in the conference room and there was no sign posted for no smoking in the area.

In an interview with staff, staff stated that they were unaware that a sign needed to be posted.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities, in accordance with 1999 NFPA 70. This was evidenced by the permanent use of extension cords, and by equipment stored in front of electrical panels. This deficient practice affected staff and residents in one of eight smoke compartments at the Main Campus, and one of two smoke compartments at the Out-patient Clinic. This could result in the ignition of fire, or a delay in access to electrical panels in an emergency.

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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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

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.

Findings:

San Mateo Medical Center Main Campus
During a tour of the facility with Engineering Staff on 8/23/10, at 11:45 a.m., the Storage Room in Physical Therapy had two electrical panels which had a patient lift and two boxes stored in front of the electrical panels.

Out-patient Services Fair Oaks Adult Clinic
During a tour of the facility with Administrative Staff on 8/24/10 electrical wiring and utilities were observed in the following locations:

1. At 10:10 a.m., the copy machine was plugged into a multi-outlet extension cord.
2. At 10:25 a.m., the Storage Room had an extension cord that was attached to the wall, traveling up the wall through the ceiling tile around the door jamb, and down the other side of the wall. Staff stated that the cord is no longer in use, but had not been removed.
3. At 10:38 a.m., a coffee pot was plugged into an extension cord, instead of into a fixed electrical outlet, in the area near the Fire Alarm Control Panel Room.
4. At 10:39 a.m., the Electrical Room had a television and a shopping cart stored in front of the electrical panels.









27254

Based on observation and staff interview, the facility failed to comply with regulations regarding electrical wiring and utilities as evidenced by the use of surge protectors for motorized items, and by surge protectors that were plugged into other surge protectors instead of directly into wall outlets. These deficient practices affected one of two smoke compartments on the second floor of the Clinics Building, one of two smoke compartments in the Administration Building, and one of two smoke compartments in the Willow Clinic. These conditions could result in the potential to ignite an electrical fire.

NFPA 70 National Electrical Code
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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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 a staff member, the following observations were made:
Main Campus:
1. On 8/23/10, at 11:41 a.m., in the Clinics Building on the third floor, in room 3SS030, an extension cord was used for a telephone and a video monitor. Staff stated that the equipment is used for conference calls.
2. On 8/23/10, at 2:49 p.m., in the Coroners Division of the Administration Building on the first floor in the technicians office, a small refrigerator and microwave were plugged into a power strip instead of directly into the wall outlet.

Willow Clinic:
1. On 8/26/10, at 9:41 a.m., in the Staff Break room, computer equipment was plugged into a power strip, that was plugged into another power strip instead of directly into the wall outlet.
2. On 8/26/10, at 9:54 p.m., in the lunch room of the Dental Clinic, a microwave and two small refrigerators were plugged into a power strip, instead of directly into the wall outlet.

Based on document review and interview, the facility failed to follow its fire watch policy to insure that if the fire alarm system is out of service for four or more hours in a 24 hour period that the authority having jurisdiction (AHJ) would be notified, and the facility would be evacuated, or an approved fire watch would be initiated. This was evidenced by the facility failing to provide documentation of a fire watch during malfunction of the fire alarm system. This could result in the facility's occupants being unprotected in the event of a fire.

Findings:

During a review of the facility's records with Administrative Staff on 8/24/10, at 10:50 a.m., Administrative Staff stated that the fire alarm system was not functioning properly because the monitoring company was not receiving signals during fire alarm testing. Documentation provided from the Sprinkler Vendor and Fire Alarm Vendor dated 6/25/10 and 7/15/10 confirmed that the monitoring company was not receiving signals from the Fire Alarm Control Panel during testing.

Documentation for the facility's fire watch policy was provided during record review on 8/25/10 at 10:15 a.m. The fire watch policy stated that the Fire Watch Protocol would be initiated when the fire alarm system and/or sprinkler system malfunctioned. This policy is applicable to medical and all health and hospital facilities, including off-site clinics.

No documentation for an initiated fire watch was provided for the time period prior to 8/25/10 at 9:00 a.m.