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Based on observation, the facility failed to maintain the integrity of the building's construction, as evidenced by penetrations or unsealed openings in the ceilings and walls. This could result in the passage of smoke in the event of a fire, and affected 7 of 15 floors in the Main Hospital.

Findings:

During a tour of the facility with Plant Operations Staff 3, and Carpenters 1 and 2 on 1/23/12 through 1/26/12, the ceilings and walls were observed.

Main Hospital:

1. On 1/23/12 at 2:42 p.m. in Room 8609 (Mechanical Room, 8th Floor University Tower), there were two approximately 1/8-inch penetrations around a 1/2-inch conduit above the Main Drain, an approximately 3/4-inch penetration at the top left of a junction box, and an approximately 1/2-inch L-shaped penetration around the junction box above the Main Drain.

2. On 1/24/12 at 3:41 p.m., the escutcheon plate on the sprinkler in the corner of Room 6683 (Nurse Manager's Office, 6th Floor University Tower) was missing.

3. At 3:46 p.m., the escutcheon plate on the sprinkler in Room 6603 (6th Floor University Tower) was not flush with the ceiling and exposed an approximately 2 1/2-inch by 1/4-inch penetration.

4. At 4:04 p.m., there was an approximately 1-inch penetration in the northeast corner of the ceiling in Room 6201 (6th Floor North Wing).

5. On 1/25/12 at 10:15 a.m., there were two penetrations in the ceiling of the Medical Air Storage Room located between Rooms 4208 and 4210 (4th Floor North Wing). One of the penetrations measured approximately 2 1/2 inches by 1/2 inch around a 2 1/2-inch pipe and several cables. The second penetration measured approximately 1 3/4 inches by 1/8 inch around a 2 1/2-inch pipe.

6. On 1/26/12 at 10:55 a.m., two of three escutcheons in Room 1518 (Processing Room, 1st Floor East Wing) were missing.


25385

Findings:

During a tour of the facility walls were inspected throughout the facility.

Main Hospital:

1. On 1/24/12, at 3:10 p.m., there was a sprinkler escutcheon in Room 5654 that was not flush to the ceiling. This created an approximately one-half inch unsealed penetration around the sprinkler pipe.

2. On 1/24/12, at 3:41 p.m., there was an approximately one and one-half inch unsealed penetration in the wall inside Room 5102. This penetration was on the right hand side of the header facing towards the corridor.

3. On 1/24/12, at 3:46 p.m., there were two unsealed penetrations in the ceiling of Room 5104. These penetrations were caused by two three-quarter inch conduits passing through the wall. One conduit was not sealed on the end and the other one had a one-quarter inch gap between the conduit and the wall.

4. On 1/25/12, at 9:12 a.m., there was an approximately one inch by twelve inch unsealed penetration in the wall of 5214 L. This penetration was at baseboard height.

5. On 1/25/12, at 10:22 a.m., there was an approximately 18 inch by 24 inch sheetrock patch in the wall in Room 2237 A that had between a one-quarter inch and one-half inch unsealed opening around the edges. The location of this penetration looked like it might be on the common wall separating the Second Floor North Wing from the Second Floor East Tower. This wall was shown on the facility floor plan as a two hour fire-rated wall and was separating the decommissioned portion of the East Wing from the North Wing.
Plant Operations Staff 1 stated that the wall might be a common wall with the East Wing and that it was very close on the diagram.

6. On 1/26/12, at 8:41 a.m., there was an approximately three inch round damaged area in the wall behind the door to the CT Procedure Room 1P714.

7. On 1/26/12, at 10:48 a.m., the fire-rated attic access door in the ceiling of Room 1690 was left in the open position. This access door was approximately 18 inches by 24 inches in size. Plant Operations Staff 1 closed that door at that time.

8. On 1/26/12, at 10:55 a.m., there was an approximately three inch round unsealed penetration in the wall near the left door jamb facing the Gift Shop from Room 1651.



27893

Findings:

During a facility tour with staff, the walls and ceilings in the facility were observed.

Main Hospital:

1. On 1/25/12 at 9:32 a.m., there were eight approximately one inch diameter unsealed penetrations in a wall of Room 3129.

2. On 1/25/12 at 9:47 a.m., there was an approximately two inch diameter unsealed penetration in a wall of Room 3656. The penetration was located in the north wall of that room.

3. On 1/25/12 at 10:02 a.m., there was an approximately two and one half inch diameter unsealed penetration in a wall of Storage Room 3755. The penetration was located in the door side wall of that room.

4. On 1/25/12 at 11:13 a.m., there was an approximately six inch by three inch unsealed penetration in a wall of the Cardiac Perfusion Workroom 3P931.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors that were obstructed from closing or latching. This affected 12 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings and could result in a delay to contain smoke or fire to a room.

NFPA 101, 2000 edition
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.
*Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Main Hospital:

1. On 1/23/12 at 3:12 p.m., the door to Patient Room 11789 failed to latch when in the closed position. The door failed to latch due to misalignment of the latching pin and striker plate.

2. On 1/23/12 at 3:17 p.m., the roll down fire door near the 11th Floor Central Receiving Desk was observed. A clear container and a pen holder were observed to be positioned directly in the roll down path of the fire door.

3. On 1/23/12 at 3:43 p.m., the door to Patient Room 8107 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the retracted position.

4. On 1/23/12 at 3:49 p.m., the door to the Janitor Closet Room 8122 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

5. On 1/23/12 at 3:55 p.m., the door to the EKG Machine and Supplies Room 8140 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the retracted position.

6. On 1/23/12 at 3:59 p.m., the door to Patient Room 8135 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

7. On 1/25/12 at 9:28 a.m., the cross corridor door near Room 3507C was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the retracted position.

8. On 1/25/12 at 9:30 a.m., the door to Housekeeping Closet Room 3114 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

9. On 1/25/12 at 9:32 a.m., the door to Closet Room 3129 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was not equipped with a latching pin.

10. On 1/25/12 at 9:34 a.m., the door to Staff Room 3131 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

11. On 1/25/12 at 10:15 a.m., the door to Patient Room 3812 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a wooden door wedge placed under the door leaf.

12. On 1/25/12 at 11:07 a.m., the door to the Equipment Storage Room 3P935 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the opposing door leaf.

13. On 1/25/12 at 11:33 a.m., the door to the Equipment Storage B Room 3P715 near Room 3P714 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the opposing door leaf.

14. On 1/25/12 at 11:34 a.m., the door to the Equipment Storage A Room 3P714 across from Operating Room 21 (Room 3P719A) was equipped with a self-closing device. The door was obstructed from closing due to medical equipment that was located directly in the swing path of the door.

15. On 1/25/12 at 1:30 p.m., the door to the Clean Utility Room 3P571 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

16. On 1/25/12 at 1:35 p.m., the door to the Clean Utility Room 3P559 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

17. On 1/25/12 at 1:41 p.m., the door to the Anesthesia Charge Room 3P647 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

18. On 1/25/12 at 1:45 p.m., the door to the Staff Room 3P648 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

19. On 1/25/12 at 1:51 p.m., the door to the Housekeeping Room 3P421 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door failed to latch due to misalignment of the latching pin and striker plate.

20. On 1/25/12 at 2:02 p.m., the door to the Conference Room 3P414 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

21. On 1/25/12 at 2:24 p.m., the door to Room 1426 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Cancer Center:

1. On 1/27/12 at 9:41 a.m., one of two roll down fire doors to the First Floor Pharmacy Room 1008 was obstructed from closing due to a credit card reading machine located directly in the roll down path of the door.

2. On 1/27/12 at 9:50 a.m., the roll down fire door to the Clinical Laboratory Room 1013 was obstructed from closing by a plastic sign and in-box tray located directly in the roll down path of the door.

Otolaryngology Clinic:

1. On 1/27/12 at 10:15 a.m., the door to the Breakroom 5102 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to misalignment of the latching pin and striker plate.

2. On 1/27/12 at 10:19 a.m., the door located across from Pod 4 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 1/27/12 at 10:22 a.m., the door to Pod 4 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to misalignment of the latching pin and striker plate.


25385

Findings:

During a tour of the facility with Staff, doors were inspected throughout the facility.

Main Hospital:

1. On 1/23/12, at 3:00 p.m., there was a blood pressure monitor stored in the travel area of the corridor door in Room 12803 impeding the door from closing .

2. On 1/23/12, at 3:02 p.m., there was a pocket folder hanging in the travel area of the corridor door in Room 12801 impeding the door from closing.

3. On 1/23/12, at 3:57 p.m., the corridor door to patient Room 10783 did not positive latch when released from an open position.

4. On 1/24/12, at 8:55 a.m., the corridor door to Patient Room 8687 did not positive latch when released from its magnetic hold-open device from an open position, leaving an approximately 1/8 inch gap.

5. On 1/24/12, at 8:58 a.m., the corridor door to Supply Room 8680B was impeded from closing by a recycle bin located in the travel area of the door.

6. On 1/24/12, at 10:25 a.m., the corridor door to the Doctors' Room 7804 did not positive latch when released from an open position.

7. On 1/24/12, at 3:55 p.m., the corridor door to Room 5105 did not positive latch when released from an open position.

8. On 1/25/12, at 9:12 a.m., the self-closing door to the Breakroom 5207, was being held open with a door wedge. This room contained a microwave oven. This door was also tested by releasing it from an open position and did not positive latch.

9. On 1/25/12, at 9:38 a.m., the door to Office 5016A had a door wedge holding the one and one-half hour fire-rated door open. There was also a trash can holding the corridor door open in this area.

10. On 1/25/12, at 9:45 a.m., Room 5208 EEG Lab rolling fire door was impeded from closing by a tissue box.

11. On 1/25/12, at 10:02 a.m., the door to the Sleep Disorder Room was propped open.

12. On 1/25/12, at 1:48 p.m., the rolling fire door in the Laboratory was impeded from closing by a decorative cardboard container with a light in it.

13. On 1/25/12, at 2:44 p.m., the burn unit door to room 2P445 was being held open with a trash can.

14. On 1/25/12, at 2:45 p.m., the door to Supply Room 1, 2P459 did not positive latch when tested.

15. On 1/25/12, at 3:25 p.m., the Emergency Room 1P660 door was held open by a wedge in the corridor door.

16. On 1/25/12, at 3:34 p.m., the rolling fire doors to Reception Room 1P653 were impeded from closing by a telephone sitting on the ledge.

17. On 1/26/12, at 8:41 a.m., the corridor door near 1P714 did not positive latch when released from its hold-open device.

18. On 1/26/12, at 8:50 a.m., the door to Room 1P758 did not positive latch when released from its magnetic hold-open device. This door was damaged at the top. Staff stated that they thought that something had run into the door.

19. On 1/26/12, during fire alarm testing at 1:50 p.m., the doors to Patient Rooms 8113A and 8115A did not close upon activation of the fire alarm system.

Same Day Surgery Center:

1. On 1/26/12, at 5:05 p.m., the door to the Sterile Supply Room 1145 was impeded from closing by a supply cart.

2. On 1/26/12, at 5:08 p.m., the door to the Soiled Utility Room was being held open by a storage rack.

Pain Clinic:

1. On 1/27/12, between 7:45 and 7:50 a.m., the four Procedure Rooms had kick-type door stops attached to the bottom of the doors.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12 through 1/26/12, the corridor and interior doors were observed.

Main Hospital:

1. On 1/24/12 at 2:24 p.m., the door to Room 6777 (6th Floor Davis Tower) was obstructed from closing by a cord to a charting cart parked in the corridor.

2. On 1/25/12 at 11:05 a.m., the door to Room 4132 B (4th Floor North Wing) was held open by a door stop.

3. At 4:40 p.m., the door to Room 0629 (Ground Floor East Wing) was obstructed from closing by a door stop that was taped to the floor.

4. At 4:41 p.m.,the door to Room 0628 was held open by a door stop.

5. On 1/26/12 at 9:01 a.m., the door to Room 1910 B (Pediatric Physicians' Reading and Consultation Room, First Floor Davis Tower) was propped open and obstructed from closing by a garbage can.

6. At 9:14 a.m., the doors to Room 1874 and 1870 A (Nuclear Medicine Uptake Rooms, First Floor Davis Tower) were held open by door stops.

Based on observation, the facility failed to maintain their stairways. This was evidenced by one door to a stairway that failed to latch when closed. This affected 1 of 15 floors in the Main Hospital and could result in a delay to contain smoke or fire to a floor.

Findings:

During a facility tour with staff, the stairways in the facility were observed.

Main Hospital:

1. On 1/23/12 at 2:44 p.m., the door to the 11th Floor Stairway A was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch.

Based on observation and interview, the facility failed to mark all exits with readily visible signs in accordance with 2000 NFPA 101. This was evidenced by temporary exit signs that were not properly illuminated. This was also evidenced by the lack of posted exit signs and exit signs that conflicted with or made the direction of exit egress confusing. This deficient practice affected staff and patients on 3 of 15 floors in the Main Hospital and 1 of 5 Outpatient Buildings and could potentially result in injury or delay during an evacuation.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

Findings:

During a tour of the facility with Staff, exit signs were inspected throughout the facility.

Main Hospital:

1. On 1/23/12, at 3:10 p.m., the Braille exit sign located at the exit door to Stairwell "A" on the 12th floor was missing.

2. On 1/26/12, between 9:25 and 9:45 a.m., the corridor door to Cardio Vascular Services had an exit sign above the door but also had a piece of paper attached to the door stating that it was not a exit and that it did not function properly. The door was tested and it did, in fact, function properly. When asked, Cardio Vascular Staff stated that it was a problem with the door locking mechanism, and not the exit itself. Staff removed the sign at that time.

3. On 1/26/12, at 11:03 a.m., the area located on the first floor that redirected the original path of egress from stairwell 14 to the outside of the building, through the First Floor Corridor 1680 and into the main corridor 1601, had exits that were unclear due to conflicting signage and low lighting levels. This exit was being redirected because of construction outside of the emergency exit door at the bottom of the stairwell.

A. At the bottom of the stairs was a temporary exit sign on red 8 1/2 by 11 inch paper. This exit sign had an arrow that was pointing in a right turn direction to another exit sign at a door approximately eight feet away, but was also pointing at an original sign on the door that stated, "Emergency Exit Only alarm will sound use Main Entrance".

B. Following the path of egress directed by the temporary exit signs to the main corridor 1601, it was observed that lighting levels in the corridor were lower than other corridors in the building. In this corridor there were two light elements that were burned out and the lights in the area to the final exit sign leading to the exit discharge into the main corridor 1601 were shut off. Because these exit signs were not internally illuminated and relied on the external corridor lighting to illuminate the signs, Plant Operations Staff turned the lights back on.
During and interview on 1/27/12, between 2:00 and 3:00 p.m., when asked, Fire Officer 1 stated that the redirected path of egress would be in effect for approximately two to seven days. Documentation was provided for interim life safety measures to be implemented during this time period.

Pain Clinic:

1. On 1/27/12, at 7:38 a.m., the exit door sign leading into the corridor was illuminated. Below this sign was a paper exit sign the was attached to the door that stated that it was not an exit with an arrow redirecting egress through the Lobby area. Plant Operations Staff 1 stated that the sign would be replaced with one that stated "Emergency Exit Only".

2. On 1/27/12, at 9:07 a.m., the Clinic portion of the Pain Clinic had a Braille-only exit sign on the wall that led through an office that had an exit door leading into the corridor. This exit was one of two exits that are remote from each other in the Pain Clinic Suite. When asked, Clinic Staff stated that the doors are considered exits and that they are used during evacuation drills.

Based on observation, the facility failed to maintain the fire resistance rating of their smoke barrier walls, as evidenced by unsealed penetrations. This could result in the spread of smoke between compartments, and affected 6 of 15 floors in the Main Hospital.

NFPA 101, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.
8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Plant Operations Staff 3 and 4 and Carpenters 1 and 2 on 1/23/12 through 1/24/12, the smoke barrier walls were observed.

Main Hospital:

1. On 1/23/12 at 2:05 p.m., there was an approximately 1/4-inch unsealed penetration around a 3/4-inch conduit above Room 11703 in the Davis Tower.

2. At 3:18 p.m., there were two unsealed penetrations in the smoke barrier wall above Room 7602 in the Davis Tower. One penetration measured approximately 1/4 inch around a 1/8-inch cable; the other penetration was approximately 1/4 around a 1/2-inch conduit and five cables.

3. At 3:28 p.m., there were two unsealed penetrations above Room 7704 in the Davis Tower. One penetration measured approximately 2 1/2 inches and surrounded a conduit and three cables. The other penetration measured approximately 1 inch by 1/4 inch, and surrounded a 1/2-inch conduit.

4. At 3:44 p.m., there were four approximately 1/8-inch penetrations and one approximately 1 inch by 1/8 inch unsealed penetration around a 1/2-inch conduit above Room 7742 in the Davis Tower.

5. At 3:55 p.m., there were two approximately 3/4 inch by 1/8 each above Room 5742 in the Davis Tower. They each surrounded a 3/4-inch conduit.

6. On 1/24/12 at 10:35 a.m., there was an approximately 3/4-inch penetration around a 3/4-inch conduit with one cable running through it. The smoke barrier wall was located above and to the right of Room 1702 in the Davis Tower.

7. On 1/25/12 at 1:51 p.m., there was an approximately 1-1/4 inch penetration in the two-hour wall in Space 4740 A (Interstitial Space, 4th Floor Davis Tower).



25385

Findings:

During a tour of the facility with Staff, fire-rated walls were inspected throughout the facility.

Main Hospital:

1. On 1/23/12, at 3:30 p.m., the room identified on the facility floor plan as the Ante Room 10724A had three four-inch sleeves that traveled through the one-hour fire wall into Telephone Room 10722. Two of these four inch sleeves were not sealed with a fire-rated material on either end and one sleeve had an approximately one-half inch unsealed area on one side of the penetrating item and the wall.
Plant Operations Staff 1 confirmed that the sleeves were not sealed.

Based on observation, the facility failed to maintain its fire barrier doors, as evidenced by fire barrier doors that were obstructed from closing or latching and unsealed gaps at door to door meeting edges. This could result in the passage of smoke in the event of a fire, and affected 3 of 15 floors in the Main Hospital.

NFPA 101, 2000 edition
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings:

During a tour of the facility with Plant Operations Staff 3 and Technicians 1 and 2 on 1/24/12 and 1/26/12, the fire doors were observed and tested.

Main Hospital:

1. On 1/24/12 at 2:44 p.m., a 16" by 10 3/4" sign ("Welcome to Davis 6 Cardiology") on the ledge in the receptionist area obstructed the path to closure of the drop-down door.

2. On 1/26/12 at 1:01 p.m. during alarm testing, the right side of the fire door facing north in the Davis Tower 14th Floor elevator lobby failed to latch.

3. At 2:09 p.m. during alarm testing, the left side of the fire door facing north in the Davis Tower 6th Floor elevator lobby failed to close and exposed an approximately 12-inch gap between both sides.

4. At 2:43 p.m. during alarm testing, the fire doors near the 3rd Floor Pavilion elevators failed to close.

5. At 2:55 p.m. during alarm testing, the strobes activated, but the fire doors did not close and the bells did not alarm (there was a low humming sound instead) on 3rd Floor Davis Tower. The test was performed twice with the same results.


25385

Findings:

Main Hospital:

During a tour of the facility with Staff, smoke barrier doors were tested throughout the facility

1. On 1/23/12, at 1:30 p.m., the left leaf of the cross corridor doors 14710 facing the elevators did not close completely leaving an approximately one-half inch gap.

2. On 1/23/12, at 1:51 p.m., the right leaf of the cross corridor doors 14765 did not close completely leaving an approximately four inch gap.

3. On 1/26/12, at 2:30 p.m., the right leaf facing south of the cross corridor doors 3501 did not close completely during fire alarm testing leaving an approximately five inch gap.





27893

Findings:

Main Hospital:

1. On 1/25/12 at 10:19 a.m., the west-end Elevator Lobby Doors near the Labor and Delivery Waiting Area were equipped with self-closing devices. The doors were placed from the open position to the closed position. There was an approximately one half inch wide gap between the meeting edges of the door leaves. The doors were not equipped with an astragal, rabbet, or beveled edges.

2. On 1/25/12 at 10:22 a.m., the Freight Elevator Lobby Doors near Room 3834 were equipped with self-closing devices. The doors were placed from the open position to the closed position. There was an approximately three eighths inch wide gap between the meeting edges of the door leaves. The doors were not equipped with an astragal, rabbet, or beveled edges.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by doors to hazardous areas that were obstructed from closing or latching and doors to hazardous areas that were not equipped with self-closing or automatic closing devices. This affected 2 of 15 floors in the Main Hospital and 2 of 5 Outpatient Buildings and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Main Hospital:

1. On 1/25/12 at 8:48 a.m., the door to the Biohazard Room 3216 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

2. On 1/25/12 at 10:00 a.m., the door to the Soiled Utility Room 3753 was not equipped with a self-closing or automatic closing device.

3. On 1/25/12 at 11:10 a.m., the door to the Biohazard Room 3P934 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

4. On 1/25/12 at 11:30 a.m., the stairway side doors to the Soiled Holding Room 3P718 were equipped with self-closing devices. The doors were obstructed from closing due to sharps containers that were positioned in the swing path of the doors.

5. On 1/25/12 at 1:25 p.m., the door to the Soiled Utility Room 3P612 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

Placer Center for Health:

1. On 1/26/12 at 9:17 a.m., the door to the Soiled Utility Room 1248 was not equipped with a self-closing or automatic closing device.

Otolaryngology Clinic:

1. On 1/27/12 at 10:40 a.m., the door to the Soiled Utility Room 6208 was not equipped with a self-closing or automatic closing device.


25385

Findings:

During a tour of the facility with Staff , hazardous area enclosures were observed.

Main Hospital:

1. On 1/25/12, at 9:52 a.m., the door to Storage Room 53071 in the Sleep disorder Room had the self closing device removed from the door. This door was a one hour fire rated door.

Based on observation and staff interview, the facility failed to ensure that quantities of flammable liquids in its laboratory did not exceed the maximum amount allowed in accordance with 1999 NFPA 99. This was evidenced by flammable liquids in excess of one gallon per 100 sq. ft. or two gallons per 100 sq. ft. if in an approved storage cabinet. This deficient practice could potentially result in the spread of smoke and/or fire.

10-7.2.2 Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gallon per 100 sq. ft. The total volume of Class I, II, and IIIA liquids including those contained in an approved storage cabinet and safety cans shall not exceed 2 gallons per 100 sq. ft.

Findings:

During a tour of the facility with Staff, laboratories were inspected.

Main Hospital:

On 1/25/12, at 2:00 p.m., the Micro Biology Laboratory across the corridor from the Main Laboratory had three boxes labeled Methanol 4 x 4 L which equals 12.68 gallons placed on the floor on top of boxes of other lab materials. Lab Staff 2 was asked about the methanol and Staff stated that they did not expect to see it in the room and that it may have just come in as a shipment. During a reinspection of the area on 1/26/12, between 8:30 and 8:40 a.m., the boxes of methanol had been removed.

Based on observation and interview, the facility failed to maintain emergency illumination in accordance with 1999 NFPA 99. This was evidenced by a battery-powered emergency lighting unit in an anesthetizing location which had one of two bulbs burned out. This deficient practice affected one of four operating rooms at the Same Day Surgery Center and could potentially result in a loss of lighting in the operating room during a power outage.

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)

Findings:

Same Day Surgery Center:

1. During a tour of the facility with Surgery Manager 1 on 1/26/12, at 5:01 p.m., the battery back-up lighting unit in Operating Room 1 had one of two bulbs burned out. The surgery Manager Confirmed the observation.

Based on observation and interview, the facility failed to maintain its fire alarm system, as evidenced by manual fire alarm boxes (pull stations) that were not mounted within the required height, by pull stations that were blocked or obscured from view, by pull stations that were not provided within the required travel distance from each other, and by a set of occupancy separation doors that were disabled. This could result in staff's inability to readily access the pull stations in the event of a fire, and affected 7 of 15 floors in the Main Hospital.

NFPA 72, 1999 Edition
2-8.1 Mounting. Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3 1/2 ft (1.1 m) and not more than 4 1/2 feet (1.37 m) above floor level.
2-8.2 Location and Spacing.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
2-8.2.4 Additional manual fire alarm boxes shall be provided so that the travel distance to the nearest fire alarm box will not be in excess of 200 ft (61 m) measured horizontally on the same floor.

Findings:

During a tour of the facility with Plant Operations Staff 3, Carpenter 2, and Techs 1 and 2 on 1/24/12 through 1/26/12, the manual fire alarm pull stations were observed.

Main Hospital:

1. On 1/24/12 at 11:36 a.m., the pull station located to the right of the ASU Auditorium Elevator #8 was mounted 59-1/2 inches from the floor to the operable part (center) of the pull station.

2. At 11:37 a.m., the pull station located to the left of Room 1310 on the First Floor South Wing was mounted 59-1/2 inches from the floor to the center of the pull station.

3. At 11:39 a.m., the pull station located to the right of Room 037 on the Ground Level was mounted 58 inches from the floor to the center of the pull station.

4. At 1:10 p.m., the pull station located to the left of Room 0121 on the Ground Level was mounted 59-1/2 inches from the floor to the center of the pull station.

5. At 2:30 p.m., clear access to the pull station located at Nurses' Station #2 on the 6th Floor East Wing was obstructed by a Pyxis machine.

6. At 3:02 p.m., clear access to the pull station located at Nurses' Station #4 on the 6th Floor East Wing was obstructed by a wastebasket and a Pyxis machine. It was obscured from view by a backup emergency telephone.

7. At 3:48 p.m., the pull station located to the right of Room 6123 (6th Floor East Wing) was mounted 60-1/2 inches from the floor to the center of the pull station.

8. At 3:50 p.m., the pull station located across from Room 6117 (6th Floor East Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

9. At 3:53 p.m., the pull station located next to Room 6110 (6th Floor East Wing) was obstructed by a five-tier file cabinet.

10. At 4:00 p.m., the pull station located across from the Level 6 East Elevators was mounted 59-1/2 inches from the floor to the center of the pull station.

11. At 4:13 p.m., the pull station at the Exit by Room 6219 (6th Floor North Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

12. At 4:25 p.m., the pull station at the Exit by Room 6013 (6th Floor North Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

13. At 4:45 p.m., the pull station at the Exit across from Room 6314 (6th Floor South Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

14. On 1/25/12 at 10:48 a.m., the pull station outside the Pharmacy (Room 4123 4th Floor East Wing) was mounted 59-1/4 inches from the floor to the center of the pull station.

15. At 2:56 p.m., there were no pull stations located within the 16,389 square-foot Central Processing Department. The nearest pull stations were 34 feet outside the Clean side door and 18 feet outside the Decontamination side door.

16. On 1/26/12 at 2:30 p.m., a gurney was stored in front of the pull station in the Service Elevator Lobby by Room 3826 (Nourishment Room, 3rd Floor Davis Tower).


25385

Findings:

Main Hospital:

1. On 1/24/12, at 4:00 p.m., the fire alarm manual pull station in the corridor near Room 5002 was located on the wall approximately 60 inches above the floor.

During fire alarm testing with staff, fire alarm devices were tested throughout the facility.

2. On 1/26/12, at 3:07 p.m., the smoke detector in corridor 2143 was tested with canned smoke. This smoke detector activated the fire alarm audible devices in the area, but the 90 minute occupancy separation doors in corridor 2160 and 2600A failed to release from their magnetic hold open devices. Plant Operations Staff 5 returned from the fire alarm panel located in Mechanical Room 2004 and stated the the switch in the FACP had been switched to disable the fire doors. Staff re-tested the smoke detector and this time the 90 minute fire door released from their magnetic hold open devices.





27893

Findings:

Main Hospital:

1. On 1/25/12 at 8:57 a.m., the manual fire alarm pull station near Room 3219 was mounted on the wall approximately five feet high from the floor level to activation handle.

2. On 1/25/12 at 9:04 a.m., the manual fire alarm pull station near Room 3232 was mounted on the wall approximately five feet high from the floor level to activation handle.

3. On 1/25/12 at 9:10 a.m., the manual fire alarm pull station near the 3rd Floor Bed Ramp was mounted on the wall approximately five feet high from the floor level to activation handle.

4. On 1/25/12 at 9:35 a.m., the manual fire alarm pull station near Room 3123 was mounted on the wall approximately five feet high from the floor level to activation handle.

Based on record review, observation, and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for smoke sensitivity and one smoke detector that had paint on it. This affected all 9 of 15 floors in the Main Hospital and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review with staff, the facility's smoke detector inspection and test records were reviewed.

Main Hospital:

1. On 1/24/12 at 4:01 p.m., the facility's smoke detector sensitivity test records were requested. There were no records that indicated the facility smoke detectors in the North, South, or East Towers had been tested for smoke sensitivity. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the smoke detectors in the North, South, and East Towers were cleaned annually. Fire Officer 1 indicated that the smoke detectors in the North, South, and East Towers had not been tested for smoke sensitivity within the past 2 years.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/25/12, the smoke detectors were observed.

Main Hospital:

At 10:40 a.m., there was green spray paint on the smoke detector in Room 4004 (Electrical Room, 4th Floor North Wing).

Based on observation, record review, and interview, the facility failed to maintain its automatic sprinkler system in accordance with NFPA 25, as evidenced by paint or debris on some of the sprinklers, by items stored less than 18 inches below a deflector, by a bent deflector on one of the sprinklers, by a fire sprinkler valve that had obstructed access, and the facility's failure to conduct quarterly sprinkler alarm tests. This could result in an obstruction to the sprinklers' spray patterns, which could lead to the sprinklers malfunctioning in the event of a fire, and affected 15 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is
attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer 's instructions.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a tour of the facility with the Plant Operations Staff 3, Carpenter 2, and Technician 1 and 2 on 1/24/12 through 1/26/12, the automatic sprinkler system was observed.

Main Hospital:

1. On 1/24/12 at 3:26 p.m., office supplies were stored approximately 6 inches below the sprinkler's deflector in the Storage Room across from Room 6613 (Tower Level 6 CICU).

2. At 3:45 p.m., the sprinkler outside the Nurse Manager's Office (Room 6683) was loaded with debris.

3. On 1/25/12 at 12:58 p.m., there was paint on the deflector to the right of Room 4671 (Soiled Utility Room) located in the University Tower ENT Unit.

4. At 1:25 p.m., the sprinkler in the charting area behind the Nurses' Station (across from Room 4681) was loaded with debris.

5. At 2:13 p.m., there was paint on the deflector in Room OP 651 (Restroom/Shower).

6. At 2:37 p.m., the deflector in the northeast corner of the Decontamination side in the Central Processing Department (Room OP 722) was bent.

7. At 4:15 p.m., printer cartridges were stored approximately 7 inches below the deflector in Room 0788 K (Davis Tower).

8. On 1/26/12 at 10:30 a.m., 6 of 6 drop-down sprinklers in the Sim suite (Room 1523) were painted.


27893

Findings:

During record review, interview, and a facility tour with staff, the facility's automatic fire sprinkler system was observed.

Main Hospital:

1. On 1/24/12 at 3:19 p.m., the facility's quarterly automatic fire sprinkler system test records were requested. There was no record that indicated the facility had conducted automatic fire sprinkler system tests during the 2nd quarter of 2011. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that he had recently changed the testing frequency from semi-annually to quarterly for the facility's automatic fire sprinkler system alarm devices. Fire Officer 1 confirmed that the automatic fire sprinkler system alarm devices were not tested during the 2nd quarter of 2011.

2. On 1/25/12 at 10:09 a.m., the sprinkler head in the Storage Closet Room 3770A was covered with dusty debris. The sprinkler was missing a concealment cap.

3. On 1/25/12 at 11:20 a.m., the fire department valve near the north end of the 3rd Floor Surgery 20's Core was observed. The valve was located in a recessed corridor cabinet. The handle to open the cabinet had broken off and was missing.

Same Day Surgery Center/Cancer Center/Otolaryngology Clinic/Pain Clinic:

1. On 1/24/12 at 3:19 p.m., the quarterly automatic fire sprinkler system test records for the Same Day Surgery Center, Cancer Center, Otolaryngology Clinic, and Pain Clinic were requested. All four of the Outpatient Buildings were missing two of four quarterly automatic fire sprinkler tests. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the automatic fire sprinkler system alarm devices at the four Outpatient Buildings were being tested on a semi-annual basis.

Based on observation and interview, the facility failed to maintain its fire extinguishers, as evidenced by blocked and obscured fire extinguishers, by the presence of an unmounted and outdated fire extinguisher, by a fire extinguisher that was mounted above the required height, and by fire extinguishers at nurses' stations that were mounted below the required height. This could result in damage to the fire extinguisher if unmounted, in the fire extinguisher malfunctioning if outdated, and in staff not being able to properly access the fire extinguishers in the event of a fire if not mounted at the proper height. These deficient practices affected 7 of 15 floors in the Main Hospital.

NFPA 101, 2000 edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard or Portable Fire Extinguishers.

NFPA 10, 1998 Edition
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 a 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. Wheel-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 ? 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).
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

Findings:

During a tour of the facility with Plant Operations Staff 3, Carpenters 1 and 2, and Techs 1 and 2 on 1/23/12 through 1/26/12, the fire extinguishers were observed.

Main Hospital:

1. On 1/23/12 at 2:13 p.m., there was an unmounted and outdated fire extinguisher in Room 10721 (Electrical Room, 10th Floor Davis Tower).

2. At 3:12 p.m., the fire extinguisher located across from the 7th Floor University Towers Elevators between the East Wing and the Towers was inaccessible. There was no handle on the cabinet; the Plexiglas cover was bent to gain access.

3. On 1/24/12 at 2:47 p.m., the fire extinguisher at the 6th Floor Davis Tower Registration Counter was mounted in a floor-level cabinet. The clearance between the bottom of the fire extinguisher and the floor measured approximately 2-1/4 inches.

4. At 2:50 p.m., the clearance between the bottom of the fire extinguisher and the floor at the 6th Floor Davis Tower Nurses' Station 1 measured approximately 2-1/4 inches.

5. At 2:52 p.m., the clearance between the bottom of the fire extinguisher and the floor at the 6th Floor Davis Tower Nurses' Station 3 measured approximately 2-1/4 inches.

6. At 2:54 p.m., the clearance between the bottom of the fire extinguisher and the floor at the 6th Floor Davis Tower Nurses' Station 4 measured approximately 2-1/4 inches.

7. On 1/26/12 at 10:35 a.m., the fire extinguisher inside Room 1523 (1st Floor South Wing) was mounted at 63 inches.

8. At 1:58 p.m. during fire alarm testing, Nursing Staff 1 at the 7th Floor Davis Tower Nurses' Station 3 did not immediately identify the location of the nearest fire extinguisher when interviewed. The nearest fire extinguisher was located there in Station 3. Nursing Staff 2 pointed to where the extinguisher was located because Nursing Staff 1 did not see it. It was obscured from view and obstructed by a trash can.


25385

Findings:

During a tour of the facility with Staff, fire extinguishers were inspected throughout the facility.

Main Hospital:

1. On 1/25/12, at 8:52 a.m., the fire extinguisher located at the East Wing Nurses Station near Room 5133 did not have a sign above the extinguisher. This extinguisher was also blocked for access and partially blocked by view by a wheeled work station placed in front of it.

2. On 1/25/12, at 2:22 p.m., Room 2P938 had a fire extinguisher sitting on the floor with no mounting brackets or inspection tag on it.





27893

Findings:

During a facility tour with staff, the portable fire extinguishers in the facility were observed.

Main Hospital:

1. On 1/25/12 at 10:32 a.m., two portable fire extinguishers located in the 3rd Floor Pavilion Shell Space were observed. The service tags on the portable fire extinguishers indicated that they had last been serviced on 7/9/10. The portable fire extinguishers were approximately six months overdue for an annual service. The reverse side of the service tags indicated that the portable fire extinguishers at that location were inspected monthly. Comments were written on tag by the individual performing the monthly inspections. The comments included "overdue" and "needs service."

2. On 1/25/12 at 11:20 a.m., a portable fire extinguisher near the north end of the 3rd Floor Surgery 20's Core was observed. The portable fire extinguisher was located in a recessed corridor cabinet. The handle to open the cabinet had broken off and was missing.

Based on observation and record review, the facility failed to adhere to their smoking policy. This was evidenced by cigarette butts located on the grounds of a non-smoking campus. This affected 1 of 15 floors in the Main Hospital and could result in a cigarette butt ignited fire emergency.

Findings:

During record review and a facility tour with staff, the facility's smoking policy was observed.

Main Hospital:

1. On 1/27/12 at 11:08 a.m., there were approximately 150-200 cigarette butts observed on the ground near the exit stairs from the Pavilion Cafeteria Patio. The facility's smoking policy was reviewed. The smoking policy indicated that the facility prohibits smoking on the main campus.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices in accordance with 2000 NFPA 101, 1999 NFPA 99, and 1999 NFPA 70. This was evidenced by unapproved portable heaters in non-sleeping staff areas of the facility that did not have proper clearance from combustible materials in accordance with the manufacturer's labeled instructions and portable space heaters plugged into extension cords. This deficient practice affected all staff and patients in 4 of 15 floors in the Main Hospital and 1 of 5 Outpatient Buildings and could potentially result in the ignition of fire.

NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator 's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with Staff, electrical equipment was inspected throughout the facility.

Main Hospital:

1. On 1/25/12, at 1:32 p.m., the Second Floor Pavilion Laboratory had a portable heater located in the Blood Bank Office area of the lab under a desk.

2. On 1/25/12, at 1:35 p.m., the northwest office area of the lab had two portable heaters under desks. One heater was the type that had the heating elements visible and was near a handbag and papers.

3. On 1/25/12, at 3:10 p.m., Office 1P671 had a portable electric heater under a desk.

These heaters all had labeled high temperature warnings with three feet of clearance required.

Plant Operations Staff 1 confirmed that the heaters had not been tested and accepted by the facility.


27893

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

Main Hospital:

1. On 1/25/12 at 9:14 a.m., a non-facility approved portable space heater was observed in Staff Room 3304A. Facility staff could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

Cancer Center:

1. On 1/27/12 at 9:32 a.m., a facility approved portable space heater was observed at the 1st Floor Reception Desk. The space heater was plugged into a surge protected multi-outlet extension cord. The space heater was located under a desk and within three feet of combustibles and furnishings.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12, portable space heaters were observed.

Main Hospital:

1. At 4:38 p.m., portable space heaters at Cubicle 1 and Cubicle 2 in Room 6312 (6th Floor South Wing). Both space heaters were situated under the desks in a manner that did not allow 3 feet of space between the heaters and the office furniture.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by an exit door that was locked against egress with no key immediately available, items that were stored in the path of egress in an exit access and discharge, and office doors that could not be fully opened. This deficient practice had the potential to affected all staff and patients on 3 of 15 floors and could potentially result in injury or a delayed evacuation in the event of an emergency.

NFPA 101, 2000 edition
3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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.

Findings:

During a tour of the facility with Staff, exits and egress routes were inspected throughout the facility

Main Hospital:

1. On 1/24/12, at 11:15 a.m., the exit door located in the South Stairwell of the University Tower was impeded by three chairs and a piece of moulding lying on the floor. Two chairs were located in the exit path on the egress side of the door. When the door was tested, it was difficult to push open because there was a rocking chair located on the nonegress side of the door. There was also an approximately three foot long by five inch wide piece of moulding lying on the same side of the door as the rocking chair. Staff removed the items at that time.

2. On 1/25/12, at 9:55 a.m., the door to Office 5307C could not be opened more than approximately 20 inches. This door had items stored behind it which prevented it from opening fully.

3. On 1/26/12, Room 1852 had papers in piles on the floor that prevented that door from opening fully.

4. On 1/26/12, at 11:03 a.m., there was an exit door on the first floor of the University Tower in Stairwell 14 that was locked against egress. This door was being used as a temporary exit from the stairwell because of new construction in progress outside of the original exit door. This new exit access was redirected from the stairwell through the First Floor corridor 1680 and into the main corridor 1601 into the building. Plant Operations Staff 1 unlocked that door at that time and called to have the locking mechanism removed.

Based on observation, the facility failed to regulate the placement of excessive combustible personal furnishings and/or decorations as evidenced by papers loosely pinned to walls and doors. This deficient practice affected all staff and patients on 1 of 15 floors in the Main Hospital and could potentially result in the spread of smoke and/or fire.

NFPA 101, 2000 edition
19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings,
in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a tour of the facility with Staff,

Main Hospital:

1. On 1/24/12, at 10:17 a.m., the Doctors' Room 7804 had loose papers and photographs pinned to the four walls. Approximately 60 percent of the area of the wall had paper attached to both the walls and/or on the bulletin boards. Facing into the room from the exit, the right hand wall had an approximately four foot by 13 foot cloth-covered bulletin board that had more than 34 pieces of 8 1/2 inch by 11 inch paper loosely attached, and three 18 inch by 24 inch posters pinned to it. On the left side of the room were two approximately four foot by three foot bulletin boards which had 17 8 1/2 inch by 11 inch pieces of paper loosely pinned to it. The other bulletin board had 9 8 1/2 inch by 11 inch pieces of paper loosely pinned to it. The wall with the exit door had an approximately two foot by three foot area with photographs pinned to the wall.

2. On 1/24/12, at 10:34 a.m., the surface area of the corridor door to Report Room 7814 was covered with greater than 10% loose papers.

3. On 1/24/12, at 10:57 a.m., the corridor by Room 7676 had two pillow pouches attached to the door with approximately 30 pieces of paper in them plus another three pieces of 8 1/2 inch by 11 inch papers attached directly to the door.

Based on observation, the facility failed to protect its medical gas storage areas in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored secured together instead of individually, cylinders that were unsecured, electrical fixtures below five feet high from floor level, oxygen cylinder areas not equipped with precautionary signs, empty cylinders stored with full cylinders, and oxygen cylinders stored near combustibles. This deficient practice affected 5 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings. This could potentially result in an oxygen cylinder initiated emergency or a delay in obtaining an oxygen cylinder.

NFPA 99, 1999 edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4-3.5.2 Gas System Policies-Level 1.
13. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. Such cylinders shall not be stored valve, or safety device. Such cylinders shall not be stored near elevators, gangways, or in locations where heavy moving objects will strike them or fall on them.
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
4-3.5.2.2 Storage of Cylinders and Containers Level 1.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage.
8-3.1.11 Storage Requirements.
8-3.1.11.1 Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2. 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1 (b) 27.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a tour of the facility with staff, Medical gas storage areas were inspected.

Main Hospital:

1. On 1/25/12, at 9:25 a.m., Room 5204 PFT Lab had one H size tank that was sitting free standing on the floor.

Same Day Surgery:

2. On 1/26/12, at 5:40 p.m., the Oxygen Storage Area located on the outside of the building had 17 H size oxygen tanks that were not individually secured.

Pain Clinic:

3. On 1/27/12, the Oxygen Storage area located on the outside of the Ellison Building had 14 H size tanks that were secured together with one chain.


27893

Findings:

During a facility tour with staff, the facility's oxygen cylinder storage locations were observed.

Main Hospital:

1. On 1/25/12 at 11:09 a.m., a light switch inside the Medical Gas Cylinder Storage Room 3P933 was approximately four feet high from floor level and not the required 60 inches.

Placer Center for Health:

1. On 1/26/12 at 10:21 a.m., the Oxygen Manifold Room was not equipped with precautionary signs on the outside indicating that smoking is prohibited near that location.

Cancer Center:

1. On 1/27/12 at 9:56 a.m., a light switch inside the Oxygen Manifold Room 1016A was approximately four feet high from floor level and not the required 60 inches off of the floor as required.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12 and 1/25/12, the locations of oxygen storage were observed.

Main Hospital:

1. On 1/24/12 at 3:08 p.m., an unsecured oxygen E-tank leaned against a sink in Room 6703 (6th Floor Davis Tower).

2. At 4:20 p.m., an unsecured oxygen D-tank rested in a wall closet in Room 6220 (Pulm Rehab Gym, 6th Floor North Wing).

3. On 1/25/12 at 1:13 p.m., one empty oxygen E-tank was stored in the same rack with five full tanks in a location designated for full cylinders, and six full tanks were stored with one empty tanks in a location designated for empty cylinders. The light switch in the oxygen storage area was mounted 52 inches above the floor. The oxygen cylinders were stored within the ENT Unit (4th Floor University Tower).

4. At 3:31 p.m., 51 oxygen E-tanks (48 full and 3 empty) were stored in Room 0761 (Ground Floor Davis Tower) along with gurneys, medical equipment, and cardboard boxes. There was no oxygen warning signs posted at the entrance to the room and the cylinders were stored within 5 feet of combustibles.

Based on record review, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain relative humidity levels at 35 percent or greater. This affected all facility operating rooms and anesthetizing locations and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, the facility's relative humidity records for their anesthetizing locations were observed.

Main Hospital/Same Day Surgery Center:

1. On 1/24/12 at 10:00 a.m., the relative humidity records for the facility's anesthetizing locations were requested. Onsite staff monitors and records the relative humidity levels for the 4 Operating Rooms at the Same Day Surgery Center. The facility remotely monitors the relative humidity for their 24 Operating Rooms located at the 3rd Floor Pavilion Surgery Department. The alarm setting for the offsite monitoring system was set at 25 to 60 percent. The monitoring system would only alarm if the relative humidity fell outside that range. The facility policy for humidity levels at anesthetizing locations was requested. The humidity policy indicated that the facility will maintain relative humidity between 20 and 60 percent at their anesthetizing locations.

Relative humidity levels had fallen below 35 percent at several anesthetizing locations located in the Main Hospital and at the Same Day Surgery Center on numerous days during surgical procedures. A waiver was discussed with the engineering staff.

Based on record review and interview, the facility failed to establish required laboratory emergency procedures. This was evidenced by the facility's failure to establish an emergency procedure for extinguishing clothing fires. This affected 1 of 15 Floors in the Main Hospital and could result in clothing fire injury to laboratory staff.

NFPA 99, 1999 edition
10-2.1.3 Emergency Procedures.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.
10-2.1.3.3 Emergency procedures shall be established for extinguishing clothing fires.

NFPA 101, 2000 edition
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Findings:

During record review with staff, the facility's laboratory policies and procedures were reviewed.

Main Hospital:

1. On 1/24/12 at 12:45 p.m., the laboratory specific emergency policies and procedures were reviewed. There was no emergency procedure regarding the extinguishment of clothing fires in the laboratory. Lab Staff 1 was interviewed at that time. Lab Staff 1 indicated that the facility does not have a specific procedure regarding extinguishment of clothing fires in the laboratory.

Based on record review and interview, the facility failed to maintain their emergency generator. This was evidenced by the facility's failure to conduct monthly 30 minute load tests on their emergency back up diesel generator. This affected all patients located at the Placer Center for Health and could result in a malfunctioning emergency generator.

NFPA 110, 1999 Edition
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During record review with staff, the facility's emergency generator test records were reviewed.

Placer Center for Health:

1. On 1/26/12 at 10:30 a.m., the facility's emergency generator test records were reviewed. There were no records that indicated the facility was conducting monthly 30 minute load tests at a minimum of 30 percent of the generator nameplate rating. The facility had a diesel fueled 175 kilowatt generator. Maintenance Staff 1 was interviewed at that time. Maintenance Staff 1 indicated that the generator is set to automatically run once weekly for 15 minutes under no load.

Based on observation, the facility failed to maintain its electrical wiring and equipment, as evidenced by the unauthorized use of surge protectors and extension cords, electrical wiring that was exposed, and electrical panels that did not have 3 feet of clearance. This could result in the increased risk of an electrical fire, and affected 9 of 15 floors in the Main Hospital and 1 of 5 Outpatient Buildings.

NFPA 70, 1999 edition
110-12 requires that electrical equipment be installed in a neat and workman like manner.
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
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12 through 1/26/12, the electrical wiring and equipment were observed.

Main Hospital:

1. On 1/24/12 at 3:10 p.m., a refrigerator in the Pediatrics Pharmacy (6th Floor Davis Tower) was plugged into a surge protector.

2. At 3:12 p.m., a 13.8 amp microwave oven and a 21 amp docking station ("Ready Dock C5M") were plugged into a surge protector in the Pediatrics Pharmacy Office. The surge protector was suspended 12 inches above the surface it rested upon.

3. At 4:15 p.m. in the Pulm Rehab Gym (Room 6220, 6th Floor North Wing), a surge protector with computer equipment plugged into it at Desk 1 was plugged into another surge protector at Desk 2. A third surge protector, which was suspended approximately 16 inches above the floor, was plugged into the surge protector at Desk 2.

4. At 4:23 p.m., a surge protector in Room 6206 (6th Floor North Wing) was plugged into an extension cord, which was plugged into another surge protector with computer equipment plugged into it.

5. At 4:35 p.m., a 13.8 amp microwave oven and a 13.9 amp commercial coffee maker in Room 6312 (6th Floor South Wing) were plugged into a surge protector.

6. On 1/25/12 at 8:45 a.m., a surge protector with computer equipment plugged into it in Room 4302 A (4th Floor South Wing) was suspended approximately 16-1/2 inches above the floor.

7. At 8:50 a.m., a small refrigerator and coffee maker in Room 4302 A were plugged into a surge protector.

8. At 8:55 a.m. in Room 4302 D, a surge protector with chargers and a fan plugged into it was connected to a surge protector with a plugged heater and computer equipment.

9. At 9:06 a.m., a small refrigerator was plugged into a surge protector in Room 4302 G. Another surge protector in Room 4302 G had a refrigerator and computer equipment plugged into it.

10. At 4:05 p.m. in Room 0788 I (Ground Floor Davis Tower) a surge protector with a 1300 to 1500 watt heater was connected to a surge protector with computer equipment plugged into it. The heater's ground wire was exposed and the insulation was frayed.

11. On 1/26/12 at 10:38 a.m. in Room 1514 there were three surge protectors connected to each other. Surge protector 1 with computer equipment plugged into it was connected to surge protector 2, which had a 12 volt speaker charger plugged into it. Surge protector 2 was connected to a surge protector with plugged computer equipment.

12. At 11:00 a.m. in Room 1508 (First Floor South Extension), a Stryker one-handed and a Stryker two-handed Laparoscopic Skills Stations used for training were plugged into one surge protector.

13. At 11:01 a.m. in Room 1508 E, a Stryker Laparoscopic Skills Station was plugged into a surge protector.

14. At 11:05 a.m., a surge protector with three chargers and computer equipment was plugged into another surge protector with computer equipment in Room 1508 D.


25385

Findings:

During a tour of the facility with staff, electrical equipment was inspected throughout the facility.

Main Hospital:

1. On 1/24/12, at 9:07 p.m., Office 8706 had a power strip under a desk that was suspended above the floor.

2. On 1/24/12, at 10:17 a.m., Electrical Room 7742 had a maintenance cart and an approximately six foot tall by three foot deep light bulb storage cart stored within 24 inches of a 480 volt electrical panel.

3. On 1/24/12, at 2:32, Electrical Room 5742 had an Room 7742 had an approximately six foot tall by three foot deep light bulb storage cart stored within 24 inches of an electrical panel.

4. On 1/25/12, at 9:05 a.m., Room 5203 had a power strip plugged into another power strip.

5. On 1/25/12, at 9:12 a.m., Room 5207 had a power strip suspended above the floor under a desk.

6. On 1/26/12, at 9:25 a.m., Office 5010 had a 16 gauge extension cord with no over current protection that was taped to the floor carpet. This extension cord traveled to a table which had a coffee pot and a fan plugged into it.

7. On 1/25/12, at 2:35 p.m., Room 2P938 had a coffee pot plugged into a power strip. The power strip was suspended above the floor.

Pain Clinic:

1. On 1/27/12, at 9:07 a.m., the Office near the corridor exit had an extension cord plugged into a power strip under a desk.




27893

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Main Hospital:

1. On 1/25/12 at 8:45 a.m., a phone charger in Staff Room 3210 was plugged into a surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord. A portable fan in that room was plugged into a separate orange non-surge protected multi-outlet extension cord.

2. On 1/25/12 at 8:52 a.m., a television in Staff Room 3224 was plugged into a white non-surge protected multi-outlet extension cord.

3. On 1/25/12 at 8:54 a.m., a miniature refrigerator in Staff Room 3219 was plugged into a surge protected multi-outlet extension cord.

4. On 1/25/12 at 9:47 a.m., an overhead light in Storage Room 3656 had been removed. Electrical wiring from the ceiling was exposed.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of alcohol based hand rub dispensers over or adjacent to ignition sources. This affected 7 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the alcohol based hand rub dispensers in the facility were observed.

Main Hospital:

1. On 1/25/12 at 9:18 a.m., an alcohol based hand rub dispenser in the GI Lab Recovery Room 3309 was mounted on the wall approximately three inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

2. On 1/25/12 at 9:22 a.m., an alcohol based hand rub dispenser in GI Procedure Room 8 (Room 3511B)was mounted on the wall approximately six inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

3. On 1/25/12 at 9:45 a.m., an alcohol based hand rub dispenser in the Newborn Nursery Room 3661 was mounted on the wall approximately eight inches above an electrical wall receptacle. The hand rub was sixty-one percent ethyl alcohol by volume.

4. On 1/25/12 at 9:54 a.m., an alcohol based hand rub dispenser in Room 3707 was mounted on the wall approximately six inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

5. On 1/25/12 at 10:03 a.m., an alcohol based hand rub dispenser in Room 3762 was mounted on the wall approximately eight inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

6. On 1/25/12 at 1:47 p.m., alcohol based hand rub dispensers were mounted approximately two feet above light switches in Rooms 3P447, 3P443, 3P441, 3P439, 3P437, 3P433 and 3P431. The hand rubs were sixty-two percent ethyl alcohol by volume.

7. On 1/25/12 at 3:14 p.m., an alcohol based hand rub dispenser in Storage Room 1345B was mounted on the wall approximately six inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

8. On 1/25/12 at 3:51 p.m., an alcohol based hand rub dispenser in Staff Room 1519 was mounted on the wall approximately twelve inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

Placer Center for Health:

1. On 1/26/12 at 9:00 a.m., an alcohol based hand rub dispenser in the Soiled Scope Wash Room 2919 was mounted on the wall approximately eight inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

Cancer Center:

1. On 1/27/12 at 9:51 a.m., two of two alcohol based hand rub dispensers located at the 1st Floor Blood Draw Stations were mounted on the wall approximately three inches above light switches. The hand rubs were sixty-two percent ethyl alcohol by volume.

Otolaryngology Clinic:

1. On 1/27/12 at 10:29 a.m., an alcohol based hand rub dispenser in the Recovery Room 5231 was mounted on the wall approximately twelve inches above an electrical wall receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.


25385

Findings:

During a tour of the facility with Staff, the placement of Alcohol-Based Hand Rub Dispensers near ignition sources was inspected.

Main Hospital:

1. On 1/23/12, at 1:40 p.m., Patient Room 14787 had an ABHR dispenser four inches adjacent to and above a plug receptacle.

2. On 1/23/12, at 1:55 p.m., Patient Room 14753 had an ABHR dispenser one inch adjacent to and above a plug receptacle.

3. On 1/23/12, at 2:11 p.m., Conference Room 14802B had an ABHR dispenser located above a light switch.

4. On 1/23/12, at 3:02 p.m., Conference Room 12802B had an ABHR dispenser located above a light switch.

5. On 1/24/12, at 9:56 a.m., Patient Room 7775 had an ABHR dispenser located approximately four inches above and approximately 4 inches adjacent to a receptacle.

6. On 1/24/12, at 10:01 a.m., Patient Room 7773 had an ABHR dispenser located approximately two inches adjacent to and above a receptacle.

7. On 1/24/12, at 10:40 a.m., Report Room 7814 in the Pediatrics Unit had an ABHR dispenser located approximately 12 inches above a light switch.

8. On 1/24/12, at 10:55 a.m., Intensive Care Unit Room 7671 had an ABHR dispenser located above a red emergency plug receptacle.

9. On 1/24/12, at 10:56 a.m., Patient Room 7675 had an ABHR dispenser
above a red plug outlet.

10. On 1/24/12, at 11:00 a.m., Soiled Linen Room 7678 had an ABHR dispenser above a light switch.

11. On 1/24/12, at 11:03 a.m., Patient Room 7679 had an ABHR dispenser above a light switch.

12. On 1/24/12, at 11:04 a.m., Patient Room 7677 had an ABHR dispenser above a light switch.

13. On 1/24/12, at 2:05 p.m., the NICU "Lyon" Room had two ABHR dispensers located above and less than six inches adjacent to a plug receptacle.

16. On 1/24/12, at 2:07 p.m., the NICU "Zebra" Room had an ABHR dispenser located above and less than six inches adjacent to a red plug emergency outlet.

17. On 1/24/12, at 2:20 p.m., the NICU "Rabbit" Room had an ABHR dispenser located above a red plug emergency outlet.

18. On 1/24/12, at 3:15 p.m., Emergency Room 1P661 had an ABHR dispenser located within six inches adjacent to a light switch.

19. On 1/24/12, at 3:16 p.m., Emergency Room 1P662 had two ABHR dispensers located within six inches adjacent to one light switch.

Same Day Surgery:

20. On 1/26/12, at 5:33 p.m., Room 1135 had an ABHR dispenser located four inches adjacent to and above a light switch.



29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/25/12 and 1/26/12, the alcohol based hand sanitizers (hand sanitizers) were observed.

Main Hospital:

1. On 1/25/12 at 11:03 a.m., a hand sanitizer outside Room 4111 (4th Floor East Wing) was mounted 32 inches above an outlet.

2. At 11:17 a.m., a hand sanitizer outside Room 4103 was mounted 34 inches above an outlet.

3. On 1/26/12 at 9:33 a.m., a hand sanitizer in Room 1617 E (Interventional Radiology Consultation, First Floor East Wing) was mounted 3 inches above and to the left of a light switch.

Based on observation, the facility failed to maintain the integrity of the building's construction, as evidenced by penetrations or unsealed openings in the ceilings and walls. This could result in the passage of smoke in the event of a fire, and affected 7 of 15 floors in the Main Hospital.

Findings:

During a tour of the facility with Plant Operations Staff 3, and Carpenters 1 and 2 on 1/23/12 through 1/26/12, the ceilings and walls were observed.

Main Hospital:

1. On 1/23/12 at 2:42 p.m. in Room 8609 (Mechanical Room, 8th Floor University Tower), there were two approximately 1/8-inch penetrations around a 1/2-inch conduit above the Main Drain, an approximately 3/4-inch penetration at the top left of a junction box, and an approximately 1/2-inch L-shaped penetration around the junction box above the Main Drain.

2. On 1/24/12 at 3:41 p.m., the escutcheon plate on the sprinkler in the corner of Room 6683 (Nurse Manager's Office, 6th Floor University Tower) was missing.

3. At 3:46 p.m., the escutcheon plate on the sprinkler in Room 6603 (6th Floor University Tower) was not flush with the ceiling and exposed an approximately 2 1/2-inch by 1/4-inch penetration.

4. At 4:04 p.m., there was an approximately 1-inch penetration in the northeast corner of the ceiling in Room 6201 (6th Floor North Wing).

5. On 1/25/12 at 10:15 a.m., there were two penetrations in the ceiling of the Medical Air Storage Room located between Rooms 4208 and 4210 (4th Floor North Wing). One of the penetrations measured approximately 2 1/2 inches by 1/2 inch around a 2 1/2-inch pipe and several cables. The second penetration measured approximately 1 3/4 inches by 1/8 inch around a 2 1/2-inch pipe.

6. On 1/26/12 at 10:55 a.m., two of three escutcheons in Room 1518 (Processing Room, 1st Floor East Wing) were missing.


25385

Findings:

During a tour of the facility walls were inspected throughout the facility.

Main Hospital:

1. On 1/24/12, at 3:10 p.m., there was a sprinkler escutcheon in Room 5654 that was not flush to the ceiling. This created an approximately one-half inch unsealed penetration around the sprinkler pipe.

2. On 1/24/12, at 3:41 p.m., there was an approximately one and one-half inch unsealed penetration in the wall inside Room 5102. This penetration was on the right hand side of the header facing towards the corridor.

3. On 1/24/12, at 3:46 p.m., there were two unsealed penetrations in the ceiling of Room 5104. These penetrations were caused by two three-quarter inch conduits passing through the wall. One conduit was not sealed on the end and the other one had a one-quarter inch gap between the conduit and the wall.

4. On 1/25/12, at 9:12 a.m., there was an approximately one inch by twelve inch unsealed penetration in the wall of 5214 L. This penetration was at baseboard height.

5. On 1/25/12, at 10:22 a.m., there was an approximately 18 inch by 24 inch sheetrock patch in the wall in Room 2237 A that had between a one-quarter inch and one-half inch unsealed opening around the edges. The location of this penetration looked like it might be on the common wall separating the Second Floor North Wing from the Second Floor East Tower. This wall was shown on the facility floor plan as a two hour fire-rated wall and was separating the decommissioned portion of the East Wing from the North Wing.
Plant Operations Staff 1 stated that the wall might be a common wall with the East Wing and that it was very close on the diagram.

6. On 1/26/12, at 8:41 a.m., there was an approximately three inch round damaged area in the wall behind the door to the CT Procedure Room 1P714.

7. On 1/26/12, at 10:48 a.m., the fire-rated attic access door in the ceiling of Room 1690 was left in the open position. This access door was approximately 18 inches by 24 inches in size. Plant Operations Staff 1 closed that door at that time.

8. On 1/26/12, at 10:55 a.m., there was an approximately three inch round unsealed penetration in the wall near the left door jamb facing the Gift Shop from Room 1651.



27893

Findings:

During a facility tour with staff, the walls and ceilings in the facility were observed.

Main Hospital:

1. On 1/25/12 at 9:32 a.m., there were eight approximately one inch diameter unsealed penetrations in a wall of Room 3129.

2. On 1/25/12 at 9:47 a.m., there was an approximately two inch diameter unsealed penetration in a wall of Room 3656. The penetration was located in the north wall of that room.

3. On 1/25/12 at 10:02 a.m., there was an approximately two and one half inch diameter unsealed penetration in a wall of Storage Room 3755. The penetration was located in the door side wall of that room.

4. On 1/25/12 at 11:13 a.m., there was an approximately six inch by three inch unsealed penetration in a wall of the Cardiac Perfusion Workroom 3P931.

Based on observation, the facility failed to maintain their doors. This was evidenced by doors that were obstructed from closing or latching. This affected 12 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings and could result in a delay to contain smoke or fire to a room.

NFPA 101, 2000 edition
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.
19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.
*Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a facility tour with staff, the doors in the facility were observed.

Main Hospital:

1. On 1/23/12 at 3:12 p.m., the door to Patient Room 11789 failed to latch when in the closed position. The door failed to latch due to misalignment of the latching pin and striker plate.

2. On 1/23/12 at 3:17 p.m., the roll down fire door near the 11th Floor Central Receiving Desk was observed. A clear container and a pen holder were observed to be positioned directly in the roll down path of the fire door.

3. On 1/23/12 at 3:43 p.m., the door to Patient Room 8107 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the retracted position.

4. On 1/23/12 at 3:49 p.m., the door to the Janitor Closet Room 8122 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

5. On 1/23/12 at 3:55 p.m., the door to the EKG Machine and Supplies Room 8140 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the retracted position.

6. On 1/23/12 at 3:59 p.m., the door to Patient Room 8135 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

7. On 1/25/12 at 9:28 a.m., the cross corridor door near Room 3507C was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The latching pin was stuck in the retracted position.

8. On 1/25/12 at 9:30 a.m., the door to Housekeeping Closet Room 3114 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

9. On 1/25/12 at 9:32 a.m., the door to Closet Room 3129 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was not equipped with a latching pin.

10. On 1/25/12 at 9:34 a.m., the door to Staff Room 3131 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

11. On 1/25/12 at 10:15 a.m., the door to Patient Room 3812 was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a wooden door wedge placed under the door leaf.

12. On 1/25/12 at 11:07 a.m., the door to the Equipment Storage Room 3P935 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the opposing door leaf.

13. On 1/25/12 at 11:33 a.m., the door to the Equipment Storage B Room 3P715 near Room 3P714 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the opposing door leaf.

14. On 1/25/12 at 11:34 a.m., the door to the Equipment Storage A Room 3P714 across from Operating Room 21 (Room 3P719A) was equipped with a self-closing device. The door was obstructed from closing due to medical equipment that was located directly in the swing path of the door.

15. On 1/25/12 at 1:30 p.m., the door to the Clean Utility Room 3P571 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

16. On 1/25/12 at 1:35 p.m., the door to the Clean Utility Room 3P559 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

17. On 1/25/12 at 1:41 p.m., the door to the Anesthesia Charge Room 3P647 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

18. On 1/25/12 at 1:45 p.m., the door to the Staff Room 3P648 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

19. On 1/25/12 at 1:51 p.m., the door to the Housekeeping Room 3P421 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door failed to latch due to misalignment of the latching pin and striker plate.

20. On 1/25/12 at 2:02 p.m., the door to the Conference Room 3P414 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to a wad of paper stuck inside the striker plate.

21. On 1/25/12 at 2:24 p.m., the door to Room 1426 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Cancer Center:

1. On 1/27/12 at 9:41 a.m., one of two roll down fire doors to the First Floor Pharmacy Room 1008 was obstructed from closing due to a credit card reading machine located directly in the roll down path of the door.

2. On 1/27/12 at 9:50 a.m., the roll down fire door to the Clinical Laboratory Room 1013 was obstructed from closing by a plastic sign and in-box tray located directly in the roll down path of the door.

Otolaryngology Clinic:

1. On 1/27/12 at 10:15 a.m., the door to the Breakroom 5102 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to misalignment of the latching pin and striker plate.

2. On 1/27/12 at 10:19 a.m., the door located across from Pod 4 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 1/27/12 at 10:22 a.m., the door to Pod 4 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to misalignment of the latching pin and striker plate.


25385

Findings:

During a tour of the facility with Staff, doors were inspected throughout the facility.

Main Hospital:

1. On 1/23/12, at 3:00 p.m., there was a blood pressure monitor stored in the travel area of the corridor door in Room 12803 impeding the door from closing .

2. On 1/23/12, at 3:02 p.m., there was a pocket folder hanging in the travel area of the corridor door in Room 12801 impeding the door from closing.

3. On 1/23/12, at 3:57 p.m., the corridor door to patient Room 10783 did not positive latch when released from an open position.

4. On 1/24/12, at 8:55 a.m., the corridor door to Patient Room 8687 did not positive latch when released from its magnetic hold-open device from an open position, leaving an approximately 1/8 inch gap.

5. On 1/24/12, at 8:58 a.m., the corridor door to Supply Room 8680B was impeded from closing by a recycle bin located in the travel area of the door.

6. On 1/24/12, at 10:25 a.m., the corridor door to the Doctors' Room 7804 did not positive latch when released from an open position.

7. On 1/24/12, at 3:55 p.m., the corridor door to Room 5105 did not positive latch when released from an open position.

8. On 1/25/12, at 9:12 a.m., the self-closing door to the Breakroom 5207, was being held open with a door wedge. This room contained a microwave oven. This door was also tested by releasing it from an open position and did not positive latch.

9. On 1/25/12, at 9:38 a.m., the door to Office 5016A had a door wedge holding the one and one-half hour fire-rated door open. There was also a trash can holding the corridor door open in this area.

10. On 1/25/12, at 9:45 a.m., Room 5208 EEG Lab rolling fire door was impeded from closing by a tissue box.

11. On 1/25/12, at 10:02 a.m., the door to the Sleep Disorder Room was propped open.

12. On 1/25/12, at 1:48 p.m., the rolling fire door in the Laboratory was impeded from closing by a decorative cardboard container with a light in it.

13. On 1/25/12, at 2:44 p.m., the burn unit door to room 2P445 was being held open with a trash can.

14. On 1/25/12, at 2:45 p.m., the door to Supply Room 1, 2P459 did not positive latch when tested.

15. On 1/25/12, at 3:25 p.m., the Emergency Room 1P660 door was held open by a wedge in the corridor door.

16. On 1/25/12, at 3:34 p.m., the rolling fire doors to Reception Room 1P653 were impeded from closing by a telephone sitting on the ledge.

17. On 1/26/12, at 8:41 a.m., the corridor door near 1P714 did not positive latch when released from its hold-open device.

18. On 1/26/12, at 8:50 a.m., the door to Room 1P758 did not positive latch when released from its magnetic hold-open device. This door was damaged at the top. Staff stated that they thought that something had run into the door.

19. On 1/26/12, during fire alarm testing at 1:50 p.m., the doors to Patient Rooms 8113A and 8115A did not close upon activation of the fire alarm system.

Same Day Surgery Center:

1. On 1/26/12, at 5:05 p.m., the door to the Sterile Supply Room 1145 was impeded from closing by a supply cart.

2. On 1/26/12, at 5:08 p.m., the door to the Soiled Utility Room was being held open by a storage rack.

Pain Clinic:

1. On 1/27/12, between 7:45 and 7:50 a.m., the four Procedure Rooms had kick-type door stops attached to the bottom of the doors.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12 through 1/26/12, the corridor and interior doors were observed.

Main Hospital:

1. On 1/24/12 at 2:24 p.m., the door to Room 6777 (6th Floor Davis Tower) was obstructed from closing by a cord to a charting cart parked in the corridor.

2. On 1/25/12 at 11:05 a.m., the door to Room 4132 B (4th Floor North Wing) was held open by a door stop.

3. At 4:40 p.m., the door to Room 0629 (Ground Floor East Wing) was obstructed from closing by a door stop that was taped to the floor.

4. At 4:41 p.m.,the door to Room 0628 was held open by a door stop.

5. On 1/26/12 at 9:01 a.m., the door to Room 1910 B (Pediatric Physicians' Reading and Consultation Room, First Floor Davis Tower) was propped open and obstructed from closing by a garbage can.

6. At 9:14 a.m., the doors to Room 1874 and 1870 A (Nuclear Medicine Uptake Rooms, First Floor Davis Tower) were held open by door stops.

Based on observation, the facility failed to maintain their stairways. This was evidenced by one door to a stairway that failed to latch when closed. This affected 1 of 15 floors in the Main Hospital and could result in a delay to contain smoke or fire to a floor.

Findings:

During a facility tour with staff, the stairways in the facility were observed.

Main Hospital:

1. On 1/23/12 at 2:44 p.m., the door to the 11th Floor Stairway A was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch.

Based on observation and interview, the facility failed to mark all exits with readily visible signs in accordance with 2000 NFPA 101. This was evidenced by temporary exit signs that were not properly illuminated. This was also evidenced by the lack of posted exit signs and exit signs that conflicted with or made the direction of exit egress confusing. This deficient practice affected staff and patients on 3 of 15 floors in the Main Hospital and 1 of 5 Outpatient Buildings and could potentially result in injury or delay during an evacuation.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.
7.10.1.4* Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
7.10.1.7* Visibility. Every sign required in Section 7.10 shall be located and of such size, distinctive color, and design that it is readily visible and shall provide contrast with decorations,interior finish, or other signs. No decorations, furnishings, or equipment that impairs visibility of a sign shall be permitted. No brightly illuminated sign (for other than exit purposes), display, or object in or near the line of vision of the required exit sign that could detract attention from the exit sign shall be permitted.

Findings:

During a tour of the facility with Staff, exit signs were inspected throughout the facility.

Main Hospital:

1. On 1/23/12, at 3:10 p.m., the Braille exit sign located at the exit door to Stairwell "A" on the 12th floor was missing.

2. On 1/26/12, between 9:25 and 9:45 a.m., the corridor door to Cardio Vascular Services had an exit sign above the door but also had a piece of paper attached to the door stating that it was not a exit and that it did not function properly. The door was tested and it did, in fact, function properly. When asked, Cardio Vascular Staff stated that it was a problem with the door locking mechanism, and not the exit itself. Staff removed the sign at that time.

3. On 1/26/12, at 11:03 a.m., the area located on the first floor that redirected the original path of egress from stairwell 14 to the outside of the building, through the First Floor Corridor 1680 and into the main corridor 1601, had exits that were unclear due to conflicting signage and low lighting levels. This exit was being redirected because of construction outside of the emergency exit door at the bottom of the stairwell.

A. At the bottom of the stairs was a temporary exit sign on red 8 1/2 by 11 inch paper. This exit sign had an arrow that was pointing in a right turn direction to another exit sign at a door approximately eight feet away, but was also pointing at an original sign on the door that stated, "Emergency Exit Only alarm will sound use Main Entrance".

B. Following the path of egress directed by the temporary exit signs to the main corridor 1601, it was observed that lighting levels in the corridor were lower than other corridors in the building. In this corridor there were two light elements that were burned out and the lights in the area to the final exit sign leading to the exit discharge into the main corridor 1601 were shut off. Because these exit signs were not internally illuminated and relied on the external corridor lighting to illuminate the signs, Plant Operations Staff turned the lights back on.
During and interview on 1/27/12, between 2:00 and 3:00 p.m., when asked, Fire Officer 1 stated that the redirected path of egress would be in effect for approximately two to seven days. Documentation was provided for interim life safety measures to be implemented during this time period.

Pain Clinic:

1. On 1/27/12, at 7:38 a.m., the exit door sign leading into the corridor was illuminated. Below this sign was a paper exit sign the was attached to the door that stated that it was not an exit with an arrow redirecting egress through the Lobby area. Plant Operations Staff 1 stated that the sign would be replaced with one that stated "Emergency Exit Only".

2. On 1/27/12, at 9:07 a.m., the Clinic portion of the Pain Clinic had a Braille-only exit sign on the wall that led through an office that had an exit door leading into the corridor. This exit was one of two exits that are remote from each other in the Pain Clinic Suite. When asked, Clinic Staff stated that the doors are considered exits and that they are used during evacuation drills.

Based on observation, the facility failed to maintain the fire resistance rating of their smoke barrier walls, as evidenced by unsealed penetrations. This could result in the spread of smoke between compartments, and affected 6 of 15 floors in the Main Hospital.

NFPA 101, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.
8.3.6 Penetrations and Miscellaneous Openings in Floors and Smoke Barriers.
8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
1. The space between the penetrating item and the smoke barrier shall meet one following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
2. Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Plant Operations Staff 3 and 4 and Carpenters 1 and 2 on 1/23/12 through 1/24/12, the smoke barrier walls were observed.

Main Hospital:

1. On 1/23/12 at 2:05 p.m., there was an approximately 1/4-inch unsealed penetration around a 3/4-inch conduit above Room 11703 in the Davis Tower.

2. At 3:18 p.m., there were two unsealed penetrations in the smoke barrier wall above Room 7602 in the Davis Tower. One penetration measured approximately 1/4 inch around a 1/8-inch cable; the other penetration was approximately 1/4 around a 1/2-inch conduit and five cables.

3. At 3:28 p.m., there were two unsealed penetrations above Room 7704 in the Davis Tower. One penetration measured approximately 2 1/2 inches and surrounded a conduit and three cables. The other penetration measured approximately 1 inch by 1/4 inch, and surrounded a 1/2-inch conduit.

4. At 3:44 p.m., there were four approximately 1/8-inch penetrations and one approximately 1 inch by 1/8 inch unsealed penetration around a 1/2-inch conduit above Room 7742 in the Davis Tower.

5. At 3:55 p.m., there were two approximately 3/4 inch by 1/8 each above Room 5742 in the Davis Tower. They each surrounded a 3/4-inch conduit.

6. On 1/24/12 at 10:35 a.m., there was an approximately 3/4-inch penetration around a 3/4-inch conduit with one cable running through it. The smoke barrier wall was located above and to the right of Room 1702 in the Davis Tower.

7. On 1/25/12 at 1:51 p.m., there was an approximately 1-1/4 inch penetration in the two-hour wall in Space 4740 A (Interstitial Space, 4th Floor Davis Tower).



25385

Findings:

During a tour of the facility with Staff, fire-rated walls were inspected throughout the facility.

Main Hospital:

1. On 1/23/12, at 3:30 p.m., the room identified on the facility floor plan as the Ante Room 10724A had three four-inch sleeves that traveled through the one-hour fire wall into Telephone Room 10722. Two of these four inch sleeves were not sealed with a fire-rated material on either end and one sleeve had an approximately one-half inch unsealed area on one side of the penetrating item and the wall.
Plant Operations Staff 1 confirmed that the sleeves were not sealed.

Based on observation, the facility failed to maintain its fire barrier doors, as evidenced by fire barrier doors that were obstructed from closing or latching and unsealed gaps at door to door meeting edges. This could result in the passage of smoke in the event of a fire, and affected 3 of 15 floors in the Main Hospital.

NFPA 101, 2000 edition
8.3.4.1 Doors in smoke barriers shall close the opening leaving only the minimum clearance necessary for proper operation and shall be without undercuts, louvers, or grilles.

Findings:

During a tour of the facility with Plant Operations Staff 3 and Technicians 1 and 2 on 1/24/12 and 1/26/12, the fire doors were observed and tested.

Main Hospital:

1. On 1/24/12 at 2:44 p.m., a 16" by 10 3/4" sign ("Welcome to Davis 6 Cardiology") on the ledge in the receptionist area obstructed the path to closure of the drop-down door.

2. On 1/26/12 at 1:01 p.m. during alarm testing, the right side of the fire door facing north in the Davis Tower 14th Floor elevator lobby failed to latch.

3. At 2:09 p.m. during alarm testing, the left side of the fire door facing north in the Davis Tower 6th Floor elevator lobby failed to close and exposed an approximately 12-inch gap between both sides.

4. At 2:43 p.m. during alarm testing, the fire doors near the 3rd Floor Pavilion elevators failed to close.

5. At 2:55 p.m. during alarm testing, the strobes activated, but the fire doors did not close and the bells did not alarm (there was a low humming sound instead) on 3rd Floor Davis Tower. The test was performed twice with the same results.


25385

Findings:

Main Hospital:

During a tour of the facility with Staff, smoke barrier doors were tested throughout the facility

1. On 1/23/12, at 1:30 p.m., the left leaf of the cross corridor doors 14710 facing the elevators did not close completely leaving an approximately one-half inch gap.

2. On 1/23/12, at 1:51 p.m., the right leaf of the cross corridor doors 14765 did not close completely leaving an approximately four inch gap.

3. On 1/26/12, at 2:30 p.m., the right leaf facing south of the cross corridor doors 3501 did not close completely during fire alarm testing leaving an approximately five inch gap.





27893

Findings:

Main Hospital:

1. On 1/25/12 at 10:19 a.m., the west-end Elevator Lobby Doors near the Labor and Delivery Waiting Area were equipped with self-closing devices. The doors were placed from the open position to the closed position. There was an approximately one half inch wide gap between the meeting edges of the door leaves. The doors were not equipped with an astragal, rabbet, or beveled edges.

2. On 1/25/12 at 10:22 a.m., the Freight Elevator Lobby Doors near Room 3834 were equipped with self-closing devices. The doors were placed from the open position to the closed position. There was an approximately three eighths inch wide gap between the meeting edges of the door leaves. The doors were not equipped with an astragal, rabbet, or beveled edges.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by doors to hazardous areas that were obstructed from closing or latching and doors to hazardous areas that were not equipped with self-closing or automatic closing devices. This affected 2 of 15 floors in the Main Hospital and 2 of 5 Outpatient Buildings and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Main Hospital:

1. On 1/25/12 at 8:48 a.m., the door to the Biohazard Room 3216 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

2. On 1/25/12 at 10:00 a.m., the door to the Soiled Utility Room 3753 was not equipped with a self-closing or automatic closing device.

3. On 1/25/12 at 11:10 a.m., the door to the Biohazard Room 3P934 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

4. On 1/25/12 at 11:30 a.m., the stairway side doors to the Soiled Holding Room 3P718 were equipped with self-closing devices. The doors were obstructed from closing due to sharps containers that were positioned in the swing path of the doors.

5. On 1/25/12 at 1:25 p.m., the door to the Soiled Utility Room 3P612 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

Placer Center for Health:

1. On 1/26/12 at 9:17 a.m., the door to the Soiled Utility Room 1248 was not equipped with a self-closing or automatic closing device.

Otolaryngology Clinic:

1. On 1/27/12 at 10:40 a.m., the door to the Soiled Utility Room 6208 was not equipped with a self-closing or automatic closing device.


25385

Findings:

During a tour of the facility with Staff , hazardous area enclosures were observed.

Main Hospital:

1. On 1/25/12, at 9:52 a.m., the door to Storage Room 53071 in the Sleep disorder Room had the self closing device removed from the door. This door was a one hour fire rated door.

Based on observation and staff interview, the facility failed to ensure that quantities of flammable liquids in its laboratory did not exceed the maximum amount allowed in accordance with 1999 NFPA 99. This was evidenced by flammable liquids in excess of one gallon per 100 sq. ft. or two gallons per 100 sq. ft. if in an approved storage cabinet. This deficient practice could potentially result in the spread of smoke and/or fire.

10-7.2.2 Established laboratory practices shall limit working supplies of flammable or combustible liquids. The total volume of Class I, II, and IIIA liquids outside of approved storage cabinets and safety cans shall not exceed 1 gallon per 100 sq. ft. The total volume of Class I, II, and IIIA liquids including those contained in an approved storage cabinet and safety cans shall not exceed 2 gallons per 100 sq. ft.

Findings:

During a tour of the facility with Staff, laboratories were inspected.

Main Hospital:

On 1/25/12, at 2:00 p.m., the Micro Biology Laboratory across the corridor from the Main Laboratory had three boxes labeled Methanol 4 x 4 L which equals 12.68 gallons placed on the floor on top of boxes of other lab materials. Lab Staff 2 was asked about the methanol and Staff stated that they did not expect to see it in the room and that it may have just come in as a shipment. During a reinspection of the area on 1/26/12, between 8:30 and 8:40 a.m., the boxes of methanol had been removed.

Based on observation and interview, the facility failed to maintain emergency illumination in accordance with 1999 NFPA 99. This was evidenced by a battery-powered emergency lighting unit in an anesthetizing location which had one of two bulbs burned out. This deficient practice affected one of four operating rooms at the Same Day Surgery Center and could potentially result in a loss of lighting in the operating room during a power outage.

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)

Findings:

Same Day Surgery Center:

1. During a tour of the facility with Surgery Manager 1 on 1/26/12, at 5:01 p.m., the battery back-up lighting unit in Operating Room 1 had one of two bulbs burned out. The surgery Manager Confirmed the observation.

Based on observation and interview, the facility failed to maintain its fire alarm system, as evidenced by manual fire alarm boxes (pull stations) that were not mounted within the required height, by pull stations that were blocked or obscured from view, by pull stations that were not provided within the required travel distance from each other, and by a set of occupancy separation doors that were disabled. This could result in staff's inability to readily access the pull stations in the event of a fire, and affected 7 of 15 floors in the Main Hospital.

NFPA 72, 1999 Edition
2-8.1 Mounting. Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall be not less than 3 1/2 ft (1.1 m) and not more than 4 1/2 feet (1.37 m) above floor level.
2-8.2 Location and Spacing.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
2-8.2.4 Additional manual fire alarm boxes shall be provided so that the travel distance to the nearest fire alarm box will not be in excess of 200 ft (61 m) measured horizontally on the same floor.

Findings:

During a tour of the facility with Plant Operations Staff 3, Carpenter 2, and Techs 1 and 2 on 1/24/12 through 1/26/12, the manual fire alarm pull stations were observed.

Main Hospital:

1. On 1/24/12 at 11:36 a.m., the pull station located to the right of the ASU Auditorium Elevator #8 was mounted 59-1/2 inches from the floor to the operable part (center) of the pull station.

2. At 11:37 a.m., the pull station located to the left of Room 1310 on the First Floor South Wing was mounted 59-1/2 inches from the floor to the center of the pull station.

3. At 11:39 a.m., the pull station located to the right of Room 037 on the Ground Level was mounted 58 inches from the floor to the center of the pull station.

4. At 1:10 p.m., the pull station located to the left of Room 0121 on the Ground Level was mounted 59-1/2 inches from the floor to the center of the pull station.

5. At 2:30 p.m., clear access to the pull station located at Nurses' Station #2 on the 6th Floor East Wing was obstructed by a Pyxis machine.

6. At 3:02 p.m., clear access to the pull station located at Nurses' Station #4 on the 6th Floor East Wing was obstructed by a wastebasket and a Pyxis machine. It was obscured from view by a backup emergency telephone.

7. At 3:48 p.m., the pull station located to the right of Room 6123 (6th Floor East Wing) was mounted 60-1/2 inches from the floor to the center of the pull station.

8. At 3:50 p.m., the pull station located across from Room 6117 (6th Floor East Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

9. At 3:53 p.m., the pull station located next to Room 6110 (6th Floor East Wing) was obstructed by a five-tier file cabinet.

10. At 4:00 p.m., the pull station located across from the Level 6 East Elevators was mounted 59-1/2 inches from the floor to the center of the pull station.

11. At 4:13 p.m., the pull station at the Exit by Room 6219 (6th Floor North Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

12. At 4:25 p.m., the pull station at the Exit by Room 6013 (6th Floor North Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

13. At 4:45 p.m., the pull station at the Exit across from Room 6314 (6th Floor South Wing) was mounted 59-1/2 inches from the floor to the center of the pull station.

14. On 1/25/12 at 10:48 a.m., the pull station outside the Pharmacy (Room 4123 4th Floor East Wing) was mounted 59-1/4 inches from the floor to the center of the pull station.

15. At 2:56 p.m., there were no pull stations located within the 16,389 square-foot Central Processing Department. The nearest pull stations were 34 feet outside the Clean side door and 18 feet outside the Decontamination side door.

16. On 1/26/12 at 2:30 p.m., a gurney was stored in front of the pull station in the Service Elevator Lobby by Room 3826 (Nourishment Room, 3rd Floor Davis Tower).


25385

Findings:

Main Hospital:

1. On 1/24/12, at 4:00 p.m., the fire alarm manual pull station in the corridor near Room 5002 was located on the wall approximately 60 inches above the floor.

During fire alarm testing with staff, fire alarm devices were tested throughout the facility.

2. On 1/26/12, at 3:07 p.m., the smoke detector in corridor 2143 was tested with canned smoke. This smoke detector activated the fire alarm audible devices in the area, but the 90 minute occupancy separation doors in corridor 2160 and 2600A failed to release from their magnetic hold open devices. Plant Operations Staff 5 returned from the fire alarm panel located in Mechanical Room 2004 and stated the the switch in the FACP had been switched to disable the fire doors. Staff re-tested the smoke detector and this time the 90 minute fire door released from their magnetic hold open devices.





27893

Findings:

Main Hospital:

1. On 1/25/12 at 8:57 a.m., the manual fire alarm pull station near Room 3219 was mounted on the wall approximately five feet high from the floor level to activation handle.

2. On 1/25/12 at 9:04 a.m., the manual fire alarm pull station near Room 3232 was mounted on the wall approximately five feet high from the floor level to activation handle.

3. On 1/25/12 at 9:10 a.m., the manual fire alarm pull station near the 3rd Floor Bed Ramp was mounted on the wall approximately five feet high from the floor level to activation handle.

4. On 1/25/12 at 9:35 a.m., the manual fire alarm pull station near Room 3123 was mounted on the wall approximately five feet high from the floor level to activation handle.

Based on record review, observation, and interview, the facility failed to maintain their smoke detectors. This was evidenced by the facility's failure to have their smoke detectors tested for smoke sensitivity and one smoke detector that had paint on it. This affected all 9 of 15 floors in the Main Hospital and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 72, 1999 edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review with staff, the facility's smoke detector inspection and test records were reviewed.

Main Hospital:

1. On 1/24/12 at 4:01 p.m., the facility's smoke detector sensitivity test records were requested. There were no records that indicated the facility smoke detectors in the North, South, or East Towers had been tested for smoke sensitivity. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the smoke detectors in the North, South, and East Towers were cleaned annually. Fire Officer 1 indicated that the smoke detectors in the North, South, and East Towers had not been tested for smoke sensitivity within the past 2 years.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/25/12, the smoke detectors were observed.

Main Hospital:

At 10:40 a.m., there was green spray paint on the smoke detector in Room 4004 (Electrical Room, 4th Floor North Wing).

Based on observation, record review, and interview, the facility failed to maintain its automatic sprinkler system in accordance with NFPA 25, as evidenced by paint or debris on some of the sprinklers, by items stored less than 18 inches below a deflector, by a bent deflector on one of the sprinklers, by a fire sprinkler valve that had obstructed access, and the facility's failure to conduct quarterly sprinkler alarm tests. This could result in an obstruction to the sprinklers' spray patterns, which could lead to the sprinklers malfunctioning in the event of a fire, and affected 15 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1: Sprinklers installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.
2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is
attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
2-4.1.8 Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer 's instructions.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a tour of the facility with the Plant Operations Staff 3, Carpenter 2, and Technician 1 and 2 on 1/24/12 through 1/26/12, the automatic sprinkler system was observed.

Main Hospital:

1. On 1/24/12 at 3:26 p.m., office supplies were stored approximately 6 inches below the sprinkler's deflector in the Storage Room across from Room 6613 (Tower Level 6 CICU).

2. At 3:45 p.m., the sprinkler outside the Nurse Manager's Office (Room 6683) was loaded with debris.

3. On 1/25/12 at 12:58 p.m., there was paint on the deflector to the right of Room 4671 (Soiled Utility Room) located in the University Tower ENT Unit.

4. At 1:25 p.m., the sprinkler in the charting area behind the Nurses' Station (across from Room 4681) was loaded with debris.

5. At 2:13 p.m., there was paint on the deflector in Room OP 651 (Restroom/Shower).

6. At 2:37 p.m., the deflector in the northeast corner of the Decontamination side in the Central Processing Department (Room OP 722) was bent.

7. At 4:15 p.m., printer cartridges were stored approximately 7 inches below the deflector in Room 0788 K (Davis Tower).

8. On 1/26/12 at 10:30 a.m., 6 of 6 drop-down sprinklers in the Sim suite (Room 1523) were painted.


27893

Findings:

During record review, interview, and a facility tour with staff, the facility's automatic fire sprinkler system was observed.

Main Hospital:

1. On 1/24/12 at 3:19 p.m., the facility's quarterly automatic fire sprinkler system test records were requested. There was no record that indicated the facility had conducted automatic fire sprinkler system tests during the 2nd quarter of 2011. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that he had recently changed the testing frequency from semi-annually to quarterly for the facility's automatic fire sprinkler system alarm devices. Fire Officer 1 confirmed that the automatic fire sprinkler system alarm devices were not tested during the 2nd quarter of 2011.

2. On 1/25/12 at 10:09 a.m., the sprinkler head in the Storage Closet Room 3770A was covered with dusty debris. The sprinkler was missing a concealment cap.

3. On 1/25/12 at 11:20 a.m., the fire department valve near the north end of the 3rd Floor Surgery 20's Core was observed. The valve was located in a recessed corridor cabinet. The handle to open the cabinet had broken off and was missing.

Same Day Surgery Center/Cancer Center/Otolaryngology Clinic/Pain Clinic:

1. On 1/24/12 at 3:19 p.m., the quarterly automatic fire sprinkler system test records for the Same Day Surgery Center, Cancer Center, Otolaryngology Clinic, and Pain Clinic were requested. All four of the Outpatient Buildings were missing two of four quarterly automatic fire sprinkler tests. Fire Officer 1 was interviewed at that time. Fire Officer 1 indicated that the automatic fire sprinkler system alarm devices at the four Outpatient Buildings were being tested on a semi-annual basis.

Based on observation and interview, the facility failed to maintain its fire extinguishers, as evidenced by blocked and obscured fire extinguishers, by the presence of an unmounted and outdated fire extinguisher, by a fire extinguisher that was mounted above the required height, and by fire extinguishers at nurses' stations that were mounted below the required height. This could result in damage to the fire extinguisher if unmounted, in the fire extinguisher malfunctioning if outdated, and in staff not being able to properly access the fire extinguishers in the event of a fire if not mounted at the proper height. These deficient practices affected 7 of 15 floors in the Main Hospital.

NFPA 101, 2000 edition
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard or Portable Fire Extinguishers.

NFPA 10, 1998 Edition
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 a 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. Wheel-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 ? 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).
1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1-6.6.)

Findings:

During a tour of the facility with Plant Operations Staff 3, Carpenters 1 and 2, and Techs 1 and 2 on 1/23/12 through 1/26/12, the fire extinguishers were observed.

Main Hospital:

1. On 1/23/12 at 2:13 p.m., there was an unmounted and outdated fire extinguisher in Room 10721 (Electrical Room, 10th Floor Davis Tower).

2. At 3:12 p.m., the fire extinguisher located across from the 7th Floor University Towers Elevators between the East Wing and the Towers was inaccessible. There was no handle on the cabinet; the Plexiglas cover was bent to gain access.

3. On 1/24/12 at 2:47 p.m., the fire extinguisher at the 6th Floor Davis Tower Registration Counter was mounted in a floor-level cabinet. The clearance between the bottom of the fire extinguisher and the floor measured approximately 2-1/4 inches.

4. At 2:50 p.m., the clearance between the bottom of the fire extinguisher and the floor at the 6th Floor Davis Tower Nurses' Station 1 measured approximately 2-1/4 inches.

5. At 2:52 p.m., the clearance between the bottom of the fire extinguisher and the floor at the 6th Floor Davis Tower Nurses' Station 3 measured approximately 2-1/4 inches.

6. At 2:54 p.m., the clearance between the bottom of the fire extinguisher and the floor at the 6th Floor Davis Tower Nurses' Station 4 measured approximately 2-1/4 inches.

7. On 1/26/12 at 10:35 a.m., the fire extinguisher inside Room 1523 (1st Floor South Wing) was mounted at 63 inches.

8. At 1:58 p.m. during fire alarm testing, Nursing Staff 1 at the 7th Floor Davis Tower Nurses' Station 3 did not immediately identify the location of the nearest fire extinguisher when interviewed. The nearest fire extinguisher was located there in Station 3. Nursing Staff 2 pointed to where the extinguisher was located because Nursing Staff 1 did not see it. It was obscured from view and obstructed by a trash can.


25385

Findings:

During a tour of the facility with Staff, fire extinguishers were inspected throughout the facility.

Main Hospital:

1. On 1/25/12, at 8:52 a.m., the fire extinguisher located at the East Wing Nurses Station near Room 5133 did not have a sign above the extinguisher. This extinguisher was also blocked for access and partially blocked by view by a wheeled work station placed in front of it.

2. On 1/25/12, at 2:22 p.m., Room 2P938 had a fire extinguisher sitting on the floor with no mounting brackets or inspection tag on it.





27893

Findings:

During a facility tour with staff, the portable fire extinguishers in the facility were observed.

Main Hospital:

1. On 1/25/12 at 10:32 a.m., two portable fire extinguishers located in the 3rd Floor Pavilion Shell Space were observed. The service tags on the portable fire extinguishers indicated that they had last been serviced on 7/9/10. The portable fire extinguishers were approximately six months overdue for an annual service. The reverse side of the service tags indicated that the portable fire extinguishers at that location were inspected monthly. Comments were written on tag by the individual performing the monthly inspections. The comments included "overdue" and "needs service."

2. On 1/25/12 at 11:20 a.m., a portable fire extinguisher near the north end of the 3rd Floor Surgery 20's Core was observed. The portable fire extinguisher was located in a recessed corridor cabinet. The handle to open the cabinet had broken off and was missing.

Based on observation and record review, the facility failed to adhere to their smoking policy. This was evidenced by cigarette butts located on the grounds of a non-smoking campus. This affected 1 of 15 floors in the Main Hospital and could result in a cigarette butt ignited fire emergency.

Findings:

During record review and a facility tour with staff, the facility's smoking policy was observed.

Main Hospital:

1. On 1/27/12 at 11:08 a.m., there were approximately 150-200 cigarette butts observed on the ground near the exit stairs from the Pavilion Cafeteria Patio. The facility's smoking policy was reviewed. The smoking policy indicated that the facility prohibits smoking on the main campus.

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices in accordance with 2000 NFPA 101, 1999 NFPA 99, and 1999 NFPA 70. This was evidenced by unapproved portable heaters in non-sleeping staff areas of the facility that did not have proper clearance from combustible materials in accordance with the manufacturer's labeled instructions and portable space heaters plugged into extension cords. This deficient practice affected all staff and patients in 4 of 15 floors in the Main Hospital and 1 of 5 Outpatient Buildings and could potentially result in the ignition of fire.

NFPA 99
2-1 Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
9-2.1.8.1 Manuals. The manufacturer of the appliance shall furnish operator 's, maintenance, and repair manuals with all units. These manuals shall include operating instructions, maintenance details, and testing procedures. The manuals shall include the following where applicable:
(d) Step-by-step procedures for proper use of the appliance
(e) Safety considerations in application and in servicing

1999 NFPA 70
110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

Findings:

During a tour of the facility with Staff, electrical equipment was inspected throughout the facility.

Main Hospital:

1. On 1/25/12, at 1:32 p.m., the Second Floor Pavilion Laboratory had a portable heater located in the Blood Bank Office area of the lab under a desk.

2. On 1/25/12, at 1:35 p.m., the northwest office area of the lab had two portable heaters under desks. One heater was the type that had the heating elements visible and was near a handbag and papers.

3. On 1/25/12, at 3:10 p.m., Office 1P671 had a portable electric heater under a desk.

These heaters all had labeled high temperature warnings with three feet of clearance required.

Plant Operations Staff 1 confirmed that the heaters had not been tested and accepted by the facility.


27893

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

Main Hospital:

1. On 1/25/12 at 9:14 a.m., a non-facility approved portable space heater was observed in Staff Room 3304A. Facility staff could not confirm that the portable space heater would not exceed 212 degrees Fahrenheit.

Cancer Center:

1. On 1/27/12 at 9:32 a.m., a facility approved portable space heater was observed at the 1st Floor Reception Desk. The space heater was plugged into a surge protected multi-outlet extension cord. The space heater was located under a desk and within three feet of combustibles and furnishings.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12, portable space heaters were observed.

Main Hospital:

1. At 4:38 p.m., portable space heaters at Cubicle 1 and Cubicle 2 in Room 6312 (6th Floor South Wing). Both space heaters were situated under the desks in a manner that did not allow 3 feet of space between the heaters and the office furniture.

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by an exit door that was locked against egress with no key immediately available, items that were stored in the path of egress in an exit access and discharge, and office doors that could not be fully opened. This deficient practice had the potential to affected all staff and patients on 3 of 15 floors and could potentially result in injury or a delayed evacuation in the event of an emergency.

NFPA 101, 2000 edition
3.3.121* Means of Egress. A continuous and unobstructed way of travel from any point in a building or structure to a public way consisting of three separate and distinct parts: (1) the exit access, (2) the exit, and (3) the exit discharge.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in. (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.
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.

Findings:

During a tour of the facility with Staff, exits and egress routes were inspected throughout the facility

Main Hospital:

1. On 1/24/12, at 11:15 a.m., the exit door located in the South Stairwell of the University Tower was impeded by three chairs and a piece of moulding lying on the floor. Two chairs were located in the exit path on the egress side of the door. When the door was tested, it was difficult to push open because there was a rocking chair located on the nonegress side of the door. There was also an approximately three foot long by five inch wide piece of moulding lying on the same side of the door as the rocking chair. Staff removed the items at that time.

2. On 1/25/12, at 9:55 a.m., the door to Office 5307C could not be opened more than approximately 20 inches. This door had items stored behind it which prevented it from opening fully.

3. On 1/26/12, Room 1852 had papers in piles on the floor that prevented that door from opening fully.

4. On 1/26/12, at 11:03 a.m., there was an exit door on the first floor of the University Tower in Stairwell 14 that was locked against egress. This door was being used as a temporary exit from the stairwell because of new construction in progress outside of the original exit door. This new exit access was redirected from the stairwell through the First Floor corridor 1680 and into the main corridor 1601 into the building. Plant Operations Staff 1 unlocked that door at that time and called to have the locking mechanism removed.

Based on observation, the facility failed to regulate the placement of excessive combustible personal furnishings and/or decorations as evidenced by papers loosely pinned to walls and doors. This deficient practice affected all staff and patients on 1 of 15 floors in the Main Hospital and could potentially result in the spread of smoke and/or fire.

NFPA 101, 2000 edition
19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings,
in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a tour of the facility with Staff,

Main Hospital:

1. On 1/24/12, at 10:17 a.m., the Doctors' Room 7804 had loose papers and photographs pinned to the four walls. Approximately 60 percent of the area of the wall had paper attached to both the walls and/or on the bulletin boards. Facing into the room from the exit, the right hand wall had an approximately four foot by 13 foot cloth-covered bulletin board that had more than 34 pieces of 8 1/2 inch by 11 inch paper loosely attached, and three 18 inch by 24 inch posters pinned to it. On the left side of the room were two approximately four foot by three foot bulletin boards which had 17 8 1/2 inch by 11 inch pieces of paper loosely pinned to it. The other bulletin board had 9 8 1/2 inch by 11 inch pieces of paper loosely pinned to it. The wall with the exit door had an approximately two foot by three foot area with photographs pinned to the wall.

2. On 1/24/12, at 10:34 a.m., the surface area of the corridor door to Report Room 7814 was covered with greater than 10% loose papers.

3. On 1/24/12, at 10:57 a.m., the corridor by Room 7676 had two pillow pouches attached to the door with approximately 30 pieces of paper in them plus another three pieces of 8 1/2 inch by 11 inch papers attached directly to the door.

Based on observation, the facility failed to protect its medical gas storage areas in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored secured together instead of individually, cylinders that were unsecured, electrical fixtures below five feet high from floor level, oxygen cylinder areas not equipped with precautionary signs, empty cylinders stored with full cylinders, and oxygen cylinders stored near combustibles. This deficient practice affected 5 of 15 floors in the Main Hospital and 4 of 5 Outpatient Buildings. This could potentially result in an oxygen cylinder initiated emergency or a delay in obtaining an oxygen cylinder.

NFPA 99, 1999 edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.
Exception: Shipping crates or storage cartons for cylinders.
4-3.1.1.2(a)11d Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.
4-3.5.2 Gas System Policies-Level 1.
13. Oxygen cylinders shall be protected from abnormal mechanical shock, which is liable to damage the cylinder, valve, or safety device. Such cylinders shall not be stored valve, or safety device. Such cylinders shall not be stored near elevators, gangways, or in locations where heavy moving objects will strike them or fall on them.
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.
4-3.5.2.2 Storage of Cylinders and Containers Level 1.
(b) Nonflammable Gases.
1. Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
2. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.
4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electric Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 5 ft (152 cm) above the floor as a precaution against their physical damage.
8-3.1.11 Storage Requirements.
8-3.1.11.1 Storage for nonflammable gases greater than 3000 ft3 (85 m3) shall comply with 4-3.1.1.2 and 4-3.5.2.2. 8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1 (b) 27.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a tour of the facility with staff, Medical gas storage areas were inspected.

Main Hospital:

1. On 1/25/12, at 9:25 a.m., Room 5204 PFT Lab had one H size tank that was sitting free standing on the floor.

Same Day Surgery:

2. On 1/26/12, at 5:40 p.m., the Oxygen Storage Area located on the outside of the building had 17 H size oxygen tanks that were not individually secured.

Pain Clinic:

3. On 1/27/12, the Oxygen Storage area located on the outside of the Ellison Building had 14 H size tanks that were secured together with one chain.


27893

Findings:

During a facility tour with staff, the facility's oxygen cylinder storage locations were observed.

Main Hospital:

1. On 1/25/12 at 11:09 a.m., a light switch inside the Medical Gas Cylinder Storage Room 3P933 was approximately four feet high from floor level and not the required 60 inches.

Placer Center for Health:

1. On 1/26/12 at 10:21 a.m., the Oxygen Manifold Room was not equipped with precautionary signs on the outside indicating that smoking is prohibited near that location.

Cancer Center:

1. On 1/27/12 at 9:56 a.m., a light switch inside the Oxygen Manifold Room 1016A was approximately four feet high from floor level and not the required 60 inches off of the floor as required.


29753

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12 and 1/25/12, the locations of oxygen storage were observed.

Main Hospital:

1. On 1/24/12 at 3:08 p.m., an unsecured oxygen E-tank leaned against a sink in Room 6703 (6th Floor Davis Tower).

2. At 4:20 p.m., an unsecured oxygen D-tank rested in a wall closet in Room 6220 (Pulm Rehab Gym, 6th Floor North Wing).

3. On 1/25/12 at 1:13 p.m., one empty oxygen E-tank was stored in the same rack with five full tanks in a location designated for full cylinders, and six full tanks were stored with one empty tanks in a location designated for empty cylinders. The light switch in the oxygen storage area was mounted 52 inches above the floor. The oxygen cylinders were stored within the ENT Unit (4th Floor University Tower).

4. At 3:31 p.m., 51 oxygen E-tanks (48 full and 3 empty) were stored in Room 0761 (Ground Floor Davis Tower) along with gurneys, medical equipment, and cardboard boxes. There was no oxygen warning signs posted at the entrance to the room and the cylinders were stored within 5 feet of combustibles.

Based on record review, the facility failed to maintain the relative humidity levels at their anesthetizing locations. This was evidenced by the facility's failure to maintain relative humidity levels at 35 percent or greater. This affected all facility operating rooms and anesthetizing locations and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review with staff, the facility's relative humidity records for their anesthetizing locations were observed.

Main Hospital/Same Day Surgery Center:

1. On 1/24/12 at 10:00 a.m., the relative humidity records for the facility's anesthetizing locations were requested. Onsite staff monitors and records the relative humidity levels for the 4 Operating Rooms at the Same Day Surgery Center. The facility remotely monitors the relative humidity for their 24 Operating Rooms located at the 3rd Floor Pavilion Surgery Department. The alarm setting for the offsite monitoring system was set at 25 to 60 percent. The monitoring system would only alarm if the relative humidity fell outside that range. The facility policy for humidity levels at anesthetizing locations was requested. The humidity policy indicated that the facility will maintain relative humidity between 20 and 60 percent at their anesthetizing locations.

Relative humidity levels had fallen below 35 percent at several anesthetizing locations located in the Main Hospital and at the Same Day Surgery Center on numerous days during surgical procedures. A waiver was discussed with the engineering staff.

Based on record review and interview, the facility failed to establish required laboratory emergency procedures. This was evidenced by the facility's failure to establish an emergency procedure for extinguishing clothing fires. This affected 1 of 15 Floors in the Main Hospital and could result in clothing fire injury to laboratory staff.

NFPA 99, 1999 edition
10-2.1.3 Emergency Procedures.
10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.
10-2.1.3.3 Emergency procedures shall be established for extinguishing clothing fires.

NFPA 101, 2000 edition
19.3.2.2 Laboratories. Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Findings:

During record review with staff, the facility's laboratory policies and procedures were reviewed.

Main Hospital:

1. On 1/24/12 at 12:45 p.m., the laboratory specific emergency policies and procedures were reviewed. There was no emergency procedure regarding the extinguishment of clothing fires in the laboratory. Lab Staff 1 was interviewed at that time. Lab Staff 1 indicated that the facility does not have a specific procedure regarding extinguishment of clothing fires in the laboratory.

Based on record review and interview, the facility failed to maintain their emergency generator. This was evidenced by the facility's failure to conduct monthly 30 minute load tests on their emergency back up diesel generator. This affected all patients located at the Placer Center for Health and could result in a malfunctioning emergency generator.

NFPA 110, 1999 Edition
6-3.4 A written record of the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:
(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer
6-4.1 Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
6-4.2 Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During record review with staff, the facility's emergency generator test records were reviewed.

Placer Center for Health:

1. On 1/26/12 at 10:30 a.m., the facility's emergency generator test records were reviewed. There were no records that indicated the facility was conducting monthly 30 minute load tests at a minimum of 30 percent of the generator nameplate rating. The facility had a diesel fueled 175 kilowatt generator. Maintenance Staff 1 was interviewed at that time. Maintenance Staff 1 indicated that the generator is set to automatically run once weekly for 15 minutes under no load.

Based on observation, the facility failed to maintain its electrical wiring and equipment, as evidenced by the unauthorized use of surge protectors and extension cords, electrical wiring that was exposed, and electrical panels that did not have 3 feet of clearance. This could result in the increased risk of an electrical fire, and affected 9 of 15 floors in the Main Hospital and 1 of 5 Outpatient Buildings.

NFPA 70, 1999 edition
110-12 requires that electrical equipment be installed in a neat and workman like manner.
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
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

NFPA 99 3-3.2.1.2, All patient care areas.
(d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During a tour of the facility with Plant Operations Staff 3 on 1/24/12 through 1/26/12, the electrical wiring and equipment were observed.

Main Hospital:

1. On 1/24/12 at 3:10 p.m., a refrigerator in the Pediatrics Pharmacy (6th Floor Davis Tower) was plugged into a surge protector.

2. At 3:12 p.m., a 13.8 amp microwave oven and a 21 amp docking station ("Ready Dock C5M") were plugged into a surge protector in the Pediatrics Pharmacy Office. The surge protector was suspended 12 inches above the surface it rested upon.

3. At 4:15 p.m. in the Pulm Rehab Gym (Room 6220, 6th Floor North Wing), a surge protector with computer equipment plugged into it at Desk 1 was plugged into another surge protector at Desk 2. A third surge protector, which was suspended approximately 16 inches above the floor, was plugged into the surge protector at Desk 2.

4. At 4:23 p.m., a surge protector in Room 6206 (6th Floor North Wing) was plugged into an extension cord, which was plugged into another surge protector with computer equipment plugged into it.

5. At 4:35 p.m., a 13.8 amp microwave oven and a 13.9 amp commercial coffee maker in Room 6312 (6th Floor South Wing) were plugged into a surge protector.

6. On 1/25/12 at 8:45 a.m., a surge protector with computer equipment plugged into it in Room 4302 A (4th Floor South Wing) was suspended approximately 16-1/2 inches above the floor.

7. At 8:50 a.m., a small refrigerator and coffee maker in Room 4302 A were plugged into a surge protector.

8. At 8:55 a.m. in Room 4302 D, a surge protector with chargers and a fan plugged into it was connected to a surge protector with a plugged heater and computer equipment.

9. At 9:06 a.m., a small refrigerator was plugged into a surge protector in Room 4302 G. Another surge protector in Room 4302 G had a refrigerator and computer equipment plugged into it.

10. At 4:05 p.m. in Room 0788 I (Ground Floor Davis Tower) a surge protector with a 1300 to 1500 watt heater was connected to a surge protector with computer equipment plugged into it. The heater's ground wire was exposed and the insulation was frayed.

11. On 1/26/12 at 10:38 a.m. in Room 1514 there were three surge protectors connected to each other. Surge protector 1 with computer equipment plugged into it was connected to surge protector 2, which had a 12 volt speaker charger plugged into it. Surge protector 2 was connected to a surge protector with plugged computer equipment.

12. At 11:00 a.m. in Room 1508 (First Floor South Extension), a Stryker one-handed and a Stryker two-handed Laparoscopic Skills Stations used for training were plugged into one surge protector.

13. At 11:01 a.m. in Room 1508 E, a Stryker Laparoscopic Skills Station was plugged into a surge protector.

14. At 11:05 a.m., a surge protector with three chargers and computer equipment was plugged into another surge protector with computer equipment in Room 1508 D.


25385

Findings:

During a tour of the facility with staff, electrical equipment was inspected throughout the facility.

Main Hospital:

1. On 1/24/12, at 9:07 p.m., Office 8706 had a power strip under a desk that was suspended above the floor.

2. On 1/24/12, at 10:17 a.m., Electrical Room 7742 had a maintenance cart and an approximately six foot tall by three foot deep light bulb storage cart stored within 24 inches of a 480 volt electrical panel.

3. On 1/24/12, at 2:32, Electrical Room 5742 had an Room 7742 had an approximately six foot tall by three foot deep light bulb storage cart stored within 24 inches of an electrical panel.

4. On 1/25/12, at 9:05 a.m., Room 5203 had a power strip plugged into another power strip.

5. On 1/25/12, at 9:12 a.m., Room 5207 had a power strip suspended above the floor under a desk.

6. On 1/26/12, at 9:25 a.m., Office 5010 had a 16 gauge extension cord with no over current protection that was taped to the floor carpet. This extension cord traveled to a table which had a coffee pot and a fan plugged into it.

7. On 1/25/12, at 2:35 p.m., Room 2P938 had a coffee pot plugged into a power strip. The power strip was suspended above the floor.

Pain Clinic:

1. On 1/27/12, at 9:07 a.m., the Office near the corridor exit had an extension cord plugged into a power strip under a desk.




27893

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Main Hospital:

1. On 1/25/12 at 8:45 a.m., a phone charger in Staff Room 3210 was plugged into a surge protected multi-outlet extension cord that was plugged into an orange non-surge protected extension cord. A portable fan in that room was plugged into a separate orange non-surge protected multi-outlet extension cord.

2. On 1/25/12 at 8:52 a.m., a television in Staff Room 3224 was plugged into a white non-surge protected multi-outlet extension cord.

3. On 1/25/12 at 8:54 a.m., a miniature refrigerator in Staff Room 3219 was plugged into a surge protected multi-outlet extension cord.

4. On 1/25/12 at 9:47 a.m., an overhead light in Storage Room 3656 had been removed. Electrical wiring from the ceiling was exposed.