HospitalInspections.org

Based on observation, the facility failed to ensure that doors in smoke barriers were self-closing or automatic-closing in accordance with NFPA 101. This was evidenced by smoke barrier doors that failed to close upon activation of the fire alarm system. This affected one of six floors in the Original Hospital and one of three floors in the Junipero Building. This could result in the faster spread of smoke and fire between smoke compartments, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.6 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

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.

7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the smoke barrier doors were observed.

ORIGINAL HOSPITAL -
THIRD FLOOR -

1. At 3:56 p.m., on 5/6/15, both sets of smoke barrier double doors in the pediatric intensive care unit (PICU) failed to release from their hold open devices and close upon activation of a nearby smoke detector. The doors released and closed only after the fire alarm system was reset. This deficiency occurred again at 3:58 p.m. when a smoke detector in the PICU was tested for a second time. The smoke barrier doors failed to close upon activation of the fire alarm system and only closed once the alarms were reset.


29566

JUNIPERO BUILDING -
FIRST FLOOR -

2. At 10:31 a.m., on 5/6/15, the smoke barrier double doors, with Barcode Number 0035419, were held open with electronic automatic-closing devices. One of the double doors failed to release from the automatic closing device upon activation of the fire alarm system.

Based on observation, the facility failed to ensure that means of egress were marked in accordance with NFPA 101. This was evidenced by exit doors that were marked with exit signs that were not illuminated. This affected the Cottage Outpatient Center of San Luis Obispo and could result in a delay in evacuation, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.

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.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the exit signs were observed.

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO -

1. At 10:06 a.m., on 5/5/15, the exit sign, with a directional arrow, above the patient lounge door was not internally or externally illuminated.

2. At 10:15 a.m. on 5/5/15, the exit sign above the main exit door was not internally or externally illuminated.

Based on observation and interview, the facility failed to maintain their smoke barrier openings. This was evidenced by smoke barrier doors that failed to close and latch. This was also evidenced by the failure to provide documentation confirming a fire door rating located in a 2-hour fire-rated wall. This affected one of three floors of the Junipero Building. This could result in the spread of smoke and fire from one smoke compartment to another and the increased risk of injury to patients and staff, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition.
1-5.1 Listed items shall be identified by a label. Labels shall be applied in locations that are readily visible and convenient for identification by the authority having jurisdiction after installation of the assembly.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers' installation instructions and shall be adjusted to function as described in the listing.

Findings:

During the facility tour with the staff from 5/4/15 to 5/8/15, the smoke barrier doors were observed.

JUNIPERO BUILDING -
FIRST FLOOR -
Lobby -

1. At 10:08 a.m., on 5/6/15, the door in the 2-hour wall separation between the lobby and medical-surgical floor had two labels indicating two different fire-ratings in the door jam. One label listed the door as a 20-minute fire-rated door and the second label listed the door as a 90-minute fire-rated door.

During an interview, Facilities Staff 2 and Maintenance Staff 1 stated that the door manufacturer installed the 20-minute label and a vendor installed the 90-minute label.

During an interview at 4:24 p.m., the Project Manager stated that the architect plans indicated a 2-hour wall separation with a 90-minute door. He stated that the door was certified to be a 90-minute door by an authorized vendor. The door had two conflicting fire resistance rating tags and there was no documentation confirming the true fire-rating of the door.

JUNIPERO BUILDING -
FIRST FLOOR -
Ridley Tree Medical-Surgical Wing -

2. At 10:21 a.m., on 5/6/15, the smoke barrier double doors, with Barcode Number 0035423, were held open with electronic automatic-closing devices. The doors were equipped with a fire exit hardware latching mechanism. The left door failed to fully close and latch upon activation of the fire alarm system, leaving an approximately 6 inch gap between the doors.

3. At 10:30 a.m., on 5/6/15, at 10:30 a.m., the smoke barrier double doors, with Barcode Number 0035399, were held open with electronic automatic-closing devices. The doors were equipped with a fire exit hardware latching mechanism. The left door failed to fully close and latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by the storage of maintenance materials in an enclosed space under an exit stairwell. This affected one of two exit stairwells at the Cottage Rehabilitation Hospital and could result in the faster spread of smoke and fire in the vertical opening.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.3 Stairs. Stairs complying with 7.2.2 shall be permitted.

7.1.3.2.3 An exit enclosure shall not be used for any purpose that has the potential to interfere with its use as an exit and, if so designated, as an area of refuge.

7.2.2.5.3 Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the vertical openings were observed at the facility.

COTTAGE REHABILITATION HOSPITAL (CRH) -

1. At 10:45 a.m., on 5/7/15, there were more than ten cardboard boxes of maintenance supplies observed in the space under the center stairwell. The space under the stairwell was accessible by a three foot by two foot access panel. The access panel door was not self-closing and did not have a label with a listed fire resistance rating.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by no records of monthly 30 second and annual 90 minute testing of the battery-powered emergency lights in the anesthetizing locations and the Energy Center. This affected 13 of 13 active operating rooms (ORs) at the main hospital, four of four ORs in the Outpatient Surgery Center, two of two ORs in the Eye Center, and the Energy Center. This could result in the lack of illumination during procedures in the ORs and a lack of illumination near the essential electrical equipment, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition.
18.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During document review with staff from 5/4/15 to 5/8/15, the emergency lighting maintenance records were requested.

JUNIPERO BUILDING -
SECOND FLOOR -

1. At 9:51 a.m., on 5/6/15, the light ballasts in the 13 ORs of the main hospital were equipped with battery back-up power. There were no records of monthly 30 second and annual 90 minute testing of the battery-powered emergency lights.

During an interview at 9:52 a.m., Plant Operations Staff 1 stated that there were no records of testing the battery-powered lights in the ORs. He stated that they were not being tested on a regular basis.

OUTPATIENT SURGERY (OPS) -

2. At 4:45 p.m., on 5/7/15, there were three light ballasts that were equipped with emergency battery back-up power in each of the four ORs. There were no records of testing these battery-powered emergency lights.

During an interview at 4:46 p.m., Plant Operations Staff 1 stated that these battery-powered emergency lights were installed approximately 2 months ago and have not been tested monthly since their installation.

At 8:50 a.m., on 5/8/15, a letter and invoice from the electrical contractor stated that the lights in the ORs were installed on 2/3/15. There were no records of monthly testing for March and April 2015.


29566

EYE CENTER (KNAPP BUILDING) -
3. At 11:02 a.m., on 5/5/15, the maintenance records indicated that the facility failed to conduct the annual 90 minute test of the battery-powered emergency lights.

ENERGY CENTER -
BASEMENT -
4. At 10:51 a.m., on 5/7/15, the facility failed to provide records of testing the battery-powered emergency lights in the electrical/automatic transfer switch (ATS) room.

ENERGY CENTER -
FIRST FLOOR -
5. At 10:59 a.m., on 5/7/15, facility failed to provide records of testing the battery-powered emergency lights in the electrical/generator transformer room.

During an interview, Plant Operation Staff 1 stated that no testing of the battery-powered emergency lights were conducted at the energy center because staff were unaware that the center was equipped with battery-powered lights.

Based on observation, record review, and interview, the facility failed to ensure that all facility patients, visitors, and staff were protected during an emergency. This was evidenced by the failure to ensure all building occupants were informed during a potential fire emergency, by a delay in emergency forces notification upon fire alarm activation, and by staff that were unfamiliar with emergency procedures and building life safety features. This affected the main hospital, the Outpatient Surgery Center, the Outpatient Imaging Center, and the Cottage Outpatient Center of San Luis Obispo. This deficient practice could result in a delayed response, in the event of an emergency, and increase the risk of harm to facility occupants.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.

19.3.4.3.2 Emergency Forces Notification. Fire department notification shall be accomplished in accordance with 9.6.4.
Exception: Smoke detection devices or smoke detection systems equipped with reconfirmation features shall not be required to automatically notify the fire department unless the alarm condition is reconfirmed after a period not exceeding 120 seconds.

19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.
19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.

9.6.4 Emergency Forces Notification. Where required by another section of this Code, emergency forces notification shall be provided to alert the municipal fire department and fire brigade (if provided) of fire or other emergency. Where fire department notification is required by another section of this Code, the fire alarm system shall be arranged to transmit the alarm automatically via any of the following means acceptable to the authority having jurisdiction and shall be in accordance with NFPA 72, National Fire Alarm Code:
(1) Auxiliary alarm system
(2) Central station connection
(3) Proprietary system
(4) Remote station connection
Exception: For existing installations where none of the means of notification specified in 9.6.4(1) through (4) is available, a plan for notification of the municipal fire department, acceptable to the authority having jurisdiction, shall be permitted.

NFPA 72, National Fire Alarm Code, 1999 Edition.
3-8.4.1.3 Emergency Voice/Alarm Communications. Emergency voice/alarm communications service shall be provided by a system with automatic or manual voice capability that is installed to provide voice instructions to the building occupants where it is intended that there be only partial or selective evacuation or directed relocation of building occupants in the event of a fire.
Exception: If emergency voice/alarm communications are used to automatically and simultaneously notify all occupants to evacuate the protected premises during a fire emergency, manual or selective paging shall not be required, but, if provided, shall meet the requirements of Section 3-8.4.1.3.

3-8.4.1.3.1 Application. Subparagraph 3-8.4.1.3 describes the requirements for emergency voice/alarm communications. The primary purpose is to provide dedicated manual and automatic facilities for the origination, control, and transmission of information and instructions pertaining to a fire alarm emergency to the occupants (including fire department personnel) of the building. It shall be the intent of 3-8.4.1.3 to establish the minimum requirements for emergency voice/ alarm communications.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the facility's code red response was observed and staff were interviewed about emergency procedures.

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO

1. At 9:39 a.m., on 5/5/15, the outpatient center was not equipped with a manual pull alarm. There was no fire response policy provided specific for the outpatient center.

During an interview at 9:40 a.m., Outpatient Center Staff 1 pointed to the R.A.C.E. (Rescue, Alarm, Confine, and Evacuate) and P.A.S.S. (Pull, Aim, Squeeze, and Sweep) instructions for fire response and fire extinguisher use printed on the back of his badge. He stated that in the event of a fire, he would inform occupants by yelling "Code Red" and going down to the first floor lobby to activate the fire alarm pull station.

At 10:19 a.m., Outpatient Center Staff 1 was asked to identify the location of the manual pull station on the first floor. He pointed to a fire alarm remote annunciator. There was no manual pull station observed in the building where the outpatient center was located.

At 10:20 a.m., Outpatient Center Staff 2 confirmed that there was no pull station in the building.

The facility failed to provide a fire response plan specific to this outpatient center and failed to ensure that staff were familiar with the fire protection features of the building.

SBCH: ORIGINAL HOSPITAL AND JUNIPERO BUILDING
The facility's policy was to use the phrase "Code Red" during a fire emergency.

2. The facility failed to ensure that all occupants, including patients, staff, and visitors, were informed during a potential fire emergency.

Code Red Incident 1:
At 3:09 p.m., on 5/6/15, the fire alarm notification devices were activated throughout the facility.

During an interview at 3:11 p.m., Maintenance Staff 1 stated that he was notified, through radio communication, that a smoke detector was activated in a patient room, Room 3145 on the third floor of the Junipero Building. No hospital wide overhead announcement was made to inform occupants that this alarm was not part of the fire alarm testing and the HTML marquees continued to state that fire alarm alarm testing was in progress.
Engineering and maintenance staff personnel were observed running from the second floor of the Original Hospital to the Junipero Building to investigate the source of the fire alarm.

During an interview at 3:12 p.m., Maintenance Staff 1 stated that when a fire alarm activates in the facility, engineering staff are notified first so they can investigate if there is a fire.

During an interview at 3:15 p.m., Maintenance Staff 2 and Facilities Staff 2 in Room 3145 stated that it was a malfunctioning smoke detector that was activated when the patient created airflow with his blanket.

During an interview at 3:20 p.m., Safety Staff 1 and Facilities Staff 1 stated that it was the hospital's policy that during construction hours, from 7 a.m. to 3:30 p.m., engineering staff would investigate the fire alarms to determine if they are false alarms.

During the code red incident, other than engineering and security staff, occupants were not aware that the alarm activated at 3:09 p.m. was not part of the fire alarm testing conducted that day.

Code Red Incident 2:
At 4:49 p.m., on 5/7/15, the fire alarm notification devices were activated throughout the facility.

No announcement was made to alert occupants of the situation. There was no HTML marquee near the conference rooms and administration offices in the 1 East floor of the Original Hospital. When an administrative staff was interviewed, she stated that she thought it was fire alarm testing. The fire alarms were on for approximately 5 minutes.

Based on the "Code Red Report" from the Private Branch Exchange (PBX), the alarm was activated at 4:49 p.m. in Public Bathroom 1879 (first floor of the Junipero Building near the cafeteria) and engineering authorized an "all clear" at 5:04 p.m. The report indicated that messages to the Text Board (HTML Marquees) and a Cottage Alert Messaging System (CAMS) alert was sent out to staff computers.

No announcement was made to notify the rest of the building occupants without a nearby marquee and without access to a staff computer with CAMS.

Code Red Incident 3:
At 9:07 a.m., on 5/8/15, while in the Private Branch Exchange (PBX) room, the fire alarms were activated. PBX communicated via two-way radio to security and engineering staff that the code red was coming from 5 East Room 7 patient bathroom. PBX staff also sent out a message on the marquees and sent a CAMS alert to staff computers. No announcement was made to the rest of the building occupants.

During an interview at 9:08 a.m., PBX Operator 1 stated that when Code Reds come in, security and engineering are notified. Messages were sent to Message Net that displays the location of the fire on the marquees and a CAMS emergency message was sent to all staff computers. She stated that they did not do an overhead announcement to inform visitors, patients, and other staff that may not be near a marquee or computer.

At 9:10 a.m., Plant Operations Staff 1 received a message that the alarm was due to a patient smoking an electronic-cigarette in the bathroom.

9:22 a.m., it was determined that the smoke detector in the bathroom of 5E07 was the one activated. The room was located directly across from the Psych Unit Nurses Station.

During an interview at 9:23 a.m., Psych Unit Charge Nurse stated that she did not know the fire alarms were coming from her department until she saw the message on the scrolling marquee across from the nurses station.

Per observation of the three incidents and staff interview, only select staff (engineering and security) were immediately notified of the source location of a Code Red alarm. It was observed that facility staff did not respond to the fire alarm until notified via a marquee or CAMS that the code red was in their area.

3. During an interview at 3:15 p.m., on 5/5/15, Safety Staff 1 stated that it was the hospital's policy that between 7:00 a.m. to 3:30 p.m., Monday through Friday, that PBX was not allowed to call 911 until they get permission from security staff or engineering staff after they have investigated the source of fire alarms.

The hospital's fire response policy stated that staff were to dial 599 (PBX) during R.A.C.E procedures. She stated that it was the hospital's policy that no staff be allowed to call 911 until PBX received permission from engineering.

Safety Staff 1 provided a letter from the City of Santa Barbara Fire Department dated 9/19/12. The fire department allowed the delayed notification when alarms were activated due to construction (on Mondays to Fridays from 7:00 a.m. to 3:30 p.m.) under strict conditions. One of the conditions stated: "In all cases where the cause cannot be determined or where the cause is unrelated to construction activity, the fire department shall be notified to investigate."

Since this permission letter was drafted in 2012, the facility has installed a new fire alarm system. Per fire watch logs and trouble signals on the panel, fire alarm devices were disabled at the construction zones. The three Code Red incidents listed previously took place in patient rooms and public areas. The fire department was not notified per PBX Code Red reports, including the incident at 4:49 p.m. on 5/7/15 where it took engineering approximately 15 minutes to authorize an "all clear."

During an interview at 10:48 a.m., on 5/8/15, the PBX manager stated that PBX staff were instructed to notify the fire department only after engineering instructed them to do so.

The facility failed to ensure that the emergency responders would be notified in a timely manner in the event of a fire.


29566

ORIGINAL HOSPITAL -
FIRST FLOOR -

4. During an interview at 8:50 a.m., on 5/6/15, PBX Staff 3 stated if a partial or full evacuation at the facility was ordered, she would she would not know what actions to take. She stated that she could not remember being trained on evacuation procedures.
PBX Staff 3 was unfamiliar with the evacuation procedures.

During an interview at 9:55 a.m., on 5/6/15, EVS Staff 1 stated she would called 911 if she discovered a fire and would check the fire alarm sub-station panel as part of her fire response procedures. EVS staff 1 stated she would not know what actions to take during a partial or full evacuation of the building.

ORIGINAL HOSPITAL -
FIRST FLOOR -
COTTAGE CAFE -

During an interview at 3:39 p.m., on 5/6/15, Dietary Staff 3 stated that she had not participated in any fire or disaster drills in approximately 2 years and did not know the facility's evacuation procedures.

During an interview at 3:40 p.m., on 5/6/15, Dietary Staff 4 stated that she had not participated in any fire or disaster drills in approximately 2 years.

OUTPATIENT SURGERY CENTER -

During an interview at 3:05 p.m., on 5/7/15, Surgical Staff 1 stated the fire department would be automatically called when she dialed PBX and dialing 5555 will automatically connect to the fire department.

Facility staff were unfamiliar with the facility's emergency fire and disaster policy and procedures.

OUTPATIENT IMAGING CENTER -

5. The Imaging Center was located in a flood zone equipped with flood gates to prevent flooding of the first floor, where all the radiology equipment was. The Imaging Center was protected by flood gates that were required by the local authority having jurisdiction.

During an interview at 12:01 p.m., on 5/7/15, Radiology Staff 2 stated that she had not participated in disaster drills or inservices regarding the flood gates. Radiology Staff 2 stated she did not know that the building was equipped with flood gates.

During an interview at 12:02 p.m., on 5/7/15, Radiology Staff 1 acknowledged that she had not participated in disaster drills regarding the flood gates and did not know they were there.

During an interview at 12:03 p.m., on 5/7/15, Center Director 2 stated that he was told about the flood gates when the building was first opened and licensed but no drills were conducted with a flood scenario and use of the flood gates.

Facility staff were unfamiliar with unit specific emergency systems.

Based on record review and interview, the facility failed to prepare staff to respond to fire emergencies. This was evidenced by the facility's failure to ensure all staff participated in fire drills and by the failure to conduct fire drills at a minimum of once per staff shift per quarter. This affected the main hospital, Outpatient Surgery Center, Cottage Rehabilitation Hospital, and the Cottage Outpatient Center of San Luis Obispo. This could result in a delayed staff response to a fire or disaster emergency.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 * Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

39.7.1 Drills. In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.

39.7.2 Extinguisher Training. Designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers.

4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.
4.7.2 Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the
authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.
4.7.3 Competency. Responsibility for the planning and conduct of drills shall be assigned only to competent persons qualified to exercise leadership.
4.7.4 Orderly Evacuation. In the conduct of drills, emphasis shall be placed on orderly evacuation rather than on speed.
4.7.5 Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.
4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

During document review with Plant Operations Staff 1 and Safety Staff 1 from 5/4/15 to 5/8/15, the fire and disaster drills records were reviewed. The facility's Code Red Fire Response Plan indicated that during a fire drill, all employees in all departments were expected to participate.

Original Hospital -

1. On 5/4/15 at 9:48 a.m., Safety Staff 2 was interviewed. Safety Staff 2 described the facility's varying shift times. The facility's Code Red Fire Response Plan indicated that during a fire drill, all employees in all departments were expected to participate. Safety Staff 2 confirmed that all facility staff present during each fire drill were expected to participate.

On 5/4/15 at 9:50 a.m., fire drills records did not indicate that all department-employees participated in the fire drills during the last 12 months.

There were no employee signatures from environmental staff and cafe staff for 3/2/15 day shift drill, for the 4/1/15 evening shift drill, and for the 11/12/14 day shift drill.

There were 2 nursing signatures for 3/2/15 day shift drill.

There were 6 staff signatures for 2/10/15 night shift drill.

There was no other documentation that confirmed all staff, present on the day and time of the drills, participated in each fire drill.

2. On 5/7/15 at 8:35 a.m., there were no records that indicated NOC shift fire drills were completed during the second and fourth quarters during the past 12 months.

3. On 5/7/15 at 8:35 a.m., there were no records that indicated PM shift fire drills were completed during the second and third quarters during the past 12 months.

4. On 5/7/15 at 8:35 a.m., there were no records that indicated an AM shift fire drill was completed during the first quarter during the past 12 months.

Cottage Rehabilitation Hospital

5. On 5/7/15 at 8:40 a.m., there were no records that indicated PM and NOC shift fire drills were completed during the first quarter during the past 12 months.

6. On 5/7/15 at 8:40 a.m., there were no records that indicated an AM shift fire drill was completed during the second quarter during the past 12 months.

Outpatient Surgery Center

7. On 5/7/15 at 3:06 p.m., Surgical Staff 1 was interviewed. Surgical Staff 1 stated that fire drills were conducted two or three times per year. There were no records that indicated that the Outpatient Surgery Center had conducted fire drills quarterly for each staff shift.


29665

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO

8. At 9:30 a.m., on 5/5/15, records provided indicated that the most recent fire drill conducted at the outpatient center was held on 1/20/15.

During an interview at 9:31 a.m., Outpatient Center Staff 1 stated that fire drills were held annually but the records for previous drills were not available.

At 9:37 a.m., a binder containing drills conducted in 2006 and prior was provided. There were no records of fire drills conducted between 2006 and 2015. There were no records that indicated that the Cottage Outpatient Center of San Luis Obispo had conducted fire drills quarterly for each staff shift.

Based on observation and interview, the facility failed to ensure that the fire alarm system provided an effective warning of a fire. This was evidenced by a delay in the annunciation of the audible alarms upon fire alarm system activation, by interval pauses of the audible alarms when activated, and by areas in the facility where the fire alarm system could not be heard. This affected the main hospital and the Outpatient Surgery Center. These deficiencies could result in a delayed notification of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition.
4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.

9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.4.2.2 Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device.
Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.

Findings:

During fire alarm testing with staff from 5/4/15 to 5/8/15, the fire alarm notification devices were observed.

JUNIPERO BUILDING -
FIRST FLOOR -

1. At 11:14 a.m., on 5/6/15, there was a delay in the activation of audible alarms from the time the strobes were activated. In the Radiology department, strobes were activated immediately upon testing a fire alarm initiating device in the area. The fire alarm strobes were active for 14 seconds before the audible alarms sounded.

OUTPATIENT SURGERY (OPS) -

2. At 2:47 p.m., on 5/7/15, no fire alarm signals could be heard in the women's locker room during fire alarm testing.

3. At 2:51 p.m., on 5/7/15, no fire alarm signals could be heard in the men's locker room during fire alarm testing.

4. At 2:52 p.m., on 5/7/15, the fire alarm bells at OPS did not make a continuous noise. The chimes were active for five seconds and then paused and then chime for five seconds again. There was a five second delay between chiming intervals.

5. At 5:01 p.m., on 5/7/15, the fire alarm system was tested. There was one audible notification device in the surgical corridor between Operating Rooms (ORs) 2 and 3. No fire alarm signal could be heard in OR 4 and no fire alarm signal could be heard in OR 1 during testing. The ORs were empty and the machines were turned off.


29566

ORIGINAL HOSPITAL -
6. At 4:30 p.m., on 5/6/15, the audible alarm of the fire alarm notification system was not a continuous sound. There was a five second delay between each chime sequence.

During an interview at 4:31 p.m., Safety Staff 1 stated that the delay in fire alarm chiming sequence was due to an issue with the vendor who installed the system.

During an interview at 4:35 p.m., Facilities Staff 1 stated the delay in the fire alarm chime sequence caused confusion because it made it seem like the emergency was over during the paused intervals.

Outpatient Surgery Center

7. At 2:52 p.m., on 5/7/15, the fire alarms could not be heard in Pre- Operation Rooms 1 and 2.

During an interview, Surgical Staff 1 confirmed that the fire alarm signals could not be heard in Pre-Operation Rooms 1 and 2. She stated that it had been that way for some time.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by incomplete documentation for annual inspections of the fire alarm systems, by inspections of the fire alarm systems conducted by staff that did not have the certification to do so, by notification devices that failed, and by the failure to conduct fire alarm testing at one offsite location. This affected the main hospital and two of five offsite facilities. This deficient practice could result in a malfunctioning fire alarm system.

NFPA 101, Life Safety Code, 2000 Edition.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.


NFPA 72, National Fire Alarm Code, 1999 Edition.
Definitions Chapter 1
Certification of Personnel. A formal program of related instruction and testing as provided by a recognized organization or the authority having jurisdiction.

1-6.2.1.1 All fire alarm systems that are modified after the initial installation shall have the original record of completion revised to show all changes from the original information and shall include a revision date.

1-6.2.2 Every system shall include the following documentation, which shall be delivered to the owner or the owner's representative upon final acceptance of the system:
(1) An owner's manual and installation instructions covering all system equipment
(2) Record drawings

1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems.
Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies fire alarm certified
(3) International Municipal Signal Association fire alarm certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization listed by a national testing laboratory for the servicing of fire alarm systems

7-1.6.2.1 Reacceptance testing shall be performed after any of the following:
(1) Added or deleted system components
(2) Any modification, repair, or adjustment to system hardware or wiring
(3) Any change to site-specific software.
All components, circuits, systems operations, or site-specific software functions known to be affected by the change or identified by a means that indicates the system operational changes shall be 100 percent tested. In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested, and correct system operation shall be verified. A revised record of completion in accordance with 1-6.2.1 shall be prepared to reflect any changes.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies, requires annual testing of:
1. Control Equipment - Building Systems Connected to Supervising Station
a. Functions
b. Fuses
c. Interfaced Equipment
d. Lamps and LEDs
e. Primary (Main) Power Supply
f. Transponders
6. Batteries - Fire Alarm Systems
d. Sealed Lead-Acid Type
1. Charger Test (Replace battery every 4 years.)
2. Discharge Test (30 minutes)
9. Control Unit Trouble Signals
14. Remote Annunciators
15. Initiating Devices
19. Alarm Notification Appliances

7-4.1 Fire alarm system equipment shall be maintained in accordance with the manufacturer's instructions. The frequency of maintenance shall depend on the type of equipment and the local ambient conditions.

7-4.2 The frequency of cleaning shall depend on the type of equipment and the local ambient conditions.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business
address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the fire alarm systems were observed and maintenance records were reviewed.

SBCH: ORIGINAL HOSPITAL AND JUNIPERO BUILDING

1. At 3:34 p.m., on 5/4/15, records of the annual inspection and testing of the fire alarm system was requested. Staff provided a binder that indicated that all initiation devices at the facility were tested on 4/14/15. There were no records of the remaining fire alarm system components that were required to be tested annually.

2. At 3:35 p.m., the records showed that the annual inspection of the fire alarm system at the main hospital was conducted by Safety Staff 2. Records also indicated that Safety Staff 2 conducted the annual inspections of the fire alarm systems at the Eye Center on 12/6/14, the Imaging Center on 12/26/14, and the Outpatient Surgery Center on 11/28/14.

During an interview at 3:36 p.m., Plant Operations Staff 1 stated that Safety Staff 2 was certified and trained to conduct the annual testing of the fire alarm system.

Records provided by the facility indicated that Safety Staff 2's Level II certification in fire protection engineering technology from the National Institute for Certification in Engineering Technologies (NICET) had expired on 1/1/10. The NICET online database indicated that Safety Staff 2's last certification expired on 1/1/13 but that certificate was not provided by the facility.

At 1:46 p.m., on 5/7/15, during a personnel review meeting, a copy of Safety Staff 2's job description (Job Code 6406) was provided. Per the document provided by human resources (HR), the facility did not require Safety Staff 2 to maintain any "certifications, licenses, registrations" to conduct his duties.

During an interview at 1:47 p.m., HR Representative 1 confirmed that based on the job description, Safety Staff 2 was not required to maintain any certification.

At 8:45 a.m., on 5/8/15, facility staff provided a copy of Safety Staff 2's application for his NICET recertification. The application was dated 5/7/15 and indicated that his certification had expired on 1/1/13.

Safety Staff 2's NICET certification was expired during the times he conducted the annual inspections of the fire alarm systems at the main hospital, the Eye Center, the Imaging Center, and the Outpatient Surgery Center.

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO

3. At 10:01 a.m., on 5/5/15, it was observed that the building was equipped with an automatic sprinkler system and a fire alarm panel. There were no records of the annual inspection of the fire alarm system.

4. At 10:17 a.m., on 5/5/15, fire alarm system testing was not conducted during the survey of the Cottage Outpatient Center of San Luis Obispo. Facilities Staff 1 was informed that, as part of the validation survey, fire alarms would be tested at the main hospital and all offsite facilities. Facilities Staff 1 was informed at approximately 11:00 a.m. on 5/4/15 that the Cottage Outpatient Center of San Luis Obispo would be surveyed the following day and arrangements would need to be made for fire alarm testing.

During an interview at 10:18 a.m., Facilities Staff 1 stated that arrangements were not made to conduct fire alarm system testing at the outpatient center.

ORIGINAL HOSPITAL -
FIRST FLOOR -

5. At 2:29 p.m., on 5/6/15, a fire alarm pull station in the 1 East building was tested. One combination horn/strobe notification device, inside conference room Gibraltar 2, had a horn that failed. A second combination horn/strobe notification device, directly outside Gibraltar 2, had a horn that failed.

COTTAGE REHABILITATION HOSPITAL (CRH)

6. At 9:01 a.m., on 5/7/15, documents showed that the annual inspection of the fire alarm system at CRH was conducted by a vendor on 5/12/14. The document did not show that the technician tested the fire alarm notification devices. There was a supplementary document provided, with the hospital's letterhead, titled "Notification Devices. Testing 2014" that was not attached to the vendor's report. The document indicated that all notification devices passed testing but did not include the signature or name of who tested the devices and did not include a date of testing other than the year 2014. Documentation for testing the notification devices was incomplete.


29566

SBCH: ORIGINAL HOSPITAL AND JUNIPERO BUILDING -

7. At 9:02 a.m., on 5/5/15, records indicated the last inspection and test on the fire alarm panel Node in 3 East was done 1/15/14.

Records indicated the last inspection and test on the fire alarm panel Node 17 in 5 South was conducted on 1/28/14.

Records indicated the last inspection and test on the fire alarm panel Node 21 in 4 South was conducted on 5/2/14.

Records indicated the last inspection and test on the fire alarm panel Node 34 in 3 West was conducted on 4/18/14.

All of the records were for acceptance testing of the nodes by a vendor. There were no records indicating that the nodes were tested in 2015. The facility failed to provide records of current annual testing for all nodes at the facility and failed to indicate how many nodes there were and their respective locations.

ORIGINAL HOSPITAL -
ROOF HELIPAD -

8. On 5/6/15 at 11:44 a.m., two of three audible fire alarm chimes, located around the Helipad, failed to activate during fire alarm system testing.

9. On 5/6/15 at 11:53 a.m., three of three fire alarm strobes, located around the Helipad, failed to activate during the fire alarm testing.

Based on observation, record review, and interview, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was dirty and caused a nuisance alarm, by no manufacturer's specifications provided for that detector, and by one smoke detector that failed when tested. This affected one of six floors in the Original Hospital and one of three floors in the Junipero Building. This could result in a delayed notification of smoke, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
18.3.4.5.1 Detection systems, where required, shall be in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

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.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the smoke detection system was observed.

JUNIPERO BUILDING -
THIRD FLOOR -

1. At 3:09 p.m., on 5/6/15, the smoke detector in the bathroom of Patient Room 3145 was activated.

During an interview at 3:15 p.m., Facilities Staff 2 and Maintenance Staff 2 stated that the patient was creating airflow with his blanket and that triggered the smoke detector.

At 9:00 a.m., on 5/7/15, Plant Operations Staff 1 provided a picture of the detector in Room 3145, that was replaced on 5/6/15 by engineering staff after it was triggered. The smoke detector was covered with a thick layer of lint and dust around the sensing chamber. He stated that the airflow created by the patient pushed the dirt into the sensing chamber and caused the detector to activate. He provided a print out of the detector's sensitivity readings from the panel which showed that the detector's sensitivity reading increased from 74 on 4/5/13 to 96 on 5/4/15. He stated that the detector was programmed to activate a trouble signal when the sensitivity value reached 125 per the manufacturer's specifications.
The manufacturer's specifications for the detector were requested to determine if the detector was out of its listed sensitivity range but that information was not provided.


ORIGINAL HOSPITAL -
THIRD FLOOR -

2. At 4:11 p.m., on 5/6/15, Smoke Detector 122-105 in the the 3 East corridor, outside Room 3629, was tested with artificial canned smoke by Maintenance Staff 1. At 4:14 p.m., the smoke detector failed to activate the fire alarm system after being tested with artificial canned smoke three times.

Based on observation, the facility failed to maintain their automatic sprinkler system control valves. This was evidenced by one supervised outside screw and yoke (OS&Y) valve that failed to initiate a remote trouble signal when closed. This affected the Outpatient Surgery Center and could result in a delayed notification of a suspension in water supplied to the automatic sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.2 Supervision.
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the supervised sprinkler control valves were observed.

OUTPATIENT SURGERY (OPS) -

1. At 3:15 p.m., on 5/7/15, Maintenance Staff 1 tested an exterior outside screw and yoke (OS&Y) sprinkler control valve. Closure of the valve failed to initiate a supervisory trouble alarm at the fire alarm panel across from the reception desk.

Based on observation, record review, and interview, the facility failed to maintain their fire extinguishing systems. This was evidenced by incomplete testing and repair records of their automatic sprinkler systems, by no records of five year tests of the clean agent extinguishing systems, by the failure to provide the correct supply of spare sprinkler heads, by sprinkler heads that were corroded and missing escutcheon rings, by damaged fire department connection swivels, and by sprinkler pipes that were subjected to external loads. This affected the main hospital and five of five offsite locations. These deficient practices could result in a delay in extinguishing a fire and an increased risk of harm to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

9.7.3 Other Automatic Extinguishing Equipment.
9.7.3.1 In any occupancy where the character of the potential fuel for fire is such that extinguishment or control of fire is effectively accomplished by a type of automatic extinguishing system other than an automatic sprinkler system, such as water mist, carbon dioxide, dry chemical, foam, Halon 1301, water spray, or a standard extinguishing system of another type, that system shall be permitted to be installed in lieu of an automatic sprinkler system. Such systems shall be installed, inspected, and maintained in accordance with appropriate NFPA standards.

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

NFPA 12 A, Standard on Halon 1301, Fire Extinguishing Systems, 1997 Edition
4-3.2 All hoses shall be tested every 5 years in accordance with 4-3.1.

NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems, 2000 Edition.
4-1.1 At least annually, all systems shall be thoroughly inspected and tested for proper operation by competent personnel. Discharge tests are not required.
4-1.2 The inspection report with recommendations shall be filed with the owner.
4-1.3 At least semiannually, the agent quantity and pressure of refillable containers shall be checked.
4-2.1 U.S. Department of Transportation (DOT), Canadian Transport Commission (CTC), or similar design clean agent containers shall not be recharged without retesting if more than 5 years have elapsed since the date of the last test and inspection. For halocarbon agent storage containers, the retest shall be permitted to consist of a complete visual inspection as described in 49 CFR 173.34(e)(10).
Transporting charged containers that have not been tested within 5 years could be illegal. Federal and local regulations should be consulted.
4-2.2 Cylinders continuously in service without discharging shall be given a complete external visual inspection every 5 years or more frequently if required. The visual inspection shall be in accordance with Section 3 of CGA C-6, Standard for Visual Inspection of Steel Compressed Gas Cylinders, except that the cylinders need not be emptied or stamped while under pressure. Inspections shall be made only by competent personnel and the results recorded on both of the following:
(1) A record tag permanently attached to each cylinder
(2) A suitable inspection report
A completed copy of the inspection report shall be furnished to the owner of the system or an authorized representative. These records shall be retained by the owner for the life of the system.
4-3.2.1 All hose shall be tested every 5 years.
4-3.2.2 All hose shall be tested at 11/2 times the maximum container pressure at 130°F (54.4°C). The testing procedure shall be as follows:
(a) The hose is removed from any attachment.
(b) The hose assembly is then placed in a protective enclosure designed to permit visual observation of the test.
(c) The hose must be completely filled with water before testing.
(d) Pressure then is applied at a rate-of-pressure rise to reach the test pressure within a minimum of 1 minute. The
test pressure is maintained for 1 full minute. Observations are then made to note any distortion or leakage.
(e) If the test pressure has not dropped or if the couplings have not moved, the pressure is released. The hose assembly is then considered to have passed the hydrostatic test if no permanent distortion has taken place.
(f) Hose assembly passing the test must be completely dried internally. If heat is used for drying, the temperature must not exceed the manufacturer ' s specifications.
(g) Hose assemblies failing a hydrostatic test must be marked and destroyed and be replaced with new assemblies.
(h) Each hose assembly passing the hydrostatic test is marked to show the date of test.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
5-5.5 Obstructions to Sprinkler Discharge.
5-5.5.1 Performance Objective. Sprinklers shall be located so as to minimize obstructions to discharge as defined in 5-5.5.2 and 5-5.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. (See Figure A-5-5.5.1.)
5-5.5.2 Obstructions to Sprinkler Discharge Pattern Development.
5-5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 5-5.5.2.
5-5.5.2.2 Sprinklers shall be positioned in accordance with the minimum distances and special exceptions of Sections 5-6 through 5-11 so that they are located sufficiently away from obstructions such as truss webs and chords, pipes, columns, and fixtures.
5-5.5.3 Obstructions that Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 5-5.5.3.
5-5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 ft (1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors.
Exception: Obstructions that are not fixed in place such as conference tables.
5-5.5.3.2 Sprinklers installed under open gratings shall be of the intermediate level/rack storage type or otherwise shielded from the discharge of overhead sprinklers.
5-5.6 The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.
Exception No. 1:Where other standards specify greater minimums, they shall be followed.
Exception No.2: A minimum clearance of 36 in. (0.91 m) shall be permitted for special sprinklers sprinklers.
Exception No. 3: A minimum clearance of less than 18 in. (457 mm) between the top of storage and ceiling sprinkler deflectors shall be permitted where proven by successful large-scale fire tests for the particular hazard.
Exception No. 4: The clearance from the top of storage to sprinkler deflectors shall be not less than 3 ft (0.9 m) where rubber tires are stored.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

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.

2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types and temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating installed shall be provided. The cabinet shall be so located that it will not be exposed to moisture, dust, corrosion, or a temperature exceeding 100°F (38°C).
Exception: Where dry sprinklers of different lengths are installed, spare dry sprinklers shall not be required, provided that a means of returning the system to service is furnished.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-3.2 Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

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

Table 9-1 Summary of Valves, Valve Components, and Trim Inspection, Testing, and Maintenance indicates that backflow prevention assemblies are required to be tested annually in accordance with Section 9-6.2.

9-6.2.1 All backflow preventers installed in fire protection system piping shall be tested annually in accordance with the following:
(a) A forward flow test shall be conducted at the system demand, including hose stream demand, where hydrants or inside hose stations are located downstream of the backflow preventer.
(b) A backflow performance test, as required by the authority having jurisdiction, shall be conducted at the completion of the forward flow test.
Exception No. 1: For backflow preventers sized 2 in. (50.8 mm) and under, it shall be acceptable to conduct the forward flow test without measuring flow, where the test outlet is of a size to flow the system demand.
Exception No. 2: Where water rationing shall be enforced during shortages lasting more than 1 year, an internal inspection of the backflow preventer to ensure the check valves will fully open shall be acceptable in lieu of conducting the annual forward flow test.
Exception No. 3: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be completed at the maximum flow rate possible.
Exception No. 4: The forward flow test shall not be required where annual fire pump testing causes the system demand to flow through the backflow preventer device.

9-6.2.2 All backflow devices installed in fire protection water supply shall be tested annually at the designed flow rate of the fire protection system, including hose stream demands, if appropriate.
Exception: Where connections of a size sufficient to conduct a full flow test are not available, tests shall be conducted at the maximum flow rate possible.

9-6.3.1 Maintenance of all backflow prevention assemblies shall be conducted by a trained individual following the manufacturer's instructions in accordance with the procedure and policies of the authority having jurisdiction.

9-7 Fire Department Connections.
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 facility tour with staff from 5/4/15 to 5/8/15, the automatic fire extinguishing systems were observed and maintenance records were reviewed.

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO

1. At 9:59 a.m., on 5/5/15, records provided indicated that a sprinkler system annual test was conducted on 8/15/13. There were no records of any quarterly testing and no records of a current annual sprinkler system inspection.

During an interview at 10:00 a.m., Outpatient Center Staff 2 indicated that the building's landlord would not provide any additional sprinkler system maintenance records.

2. At 10:22 a.m., on 5/5/15, the sprinkler riser in the first floor parking garage was observed. The riser was tagged with an annual certification sticker dated August 2013. There was a sticker dated February 2011, where it was marked by the vendor as the date of an annual test, not a five year test. There was a handwritten note on the 2011 sticker that stated that it was the five-year certification tag. There was no documentation provided to confirm that a five-year certification was conducted in 2011.

EYE CENTER (KNAPP BUILDING) -

3. At 2:44 p.m., on 5/5/15, the closet in the reception office had a sprinkler head that was missing an escutcheon ring.

4. At 2:49 p.m., on 5/5/15, the sprinkler head near the chandelier in the front entrance was missing an escutcheon ring.

ORIGINAL HOSPITAL -
BASEMENT OF WEST WING -

5. At 2:30 p.m., on 5/6/15, Maintenance Staff 1 opened the Inspector's Test Valve (ITV) in the west stairwell. The ITV was leaking at the turn wheel.

ORIGINAL HOSPITAL -
THIRD FLOOR OF WEST WING -

6. At 3:48 p.m., on 5/6/15, there was a metallic guard attached to the sprinkler system piping in the housekeeping closet of the Dialysis Unit. The metallic guard was approximately 2 feet high by 1 foot wide and was hung on the sprinkler pipe with three clasp connections. No information was provided confirming the metallic guard was a listed component of the sprinkler system and if the external load it exerted on the piping was approved.

During an interview at 3:49 p.m., Maintenance Staff 1 stated that the guard was to protect the sprinkler control valve from damage by housekeeping equipment. He stated that it had been there for years.

COTTAGE REHABILITATION HOSPITAL (CRH) -

7. At 10:46 a.m., on 5/7/15, there was a cardboard box of corner guards leaning against the sprinkler pipe in the space under the center stairwell.

OUTPATIENT SURGERY (OPS) -

8. At 3:22 p.m., on 5/7/15, the swivels and plug caps on the fire department connections (FDCs) failed to rotate smoothly and were stuck in place.

ORIGINAL HOSPITAL -
SECOND FLOOR -

9. At 3:39 p.m., on 5/7/15, the swivels and plug caps outside the main lobby failed to rotate smoothly and were stuck in place.


29566

SBCH: ORIGINAL HOSPITAL AND JUNIPERO BUILDING -

10. At 11:05 a.m., on 5/5/15, the five-year sprinkler testing report provided, dated 10/10, indicated that the system failed inspection. Deficiencies listed were: "Central Riser: 4 inch fire department check valve is unserviceable and should be replaced; FSTEW Riser: 4 inch valve was rusted and shut in place and 5th floor riser failed." There were no records provided to show that corrective actions had been completed.

During an interview, Plant Operation Staff 1 stated that the corrections were made with the approval from the authority having jurisdiction and that the facility would provide the documents. No documents were not provided during the survey that confirmed corrective actions had been completed.

MAIN ELECTRICAL ROOM -

11. At 2:15 p.m., on 5/7/15, the facility failed to provide documents of a five year test conducted on the Halon extinguishing system hoses.

TELEPHONE ROOM -

12. At 2:20 p.m., on 5/7/15, the facility failed to provide documents of a five year test conducted on the Halon 1301 extinguishing system hoses.

IMAGING CENTER -

13. At 12:14 p.m., on 5/7/15, four sprinkler heads showed signs of corrosion on their deflectors and escutcheon rings, under the second floor patio.

14. At 12:21 p.m., on 5/7/15, on the first floor patio, the sidewall sprinkler head deflector and escutcheon ring were corroded.

15. At 12:22 p.m., on 5/7/15, the facility spare sprinkler box was not equipped with a sidewall sprinkler head.

16. At 2:22 p.m., on 5/7/15, facility failed to provide documents to show that a five year hose test was conducted for the clean agent fire extinguishing system.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by one fire extinguisher that was mounted more than 5 feet above floor level, by one fire extinguisher that was missing a hose attachment, and by one fire extinguisher that was unsecured and obstructed. This could cause a delay in extinguishing a fire and the increased potential of harm to patients and staff in the event of a fire emergency. This affected one of six floors of the Original Hospital and two of five offsite locations.

NFPA 101, Life Safety Code, 2000 Edition.
39.3.5 Extinguishment Requirements. Portable fire extinguishers shall be provided in every business occupancy in accordance with 9.7.4.1.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

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 for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb(18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft.(1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb. (18.14 kg)(except wheeled type)shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft.(1.07 m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in.(10.2 cm).

4-2.1 Inspection. A "quick check" that a fire extinguisher is available and will operate. It is intended to give reasonable assurance that the fire extinguisher is fully charged and operable. This is done by verifying that it is in its designated place, that it has not been actuated or tampered with, and that there is no obvious or physical damage or condition to prevent its operation.

4-3.2 Procedures. Periodic inspection of fire extinguishers
shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the portable fire extinguishers were observed.

ORIGINAL HOSPITAL -
SECOND FLOOR -

1. At 9:55 a.m., on 5/6/15, the fire extinguisher in the Cottage Cafe was mounted approximately 66 1/2 inches from the floor.


29665

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO

2. At 10:12 a.m., on 5/5/15, the outpatient center had two portable fire extinguishers; one located in the main hallway and the second located in the patient lounge. The fire extinguisher in the patient lounge was located in the cabinet under the dishwashing sink. The extinguisher was obstructed from view and access. The fire extinguisher was also free standing in the cabinet and was unsecured.

During an interview at 10:13 a.m., Outpatient Center Staff 1 stated that the extinguisher had always been kept under the sink.

EYE CENTER (KNAPP BUILDING) -

3. At 2:56 p.m., on 5/5/15, the fire extinguisher in the Laser and Procedure Room was missing its hose. Based on the instructions printed on the fire extinguisher by the manufacturer, the hose was part of the equipment used for aiming and sweeping the extinguishing agent.

Based on observation, the facility failed to ensure that appliances were installed safely. This was evidenced by a laundry dryer exhaust that was vented into a combustible storage bin in a patient care unit. This affected one of six floors of the Original Hospital. This could increase the risk of a lint fire and cause harm to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition
19.5.2 Heating, Ventilating, and Air Conditioning.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications.
Exception: As modified in 19.5.2.2.

9.2.2 Ventilating or Heat-Producing Equipment. Ventilating or heat-producing equipment shall be in accordance with NFPA 91, Standard for Exhaust Systems for Air Conveying of Vapors, Gases, Mists, and Noncombustible Particulate Solids; NFPA 211, Standard for Chimneys, Fireplaces, Vents, and Solid Fuel-Burning Appliances; NFPA 31, Standard for the Installation of Oil-Burning Equipment; NFPA 54, National Fuel Gas Code; or NFPA 70, National Electrical Code, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 54, 1999 Edition
Clothes Dryer. A device used to dry wet laundry by means of heat derived from the combustion of fuel gases.

Clothes Dryer, Type 1. Factory-built package, multiply produced. Primarily used in family living environment. May or may not be coin-operated for public use. Usually the smallest unit physically and in function output.

Clothes Dryer, Type 2. Factory-built package, multiply produced. Used in business with direct intercourse of the function with the public. May or may not be operated by public or hired attendant. May or may not be coin-operated. Not designed for use in individual family living environment. May be small, medium, or large in relative size.

6.4 Clothes Dryers.
6.4.1 Clearance.
(a) Listed Type 1 clothes dryers shall be installed with a minimum clearance of 6 in. (15 cm) from adjacent combustible material, except that clothes dryers listed for installation at lesser clearances shall be permitted to be installed in accordance with their listing. Type 1 clothes dryers installed in closets shall be specifically listed for such installation.
(b) Listed Type 2 clothes dryers shall be installed with clearances of not less than shown on the marking plate and in the manufacturers ' instructions. Type 2 clothes dryers designed and marked " For use only in noncombustible locations " shall not be installed elsewhere.
(c) Unlisted clothes dryers shall be installed with clearances to combustible material of not less than 18 in. (460 mm). Combustible floors under unlisted clothes dryers shall be protected in an approved manner.

6.4.2 Exhausting to the Outdoors.
(a) Type 1 and Type 2 clothes dryers shall be exhausted to the outside air.

6.4.3 Provisions for Make-Up Air.
(a) Make-up air shall be provided for Type 1 clothes dryers in accordance with the manufacturers ' installation instructions.
(b) Provision for makeup air shall be provided for Type 2 clothes dryers, with a minimum free area (see 5.3.5) of 1 in.2 (6.5 m2) for each 1000 Btu/hr (2200 mm2/kW) total input rating of the dryer(s) installed.

6.4.4 Exhaust Ducts for Type 1 Clothes Dryers.
(a) A clothes dryer exhaust duct shall not be connected into any vent connector, gas vent, chimney, crawl space, attic, or other similar concealed space.
(b) Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system.

6.4.5 Exhaust Ducts for Type 2 Clothes Dryers.
(a) Exhaust ducts for Type 2 clothes dryers shall comply with 6.4.4.
(b) Exhaust ducts for Type 2 clothes dryers shall be constructed of sheet metal or other noncombustible material. Such ducts shall be equivalent in strength and corrosion resistance to ducts made of galvanized sheet steel not less than 0.0195 in. (0.5 mm) thick.
(c) Type 2 clothes dryers shall be equipped or installed with lint-controlling means.
(d) Exhaust ducts for Type 2 clothes dryers shall have a clearance of at least 6 in. (150 mm) to combustible material.
Exception: Exhaust ducts for Type 2 clothes dryers shall be permitted to be installed with reduced clearances to combustible material, provided the combustible material is protected as described in Table 6.2.3(b).
(e) Where ducts pass through walls, floors, or partitions, the space around the duct shall be sealed with noncombustible material.
(f) Multiple installations of Type 2 clothes dryers shall be made in a manner to prevent adverse operation due to back pressures that might be created in the exhaust systems.

Findings:

During tour of facility with the Facilities Staff 1 from 5/4/15 to 5/8/15, the Psych Unit was observed.

ORIGINAL HOSPITAL -
FIFTH FLOOR -

1. At 4:57 p.m., on 5/6/15, there was a clothes dryer located in a closet of the therapy room. The exhaust hose was vented into a plastic combustible storage bin adjacent to the dryer. There was a second hose attached to the top of the bin and vented through the wall of the "outdoor" therapy room where there was a louvered screen in the wall where the exhaust hose was vented. The dryer was not vented to the outside air.

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by kitchen hoods that were contaminated with grease-laden deposits. This was also evidenced by the failure to provide documentation indicating the frequency of hood cleaning. This affected one of three floors in the Junipero Building and one of six floors in the Original Hospital. This could result in the increased risk of a grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking
Systems serving solid fuel cooking operations shall be inspected monthly.
Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking shall be inspected quarterly.
Systems serving moderate-volume cooking operations shall be inspected semi-annually.
Systems serving low-volume cooking operations, such as churches, day camps, seasonal businesses, or senior centers, shall be inspected annually.

8-3.1.1 Upon inspection, if found to be contaminated with deposits from grease-laden vapors, the entire exhaust system shall be cleaned by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Section 8-3.

8-3.1.2 When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the servicing company. It shall also include areas not cleaned.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the commercial cooking equipment at the main hospital was observed.

JUNIPERO BUILDING -
FIRST FLOOR -

1. On 5/4/15, at 12:20 p.m., the two filters above the griddle in Hood 3, located in the main kitchen, were approximately 50 percent covered in grease. When the filters were removed by kitchen staff, the fusible link and duct behind the filters were completely covered in grease.

On 5/4/15, at 12:21 p.m., a sticker on Hood 3 indicated that it was last cleaned by a vendor in April 2015. There were no records provided that indicated how often the five hoods in the main kitchen and the cafeteria were professionally cleaned.

During an interview at 12:22 p.m., Dietary Staff 1 stated that the hoods were cleaned professionally every month and that the facilities department would provide those records.

Records showing how often the hoods were professionally cleaned were not provided during the survey.


29566

ORIGINAL HOSPITAL -
SECOND FLOOR -

2. At 3:35 p.m., on 5/6/15, the inside of the kitchen hood at the Cottage Cafe had a build up of grease on the suppression pipes and the inside wall of the hood.

Based on observation and interview, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by items blocking the egress paths and corridors. This could result in the delay in the evacuation of the facility and the increased risk of injury to the patients and staff due to an emergency. This affected one of six floors in the Original Hospital and one of three floors in the Junipero Building.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the exits were observed.

ORIGINAL HOSPITAL -
SECOND FLOOR -

1. At 3:01 p.m., on 5/6/15, there was an industrial copier located in the egress exit path, near the exit door to the public way, of the Emergency Department.


29665

ORIGINAL HOSPITAL -
SECOND FLOOR -

2. At 12:39 p.m., on 5/4/15, there was an approximately 20 foot by 20 foot designated ambulance parking area outside the 2 West exit door of the Emergency Department (ED). There were ten gurneys and two wheelchairs in the designated ambulance parking area that obstructed the exit path from the 2 West exit door.

At 3:00 p.m., on 5/6/15, there were ten gurneys, two wheelchairs, and ten boxes stored and located in-front of the exit door to the public way and the ambulance bay.

At 3:28 p.m., on 5/7/15, there were 11 gurneys and more than ten cardboard boxes in the ambulance parking that impeded egress from the ED 2 West exit door.


JUNIPERO BUILDING -
SECOND FLOOR -

3. At 9:30 a.m., on 5/6/15, there were three beds and a weight scale in the exit corridor outside the Bed 1 alcove in the Pre-Op area.

During an interview at 9:31 a.m., Pre-Op Nurse 1 stated that the beds were there temporarily because they were just cleaned. She stated that the scale was always kept in the corridor.

Based on observation and interview, the facility failed to ensure that decorations and furnishings used were not of highly flammable character. This was evidenced by the use of plastic tarp-like curtains draped in front of roll-down WON doors. This affected one of six floors in the Original Hospital. This could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.1 Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. (See 19.3.5.5.)
Exception: Curtains at showers.

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.

10.3.1 Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the furnishings and decorations were observed.

ORIGINAL HOSPITAL -
SECOND FLOOR -

1. At 3:41 p.m., on 5/7/15, there was an approximately 11 foot 9 inch wide by 8 foot 6 inch high plastic tarp draped in front of the Cottage Cafe roll-down WON door. Portions of the WON door near the top were repaired with duct tape. The facility failed to confirm if the tarp was flame retardant.

2. At 3:42 p.m., on 5/7/15, there was an approximately 11 foot 9 inch wide by 8 foot 6 inch high plastic tarp draped in front of the Gift Shop roll-down WON door. The facility failed to confirm if the tarp was flame retardant.

Based on observation, the facility failed to maintain their medical gas cylinders. This was evidenced by medical gas cylinders that were stored in close proximity to the ignition sources and by medical gas cylinders that were not secured. This affected the main hospital and two of five offsite locations. This could cause a potential hazardous situation, a possible fire, and the potential risk of injury to patients and staff.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

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

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers-Level 1.
(b) Special Precautions-Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the medical gas cylinders were observed.


29665

EYE CENTER (KNAPP BUILDING) -

1. At 3:06 p.m., on 5/5/15, there were six oxygen H-tanks stored directly adjacent to the air handlers and a heat pump in the Knapp Building mechanical yard. The cylinders were less than 20 feet away from ignition sources.

JUNIPERO BUILDING -
SECOND FLOOR -

2. At 9:57 a.m., on 5/6/15, there were 17 full oxygen E-cylinders and 2 empty oxygen E-cylinders stored in the equipment storage room, across from Operating Room 10. The room was not labeled as an oxygen storage room and there were combustible tarps and blankets covering equipment in the room located less than 5 feet away from the cylinders.

JUNIPERO BUILDING -
FIRST FLOOR -

3. At 11:26 a.m., on 5/6/15, there were three nitrous oxide D-cylinders stored in the medical gas racks in Staging Area 1. The D-cylinders were stored in racks equipped with chains designed to secure the larger H-size medical gas tanks. The nitrous oxide D-cylinders were not secured.

OUTPATIENT SURGERY (OPS) -

4. At 2:59 p.m., on 5/7/15, the medical gas storage room was observed. There was only one chain around more than 10 medical gas H-tanks. There were two nitrous oxide H-tanks that were approximately 6 inches away from the chain and were not secured. The H-tanks could be tilted approximately 45 degrees.

Based on observation and record review, the facility failed to maintain their piped-in medical gas systems. This was evidenced by piped-in medical gas manifolds that were housed in a combustible shed, by the obstruction of emergency shut-off valves, and by the failure to provide self-closing doors for rooms housing the medical gas supply system. This affected one of six floors of the Original Hospital and two of five offsite locations. This could result in the increased risk of hazardous conditions involving oxidizing gases and could increase the risk of harm to patients.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
2. Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.

10. Location of Supply Systems.
a. Except as permitted by 4-3.1.1.2(a)10c, supply systems for medical gases or mixtures of these gases having total capacities (connected and in storage) not exceeding the quantities specified in 4-3.1.1.2(b)1 and 2 shall be located outdoors in an enclosure used only for this purpose or in a room or enclosure used only for this purpose situated within a building used for other purposes.

11. Construction and Arrangement of Supply System Locations. a. Walls, floors, ceilings, roofs, doors, interior finish, shelves, racks, and supports of and in the locations cited in 4-3.1.1.2(a)10a shall be constructed of non-combustible or limited-combustible materials.

4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

4-5.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(b) Nonflammable Gases (3000 ft3 or less; In-Storage, Connected, or both).
3. Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the piped-in medical systems were observed.

ORIGINAL HOSPITAL -
SECOND FLOOR -

1. At 3:30 p.m., on 5/7/15, there was a crash cart and electrocardiogram machine stored directly in front of the piped-in oxygen emergency shut-off valve, near the nurses station in the Emergency Department.

IMAGING CENTER -

2. At 12:24 p.m., on 5/7/15 the piped-in medical gas supply room door was not equipped with a self-closing device. The room was adjacent to the exit egress path to the public way.

3. At 12:25 p.m., on 5/7/15, the piped-in vacuum system room door was not equipped with a self-closing device. The room was adjacent to the exit egress path to the public way.


29665

EYE CENTER (KNAPP BUILDING) -

4. At 12:01 p.m., on 5/6/15, there was a shed containing the piped-in medical gas manifolds in the Knapp Building mechanical yard. The shed was approximately 5 feet 4 inches away from the air handlers in the yard. The side of the shed containing the doors, which faced the air handlers, was made of plywood and there was no labeling on the shed doors to indicate if the shed had at least a 1-hour fire resistive rating.

At 8:28 p.m., on 5/7/15, the blue prints of the Knapp Building mechanical yard, that did not have an approval stamp from any local building department, indicated that the medical gas shed was constructed of 3/4 inch plywood and the doors were made of plywood with rough redwood veneer. The plans did not indicated that the shed had a fire resistive rating of at least 1-hour.

Based on record review, the facility failed to establish emergency procedures for controlling chemical spills. This was evidenced by the facility's failure to provide a documented policy and procedure for controlling chemical spills. This affected one of six floors in the Original Hospital and could result in a delayed response to a chemical spill.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 12 Hospital Requirements
12-4.2 Laboratories. Laboratories in hospitals shall comply with the requirements of Chapter 10 as applicable and the requirements of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, as applicable.

10-2.1.3.2 Emergency procedures shall be established for controlling chemical spills.

Findings:

During tour of the facility with staff from 5/4/15 to 5/8/15, documents were requested. At 11:00 a.m., on 5/4/15, in a documentation checklist, facility staff were requested to provide documentation pertaining to specific emergency procedures for the laboratory.

1. The policy for chemical spill clean up was requested but not provided during the survey.

Based on record review, the facility failed to maintain their laboratory fume hoods. This was evidenced by the failure to provide records of fume hood test and inspections. This affected one of six floors of the Original Hospital. This could result in the increased potential for a fume hood exhaust system malfunction and the increased risk of hazardous conditions.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 12 Hospital Requirements
12-3.7.2 Laboratories. Equipment shall conform to the nonpatient electrical equipment requirements in Chapter 7.

12-4.2 Laboratories. Laboratories in hospitals shall comply with the requirements of Chapter 10 as applicable and the requirements of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, as applicable.

10-3.5 Fume Hoods. Fume hoods shall conform to 5-4.3 and 5-6.2.

5-4.3.4 Fume hood ventilating controls shall be so arranged that shutting off the ventilation of one fume hood will not reduce the exhaust capacity or create an imbalance between exhaust and supply for any other hood connected to the same system.
The operation of these controls shall be tested annually by a qualified person who shall certify the result of the test.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 1996 Edition
6-13.1 When installed or modified and at least annually thereafter, laboratory hoods, laboratory hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested. The following inspections and tests, as applicable, shall be made:
(a) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 5-5.2 );
(b) Flow monitor;
(c) Low airflow and loss-of-airflow alarms at each alarm location;
(d) Face velocity;
(e) Verification of inward airflow over the entire hood face; and
(f) Changes in work area conditions that might affect hood performance.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the hospital's laboratory was observed and maintenance records were requested.

ORIGINAL HOSPITAL -
THIRD FLOOR -

1. At 11:00 a.m., on 5/4/15, Facilities Staff 1 was provided with a list of documents required for review during the survey. One of the items included on the list were the laboratory fume hood inspection reports.

At 12:15 p.m., on 5/6/15, the laboratory fume hood inspection reports had not been provided and were requested again from facility staff.

At 10:05 p.m., on 5/7/15, the laboratory fume hood inspection reports were not provided and were requested again from the laboratory manager. The documents were not provided during the survey.

Based on record review and interview, the facility failed to ensure that laboratory staff were familiar with safety procedures. This was evidenced by the failure to provide documentation of laboratory specific emergency procedures. This affected one of six floors in the Original Hospital and could result in laboratory hazard.

Findings:

During tour of the facility with staff from 5/4/15 to 5/8/15, the laboratory staff was interviewed and documents were requested. At 11:00 a.m., on 5/4/15, in a documentation checklist, facility staff were requested to provide documentation pertaining to specific emergency procedures for the laboratory.

1. During an interview at 10:06 a.m., on 5/7/15, Laboratory Staff 1 stated he was unfamiliar with procedures of a partial or full evacuation to a safe area.

At 10:08 a.m., on 5/7/15, documentation for laboratory specific fire and disaster emergency procedures were requested from the laboratory manager. These documents were not provided during the survey.

Based on observation and interview, the facility failed to maintain their emergency generators. This was evidenced by items that blocked remote alarm annunciators, the failure to confirm if one generator location had the required emergency lighting, and by the failure to provide a remote alarm annunciator for one generator. This affected the main hospital and the Community Rehabilitation Hospital. This could result in a delay in repairing a generator malfunction and the increased risk of complete loss of power, in the event of a power outage.

NFPA 101, Life Safety Code, 2000 Edition,
9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked "run-off-automatic" to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.
3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

5-3.1 The level 1 and Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room shall be supplied from the load side of the transfer switch.

Findings:

During a tour of the facility with staff from 5/4/15 to 5/8/15, the emergency generators were observed.

SBCH: ORIGINAL HOSPITAL AND JUNIPERO BUILDING -

1. At 8:41 a.m., on 5/6/15, there were computer screens and a printer blocking access to the hot water generator annunciator alarm panel, located in PBX on the first floor.

At 9:11 a.m., on 5/8/15, the two generator hot water alarm panels were observed to be blocked again by a printer and two computer monitors in PBX.

ENERGY CENTER -
FIRST FLOOR -

2. At 11:08 a.m., on 5/7/15, it could not be confirmed during the survey if the generator room had the required battery-powered emergency lights.

During an interview at 11:09 a.m., Plant Operation Staff 1 stated he was not sure if the generator room was equipped with battery-powered emergency lights. If the room was equipped with battery-powered emergency lights, Plant Operation Staff 1 indicated that the facility was not testing them.


29665

Cottage Rehabilitation Hospital (CRH) -

3. At 10:26 a.m., on 5/7/15, there was no generator remote audible alarm or derangement signal at a regularly attended work station.

During an interview at 10:27 a.m., Facilities Staff 2 and Safety Staff 1 confirmed that there was no remote annunciator for the generator. They stated that they were planning to install a remote annunciator for the generator based on the findings of a recent accrediting agency survey.

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips and extension cords in lieu of permanent wiring and by the use of electrical equipment in a hazardous way. This affected the Outpatient Center of San Luis Obispo and could result in the increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
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 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 5/4/15 to 5/8/15, the electrical wiring was observed.

COTTAGE OUTPATIENT CENTER OF SAN LUIS OBISPO

1. At 9:56 a.m., on 5/5/15, there was a six-plug power strip plugged into a seven-plug power strip under one of three desks in the staff office.

2. At 9:57 a.m., on 5/5/15, there was a space heater plugged into the six-plug power strip under the desk cited in the previous deficiency. The manufacturer's instructions on the body of the space heater instructed to keep the heater at least 3 feet away from electrical cords, drapery, and other furnishings. The space heater was directly adjacent to a plastic waste basket and to two power strips under the wooden desk.

3. At 10:02 a.m., on 5/5/15, there was a six-plug power strip plugged into a second six-plug power strip behind the file cabinets in the staff office.

4. At 10:10 a.m., on 5/5/15, there was refrigerator plugged into a six-plug power strip in the patient lounge. The six-plug power strip was plugged into a second six-plug power strip that had a microwave plugged into it.