HospitalInspections.org

Sutter Memorial Hospital
During a tour of the facility with Staff, fire-rated walls were observed.
10. On 1/17/13, at 9:05 a.m., there was a two inch by four inch unsealed penetration in the wall in Imaging Room R 202. A metal framing stud could be seen in the wall.

11. On 1/17/13, at 9:59 a.m., the corridor wall in the Laboratory Flammable Liquids Storage Room had an approximately one inch unseal penetration in the upper corner of the east wall.

12. On 1/17/13, at 10:04 a.m., there were two unsealed penetrations in the northwest wall of Laboratory.


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Sutter Memorial Hospital
13. On 1/17/13 at 10:19 a.m., 1 of 3 sprinklers was shifted to one side. There was an approximately 1/4 inch penetration in the ceiling in Central Pharmacy E011.



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Sutter Memorial Hospital
14. On 1/17/13 at 9:54 a.m., there was an approximately 1/2 inch penetration behind one of seven conduits above Electrical Panel 3NL Sect. 1. The penetration was located behind Pipe 5.

15. On 1/17/13 at 10:50 a.m., in the Female Locker Room (Room C242), there was an approximately 7 inch by 2 1/4 inch penetration above the Simplex panel.

16. On 1/17/13 at 11:05 a.m., in the Clean Utility Room (Room C240), there was an approximately 1 inch by 1/2 inch penetration in the ceiling near the dumbwaiter.

Based on observation, the facility failed to maintain the integrity of the building's construction, as evidenced by penetrations in the walls and ceilings. This could result in the passage of smoke in the event of a fire and affected four of six floors at Sutter General and four of eight floors at Sutter Memorial.

Findings:

During a tour of the facility with maintenance staff, the walls and ceiling were observed.

Sutter General Hospital
1. On 1/17/13 at 2:03 p.m., at the west access door, there was an approximately 3 inch by 1 inch penetration in the right wall near the second column in the South Mechanical Room stairwell located in the Basement.

2. On 1/17/13 at 2:10 p.m., at the east access door, there was an approximately 2 inch by 1 1/2 inch penetration in the right wall near the first column in the South Mechanical Room stairwell located in the Basement.




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Sutter General Hospital
3. On 1/14/13, at 10:37 a.m., Soiled Utility Room 4447 had two unsealed penetrations in the corridor wall inside of the room. These penetrations were approximately one-half inch and one-quarter inch in size and were in the center of the wall. This was a one hour fire-rated wall.

4. On 1/14/13, at 10:47 a.m., Room 4448 had eight unsealed penetrations in the corridor wall inside of the room. These penetrations were approximately one-quarter inch in size. This was a one hour fire-rated wall.

5. On 1/14/13, at 11:05 a.m., The Information Technology Room 4D102 had an approximately two inch unsealed penetration in the wall opposite the door.

6. On 1/14/13, at 11:38 a.m., the The First Floor Information Technology Room in Radiology had a one-half inch rigid conduit traveling through the wall that was not sealed on the end. This conduit had yellow data cables in it.

7. On 1/14/13, at 11:57 a.m., the First Floor Film Fill Room had two unsealed penetrations in it. One penetration was caused by a data cable box that was displaced, creating an approximately one-half inch unsealed area around the box. The other penetration was one- half inch by one inch in size. Both penetrations were located in the northeast portion of the wall.








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Sutter General Hospital
8. On 1/14/13 at 10:40 a.m., there were three approximately 1/4 inch penetrations in the left wall and two approximately 1/4 inch penetrations in the front wall in the East Medication Room Nurses' Station.

9. On 1/14/13 at 11:51 a.m., there were six approximately 1/2 inch to 1/4 inch penetrations in the wall in Storage Room 2212B.

Based on observation and interview, the facility failed to maintain all corridor doors. This was evidenced by a corridor door that was obstructed and failed to release. This affected one of six floors in Sutter General Hospital and three of eight floors at Sutter Memorial and could result in the inability to contain a fire in a room.

Findings:

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

Sutter General Hospital
1. On 1/14/13 at 10:12 a.m., the self-closing door to Room 5B114 was obstructed by a chair that prevented the door from closing.

Sutter Memorial
2. On 1/17/13 at 9:26 a.m., the self-closing door to Janitorial Room E521 failed to latch.

3. On 1/17/13 at 9:35 a.m., the door to Room C425 failed to latch.




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Sutter Memorial Hospital
4. On 1/17/13, at 8:50 a.m., the self-closing inner door to the first floor CT Scan Room was being held open by a door wedge.

5. On 1/17/13, at 11:24 a.m., the corridor door to the first floor Cath Lab did not positive latch when tested by releasing the door from an open position.

6. On 1/17/13, at 11:24 a.m., the west door to the first floor Cath Lab had a broken door closure.

7. On 1/17/13, at 1:30 p.m., the corridor door in the Surgery Sterile Core had the latching mechanism taped open preventing the door from positive latching.

Sutter Memorial Hospital
4. On 1/17/13, at 8:50 a.m., the automatic closing corridor door R165 to the Ultra Sound Darkroom did not close upon testing of the door closure from a fully open position. On 1/18/13, at 10:07 a.m., when a pull station was activated door R165 did not release from the hold open device. Staff stated that the door solenoid was not working.



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Sutter Memorial Hospital
5. On 1/18/13 at 9:53 a.m., on the First Floor, Fire Doors N101, N101B, and N101C failed to close when the fire alarm system was tested. The fire doors closed two minutes later, at 9:55 a.m. The fire alarm system was tested again at 9:57 a.m. and 10:05 a.m. The fire doors closed at those times.

Based on observation and interview, the facility failed to maintain exit passageways as evidenced by cross-corridor doors that did not close when the fire alarm system was activated. This could result in the passage of smoke in the event of a fire, and affected two of six floors at Sutter General, one of eight floors at Sutter Memorial and one floor of the Buhler building.

NFPA 101, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During a tour of the facility with staff on 1/16/13, the corridor doors were observed and tested.

Sutter General Hospital
1. On 1/16/13 at 10:51 a.m., First Floor Door 1-2 failed to close when the fire alarm system was tested.

When interviewed at 10:52 a.m., Registered Nurse Staff 7 stated that the door failed to close because the sensor was blocked by a patient on a gurney.
At 10:56 a.m., testing of the fire alarm system continued. Engineer Staff 5 stood in front of the sensor to determine if door closure would be affected. The door closed when the fire alarm system was activated.


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Sutter General Hospital
2. On 1/16/13, at 10:14 a.m., during fire alarm testing, corridor doors 3164, 3130, 3-8, and 3DH001 took longer than 45 seconds to close. Engineering Staff 7 stated that the door timers in the fire alarm control panel were set to release too high. Staff readjusted the doors and re-tested them. The doors closed in less then 30 seconds.


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Buhler Building
3. On 1/14/13 at 3:18 p.m., the door in the Waiting Room in Suite 315 failed to release from the magnetic hold-open device during fire alarm testing. Engineer 7 stated that the door should release because it was on a magnetic hold device and should be connected to the fire alarm system.

Based on observation, the facility failed to maintain its exit locations. This was evidenced by exit signs that pointed (direction arrow) to an unapproved path of egress. This affected one of six floors in Sutter General and four of eight floors at Sutter Memorial and could result in a delayed evacuation when an exit path is not identified in the event of an emergency.

Findings:

During a tour of the facility with staff, the exit arrows were observed.

Sutter General Hospital
1. On 1/14/13 at 11:10 a.m., in the north construction corridor by Room 2110, the exit sign arrow was pointing to the left toward a wall and not an exit door.

Sutter Memorial Hospital
2. On 1/17/13 at 8:37 a.m., the exit sign arrow in Room C704 was pointing to the left, directing occupants to the outside patio on the 7th floor.

3. On 1/17/13 at 8:59 a.m., the exit sign arrow 13A6C05 in Room C620 was pointing to the right, directing occupants to a wall on the 6th floor.

4. On 1/17/13 at 10:25 a.m., the exit sign arrow 13ABAS04 was pointing to the left, directing occupants to a wall, by fire door E012 in the Basement.

5. On 1/17/13 at 10:51 a.m., the exit arrow 13A1Diet21 was pointing to the left, directing occupants to a wall in the Kitchen.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls, as evidenced by penetrations in the walls. This could result in the spread of smoke between compartments and affected four of six floors at Sutter General and three of eight floors at Sutter Memorial.

Findings:

During a tour of the facility with staff, the smoke barrier walls were observed.

Sutter General Hospital
1. On 1/15/13 at 8:53 a.m., there were six penetrations in the smoke barrier wall above Fire Door 5-3 that ranged in size from 1/2 inch to 2 inches.

2. On 1/15/13 at 9:05 a.m., there was an approximately 1 1/4 inch by 3/8 inch penetration in the smoke barrier wall above Fire Door 5-10.

3. On 1/15/13 at 9:55 a.m., there was an approximately 2 inch by 1 inch penetration in the smoke barrier wall above Fire Door 3-3.

4. On 1/15/13 at 10 a.m., there were three penetrations in the smoke barrier wall above Fire Door 3-5. Each penetration measured approximately 1 inch by 1/4 inch.

5. On 1/15/13 at 10:23 a.m., there was an approximately 2 inch penetration in the smoke barrier wall above Fire Door 2-4. The penetration was caused by an unsealed 2 inch conduit with data cables.

6. On 1/15/13 at 11:14 a.m., there was an approximately 1/2 inch penetration in the smoke barrier wall adjacent to Room 1171.

Sutter Memorial Hospital
7. On 1/17/13 at 2:13 p.m., there was an approximately 1/2 inch penetration on the left side of a 1 inch conduit in the smoke barrier wall above Fire Door N502.

8. On 1/17/13 at 2:54 p.m., there was an approximately 3/4 inch unsealed penetration that surrounded three data cables in the smoke barrier wall above Fire Door C301.

9. On 1/17/13 at 3:01 p.m., there were two penetrations (approximately 3/4 inch and 1/4 inch) in the smoke barrier wall above Fire Door N300.

10. On 1/17/13 at 3:22 p.m., there were two penetrations in the smoke barrier wall above Fire Door E200 located across the hall from Elevators 6 and 7. One penetration measured approximately 3 inches and was crescent-shaped in size located on the left side of a 2 inch conduit with data cables. Another penetration measured approximately 3 inches by 1 1/4 inches, and surrounded four 1/2 inch conduits.

11. On 1/17/13 at 3:34 p.m., there was an approximately 1/2 inch penetration in the smoke barrier wall above Fire Door 2DH001A.

Findings:

During a tour of the facility with Staff, cross-corridor doors were observed.

Sutter Memorial Hospital
3. On 1/17/13, at 1:28 p.m., the west leaf of cross corridor doors 1DH007 near Room N166 did not positive latch. These were one hour fire doors.

4. On 1/18/13, at 9:45 a.m., the left leaf of the cross-corridor fire doors E206A on the Nursing Station side did not positive latch.

Based on observation, the facility failed to maintain its fire doors, as evidenced by fire doors that did not latch when the fire alarm system was tested. This could result in the passage of fire and smoke in the event of a fire, and affected two of six floors at Sutter General Hospital and two of eight floors at Sutter Memorial Hospital.

NFPA 80, 1999 Edition
Standard for Fire Doors and Fire Windows
2-4.1.2 A closing device shall be installed on every fire door.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.
Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.

Findings:

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

Sutter General Hospital
1. On 1/16/13 at 10:39 a.m., the left side of the Second Floor Fire Door 2-7 (facing south) failed to latch when tested.



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Sutter General Hospital
2. On 1/16/13, at 11:35 a.m., during fire alarm testing, the one and one-half hour fire-rated cross-corridor doors near the South Mechanical Room BC07 did not close fully and latch. There was an approximately four inch gap between the latch edges of the door leafs. A strong air current could be felt blowing through the gap in the door.

Based on observation and interview, the facility failed to protect its hazardous areas as evidenced by a a gift shop that contained combustible decorations that posed a degree of hazard greater than that normal to the general occupancy of the building and was not protected with smoke-resisting partitions. This was also evidenced by the Gift Shop Storage Room door being held open to the corridor. This affected all staff and patients on one of eight floors at Sutter Memorial Hospital and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

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

1. On 1/17/13, at 11:19 a.m., the fully sprinklered gift shop that was open to the corridor had an amount of combustibles classifying it as "hazardous". The south wall of the gift shop had stuffed animals that covered approximately 90% of the gift shop wall. These stuffed animals were also within approximately six inches of a light fixture. On the opposite side of the corridor were three greeting card stands that were full of greeting cards.

2. The Gift Shop Storage Room door was being held open by a stack of boxes. This door had a self-closing mechanism on the door.

Based on observation, the facility failed to maintain all exit doors, as evidenced by an exit door that was blocked on the egress side. This could result in delayed evacuation in the event of a fire and affected one of six floors at Sutter General.

Findings:

During a tour of the facility with staff, all exit doors were observed.

Sutter General Hospital
1. On 1/14/13 at 3:36 p.m., in Room BD15, Exit Door BD15A was blocked on the egress side by several (approximately eight) plastic linen bins. Each bin measured approximately 60 inches by 36 inches by 48 inches.

Sutter Memorial Hospital
3. On 1/17/13, at 9:59 a.m., the battery back-up lights in First Floor Laboratory Corridor leading to the Waiting Room failed to illuminate when tested by pushing the test button. Engineering Staff 2 also tested the lights with the same result.


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During a tour of the facility with Staff, battery-powered lighting units were observed.

Sutter Memorial Hospital
4. On 1/15/13 at 3:25 p.m., the documentation titled, "U Battery Emergency Light (M) & (A)" indicated 15 units failed in 12 months. In 10/31/12-6 failed, 9/30/12-4 failed, 5/31/12-3 failed, and 2/29/12-2 failed. Engineer staff 1 stated he did not have follow-up record indicating whether it was corrected or not.


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Sutter Memorial Hospital
5. On 1/17/13 at 4:05 p.m., a battery-operated emergency light in the Basement Mechanical Room (Room C023) failed to illuminate when the light was tested.

Based on observation, document review, and interview, the facility failed to provide and maintain its emergency back-up lighting as evidenced by the failure to (1) test the battery back-up lighting at 30 seconds monthly, (2) Emergency lighting units that failed to illuminate and (3) failure to provide battery-powered emergency lights at its generator set location. This affected all staff and patients in Sutter General and Sutter Memorial Hospital, and could result in failure of battery-powered emergency lighting and the loss of lighting at the emergency generator location.

2000 NFPA 101
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. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1999 NFPA 110 5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Findings:

During document review and interview with staff, the emergency back-up lighting units were observed and documents were requested.

Sutter General Hospital
1. On 1/15/13 at 3:10 p.m., the documentation indicated 1 of 12 months that the emergency lighting was not tested. There was no monthly testing in June 2012 for the unit in Angio. Secretary staff stated the Angio unit was added in April, but did not get updated to be tested in June 2012.



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During a tour of the facility with Staff, battery-powered back up lighting units were observed.

Sutter General Hospital
2. On 1/15/13, at 9:50 a.m., the facility's generator set location at the Central Plant did not have battery-powered emergency lighting units in the enclosed room. When asked, Engineering Staff 1 stated that he did not see any battery-powered light, but that they could be added.

Based on observation, document review, and interview, the facility failed to maintain its emergency exit signs. This was evidenced by exit signs that failed to display the expiration dates and were not tested 30 seconds monthly and 90 minutes annually. This affected one of eight floors in the Buhler building, six of six floors at Sutter General, eight of eight floors at Sutter Memorial Hospital, and one of six floors in the Fort Sutter building. This could result in the loss of illuminated exit signs during an emergency.

NFPA 101, 2000
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During tour, document review, and interview with staff, the emergency exit signs were observed and documentation requested.

Buhler building
1. On 1/14/13 at 1:45 p.m., two self-illuminated exit signs in Suite 315 failed to provide the expiration date, as required, underneath the specification life span slot. Engineer 1 stated he thought it was a five year life span. He further indicated there is a sticker, but it was not legible for review.

Sutter General Hospital
2. On 1/15/13 at 3:43 p.m., the documentation titled, "F exit signs (m)" failed to indicate when the 90 minutes test were completed.

Fort Sutter
3. On 1/15/13 at 3:55 p.m., there was no documentation for 30 second monthly and 90 minutes annually tests. Engineer staff 1 stated that it is a leased building and he does not maintain the building.





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Sutter General Hospital
6. On 1/14/13 at 2:50 p.m., in the Basement, the exit sign near Fire Door BX01 failed to remain illuminated when tested.

Sutter Memorial Hospital
4. On 1/15/13 at 3:35 p.m., the documentation titled, "Exit sign" failed to indicate when the 90 minute test was completed. Engineer 4 stated all exit signs with the test button did not have a battery equipped with the exit signs.

5. On 1/17/13 at 10:10 a.m., the photo illuminated exit sign outside Sterile Processing that pointed toward Stairwell 2 failed to display the expiration date, as required underneath the specification life span slot, in the Basement.

Based on document review and interview, the facility failed to ensure fire drills were conducted as required and failed to ensure that all staff responded in the event of a fire emergency. This was evidenced by no fire drills conducted as required and three staff that were not familiar with what actions to take in the event of a fire. This affected all patients in Sutter General and Memorial Hospital, and 1 of 6 floors in the Fort Sutter building. This could potentially result in a delay in staff or first responders' responses in the event of a fire.

NFPA 101, 2000
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.

Findings:

During document review and interview with staff, fire drills documentation was requested and interviews were conducted on fire and life safety procedures.

Fort Sutter Oncology at Infusion
1. On 1/15/13 at 4:23 p.m., there were no documents provided that indicated fire drills were conducted on the 6th floor, suite 690. Engineer staff 1 stated he requested the fire drill records and never received them.

Sutter General Hospital
2. On 1/16/13 at 10 a.m., a unit secretary staff on the 4th floor north was asked what would she do in the event of a fire. The unit secretary staff stated she would call 4000, the hospital emergency number. She failed to indicate the use of the fire alarm to notify other departments. A unit charge nurse thought that by calling 4000, it would activate the fire alarm system. Engineer staff 1 explained that by calling 4000, it only notified dispatch of where the fire was, and would not activate the fire alarm. He explained that fire alarm is required to be activated by staff.

3. On 1/16/13 at 11:26 a.m., a Pharmacy Technician staff in the Basement was asked what would she do in the event of a fire. The Pharmacy Technician staff stated she would call 4000 and that staff in the pharmacy would know what to do. She failed to indicate the use of fire alarm to notify other departments. Engineer staff 1 stated they should be activating the fire alarm system and then calling 4000.

Based on observation, testing, document review, and staff interview, the facility failed to maintain its fire alarm system to insure the safety of patients as evidenced by the:

1. Failure of the fire alarm system to provide visual and audible notification in two of two Emergency Department Suites. Patients and staff in the affected area would not be able to hear a fire alarm signal inside of the affected suite.
2. Failure of the fire alarm XLS panel connected to the Emergency Department on the first floor to communicate an audible or visual trouble signal to the main hospital fire alarm panel.
3. Failure to test the system for integrity after changes have been made to the fire alarm system such as relocating, decommissioning or modifying the fire alarm system.
4. Failure to monitor and follow the internal Hospital policy titled, "Notification of activity " which involves staff review and approval procedures designed to ensure that critical construction activity has been approved by the Hospital staff.

This deficient practice affected all staff and patients in the Emergency Department and could potentially result in a delay in response by staff and the spread of smoke and/or fire in both the Emergency Department and the rest of the hospital.

2000 NFPA 101
9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation

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.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

9.6.3 Occupant Notification.
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.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

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.

1999 NFPA 72
7-1.6.2* Reacceptance Testing.
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.

7-1.6.2.2 Changes to all control units connected or controlled by the system executive software shall require a 10 percent functional test of the system, including a test of at least one device on each input and output circuit to verify critical system functions such as notification appliances, control functions, and off-premises reporting.

1-6.1 Approval and Acceptance.
1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

3-8.3.2.2 Automatic Fire Alarm Signal Initiation. Automatic fire alarm-signal initiation devices that have integral trouble signal contacts shall be connected to the initiating device circuit so that a trouble condition within a device does not impair alarm transmission from any other initiating device.
Exception: Where the trouble condition is caused by electrical disconnection of the device or by removing the initiating device from its plugin base.

3-8.4.4.2.1 Relays or modules providing transmission of trouble signals to a supervising station shall be arranged to provide fail-safe operation.
3-8.4.4.2.2 Means provided to transmit trouble signals to supervising stations shall be arranged so as to transmit a trouble signal to the supervising station for any trouble condition received at the protected premises control unit, including loss of primary or secondary power.

Findings:

Sutter General Hospital
1. During fire alarm testing on 1/16/13, at 10:48 a.m., the fire alarm control panel (FACP) model XLS located on the first floor outside of the elevators near the Emergency Department had a yellow trouble light visible. The FACP message stated, "Disabled Active Booster Power Supply Activation Signal Local Trouble ACT Map Fault". Engineering Staff 7 (ES7) was asked if the trouble could be cleared before testing began on that floor.

At 10:52 a.m., this surveyor observed and heard ES7 communicate with the Main FACP Technician and ask him to reset the main FACP to clear the XLS model fire alarm panel. The XLS model fire alarm panel remained in a trouble condition.
ES7 stated that he was going to try to reset and clear the trouble at the XLS model fire alarm panel itself. The XLS model fire alarm panel remained in a trouble condition.

At 10:54 a.m., ES7 was asked what areas the XLS FACP monitored and he stated the Emergency Department.

At 10:52 a.m., this surveyor had staff activated a water flow near Room 1110 to simulate the activation of one fire suppression sprinkler head on that floor of the building. The fire alarms could be heard outside of the Emergency Department.

At 10:56 a.m., a fire alarm pull station used to activate the fire alarm near Room 1188 was activated. The pull station did not activate a chime or strobe inside of the Emergency Department (ED). After the fire alarm pull station was activated, ES1 confirmed that the chimes and strobes (flashing lights) did not activate and stated, "It is very silent in here". ES3 walked outside the ED and stated that the chimes and strobes were active outside the ED.

At 11:00 a.m., Engineer Staff 1 stated he did not hear any chimes initiated inside the ED department and it was very silent. Engineer staff 1 walked outside of the ED department and noted the chimes and strobes in the corridor were still active, but they were not audible inside the ED department.

During an interview at 11:00 a.m., Nurse 1 and 2 inside the ED stated they heard chimes/strobes going off all day, but were not sure if the chimes or strobes inside the ED department were activated. Engineer staff 1 informed the two nurses that the chimes or strobes were not working and to pay attention to overhead announcements in the event of a fire.

At 11:16 a.m., smoke detector 145 inside the ED was tested with artificial smoke. The smoke detector did not activate chimes or strobes inside the ED, but it did activated chimes and strobes outside of the ED.
At 11:45 a.m., Engineer Staff 1 radioed to Engineer Staff 7 and stated that the XLS model fire alarm panel had been in trouble since Monday (1/14/13).
Engineer Staff 1 confirmed and indicated the XLS fire alarm panel was in trouble since Monday. Engineer staff 1 stated he would find out more information and inform surveyor.

At 1:10 p.m., Engineer Staff 1 stated that the electrician from Decker Electric, which is a sub-contractor, hired through Siemens Fire Alarm Company, may have known the system was in trouble and failed to notify the hospital. He further indicated the electrician relocated the smoke detectors outside of the construction zone and did not notify anybody that the system was in trouble. He will check with the PBX staff if they noticed anything unusual that came during that time.

During an interview with Engineering Staff 1 at 1:10 p.m., Staff stated that the XLS Model fire alarm panel was not communicating the trouble with the main fire alarm control panel and they were not sure why.

2. At 2:25 p.m., Engineer staff 1 stated the PBX (private branch exchange) did not notice anything unusual. He further stated if there was a trouble, the central monitoring station should have called and notified the facility; in this case, there was no call from the central monitored station.

3. At 2:47 p.m., Engineer staff 1 stated that any time there was work to be done to the fire alarm panel, the documentation titled " Notification of Activity " was required to be filled out and approved. In this case, he did not receive any notification of activity form or any verbal notice that there would be work done on the fire alarm system.
At 3:04 p.m., the technician from Siemens stated he knew about the work the electrical subcontractor was doing and felt that they did not do anything wrong by relocating the smoke detectors to a safe place. He indicated when they were done relocating the smoke detectors to a safe place; he walked by the main fire alarm panel and noticed it was green for normal. He did not look at the XLS fire alarm panel.

4. At 3:30 p.m., Engineer Staff 1 stated he did not receive any notice from the electrician and technician that they were relocating smoke detectors. Engineering Staff 1 thought that when they relocated the smoke detectors in the wrong sequence of order, that they would get a trouble signal at the fire alarm panel. Engineer Staff 1 further indicated that the order request from the IOR was to decommission (remove) the devices instead of relocating the devices.
On 1/17/13 at 8:30 a.m., Engineer Staff 1 provided a letter from Inspector of Record (IOR) indicating the order request was to remove the Honeywell devices.

Based on record review, observation, and interview, the facility failed to test and maintain all of its fire alarm system components as evidenced by the following:

1. Smoke detectors that had not been tested during the Annual Alarm Device Certification Report.

2. A chime/strobe that failed to emit an audible sound during fire alarm testing.

3. Fire door magnetic hold-open devices that re-energized when the Fire Alarm Control Panel (FACP) was silenced but was still in active alarm.

4. A smoke detector that had tape covering the outside of it.
This finding affected four of six floors at Sutter General Hospital, four of eight floors at Sutter Memorial Hospital, and one of three offsite buildings, and could potentially result in deficiencies with the smoke detector going unnoticed resulting in the spread of smoke and/or fire.

2000 NFPA 101
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.

9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

1999 NFPA 72
1-5.4.2.2. 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.
33.3.3.4.4 Occupant Notification. Occupant notification shall be provided automatically, without delay, by internal audible alarm in accordance with 9.6.3

Findings:

Sutter General Hospital
During document review with Staff, documentation for fire alarm testing and inspection was reviewed.

1. On 1/15/13, at 9:50 a.m., the facility failed to provide documentation indicating that all smoke detectors in the facility had been tested for functionality within the past year.

Documentation provided titled "Smoke Detectors" dated 6/11/12, showed in the comments field of the the report that 164 devices were listed as not found or not tested.

During a tour of the building with Engineering Staff 2 and 7 on 1/16/13 between 2:00 p.m. and 3:00 p.m., this surveyor visited a sample of locations on the first, second, and third floors to determine if detectors that had been listed as " listed as not found or not tested" were in fact at those locations. The following detectors were found:

Device number 23 Room 1134
Device number 31 Room C118
Device number 34 Room 1137A
Device number 49 Room 1105
Device number 71 Entrance by Rotunda Doors
Device number 66 Kitchen 2212
Device number 67 Kitchen by corridor 2211
Device number 69 Kitchen 2111B

On 1/16/13, at 2:10 p.m., device number 197 inside Supply Room 4451 blinked and was found. When asked, Engineering Staff 4 stated that the detector was the original detector.

When asked, Engineering Staff 7 confirmed that the detectors were still at their original locations. Staff also stated that many of the areas on the annual certification were in construction locations and no longer existed.
No documentation was provided indicating the how many of the above mentioned 164 detectors were not decommissioned due to construction and were able to be tested.




27994

Fort Sutter Oncology at Infusion Suite 690
2. On 1/15/13 at 9:18 a.m., the documentation titled "Alarm System" dated 5/18/12, was incomplete. The report failed to indicate that devices in Suite 690 were tested.

Sutter Memorial Hospital
During fire alarm testing with Staff, fire alarm system components were observed.

3. On 1/17/13, at 10:54 a.m., the smoke detector in the Administration Office Storage Room 201 was taped on the outside with blue masking tape. Staff stated that the room was being painted and would be finished by the end of the day. No one was in the room painting at that time.

4. On 1/18/13, at 8:34 a.m., the cross-corridor door hold-open magnets to doors E700 were re-energized when the fire alarm control panel was silenced only and not reset. The panel was still in active alarm.

5. On 1/18/13, at 9:58 a.m., the cross-corridor door hold-open magnets to doors C100 were re-energized when the fire alarm control panel was silenced only and not reset. The panel was still in active alarm.

6. On 1/18/13, at 9:58 a.m., the cross-corridor door hold-open magnets to doors 1DH002 were re-energized when the fire alarm control panel was silenced only and not reset. The panel was still in active alarm.




27994

Sutter Memorial Hospital
7. On 1/18/13 at 9:05 a.m., fire alarm system was activated and the audible alarm devices were silenced, the fire alarm system re-energized all of the magnetic hold open devices on the fire/smoke doors 5DH029 and 5DH030.

8. On 1/18/13 at 9:06 a.m., fire alarm system was activated and the audible alarm devices were silenced, the fire alarm system re-energized the magnetic hold open devices on the fire/smoke doors 5DH027 and 5DH028.

9. On 1/18/13 at 9:11 a.m., the manual pull alarm 3-109-104PB took 29.8 seconds to activate the fire alarm system, on the 4th floor.

10. On 1/18/13 at 9:53 a.m., fire alarm system was activated and the audible alarm devices were silenced, the fire alarm system re-energized the magnetic hold open devices on the fire/smoke door E130B.




29753

Sutter Memorial
11. On 1/18/13 at 9:53 a.m., Strobe/Chime 1AV019 near Fire Door N101 failed to activate when the fire alarm system was tested. The fire alarm system was tested again at 9:57 a.m. and 10:05 a.m. Strobe Chime 1AV019 activated at those times.

Based on record review, observation, and interview, the facility failed to provide documentation of maintenance, inspection, and testing of all smoke detectors as evidenced by incomplete testing and documentation for smoke-sensitivity testing. This deficient practice affected all staff and patients on four of six floors at Sutter General Hospital and could potentially result in deficiencies (false alarms or no alarms) with the smoke detectors going unnoticed.

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

Findings:

Sutter General Hospital
During document review with Staff, documentation for smoke detector sensitivity testing was reviewed.

1. On 1/15/13, at 9:50 a.m., the facility failed to provide documentation indicating that all smoke detectors in the Hospital had been tested for sensitivity within the past two years.

Documentation provided titled "Smoke Detector Sensitivity Testing" dated 6/14/12, showed in the comments field of the report that 76 devices did not have access, were not found, were too high, or were not labeled.

During a tour of the building with Engineering Staff 2 and 7 on 1/16/13 between 2:00 p.m. and 3:00 p.m., this surveyor visited a sample of locations on the first, second, and third floors to determine if detectors that had been listed as "not having access, were not found, were too high, or were not labeled" were in fact at those locations. The following detectors were located:

Device number 23 Room 1134
Device number 31 Room C118
Device number 34 Room 1137A
Device number 49 Room 1105
Device number 71 Entrance by Rotunda Doors
Device number 103 Elevator Lobby Honeywell panel side
Device number 104 Elevator Lobby Honeywell panel side
Device number 66 Kitchen 2212
Device number 67 Kitchen by corridor 2211
Device number 69 Kitchen 2111B

On 1/16/13, at 2:10 p.m., device number 197 inside Supply Room 4451 blinked and was found. When asked, Engineering Staff 4 stated that the detector was the original detector.

When asked, Engineering Staff 7 confirmed that the detectors were still at their original locations. Staff also stated that many of the detectors on the annual certification were in construction locations and no longer existed.
No documentation was provided indicating the how many of the above mentioned 76 detectors were not decommissioned due to construction and were able to be tested.

During record review with Staff on 1/15/13, documentation for fire sprinkler system testing and inspection records were reviewed.

Sutter Memorial Hospital
13. At 9:50 a.m., documentation provided titled "Inspection, Testing, and Maintenance Fire Sprinkler System" documented in the deficiencies and comments section of the the report that the "Grinnell Dura Speed heads are over fifty years old in the Central and East wing".

During a tour of the facility with Staff on 1/18/13, at 10:14 a.m., Duraspeed sprinkler heads were observed in the Basement East Wing. When asked, Engineering Staff 1 stated that the only areas affected would be small areas of the Fourth and Fifth floors and Basement, and the laundry and Trash Chutes between floors. Sprinkler heads over 50 years old may need to be replaced.





29753

Sutter Memorial Hospital
14. On 1/17/13 at 8:46 a.m., the sprinkler in the Trash Chute (C335) was loaded with grease, dust, and lint.

15. On 1/14/13 at 9:40 a.m., in Room N314 (Supplies Closet), there was paint on the sprinkler's strut.

16. On 1/17/13 at 10:35 a.m., in Room W224 (Neonatal Intensive Care Unit, Room D), one of six sprinklers was loaded with dust and lint. The affected sprinkler was the second sprinkler on the left on the south side of the room.

17. On 1/17/13 at 11:33 a.m., in Room E238 (Clean Utility Room), there was an oily green substance on the sprinkler.

18. On 1/17/13 at 11:39 a.m., in Room E215 (Housekeeping Closet), there was an oily yellow substance, dust, and lint on the deflector.

Based on document review and staff interview, the facility failed to test and maintain its automatic sprinkler system. This was evidenced by the following:

1. Noted deficiencies on the annual sprinkler system testing and inspection report that had not yet been repaired

2. Missing quarterly sprinkler inspection and testing.

3. Sprinkler heads that were loaded or covered with dust, paint, cobwebs or corrosion.
.
These findings affected five of six floors at Sutter General Hospital, three of eight floors at Sutter Memorial Hospital and two of three offsite buildings and could potentially result in the spread of smoke and/or fire.

NFPA 101, 2000 Edition,
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 25, 1998 edition
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

2-3 Testing.
2-3.1 Sprinklers.
2-3.1.1* Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10- year intervals.

Exception No. 1: Sprinklers manufactured prior to 1920 shall be replaced.

Exception No. 2: Sprinklers manufactured using fast response elements that have been in service for 20 years shall be tested. They shall be retested at 10-year intervals.

Exception No. 3:* Representative samples of solder-type sprinklerswith a temperature classification of extra high [325°F (163°C)] orgreater that are exposed to semicontinuous to continuous maximum allowable ambient temperature conditions shall be tested at 5-year intervals.

Exception No. 4: Where sprinklers have been in service for 75 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to
the authority having jurisdiction for field service testing. Test procedures shall be repeated at 5-year intervals.

2-3.1.2 A representative sample of sprinklers shall consist of a minimum of not less than 4 sprinklers or 1 percent of the number of sprinklers per individual sprinkler sample, whichever is greater.
2-3.1.3 Where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers represented by that sample shall be replaced. (See 2-4.1.1.)

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with staff, sprinkler system components were observed

Sutter General Hospital
1. On 1/14/13 at 10:42 a.m., a sprinkler in the Housekeeping Closet 5C15 had paint on the strut.

2. On 1/14/13 at 10:43 a.m., a corridor sprinkler by Room 5C03 had lint build up around the head.

3. On 1/14/13 at 11:15 a.m., 1 of 8 sprinklers in Room 2310 had lint build up around the head.

4. On 1/14/13 at 11:43 a.m., a sprinkler in the Dietary Storage Room 2212G had paint on the deflector plate.

5. On 1/14/13 at 11:46 a.m., 3 of 10 sprinklers inside the Kitchen tray line area were corroded with dark grease and corrosion around the sprinkler heads.

Buhler building
6. On 1/14/13 at 3:10 p.m., the Inspector Test Valve (ITV) on the rooftop failed to activate the alarms within 90 seconds. The first time it took more than a minute and forty six seconds to activate the alarm. The second time it took more than two minutes. Engineer staff 1 stated that it failed to emit a sound within 90 seconds. The documentation titled "Water Flow Switches" dated 11/21/12 indicated it took 85 seconds and passed.

Sutter Fort
8. On 1/14/13 at 1:41 p.m., a corridor sprinkler by Station 14 had lint build up.
Sutter Fort-Oncology at Sutter Suite 215 and 315

9. Documentation provided titled "Inspection, Testing, and Maintenance Fire Sprinkler System" indicated that the quarterly sprinkler inspection and testing was done on 12/28/12 only. Engineering Staff 1 stated that it is a leased building and that the facility will probably take over the testing.



29753

Findings:

Sutter General
10. On 1/14/13 at 10:13 a.m., there was a piece of plastic on the deflector of one of three sprinklers in Room 3162. The sprinkler was located above the cleaning equipment storage area.

11. On 1/14/13 at 10:15 a.m., the sprinkler above the sink in Room 3160 (Women's Restroom) was loaded with dust and lint.

12. On 1/14/13 at 3:32 p.m., there was a piece of plastic on the deflector of one of two sprinklers in Room BD32 (Dirty Linen Room). The sprinkler was located near the loading dock drop-down door.

Findings:

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

Sutter Memorial Hospital
6. On 1/17/13, at 10:10 a.m., the fire extinguisher in the northeast corner of the Laboratory had a trash can placed in front of it.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by fire extinguishers that were mounted too high, that were not fully accessible and not fully charged, and were past due for their annual inspection. This affected one of six floors at Sutter General and one of eight floors at Sutter Memorial and could result in increased potential for portable fire extinguisher malfunctions.

1998 NFPA 10
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lbs shall be installed so that the top of the fire extinguishers is not more than 5 ft above the floor. Fire extinguishers having a gross weight greater than 40 lbs shall be so installed that the top of the fire extinguishers is not more than 3 1/2 feet above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inch.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30- day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

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

4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

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

Sutter General
1. On 1/14/13 at 11:45 a.m., a portable K class fire extinguisher inside the kitchen was mounted with the handle at approximately 61 inches from the floor.

2. On 1/14/13 at 11:50 a.m., a portable K class fire extinguisher in the serving area was mounted with the handle at approximately 70 inches from the floor.


25385

Sutter General Hospital
3. On 1/14/13, at 2:05 p.m., the fire extinguisher located in the Staff Breakroom 1248 in the Emergency Department had a trash can placed in front of the extinguisher cabinet.

4. On 1/15/13, at 9:50 a.m., there were two fire extinguishers sitting on the floor in the Parallel Switch Gear Room in the central plant. The pressure gauge could not be read because there was a cement-like material covering portions of the outside of the extinguisher. Engineering Staff 1 stated that it looked like a spray coating.

5. On 1/15/13, at 9:52 a.m., there were two fire extinguishers located on the floor at the west end of the generator set location in the Central Plant. These extinguishers were partially discharged and the annual HMIS label had a test date of 2009.

Based on record review and interview, the facility failed to maintain all fire/smoke dampers. This was evidenced by several fire/smoke dampers that were not inspected within the past four years. This affected Sutter General Hospital and three of three outpatient facilities and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review with staff, on 1/15/13, at 9:50 a.m., the facility's fire/smoke damper inspection records were requested.

Sutter General Hospital
1. Documentation provided for damper inspection dated March 2011 indicated in the diagnosis field of the report that five electric smoke dampers in the Basement level had "No Access due to duct work and no place to install a new one. Hospital issue".

Capital Pavilion-Ambulatory Surgery at Sutter
2. Documentation provided for damper inspection dated March 2011 indicated in the diagnosis field of the report that one electric combination damper in the Basement level had "No Access due to duct work and no place to install a new one. Hospital issue".

Buhler Cancer Center-Oncology at Infusion
3. Documentation provided for damper inspection dated October 2010 indicated in the diagnosis field of the report that ten dampers documented "Need access door", two dampers documented "would not open when reenergized in closed position hospital issue", and one damper was documented as "needs fire-rated flange door".

Sutter Fort-Oncology at Sutter Suite 215 and 315
4. The facility did not provide documentation for damper inspection. When asked, Engineering Staff 1 stated that the building was a leased building.

Based on observation and interview, the facility failed to maintain its kitchen exhaust hood. This was evidenced by accumulation of greasy deposits on pipes inside the kitchen exhaust hood, and failure to provide the required type of grease filters for the kitchen suppression and exhaust system. This affected 1 of 6 floors in Sutter General Hospital and 1 of 8 floors at Sutter Memorial Hospital. This could result in an increased risk of a grease fire ignition in the kitchen.

NFPA 96, 1998 edition
3-1. Listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters shall not be used.

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 powder or other 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-System serving moderate-volume cooking operations-semi-annually.

Findings:

During tour and interview with staff, the kitchen hood exhausts were observed.

Sutter General
1. On 1/15/13 at 2:50 p.m., there was a thick accumulation of greasy deposits on pipes running through the interior kitchen exhaust hood. The hood was last cleaned on 3/22/12. Engineer staff 1 stated the exhaust hood is cleaned once a year.

Sutter Memorial Hospital
2. On 1/17/13 at 10:48 a.m., it was observed the facility had grease filters installed in the kitchen's designed suppression and exhaust system that were built with 20 panels of wire mesh screens rather than the required baffle type filter.

3. On 1/17/13 at 10:49 a.m., there was a thick accumulation of greasy deposits on pipes running through the interior kitchen exhaust hood. The hood was last cleaned in 3/22/12. Engineer staff 1 stated the exhaust hood is cleaned once a year.

Based on document review and interview, the facility failed to maintain its piped medical gas system. This was evidenced by noted discrepancies in the annual medical gas certification report that had not been repaired. This affected all patients in Sutter General, Memorial and Capital Pavilion. This could potentially result in the acceleration of fire.

NFPA 99, 1999
4-3.1.1.2 (4) Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied
4-3.1.2.7 (g) Joints in medical gas tube shall be brazed except that memory-metal couplings having temperature and pressure ratings not less than that of a brazed joint shall be permitted. Flared and compression type connections shall be prohibited throughout the piping system, including connections to station outlets, alarm devices, and other components. Unions shall not be permitted in the distribution pipeline system.
4-3.2.2.8 (a) General. To ensure continuos responsible observation, the master alarm signal panels shall be located in two separate warning locations, wired in parallel to a single sensor to indicate when the vacuum in the main line drops below the level required in 4-3.4.2.2 (c) 4b. Audible and noncancelable visual signals shall be installed in the office or principal working area of the individual responsible for the maintenance of the vacuum system and, to ensure continuous surveillance, at the telephone switchboard, the security office, or other continuously staffed locations.
4-3.1.1.9 (f) Receivers. The receiver shall be equipped with a pressure relief valve, automatic drain, sight glass and pressure gauge and shall have the capacity to ensure practical on-off operation. The receiver shall comply with section VIII, unfired pressure vessels, of the ASME boiler and pressure vessel code and shall be corrosion resistant. Piping within compressor systems upstream of the source shutoff valve shall comply with 4-2.1.2.7 and 4-3.1.2.8 except that stainless steel shall be permitted to be used as a piping material.
4-3.1.2.2.(6) All pressure switches, pressure gauges, and pressure-sensing device downstream of the source valve shall be provided with a gas specific demand check fitting to facilitate servicing, testing, or replacement.
4-3.1.1.8 (h) Emergency oxygen supply connection. Where the cryogenic oxygen supply is located outside if the building served, there shall be incorporated in the piping system and inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations.........
(e) Pressure Relief Valves.
Each central supply system shall have a pressure relief valve set at 50 percent above normal line pressure, installed downstream of the pressure regulator and upstream of any shutoff valve. This pressure relief valve shall be permitted to be set at a higher pressure, provided another pressure relief valve set at 50 percent above normal line pressure is installed in the main supply line. All pressure relief valves shall close automatically when excess pressure has been released. Pressure relief valves set at 50 percent above normal line pressure shall be vented to the outside from all gas systems, except medical air, or if the total capacity of the supply system is in excess of 3000 ft3 (85 m3) of gas. Pressure relief valves shall be of brass or bronze and specially designed for the gas service involved.
(g) Final Line Regulators.
Final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.
4-3.1.2.3 Gas Shutoff Valves.
(h) Shutoff Valves (New or Replacement). New or replacement pipeline shutoff valves shall be of a quarter-turn ball type manufactured with extensions for brazing, and with an indicating handle and shall be of metallic construction. Valves shall be the three-piece type with full-size ports.
4-3.1.2.7 Piping Materials. The provisions of this section apply to field-installed piping for the distribution of medical piped gases.
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.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled
" SOURCE VALVE FOR THE (SOURCE NAME). "
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
4-3.2.1.9 Exhausts. The exhaust from vacuum pumps shall be discharged outdoors in a manner that will minimize the hazards of noise and contamination to the hospital and its environment. The exhaust shall be located remote from any door, window, air intake, or other openings in buildings with particular attention given to separate levels for intake and discharge. Care shall also be exercised to avoid discharge locations contraindicated by prevailing winds, adjacent buildings, topography, and other influences. Outdoor exhausts shall be protected against the entry of insects, vermin, debris, and precipitation. Exhaust lines shall be sized to minimize back pressure. Discharge piping shall be free of dips or loops that might trap condensate or oil. If such discharge piping is unavoidable, a trapped drip leg shall be installed to keep the piping free of fluid buildup. Discharge of pumps utilizing a common exhaust pipe shall be fitted with a check valve, a manual valve, or arranged to permit capping of the active pipe when removing or servicing a pump.
4-3.1.2.2.(3) each local, master, and area alarm panel shall be labeled for its area if surveillance (e.g. O2, vacuum, medical air), etc., and room(s) served. Each indicator shall be separately labeled indicating the condition monitored.
4-3.1.2.3 (h) shutoff valves (new or replacement) New or replacement pipeline shutoff valves shall be of a quarter-turn ball type manufactured with extension for brazing, and with an indicating handle and shall be metallic construction. Valves shall be the three-piece type with full-size ports.

Findings:

During document review and interview with staff, the medical gas reports were reviewed.

Sutter General Hospital
1. On 1/15/13 at 3 p.m., the documentation titled "Nitrous Oxide Manifold (MF)" dated 4/3/12 had the following "NO" on the report:
A) MF Model 108014-01: items 31a and 40
B) MF Model 108011-02: items 31a and 40
C) MF Model 802AL002: items 31a and 40

Sutter Capitol Pavilion
2. On 1/15/13 at 3:15 p.m., the documentation titled "Nitrous Oxide Manifold (MF), Medical Air (MA), Medical Vacuum (MV), and Carbon Dioxide Manifold MF-1)" dated 4/3/12 had the following "NO" on the report:
A) MF Model 107011-03: items 13a, 31a, and 40
B) MF Model 107014-04: items 31a and 40
C) MA Model 4107000858: items 42a, and 39
D) MV Model 4107102656: items 17a and under "Comment"-The source valve needs to be labeled.
E) MF-1 Model 107020-02: items 13a, 31a, and 40

Sutter Memorial Hospital
3. On 1/15/13 at 3:30 p.m., the documentation titled "Nitrous Oxide Manifold (MF), Nitrogen Manifold (MF-1), Carbon Dioxide Manifold MF-2), Medical Vacuum (MV 1-4), Medical Air (MA 1-2), and Oxygen Manifold (O2)" dated 4/11/12 had the following "NO" on the report:
A) MF Model 1110-61-A: items 13a, 18, 19a-f, 28, 30c-e, 31a, c, and 40
B) MF-1 Model 273-R: items: 13a, 19c, f, 28, 30c-e, 31a, and 40
C) MF-2 Model 273-R: items: 13a, 18, 19c, f, 28, 30c-e, and 31a
D) MV-1 Model 908470-PL: items 10a-c, 17a, 19c-d
E) MV-2 Model PRV-2204: items 10a-c, 17a, 19c-d
F) MV-3 Model HC-130: items 10a-c, 17a
G) MV-4 Model PRV 3208: items 10a-c, 17a
H) MA Model M25388: items 12c, 15a, 20, 21, 22, 26c-e, 31, 32, 33, 41
I) MA Model M25388: items 12c, 15
J) MA-1 Model M25388: items 12c, 15,
K) MA-2 Model N/A: items 12c, 15, 20, 21, 22, 26c-e, 32, 33
L) O2 Job 201968: items 31c-e, 32a-c, 34a, 35b

4. On 1/15/13 at 3:45 p.m., the documentation titled, "Medical gas outlets" dated 4/11/12 had discrepancies noted as follow:
A) Outlet sheet: C030A with note 11: ceiling hose assembly
B) Outlet sheet 4: Recovery 1, 10, & 12 with note 4: leak through without adapter
C) Outlet sheet 5: OR 1A/B, 2A/B/C, 3A/B/C, 4A/B/C/D with note 11: ceiling hose assembly
D) Outlet sheet 6: OR 5A/B/E with note 11: ceiling hose assembly
E) Outlet sheet 9: R144, R155, R177 with note 4: leak through without adapter
F) Outlet sheet 26: C321 (323) with note 4: leak through without adapter
G) Outlet sheet 27: C359B (309) with note 4: leak through without adapter
H) Outlet sheet 30: Nursing director N323A/B with note 9: unable to test at this time, comment: Office outlet behind cabinets
I) Outlet sheet 35: C410A/B (419) and C415 (421) with note 4 and 3: leak through without adapter and leak with adapter inserted
J) Outlet sheet 36: C426A (425), C429B (426), C451A (412), C456B (408) with note 4: leak through without adapter
K) Outlet sheet 37: N405 (471), N408 (473), N410 (474), N412 (475), N415 (477), N421 (481), N423 (482) with note 14, 4: missing latch button, leak through without adapter.
(L) Outlet sheet 38: N426 (484), N427 (485) with note 4 and 9: leak through without adapter, unable to test at this time
(M) Outlet sheet 43: N512 (574), N516 (578), N523 (582), N524 (583) with note 4, 14: leak through without adapter, missing latch button
(N) Outlet sheet 44: N527 (585) with note 3, 4: leak with adapter inserted, leak through without adapter
(O) Outlet sheet 46: E530 (568) with note 4: Leak through without adapter
(P) Outlet sheet 47: C603B (616), C606A (617), C607A (618), C610B (619), C611B (620) with note 4: leak through without adapter
(Q) Outlet sheet 48: C625B (625), C628A (626), C628B (626), C684 (612), C649 (611), C649 (611), C661 (608) with note 14, 4, 6: other, leak through without adapter, no flow
(R) Outlet sheet 49: N607A (672), N607B (672), N608 (673), N611 (674), N614A (676), N614B (676), N619 (679) with notes 4, 14: leak through without adapter, missing latch button
(S) Outlet sheet 50: N625 (682), N628 (684) with note 4, 14: leak through without adapter, missing latch button
(T) Outlet sheet 51: E606A (645), E607A (647), E610B (649), E617B (659) with note 4: leak through without adapter
(U) Outlet sheet 52: E636B (662) with note 4: leak through without adapter

During an interview on 1/16/13 at 8:13 a.m., Engineer staff 1 stated he doesn't have any proof that indicated the work was completed, but a PO number 1139899 was provided to give authorization to get it done. He stated that the vendor may have completed the repairs but there was no documentation provided.

5. On 1/17/13 at 9:20 a.m., six vitalcom machines obstructed access to a medical gas shut off, in the central monitor station by the nurses' station, on the 5th floor.

Based on observation, document review, and interview, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by the following:
1. Medical devices that were plugged into unlisted assemblies
2. High wattage electrical equipment such as mini refrigerators, microwave ovens, and coffee machines that were plugged into power strips.
3. Power strips that were plugged into other power strips.
4. Electrical outlets that were missing covers.
5. Junction boxes that were missing covers
6. The permanent use of extension cords
7. The use of power strips in a hanging or suspended fashion creating tension to the cable joints and terminals.
8. Improper clearance in front of electrical panels
The improper use of surge protectors can result in the increased risk of an electrical fire. Blocked electrical panels can result in delayed access to the panel in the event of an emergency. These deficient practices affected all staff and patients in five of six floors at Sutter General Hospital, one of three outpatient buildings, and four of eight floors at Sutter Memorial Hospital.


NFPA 101, 2000 Edition, Existing 19.3.2 Protection from Hazards. 19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 19.5.1 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 99, 1999 Edition. 2-1-Definitions- Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
NFPA 99, 1999 Edition. 2-1-Definitions- Listed. Equipment, materials, or services included in a list published by an organization that is acceptable to the authority having jurisdiction and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets identified standards or has been tested and found suitable for a specified purpose.

NFPA 99, 1999 3-3.2.1.2, All patient care areas. (d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. NFPA 70, 1999 110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
NFPA 70, 1999 400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

363-9. Splices shall be made in listed junction boxes.

370-25. Covers and canopies. In complete installations, each box shall have a cover, face plate, or fixture canopy.

Findings:

Sutter General Hospital
During a tour of the facility with Staff, electrical wiring and equipment were observed.

1. On 1/14/13, at 11:05 a.m., there were two open junction boxes on the wall opposite the door in the Information Technology Room 4D102. One box was a four inch square and the other was a two by four inch square. Both boxes had green wires cut and exposed at the box.

2. On 1/14/13, at 11:20 a.m., there was an air conditioning machine at the front lobby entrance that was plugged into an extension cord that was taped to the floor. This air conditioner was rated at 11 amps. When asked, Engineering Staff stated that it was to prevent cold air from coming into the Main Lobby.

3. On 1/14/13, at 11:25 a.m., there was a two by four inch outlet box at the Radiology Nurses' Station that had the cover removed.

4. On 1/14/13, at 11:30 a.m., there was a two by four inch outlet box in the MRI Storage Room that had the cover removed.

5. On 1/14/13, at 11:45 a.m., there was a power strip plugged into another power strip under a desk in Room 1137D.

6. On 1/14/13, at 11:55 a.m., there was a two by four inch outlet box in the Film Fill Room that had the cover removed.

7. On 1/14/13, at 11:57 a.m., there was a two by four inch outlet box in the Radiology Tech Room that had the cover removed.

When IT Staff 1 was asked about the open junction boxes, Staff stated that they were installing new fiber optic cables and that the work would be finished within a week

Capital Pavilion-Ambulatory Surgery at Sutter
8. On 1/14/13, at 2:40 p.m., there was a APC brand non hospital grade power strip in Operating Room 5. This power strip was mounted to the pedestal of a computer stand.


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Sutter General
9. On 1/14/13 at 10:15 a.m., two IV pump machines and feeding pump were plugged into a non-hospital grade surge protector. The surge protector was strapped on a computer cart, in Room 5B44 (203).

10. On 1/14/13 at 10:18 a.m., by 5th floor Intensive Care Unit (ICU) by stairway 2 corridor, an ultra sound scanner rated at 5 amperage, a battery charger rated at 13 amperage, and a defibrillator machine were plugged into a 15 amps non-hospital grade 15 amperage surge protector. The items used exceeded the required amperage.

11. On 1/14/13 at 10:40 a.m., a surge protector with items plugged into it was hanging suspended off the floor, adding tension to the cord, in east nurse station 5.

12. On 1/14/13 at 11:16 a.m., a water dispenser rated at 5.5 amperage, a coffee machine rated at 1425 watts, and a refrigerator rated at 1.5 amperage were plugged into a non-hospital grade 15 amperage surge protector. The items used exceed the required amperage, in Room 207.

Fort Sutter
13. On 1/14/13 at 2:25 p.m., four stations had electric heater chairs, vital sign machines, and IV pump machines plugged into a non-hospital grade power strip. Engineer staff 6 stated he checked the machines and outlets, but not the power strip.

14. On 1/14/13 at 2:27 p.m., a surge protector with items plugged into it was hanging suspended off the floor, adding tension to the cord, in front desk area.


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Sutter General Hospital
15. On 1/14/13 at 10:08 a.m., a 32 inch by 18 inch by 34 inch tool cart obstructed access to Electrical Panel 3LQ1 (inside the Electrical Room), near the Surgery Waiting Room.

16. On 1/14/13 at 10:23 a.m., there were two surge protectors aboard a crash cart in the Post Acute Care Unit. A defibrillator and a suction machine were plugged into Surge Protector 1. A monitor, defibrillator, and an Uninterrupted Power Source were plugged into Surge Protector 2. Surge Protector 1 was connected to Surge Protector 2.

17. On 1/14/13 at 1:45 p.m., there were three surge protectors and one extension cord in use in the "MDF Room." A charger for the automatic line transfer switch and a black multi-outlet extension cord with a laptop power supply connected to it were plugged into Surge Protector 1. The overhead paging system, of which five of the six outlets were used, was plugged into Surge Protector 2. A printer and the overhead paging system (which occupied two of the six outlets) were plugged into Surge Protector 3. Surge Protector 3 was connected to Surge Protector 2.

18. On 1/14/13 at 3:25 p.m., in Electrical Room BD51, a utility cart with a tool chest, cleaning solution, and an on-board five foot ladder obstructed access to Electrical Panel BL4-Section 2.

Sutter Memorial Hospital
19. On 1/17/13, at 9:26 a.m., there were six wires that had been cut off that were protruding out of and old x-ray machine. These wires were near the ceiling in the the Old X-Ray Room
Engineering Staff 2 stated that the machine was no longer in use.

20. On 1/17/13, at 9:35 a.m., in Radiology Room R148, there was a four inch square junction box on the floor that had a flexible cord attached to it making it a multiple outlet extension cord with no over-current protection.

21. On 1/17/13, at 9:35 a.m., in Radiology Control Room, there was a four inch square junction box on the floor that had a flexible cord attached to it making it a multiple outlet extension cord with no over-current protection. The metal cover to this junction box was also separated on one side partially exposing the wires.




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Sutter Memorial Hospital
22. On 1/17/13 at 8:35 a.m., a 10 amperage laser printer and a 4.7 amperage water cooler machine were plugged into a non-hospital grade 15 amperage surge protector. The items used exceeded the required amperage, in Room C708.

23. On 1/17/13 at 8:47 a.m., a 1.7 amperage monitor, 8 amperage printer/fax machine, and a 1.7 amperage battery charger were plugged into a non-hospital grade 15 amperage surge protector. The items used exceeded the required amperage, in Room E706.

24. On 1/17/13 at 9:10 a.m., a 10.7 amperage laser printer, a 2.4 amperage laptop machine, 1.7 amperage monitor were plugged into a power strip. The items used exceeded the required amperage, in Room N604.

25. On 1/17/13 at 10:20 a.m., a 2 amperage label printer and an 11 amperage laser printer were plugged into a non-hospital grade 15 amp surge protector. The items used exceed the required amperage, in Room E011.

Sutter Memorial
4. On 1/17/13, at 9:40 a.m., there was an ABHR dispenser located above an outlet in X-Ray Room 11.

5. On 1/17/13, at 11:29 a.m., there was a ABHR dispenser located above an outlet in the Acute Care Unit second to the last bay on the north side of the room.

Based on observation, the facility failed to maintain the Alcohol Based Hand Rub (ABHR) sanitizers, as evidenced by ABHRs that were mounted above ignition sources. This could result in the risk of an electrical fire, and affected two of six floors at Sutter General Hospital and one of eight floors at Sutter Memorial Hospital.

Findings:

During a tour of the facility with staff, the ABHRs were observed.

Sutter General

1. On 1/14/13 at 11:52 a.m., an ABHR in Room 3117 (Doctor's Dictation Room) was mounted directly 10 inches above a light switch.

2. On 1/14/13 at 1:54 p.m., an ABHR in Room BD24 (Cleanup Room) was mounted 12 inches directly above two push button light switches.





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Fort Sutter
3. On 1/14/13 at 2:26 p.m., an alcohol based hand rub (ABHR) sanitizer in Room 657 was mounted directly above a light switch.

Sutter Memorial Hospital
During a tour of the facility with Staff, fire-rated walls were observed.
10. On 1/17/13, at 9:05 a.m., there was a two inch by four inch unsealed penetration in the wall in Imaging Room R 202. A metal framing stud could be seen in the wall.

11. On 1/17/13, at 9:59 a.m., the corridor wall in the Laboratory Flammable Liquids Storage Room had an approximately one inch unseal penetration in the upper corner of the east wall.

12. On 1/17/13, at 10:04 a.m., there were two unsealed penetrations in the northwest wall of Laboratory.


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Sutter Memorial Hospital
13. On 1/17/13 at 10:19 a.m., 1 of 3 sprinklers was shifted to one side. There was an approximately 1/4 inch penetration in the ceiling in Central Pharmacy E011.



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Sutter Memorial Hospital
14. On 1/17/13 at 9:54 a.m., there was an approximately 1/2 inch penetration behind one of seven conduits above Electrical Panel 3NL Sect. 1. The penetration was located behind Pipe 5.

15. On 1/17/13 at 10:50 a.m., in the Female Locker Room (Room C242), there was an approximately 7 inch by 2 1/4 inch penetration above the Simplex panel.

16. On 1/17/13 at 11:05 a.m., in the Clean Utility Room (Room C240), there was an approximately 1 inch by 1/2 inch penetration in the ceiling near the dumbwaiter.

Based on observation, the facility failed to maintain the integrity of the building's construction, as evidenced by penetrations in the walls and ceilings. This could result in the passage of smoke in the event of a fire and affected four of six floors at Sutter General and four of eight floors at Sutter Memorial.

Findings:

During a tour of the facility with maintenance staff, the walls and ceiling were observed.

Sutter General Hospital
1. On 1/17/13 at 2:03 p.m., at the west access door, there was an approximately 3 inch by 1 inch penetration in the right wall near the second column in the South Mechanical Room stairwell located in the Basement.

2. On 1/17/13 at 2:10 p.m., at the east access door, there was an approximately 2 inch by 1 1/2 inch penetration in the right wall near the first column in the South Mechanical Room stairwell located in the Basement.




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Sutter General Hospital
3. On 1/14/13, at 10:37 a.m., Soiled Utility Room 4447 had two unsealed penetrations in the corridor wall inside of the room. These penetrations were approximately one-half inch and one-quarter inch in size and were in the center of the wall. This was a one hour fire-rated wall.

4. On 1/14/13, at 10:47 a.m., Room 4448 had eight unsealed penetrations in the corridor wall inside of the room. These penetrations were approximately one-quarter inch in size. This was a one hour fire-rated wall.

5. On 1/14/13, at 11:05 a.m., The Information Technology Room 4D102 had an approximately two inch unsealed penetration in the wall opposite the door.

6. On 1/14/13, at 11:38 a.m., the The First Floor Information Technology Room in Radiology had a one-half inch rigid conduit traveling through the wall that was not sealed on the end. This conduit had yellow data cables in it.

7. On 1/14/13, at 11:57 a.m., the First Floor Film Fill Room had two unsealed penetrations in it. One penetration was caused by a data cable box that was displaced, creating an approximately one-half inch unsealed area around the box. The other penetration was one- half inch by one inch in size. Both penetrations were located in the northeast portion of the wall.








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Sutter General Hospital
8. On 1/14/13 at 10:40 a.m., there were three approximately 1/4 inch penetrations in the left wall and two approximately 1/4 inch penetrations in the front wall in the East Medication Room Nurses' Station.

9. On 1/14/13 at 11:51 a.m., there were six approximately 1/2 inch to 1/4 inch penetrations in the wall in Storage Room 2212B.

Based on observation and interview, the facility failed to maintain all corridor doors. This was evidenced by a corridor door that was obstructed and failed to release. This affected one of six floors in Sutter General Hospital and three of eight floors at Sutter Memorial and could result in the inability to contain a fire in a room.

Findings:

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

Sutter General Hospital
1. On 1/14/13 at 10:12 a.m., the self-closing door to Room 5B114 was obstructed by a chair that prevented the door from closing.

Sutter Memorial
2. On 1/17/13 at 9:26 a.m., the self-closing door to Janitorial Room E521 failed to latch.

3. On 1/17/13 at 9:35 a.m., the door to Room C425 failed to latch.




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Sutter Memorial Hospital
4. On 1/17/13, at 8:50 a.m., the self-closing inner door to the first floor CT Scan Room was being held open by a door wedge.

5. On 1/17/13, at 11:24 a.m., the corridor door to the first floor Cath Lab did not positive latch when tested by releasing the door from an open position.

6. On 1/17/13, at 11:24 a.m., the west door to the first floor Cath Lab had a broken door closure.

7. On 1/17/13, at 1:30 p.m., the corridor door in the Surgery Sterile Core had the latching mechanism taped open preventing the door from positive latching.

Sutter Memorial Hospital
4. On 1/17/13, at 8:50 a.m., the automatic closing corridor door R165 to the Ultra Sound Darkroom did not close upon testing of the door closure from a fully open position. On 1/18/13, at 10:07 a.m., when a pull station was activated door R165 did not release from the hold open device. Staff stated that the door solenoid was not working.



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Sutter Memorial Hospital
5. On 1/18/13 at 9:53 a.m., on the First Floor, Fire Doors N101, N101B, and N101C failed to close when the fire alarm system was tested. The fire doors closed two minutes later, at 9:55 a.m. The fire alarm system was tested again at 9:57 a.m. and 10:05 a.m. The fire doors closed at those times.

Based on observation and interview, the facility failed to maintain exit passageways as evidenced by cross-corridor doors that did not close when the fire alarm system was activated. This could result in the passage of smoke in the event of a fire, and affected two of six floors at Sutter General, one of eight floors at Sutter Memorial and one floor of the Buhler building.

NFPA 101, 2000 Edition
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.

Findings:

During a tour of the facility with staff on 1/16/13, the corridor doors were observed and tested.

Sutter General Hospital
1. On 1/16/13 at 10:51 a.m., First Floor Door 1-2 failed to close when the fire alarm system was tested.

When interviewed at 10:52 a.m., Registered Nurse Staff 7 stated that the door failed to close because the sensor was blocked by a patient on a gurney.
At 10:56 a.m., testing of the fire alarm system continued. Engineer Staff 5 stood in front of the sensor to determine if door closure would be affected. The door closed when the fire alarm system was activated.


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Sutter General Hospital
2. On 1/16/13, at 10:14 a.m., during fire alarm testing, corridor doors 3164, 3130, 3-8, and 3DH001 took longer than 45 seconds to close. Engineering Staff 7 stated that the door timers in the fire alarm control panel were set to release too high. Staff readjusted the doors and re-tested them. The doors closed in less then 30 seconds.


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Buhler Building
3. On 1/14/13 at 3:18 p.m., the door in the Waiting Room in Suite 315 failed to release from the magnetic hold-open device during fire alarm testing. Engineer 7 stated that the door should release because it was on a magnetic hold device and should be connected to the fire alarm system.

Based on observation, the facility failed to maintain its exit locations. This was evidenced by exit signs that pointed (direction arrow) to an unapproved path of egress. This affected one of six floors in Sutter General and four of eight floors at Sutter Memorial and could result in a delayed evacuation when an exit path is not identified in the event of an emergency.

Findings:

During a tour of the facility with staff, the exit arrows were observed.

Sutter General Hospital
1. On 1/14/13 at 11:10 a.m., in the north construction corridor by Room 2110, the exit sign arrow was pointing to the left toward a wall and not an exit door.

Sutter Memorial Hospital
2. On 1/17/13 at 8:37 a.m., the exit sign arrow in Room C704 was pointing to the left, directing occupants to the outside patio on the 7th floor.

3. On 1/17/13 at 8:59 a.m., the exit sign arrow 13A6C05 in Room C620 was pointing to the right, directing occupants to a wall on the 6th floor.

4. On 1/17/13 at 10:25 a.m., the exit sign arrow 13ABAS04 was pointing to the left, directing occupants to a wall, by fire door E012 in the Basement.

5. On 1/17/13 at 10:51 a.m., the exit arrow 13A1Diet21 was pointing to the left, directing occupants to a wall in the Kitchen.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls, as evidenced by penetrations in the walls. This could result in the spread of smoke between compartments and affected four of six floors at Sutter General and three of eight floors at Sutter Memorial.

Findings:

During a tour of the facility with staff, the smoke barrier walls were observed.

Sutter General Hospital
1. On 1/15/13 at 8:53 a.m., there were six penetrations in the smoke barrier wall above Fire Door 5-3 that ranged in size from 1/2 inch to 2 inches.

2. On 1/15/13 at 9:05 a.m., there was an approximately 1 1/4 inch by 3/8 inch penetration in the smoke barrier wall above Fire Door 5-10.

3. On 1/15/13 at 9:55 a.m., there was an approximately 2 inch by 1 inch penetration in the smoke barrier wall above Fire Door 3-3.

4. On 1/15/13 at 10 a.m., there were three penetrations in the smoke barrier wall above Fire Door 3-5. Each penetration measured approximately 1 inch by 1/4 inch.

5. On 1/15/13 at 10:23 a.m., there was an approximately 2 inch penetration in the smoke barrier wall above Fire Door 2-4. The penetration was caused by an unsealed 2 inch conduit with data cables.

6. On 1/15/13 at 11:14 a.m., there was an approximately 1/2 inch penetration in the smoke barrier wall adjacent to Room 1171.

Sutter Memorial Hospital
7. On 1/17/13 at 2:13 p.m., there was an approximately 1/2 inch penetration on the left side of a 1 inch conduit in the smoke barrier wall above Fire Door N502.

8. On 1/17/13 at 2:54 p.m., there was an approximately 3/4 inch unsealed penetration that surrounded three data cables in the smoke barrier wall above Fire Door C301.

9. On 1/17/13 at 3:01 p.m., there were two penetrations (approximately 3/4 inch and 1/4 inch) in the smoke barrier wall above Fire Door N300.

10. On 1/17/13 at 3:22 p.m., there were two penetrations in the smoke barrier wall above Fire Door E200 located across the hall from Elevators 6 and 7. One penetration measured approximately 3 inches and was crescent-shaped in size located on the left side of a 2 inch conduit with data cables. Another penetration measured approximately 3 inches by 1 1/4 inches, and surrounded four 1/2 inch conduits.

11. On 1/17/13 at 3:34 p.m., there was an approximately 1/2 inch penetration in the smoke barrier wall above Fire Door 2DH001A.

Findings:

During a tour of the facility with Staff, cross-corridor doors were observed.

Sutter Memorial Hospital
3. On 1/17/13, at 1:28 p.m., the west leaf of cross corridor doors 1DH007 near Room N166 did not positive latch. These were one hour fire doors.

4. On 1/18/13, at 9:45 a.m., the left leaf of the cross-corridor fire doors E206A on the Nursing Station side did not positive latch.

Based on observation, the facility failed to maintain its fire doors, as evidenced by fire doors that did not latch when the fire alarm system was tested. This could result in the passage of fire and smoke in the event of a fire, and affected two of six floors at Sutter General Hospital and two of eight floors at Sutter Memorial Hospital.

NFPA 80, 1999 Edition
Standard for Fire Doors and Fire Windows
2-4.1.2 A closing device shall be installed on every fire door.
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.
Exception: With approval by the authority having jurisdiction, where pairs of doors are provided for mechanical equipment rooms to allow the movement of equipment, the device shall be permitted to be omitted on the inactive leaf.

Findings:

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

Sutter General Hospital
1. On 1/16/13 at 10:39 a.m., the left side of the Second Floor Fire Door 2-7 (facing south) failed to latch when tested.



25385

Sutter General Hospital
2. On 1/16/13, at 11:35 a.m., during fire alarm testing, the one and one-half hour fire-rated cross-corridor doors near the South Mechanical Room BC07 did not close fully and latch. There was an approximately four inch gap between the latch edges of the door leafs. A strong air current could be felt blowing through the gap in the door.

Based on observation and interview, the facility failed to protect its hazardous areas as evidenced by a a gift shop that contained combustible decorations that posed a degree of hazard greater than that normal to the general occupancy of the building and was not protected with smoke-resisting partitions. This was also evidenced by the Gift Shop Storage Room door being held open to the corridor. This affected all staff and patients on one of eight floors at Sutter Memorial Hospital and could potentially result in the spread of smoke and/or fire from one area to another.

Findings:

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

1. On 1/17/13, at 11:19 a.m., the fully sprinklered gift shop that was open to the corridor had an amount of combustibles classifying it as "hazardous". The south wall of the gift shop had stuffed animals that covered approximately 90% of the gift shop wall. These stuffed animals were also within approximately six inches of a light fixture. On the opposite side of the corridor were three greeting card stands that were full of greeting cards.

2. The Gift Shop Storage Room door was being held open by a stack of boxes. This door had a self-closing mechanism on the door.

Based on observation, the facility failed to maintain all exit doors, as evidenced by an exit door that was blocked on the egress side. This could result in delayed evacuation in the event of a fire and affected one of six floors at Sutter General.

Findings:

During a tour of the facility with staff, all exit doors were observed.

Sutter General Hospital
1. On 1/14/13 at 3:36 p.m., in Room BD15, Exit Door BD15A was blocked on the egress side by several (approximately eight) plastic linen bins. Each bin measured approximately 60 inches by 36 inches by 48 inches.

Sutter Memorial Hospital
3. On 1/17/13, at 9:59 a.m., the battery back-up lights in First Floor Laboratory Corridor leading to the Waiting Room failed to illuminate when tested by pushing the test button. Engineering Staff 2 also tested the lights with the same result.


27994

During a tour of the facility with Staff, battery-powered lighting units were observed.

Sutter Memorial Hospital
4. On 1/15/13 at 3:25 p.m., the documentation titled, "U Battery Emergency Light (M) & (A)" indicated 15 units failed in 12 months. In 10/31/12-6 failed, 9/30/12-4 failed, 5/31/12-3 failed, and 2/29/12-2 failed. Engineer staff 1 stated he did not have follow-up record indicating whether it was corrected or not.


29753

Sutter Memorial Hospital
5. On 1/17/13 at 4:05 p.m., a battery-operated emergency light in the Basement Mechanical Room (Room C023) failed to illuminate when the light was tested.

Based on observation, document review, and interview, the facility failed to provide and maintain its emergency back-up lighting as evidenced by the failure to (1) test the battery back-up lighting at 30 seconds monthly, (2) Emergency lighting units that failed to illuminate and (3) failure to provide battery-powered emergency lights at its generator set location. This affected all staff and patients in Sutter General and Sutter Memorial Hospital, and could result in failure of battery-powered emergency lighting and the loss of lighting at the emergency generator location.

2000 NFPA 101
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. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

1999 NFPA 110 5-3 Lighting.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.
5-3.2* The intensity of illumination in the separate building or room housing the EPS equipment for Level 1 shall be 30 ft candles (32.3 lux), unless otherwise specified by a requirement recognized by the authority having jurisdiction.

Findings:

During document review and interview with staff, the emergency back-up lighting units were observed and documents were requested.

Sutter General Hospital
1. On 1/15/13 at 3:10 p.m., the documentation indicated 1 of 12 months that the emergency lighting was not tested. There was no monthly testing in June 2012 for the unit in Angio. Secretary staff stated the Angio unit was added in April, but did not get updated to be tested in June 2012.



25385

During a tour of the facility with Staff, battery-powered back up lighting units were observed.

Sutter General Hospital
2. On 1/15/13, at 9:50 a.m., the facility's generator set location at the Central Plant did not have battery-powered emergency lighting units in the enclosed room. When asked, Engineering Staff 1 stated that he did not see any battery-powered light, but that they could be added.

Based on observation, document review, and interview, the facility failed to maintain its emergency exit signs. This was evidenced by exit signs that failed to display the expiration dates and were not tested 30 seconds monthly and 90 minutes annually. This affected one of eight floors in the Buhler building, six of six floors at Sutter General, eight of eight floors at Sutter Memorial Hospital, and one of six floors in the Fort Sutter building. This could result in the loss of illuminated exit signs during an emergency.

NFPA 101, 2000
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

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. A annual test shall be be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During tour, document review, and interview with staff, the emergency exit signs were observed and documentation requested.

Buhler building
1. On 1/14/13 at 1:45 p.m., two self-illuminated exit signs in Suite 315 failed to provide the expiration date, as required, underneath the specification life span slot. Engineer 1 stated he thought it was a five year life span. He further indicated there is a sticker, but it was not legible for review.

Sutter General Hospital
2. On 1/15/13 at 3:43 p.m., the documentation titled, "F exit signs (m)" failed to indicate when the 90 minutes test were completed.

Fort Sutter
3. On 1/15/13 at 3:55 p.m., there was no documentation for 30 second monthly and 90 minutes annually tests. Engineer staff 1 stated that it is a leased building and he does not maintain the building.





29753

Sutter General Hospital
6. On 1/14/13 at 2:50 p.m., in the Basement, the exit sign near Fire Door BX01 failed to remain illuminated when tested.

Sutter Memorial Hospital
4. On 1/15/13 at 3:35 p.m., the documentation titled, "Exit sign" failed to indicate when the 90 minute test was completed. Engineer 4 stated all exit signs with the test button did not have a battery equipped with the exit signs.

5. On 1/17/13 at 10:10 a.m., the photo illuminated exit sign outside Sterile Processing that pointed toward Stairwell 2 failed to display the expiration date, as required underneath the specification life span slot, in the Basement.

Based on document review and interview, the facility failed to ensure fire drills were conducted as required and failed to ensure that all staff responded in the event of a fire emergency. This was evidenced by no fire drills conducted as required and three staff that were not familiar with what actions to take in the event of a fire. This affected all patients in Sutter General and Memorial Hospital, and 1 of 6 floors in the Fort Sutter building. This could potentially result in a delay in staff or first responders' responses in the event of a fire.

NFPA 101, 2000
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.

Findings:

During document review and interview with staff, fire drills documentation was requested and interviews were conducted on fire and life safety procedures.

Fort Sutter Oncology at Infusion
1. On 1/15/13 at 4:23 p.m., there were no documents provided that indicated fire drills were conducted on the 6th floor, suite 690. Engineer staff 1 stated he requested the fire drill records and never received them.

Sutter General Hospital
2. On 1/16/13 at 10 a.m., a unit secretary staff on the 4th floor north was asked what would she do in the event of a fire. The unit secretary staff stated she would call 4000, the hospital emergency number. She failed to indicate the use of the fire alarm to notify other departments. A unit charge nurse thought that by calling 4000, it would activate the fire alarm system. Engineer staff 1 explained that by calling 4000, it only notified dispatch of where the fire was, and would not activate the fire alarm. He explained that fire alarm is required to be activated by staff.

3. On 1/16/13 at 11:26 a.m., a Pharmacy Technician staff in the Basement was asked what would she do in the event of a fire. The Pharmacy Technician staff stated she would call 4000 and that staff in the pharmacy would know what to do. She failed to indicate the use of fire alarm to notify other departments. Engineer staff 1 stated they should be activating the fire alarm system and then calling 4000.

Based on observation, testing, document review, and staff interview, the facility failed to maintain its fire alarm system to insure the safety of patients as evidenced by the:

1. Failure of the fire alarm system to provide visual and audible notification in two of two Emergency Department Suites. Patients and staff in the affected area would not be able to hear a fire alarm signal inside of the affected suite.
2. Failure of the fire alarm XLS panel connected to the Emergency Department on the first floor to communicate an audible or visual trouble signal to the main hospital fire alarm panel.
3. Failure to test the system for integrity after changes have been made to the fire alarm system such as relocating, decommissioning or modifying the fire alarm system.
4. Failure to monitor and follow the internal Hospital policy titled, "Notification of activity " which involves staff review and approval procedures designed to ensure that critical construction activity has been approved by the Hospital staff.

This deficient practice affected all staff and patients in the Emergency Department and could potentially result in a delay in response by staff and the spread of smoke and/or fire in both the Emergency Department and the rest of the hospital.

2000 NFPA 101
9.6.2 Signal Initiation.
9.6.2.1 Where required by other sections of this Code, actuation of the complete fire alarm system shall occur by any or all of the following means of initiation, but shall not be limited to such means:
(1) Manual fire alarm initiation
(2) Automatic detection
(3) Extinguishing system operation

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.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

9.6.3 Occupant Notification.
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.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.

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.

1999 NFPA 72
7-1.6.2* Reacceptance Testing.
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.

7-1.6.2.2 Changes to all control units connected or controlled by the system executive software shall require a 10 percent functional test of the system, including a test of at least one device on each input and output circuit to verify critical system functions such as notification appliances, control functions, and off-premises reporting.

1-6.1 Approval and Acceptance.
1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

3-8.3.2.2 Automatic Fire Alarm Signal Initiation. Automatic fire alarm-signal initiation devices that have integral trouble signal contacts shall be connected to the initiating device circuit so that a trouble condition within a device does not impair alarm transmission from any other initiating device.
Exception: Where the trouble condition is caused by electrical disconnection of the device or by removing the initiating device from its plugin base.

3-8.4.4.2.1 Relays or modules providing transmission of trouble signals to a supervising station shall be arranged to provide fail-safe operation.
3-8.4.4.2.2 Means provided to transmit trouble signals to supervising stations shall be arranged so as to transmit a trouble signal to the supervising station for any trouble condition received at the protected premises control unit, including loss of primary or secondary power.

Findings:

Sutter General Hospital
1. During fire alarm testing on 1/16/13, at 10:48 a.m., the fire alarm control panel (FACP) model XLS located on the first floor outside of the elevators near the Emergency Department had a yellow trouble light visible. The FACP message stated, "Disabled Active Booster Power Supply Activation Signal Local Trouble ACT Map Fault". Engineering Staff 7 (ES7) was asked if the trouble could be cleared before testing began on that floor.

At 10:52 a.m., this surveyor observed and heard ES7 communicate with the Main FACP Technician and ask him to reset the main FACP to clear the XLS model fire alarm panel. The XLS model fire alarm panel remained in a trouble condition.
ES7 stated that he was going to try to reset and clear the trouble at the XLS model fire alarm panel itself. The XLS model fire alarm panel remained in a trouble condition.

At 10:54 a.m., ES7 was asked what areas the XLS FACP monitored and he stated the Emergency Department.

At 10:52 a.m., this surveyor had staff activated a water flow near Room 1110 to simulate the activation of one fire suppression sprinkler head on that floor of the building. The fire alarms could be heard outside of the Emergency Department.

At 10:56 a.m., a fire alarm pull station used to activate the fire alarm near Room 1188 was activated. The pull station did not activate a chime or strobe inside of the Emergency Department (ED). After the fire alarm pull station was activated, ES1 confirmed that the chimes and strobes (flashing lights) did not activate and stated, "It is very silent in here". ES3 walked outside the ED and stated that the chimes and strobes were active outside the ED.

At 11:00 a.m., Engineer Staff 1 stated he did not hear any chimes initiated inside the ED department and it was very silent. Engineer staff 1 walked outside of the ED department and noted the chimes and strobes in the corridor were still active, but they were not audible inside the ED department.

During an interview at 11:00 a.m., Nurse 1 and 2 inside the ED stated they heard chimes/strobes going off all day, but were not sure if the chimes or strobes inside the ED department were activated. Engineer staff 1 informed the two nurses that the chimes or strobes were not working and to pay attention to overhead announcements in the event of a fire.

At 11:16 a.m., smoke detector 145 inside the ED was tested with artificial smoke. The smoke detector did not activate chimes or strobes inside the ED, but it did activated chimes and strobes outside of the ED.
At 11:45 a.m., Engineer Staff 1 radioed to Engineer Staff 7 and stated that the XLS model fire alarm panel had been in trouble since Monday (1/14/13).
Engineer Staff 1 confirmed and indicated the XLS fire alarm panel was in trouble since Monday. Engineer staff 1 stated he would find out more information and inform surveyor.

At 1:10 p.m., Engineer Staff 1 stated that the electrician from Decker Electric, which is a sub-contractor, hired through Siemens Fire Alarm Company, may have known the system was in trouble and failed to notify the hospital. He further indicated the electrician relocated the smoke detectors outside of the construction zone and did not notify anybody that the system was in trouble. He will check with the PBX staff if they noticed anything unusual that came during that time.

During an interview with Engineering Staff 1 at 1:10 p.m., Staff stated that the XLS Model fire alarm panel was not communicating the trouble with the main fire alarm control panel and they were not sure why.

2. At 2:25 p.m., Engineer staff 1 stated the PBX (private branch exchange) did not notice anything unusual. He further stated if there was a trouble, the central monitoring station should have called and notified the facility; in this case, there was no call from the central monitored station.

3. At 2:47 p.m., Engineer staff 1 stated that any time there was work to be done to the fire alarm panel, the documentation titled " Notification of Activity " was required to be filled out and approved. In this case, he did not receive any notification of activity form or any verbal notice that there would be work done on the fire alarm system.
At 3:04 p.m., the technician from Siemens stated he knew about the work the electrical subcontractor was doing and felt that they did not do anything wrong by relocating the smoke detectors to a safe place. He indicated when they were done relocating the smoke detectors to a safe place; he walked by the main fire alarm panel and noticed it was green for normal. He did not look at the XLS fire alarm panel.

4. At 3:30 p.m., Engineer Staff 1 stated he did not receive any notice from the electrician and technician that they were relocating smoke detectors. Engineering Staff 1 thought that when they relocated the smoke detectors in the wrong sequence of order, that they would get a trouble signal at the fire alarm panel. Engineer Staff 1 further indicated that the order request from the IOR was to decommission (remove) the devices instead of relocating the devices.
On 1/17/13 at 8:30 a.m., Engineer Staff 1 provided a letter from Inspector of Record (IOR) indicating the order request was to remove the Honeywell devices.

Based on record review, observation, and interview, the facility failed to test and maintain all of its fire alarm system components as evidenced by the following:

1. Smoke detectors that had not been tested during the Annual Alarm Device Certification Report.

2. A chime/strobe that failed to emit an audible sound during fire alarm testing.

3. Fire door magnetic hold-open devices that re-energized when the Fire Alarm Control Panel (FACP) was silenced but was still in active alarm.

4. A smoke detector that had tape covering the outside of it.
This finding affected four of six floors at Sutter General Hospital, four of eight floors at Sutter Memorial Hospital, and one of three offsite buildings, and could potentially result in deficiencies with the smoke detector going unnoticed resulting in the spread of smoke and/or fire.

2000 NFPA 101
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.

9.6.5.1 A fire alarm and control system, where required by another section of this Code, shall be arranged to actuate automatically the control functions necessary to make the protected premises safer for building occupants.
9.6.5.2 Where required by another section of this Code, the following functions shall be actuated by the complete fire alarm system:
(1) Release of hold-open devices for doors or other opening protectives
(2) Stairwell or elevator shaft pressurization
(3) Smoke management or smoke control systems
(4) Emergency lighting control
(5) Unlocking of doors

1999 NFPA 72
1-5.4.2.2. 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.
33.3.3.4.4 Occupant Notification. Occupant notification shall be provided automatically, without delay, by internal audible alarm in accordance with 9.6.3

Findings:

Sutter General Hospital
During document review with Staff, documentation for fire alarm testing and inspection was reviewed.

1. On 1/15/13, at 9:50 a.m., the facility failed to provide documentation indicating that all smoke detectors in the facility had been tested for functionality within the past year.

Documentation provided titled "Smoke Detectors" dated 6/11/12, showed in the comments field of the the report that 164 devices were listed as not found or not tested.

During a tour of the building with Engineering Staff 2 and 7 on 1/16/13 between 2:00 p.m. and 3:00 p.m., this surveyor visited a sample of locations on the first, second, and third floors to determine if detectors that had been listed as " listed as not found or not tested" were in fact at those locations. The following detectors were found:

Device number 23 Room 1134
Device number 31 Room C118
Device number 34 Room 1137A
Device number 49 Room 1105
Device number 71 Entrance by Rotunda Doors
Device number 66 Kitchen 2212
Device number 67 Kitchen by corridor 2211
Device number 69 Kitchen 2111B

On 1/16/13, at 2:10 p.m., device number 197 inside Supply Room 4451 blinked and was found. When asked, Engineering Staff 4 stated that the detector was the original detector.

When asked, Engineering Staff 7 confirmed that the detectors were still at their original locations. Staff also stated that many of the areas on the annual certification were in construction locations and no longer existed.
No documentation was provided indicating the how many of the above mentioned 164 detectors were not decommissioned due to construction and were able to be tested.




27994

Fort Sutter Oncology at Infusion Suite 690
2. On 1/15/13 at 9:18 a.m., the documentation titled "Alarm System" dated 5/18/12, was incomplete. The report failed to indicate that devices in Suite 690 were tested.

Sutter Memorial Hospital
During fire alarm testing with Staff, fire alarm system components were observed.

3. On 1/17/13, at 10:54 a.m., the smoke detector in the Administration Office Storage Room 201 was taped on the outside with blue masking tape. Staff stated that the room was being painted and would be finished by the end of the day. No one was in the room painting at that time.

4. On 1/18/13, at 8:34 a.m., the cross-corridor door hold-open magnets to doors E700 were re-energized when the fire alarm control panel was silenced only and not reset. The panel was still in active alarm.

5. On 1/18/13, at 9:58 a.m., the cross-corridor door hold-open magnets to doors C100 were re-energized when the fire alarm control panel was silenced only and not reset. The panel was still in active alarm.

6. On 1/18/13, at 9:58 a.m., the cross-corridor door hold-open magnets to doors 1DH002 were re-energized when the fire alarm control panel was silenced only and not reset. The panel was still in active alarm.




27994

Sutter Memorial Hospital
7. On 1/18/13 at 9:05 a.m., fire alarm system was activated and the audible alarm devices were silenced, the fire alarm system re-energized all of the magnetic hold open devices on the fire/smoke doors 5DH029 and 5DH030.

8. On 1/18/13 at 9:06 a.m., fire alarm system was activated and the audible alarm devices were silenced, the fire alarm system re-energized the magnetic hold open devices on the fire/smoke doors 5DH027 and 5DH028.

9. On 1/18/13 at 9:11 a.m., the manual pull alarm 3-109-104PB took 29.8 seconds to activate the fire alarm system, on the 4th floor.

10. On 1/18/13 at 9:53 a.m., fire alarm system was activated and the audible alarm devices were silenced, the fire alarm system re-energized the magnetic hold open devices on the fire/smoke door E130B.




29753

Sutter Memorial
11. On 1/18/13 at 9:53 a.m., Strobe/Chime 1AV019 near Fire Door N101 failed to activate when the fire alarm system was tested. The fire alarm system was tested again at 9:57 a.m. and 10:05 a.m. Strobe Chime 1AV019 activated at those times.

Based on record review, observation, and interview, the facility failed to provide documentation of maintenance, inspection, and testing of all smoke detectors as evidenced by incomplete testing and documentation for smoke-sensitivity testing. This deficient practice affected all staff and patients on four of six floors at Sutter General Hospital and could potentially result in deficiencies (false alarms or no alarms) with the smoke detectors going unnoticed.

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

Findings:

Sutter General Hospital
During document review with Staff, documentation for smoke detector sensitivity testing was reviewed.

1. On 1/15/13, at 9:50 a.m., the facility failed to provide documentation indicating that all smoke detectors in the Hospital had been tested for sensitivity within the past two years.

Documentation provided titled "Smoke Detector Sensitivity Testing" dated 6/14/12, showed in the comments field of the report that 76 devices did not have access, were not found, were too high, or were not labeled.

During a tour of the building with Engineering Staff 2 and 7 on 1/16/13 between 2:00 p.m. and 3:00 p.m., this surveyor visited a sample of locations on the first, second, and third floors to determine if detectors that had been listed as "not having access, were not found, were too high, or were not labeled" were in fact at those locations. The following detectors were located:

Device number 23 Room 1134
Device number 31 Room C118
Device number 34 Room 1137A
Device number 49 Room 1105
Device number 71 Entrance by Rotunda Doors
Device number 103 Elevator Lobby Honeywell panel side
Device number 104 Elevator Lobby Honeywell panel side
Device number 66 Kitchen 2212
Device number 67 Kitchen by corridor 2211
Device number 69 Kitchen 2111B

On 1/16/13, at 2:10 p.m., device number 197 inside Supply Room 4451 blinked and was found. When asked, Engineering Staff 4 stated that the detector was the original detector.

When asked, Engineering Staff 7 confirmed that the detectors were still at their original locations. Staff also stated that many of the detectors on the annual certification were in construction locations and no longer existed.
No documentation was provided indicating the how many of the above mentioned 76 detectors were not decommissioned due to construction and were able to be tested.

During record review with Staff on 1/15/13, documentation for fire sprinkler system testing and inspection records were reviewed.

Sutter Memorial Hospital
13. At 9:50 a.m., documentation provided titled "Inspection, Testing, and Maintenance Fire Sprinkler System" documented in the deficiencies and comments section of the the report that the "Grinnell Dura Speed heads are over fifty years old in the Central and East wing".

During a tour of the facility with Staff on 1/18/13, at 10:14 a.m., Duraspeed sprinkler heads were observed in the Basement East Wing. When asked, Engineering Staff 1 stated that the only areas affected would be small areas of the Fourth and Fifth floors and Basement, and the laundry and Trash Chutes between floors. Sprinkler heads over 50 years old may need to be replaced.





29753

Sutter Memorial Hospital
14. On 1/17/13 at 8:46 a.m., the sprinkler in the Trash Chute (C335) was loaded with grease, dust, and lint.

15. On 1/14/13 at 9:40 a.m., in Room N314 (Supplies Closet), there was paint on the sprinkler's strut.

16. On 1/17/13 at 10:35 a.m., in Room W224 (Neonatal Intensive Care Unit, Room D), one of six sprinklers was loaded with dust and lint. The affected sprinkler was the second sprinkler on the left on the south side of the room.

17. On 1/17/13 at 11:33 a.m., in Room E238 (Clean Utility Room), there was an oily green substance on the sprinkler.

18. On 1/17/13 at 11:39 a.m., in Room E215 (Housekeeping Closet), there was an oily yellow substance, dust, and lint on the deflector.

Based on document review and staff interview, the facility failed to test and maintain its automatic sprinkler system. This was evidenced by the following:

1. Noted deficiencies on the annual sprinkler system testing and inspection report that had not yet been repaired

2. Missing quarterly sprinkler inspection and testing.

3. Sprinkler heads that were loaded or covered with dust, paint, cobwebs or corrosion.
.
These findings affected five of six floors at Sutter General Hospital, three of eight floors at Sutter Memorial Hospital and two of three offsite buildings and could potentially result in the spread of smoke and/or fire.

NFPA 101, 2000 Edition,
4.6.12 Maintenance and Testing.
4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.
4.6.12.4 Maintenance and testing shall be under the supervision of a responsible person who shall ensure that testing and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction.

NFPA 25, 1998 edition
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one-fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

2-3 Testing.
2-3.1 Sprinklers.
2-3.1.1* Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing. Test procedures shall be repeated at 10- year intervals.

Exception No. 1: Sprinklers manufactured prior to 1920 shall be replaced.

Exception No. 2: Sprinklers manufactured using fast response elements that have been in service for 20 years shall be tested. They shall be retested at 10-year intervals.

Exception No. 3:* Representative samples of solder-type sprinklerswith a temperature classification of extra high [325°F (163°C)] orgreater that are exposed to semicontinuous to continuous maximum allowable ambient temperature conditions shall be tested at 5-year intervals.

Exception No. 4: Where sprinklers have been in service for 75 years, they shall be replaced or representative samples from one or more sample areas shall be submitted to a recognized testing laboratory acceptable to
the authority having jurisdiction for field service testing. Test procedures shall be repeated at 5-year intervals.

2-3.1.2 A representative sample of sprinklers shall consist of a minimum of not less than 4 sprinklers or 1 percent of the number of sprinklers per individual sprinkler sample, whichever is greater.
2-3.1.3 Where one sprinkler within a representative sample fails to meet the test requirement, all sprinklers represented by that sample shall be replaced. (See 2-4.1.1.)

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

Findings:

During a tour of the facility with staff, sprinkler system components were observed

Sutter General Hospital
1. On 1/14/13 at 10:42 a.m., a sprinkler in the Housekeeping Closet 5C15 had paint on the strut.

2. On 1/14/13 at 10:43 a.m., a corridor sprinkler by Room 5C03 had lint build up around the head.

3. On 1/14/13 at 11:15 a.m., 1 of 8 sprinklers in Room 2310 had lint build up around the head.

4. On 1/14/13 at 11:43 a.m., a sprinkler in the Dietary Storage Room 2212G had paint on the deflector plate.

5. On 1/14/13 at 11:46 a.m., 3 of 10 sprinklers inside the Kitchen tray line area were corroded with dark grease and corrosion around the sprinkler heads.

Buhler building
6. On 1/14/13 at 3:10 p.m., the Inspector Test Valve (ITV) on the rooftop failed to activate the alarms within 90 seconds. The first time it took more than a minute and forty six seconds to activate the alarm. The second time it took more than two minutes. Engineer staff 1 stated that it failed to emit a sound within 90 seconds. The documentation titled "Water Flow Switches" dated 11/21/12 indicated it took 85 seconds and passed.

Sutter Fort
8. On 1/14/13 at 1:41 p.m., a corridor sprinkler by Station 14 had lint build up.
Sutter Fort-Oncology at Sutter Suite 215 and 315

9. Documentation provided titled "Inspection, Testing, and Maintenance Fire Sprinkler System" indicated that the quarterly sprinkler inspection and testing was done on 12/28/12 only. Engineering Staff 1 stated that it is a leased building and that the facility will probably take over the testing.



29753

Findings:

Sutter General
10. On 1/14/13 at 10:13 a.m., there was a piece of plastic on the deflector of one of three sprinklers in Room 3162. The sprinkler was located above the cleaning equipment storage area.

11. On 1/14/13 at 10:15 a.m., the sprinkler above the sink in Room 3160 (Women's Restroom) was loaded with dust and lint.

12. On 1/14/13 at 3:32 p.m., there was a piece of plastic on the deflector of one of two sprinklers in Room BD32 (Dirty Linen Room). The sprinkler was located near the loading dock drop-down door.

Findings:

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

Sutter Memorial Hospital
6. On 1/17/13, at 10:10 a.m., the fire extinguisher in the northeast corner of the Laboratory had a trash can placed in front of it.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by fire extinguishers that were mounted too high, that were not fully accessible and not fully charged, and were past due for their annual inspection. This affected one of six floors at Sutter General and one of eight floors at Sutter Memorial and could result in increased potential for portable fire extinguisher malfunctions.

1998 NFPA 10
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lbs shall be installed so that the top of the fire extinguishers is not more than 5 ft above the floor. Fire extinguishers having a gross weight greater than 40 lbs shall be so installed that the top of the fire extinguishers is not more than 3 1/2 feet above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 inch.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30- day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

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

4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

4-4.4* Maintenance Recordkeeping. Each fire extinguisher shall have a tag or label securely attached that indicates the month and year the maintenance was performed and that identifies the person performing the service.

Findings:

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

Sutter General
1. On 1/14/13 at 11:45 a.m., a portable K class fire extinguisher inside the kitchen was mounted with the handle at approximately 61 inches from the floor.

2. On 1/14/13 at 11:50 a.m., a portable K class fire extinguisher in the serving area was mounted with the handle at approximately 70 inches from the floor.


25385

Sutter General Hospital
3. On 1/14/13, at 2:05 p.m., the fire extinguisher located in the Staff Breakroom 1248 in the Emergency Department had a trash can placed in front of the extinguisher cabinet.

4. On 1/15/13, at 9:50 a.m., there were two fire extinguishers sitting on the floor in the Parallel Switch Gear Room in the central plant. The pressure gauge could not be read because there was a cement-like material covering portions of the outside of the extinguisher. Engineering Staff 1 stated that it looked like a spray coating.

5. On 1/15/13, at 9:52 a.m., there were two fire extinguishers located on the floor at the west end of the generator set location in the Central Plant. These extinguishers were partially discharged and the annual HMIS label had a test date of 2009.

Based on record review and interview, the facility failed to maintain all fire/smoke dampers. This was evidenced by several fire/smoke dampers that were not inspected within the past four years. This affected Sutter General Hospital and three of three outpatient facilities and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review with staff, on 1/15/13, at 9:50 a.m., the facility's fire/smoke damper inspection records were requested.

Sutter General Hospital
1. Documentation provided for damper inspection dated March 2011 indicated in the diagnosis field of the report that five electric smoke dampers in the Basement level had "No Access due to duct work and no place to install a new one. Hospital issue".

Capital Pavilion-Ambulatory Surgery at Sutter
2. Documentation provided for damper inspection dated March 2011 indicated in the diagnosis field of the report that one electric combination damper in the Basement level had "No Access due to duct work and no place to install a new one. Hospital issue".

Buhler Cancer Center-Oncology at Infusion
3. Documentation provided for damper inspection dated October 2010 indicated in the diagnosis field of the report that ten dampers documented "Need access door", two dampers documented "would not open when reenergized in closed position hospital issue", and one damper was documented as "needs fire-rated flange door".

Sutter Fort-Oncology at Sutter Suite 215 and 315
4. The facility did not provide documentation for damper inspection. When asked, Engineering Staff 1 stated that the building was a leased building.

Based on observation and interview, the facility failed to maintain its kitchen exhaust hood. This was evidenced by accumulation of greasy deposits on pipes inside the kitchen exhaust hood, and failure to provide the required type of grease filters for the kitchen suppression and exhaust system. This affected 1 of 6 floors in Sutter General Hospital and 1 of 8 floors at Sutter Memorial Hospital. This could result in an increased risk of a grease fire ignition in the kitchen.

NFPA 96, 1998 edition
3-1. Listed grease filters, baffles, or other approved grease removal devices for use with commercial cooking equipment shall be provided. Listed grease filters shall be tested in accordance with UL 1046, Grease Filters for Exhaust Ducts. Mesh filters shall not be used.

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 powder or other 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-System serving moderate-volume cooking operations-semi-annually.

Findings:

During tour and interview with staff, the kitchen hood exhausts were observed.

Sutter General
1. On 1/15/13 at 2:50 p.m., there was a thick accumulation of greasy deposits on pipes running through the interior kitchen exhaust hood. The hood was last cleaned on 3/22/12. Engineer staff 1 stated the exhaust hood is cleaned once a year.

Sutter Memorial Hospital
2. On 1/17/13 at 10:48 a.m., it was observed the facility had grease filters installed in the kitchen's designed suppression and exhaust system that were built with 20 panels of wire mesh screens rather than the required baffle type filter.

3. On 1/17/13 at 10:49 a.m., there was a thick accumulation of greasy deposits on pipes running through the interior kitchen exhaust hood. The hood was last cleaned in 3/22/12. Engineer staff 1 stated the exhaust hood is cleaned once a year.

Based on document review and interview, the facility failed to maintain its piped medical gas system. This was evidenced by noted discrepancies in the annual medical gas certification report that had not been repaired. This affected all patients in Sutter General, Memorial and Capital Pavilion. This could potentially result in the acceleration of fire.

NFPA 99, 1999
4-3.1.1.2 (4) Locations for supply systems of more than 3000 ft3 (85 m3) total capacity (connected and in storage) shall be vented to the outside by a dedicated mechanical ventilation system or by natural venting. If natural venting is used, the vent opening or openings shall be a minimum of 72 in.2 (0.05 m2) in total free area.
(c) Storage Requirements for Nonflammable Gases Less than 3000 ft3 (85 m3). Doors to such locations shall be provided with louvered openings having a minimum of 72 in.2 (0.05 m2) in total free area. Where the location of the supply system door opens onto an exit access corridor, louvered openings shall not be used, and the requirements of 4-3.1.1.2(b)3 and 4 and the dedicated mechanical ventilation system required in 4-3.1.1.2(b)4 shall be complied
4-3.1.2.7 (g) Joints in medical gas tube shall be brazed except that memory-metal couplings having temperature and pressure ratings not less than that of a brazed joint shall be permitted. Flared and compression type connections shall be prohibited throughout the piping system, including connections to station outlets, alarm devices, and other components. Unions shall not be permitted in the distribution pipeline system.
4-3.2.2.8 (a) General. To ensure continuos responsible observation, the master alarm signal panels shall be located in two separate warning locations, wired in parallel to a single sensor to indicate when the vacuum in the main line drops below the level required in 4-3.4.2.2 (c) 4b. Audible and noncancelable visual signals shall be installed in the office or principal working area of the individual responsible for the maintenance of the vacuum system and, to ensure continuous surveillance, at the telephone switchboard, the security office, or other continuously staffed locations.
4-3.1.1.9 (f) Receivers. The receiver shall be equipped with a pressure relief valve, automatic drain, sight glass and pressure gauge and shall have the capacity to ensure practical on-off operation. The receiver shall comply with section VIII, unfired pressure vessels, of the ASME boiler and pressure vessel code and shall be corrosion resistant. Piping within compressor systems upstream of the source shutoff valve shall comply with 4-2.1.2.7 and 4-3.1.2.8 except that stainless steel shall be permitted to be used as a piping material.
4-3.1.2.2.(6) All pressure switches, pressure gauges, and pressure-sensing device downstream of the source valve shall be provided with a gas specific demand check fitting to facilitate servicing, testing, or replacement.
4-3.1.1.8 (h) Emergency oxygen supply connection. Where the cryogenic oxygen supply is located outside if the building served, there shall be incorporated in the piping system and inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations.........
(e) Pressure Relief Valves.
Each central supply system shall have a pressure relief valve set at 50 percent above normal line pressure, installed downstream of the pressure regulator and upstream of any shutoff valve. This pressure relief valve shall be permitted to be set at a higher pressure, provided another pressure relief valve set at 50 percent above normal line pressure is installed in the main supply line. All pressure relief valves shall close automatically when excess pressure has been released. Pressure relief valves set at 50 percent above normal line pressure shall be vented to the outside from all gas systems, except medical air, or if the total capacity of the supply system is in excess of 3000 ft3 (85 m3) of gas. Pressure relief valves shall be of brass or bronze and specially designed for the gas service involved.
(g) Final Line Regulators.
Final line regulators shall be duplexed with suitable valving to permit service to the regulators without completely shutting down the gas piping system.
4-3.1.2.3 Gas Shutoff Valves.
(h) Shutoff Valves (New or Replacement). New or replacement pipeline shutoff valves shall be of a quarter-turn ball type manufactured with extensions for brazing, and with an indicating handle and shall be of metallic construction. Valves shall be the three-piece type with full-size ports.
4-3.1.2.7 Piping Materials. The provisions of this section apply to field-installed piping for the distribution of medical piped gases.
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.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source of supply, including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled
" SOURCE VALVE FOR THE (SOURCE NAME). "
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
4-3.2.1.9 Exhausts. The exhaust from vacuum pumps shall be discharged outdoors in a manner that will minimize the hazards of noise and contamination to the hospital and its environment. The exhaust shall be located remote from any door, window, air intake, or other openings in buildings with particular attention given to separate levels for intake and discharge. Care shall also be exercised to avoid discharge locations contraindicated by prevailing winds, adjacent buildings, topography, and other influences. Outdoor exhausts shall be protected against the entry of insects, vermin, debris, and precipitation. Exhaust lines shall be sized to minimize back pressure. Discharge piping shall be free of dips or loops that might trap condensate or oil. If such discharge piping is unavoidable, a trapped drip leg shall be installed to keep the piping free of fluid buildup. Discharge of pumps utilizing a common exhaust pipe shall be fitted with a check valve, a manual valve, or arranged to permit capping of the active pipe when removing or servicing a pump.
4-3.1.2.2.(3) each local, master, and area alarm panel shall be labeled for its area if surveillance (e.g. O2, vacuum, medical air), etc., and room(s) served. Each indicator shall be separately labeled indicating the condition monitored.
4-3.1.2.3 (h) shutoff valves (new or replacement) New or replacement pipeline shutoff valves shall be of a quarter-turn ball type manufactured with extension for brazing, and with an indicating handle and shall be metallic construction. Valves shall be the three-piece type with full-size ports.

Findings:

During document review and interview with staff, the medical gas reports were reviewed.

Sutter General Hospital
1. On 1/15/13 at 3 p.m., the documentation titled "Nitrous Oxide Manifold (MF)" dated 4/3/12 had the following "NO" on the report:
A) MF Model 108014-01: items 31a and 40
B) MF Model 108011-02: items 31a and 40
C) MF Model 802AL002: items 31a and 40

Sutter Capitol Pavilion
2. On 1/15/13 at 3:15 p.m., the documentation titled "Nitrous Oxide Manifold (MF), Medical Air (MA), Medical Vacuum (MV), and Carbon Dioxide Manifold MF-1)" dated 4/3/12 had the following "NO" on the report:
A) MF Model 107011-03: items 13a, 31a, and 40
B) MF Model 107014-04: items 31a and 40
C) MA Model 4107000858: items 42a, and 39
D) MV Model 4107102656: items 17a and under "Comment"-The source valve needs to be labeled.
E) MF-1 Model 107020-02: items 13a, 31a, and 40

Sutter Memorial Hospital
3. On 1/15/13 at 3:30 p.m., the documentation titled "Nitrous Oxide Manifold (MF), Nitrogen Manifold (MF-1), Carbon Dioxide Manifold MF-2), Medical Vacuum (MV 1-4), Medical Air (MA 1-2), and Oxygen Manifold (O2)" dated 4/11/12 had the following "NO" on the report:
A) MF Model 1110-61-A: items 13a, 18, 19a-f, 28, 30c-e, 31a, c, and 40
B) MF-1 Model 273-R: items: 13a, 19c, f, 28, 30c-e, 31a, and 40
C) MF-2 Model 273-R: items: 13a, 18, 19c, f, 28, 30c-e, and 31a
D) MV-1 Model 908470-PL: items 10a-c, 17a, 19c-d
E) MV-2 Model PRV-2204: items 10a-c, 17a, 19c-d
F) MV-3 Model HC-130: items 10a-c, 17a
G) MV-4 Model PRV 3208: items 10a-c, 17a
H) MA Model M25388: items 12c, 15a, 20, 21, 22, 26c-e, 31, 32, 33, 41
I) MA Model M25388: items 12c, 15
J) MA-1 Model M25388: items 12c, 15,
K) MA-2 Model N/A: items 12c, 15, 20, 21, 22, 26c-e, 32, 33
L) O2 Job 201968: items 31c-e, 32a-c, 34a, 35b

4. On 1/15/13 at 3:45 p.m., the documentation titled, "Medical gas outlets" dated 4/11/12 had discrepancies noted as follow:
A) Outlet sheet: C030A with note 11: ceiling hose assembly
B) Outlet sheet 4: Recovery 1, 10, & 12 with note 4: leak through without adapter
C) Outlet sheet 5: OR 1A/B, 2A/B/C, 3A/B/C, 4A/B/C/D with note 11: ceiling hose assembly
D) Outlet sheet 6: OR 5A/B/E with note 11: ceiling hose assembly
E) Outlet sheet 9: R144, R155, R177 with note 4: leak through without adapter
F) Outlet sheet 26: C321 (323) with note 4: leak through without adapter
G) Outlet sheet 27: C359B (309) with note 4: leak through without adapter
H) Outlet sheet 30: Nursing director N323A/B with note 9: unable to test at this time, comment: Office outlet behind cabinets
I) Outlet sheet 35: C410A/B (419) and C415 (421) with note 4 and 3: leak through without adapter and leak with adapter inserted
J) Outlet sheet 36: C426A (425), C429B (426), C451A (412), C456B (408) with note 4: leak through without adapter
K) Outlet sheet 37: N405 (471), N408 (473), N410 (474), N412 (475), N415 (477), N421 (481), N423 (482) with note 14, 4: missing latch button, leak through without adapter.
(L) Outlet sheet 38: N426 (484), N427 (485) with note 4 and 9: leak through without adapter, unable to test at this time
(M) Outlet sheet 43: N512 (574), N516 (578), N523 (582), N524 (583) with note 4, 14: leak through without adapter, missing latch button
(N) Outlet sheet 44: N527 (585) with note 3, 4: leak with adapter inserted, leak through without adapter
(O) Outlet sheet 46: E530 (568) with note 4: Leak through without adapter
(P) Outlet sheet 47: C603B (616), C606A (617), C607A (618), C610B (619), C611B (620) with note 4: leak through without adapter
(Q) Outlet sheet 48: C625B (625), C628A (626), C628B (626), C684 (612), C649 (611), C649 (611), C661 (608) with note 14, 4, 6: other, leak through without adapter, no flow
(R) Outlet sheet 49: N607A (672), N607B (672), N608 (673), N611 (674), N614A (676), N614B (676), N619 (679) with notes 4, 14: leak through without adapter, missing latch button
(S) Outlet sheet 50: N625 (682), N628 (684) with note 4, 14: leak through without adapter, missing latch button
(T) Outlet sheet 51: E606A (645), E607A (647), E610B (649), E617B (659) with note 4: leak through without adapter
(U) Outlet sheet 52: E636B (662) with note 4: leak through without adapter

During an interview on 1/16/13 at 8:13 a.m., Engineer staff 1 stated he doesn't have any proof that indicated the work was completed, but a PO number 1139899 was provided to give authorization to get it done. He stated that the vendor may have completed the repairs but there was no documentation provided.

5. On 1/17/13 at 9:20 a.m., six vitalcom machines obstructed access to a medical gas shut off, in the central monitor station by the nurses' station, on the 5th floor.

Based on observation, document review, and interview, the facility failed to comply with the regulations regarding electrical wiring and utilities. This was evidenced by the following:
1. Medical devices that were plugged into unlisted assemblies
2. High wattage electrical equipment such as mini refrigerators, microwave ovens, and coffee machines that were plugged into power strips.
3. Power strips that were plugged into other power strips.
4. Electrical outlets that were missing covers.
5. Junction boxes that were missing covers
6. The permanent use of extension cords
7. The use of power strips in a hanging or suspended fashion creating tension to the cable joints and terminals.
8. Improper clearance in front of electrical panels
The improper use of surge protectors can result in the increased risk of an electrical fire. Blocked electrical panels can result in delayed access to the panel in the event of an emergency. These deficient practices affected all staff and patients in five of six floors at Sutter General Hospital, one of three outpatient buildings, and four of eight floors at Sutter Memorial Hospital.


NFPA 101, 2000 Edition, Existing 19.3.2 Protection from Hazards. 19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. 19.5.1 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 99, 1999 Edition. 2-1-Definitions- Labeled. Equipment or materials to which has been attached a label, symbol, or other identifying mark of an organization that is acceptable to the authority having jurisdiction and concerned with product evaluation, that maintains periodic inspection of production of labeled equipment or materials, and by whose labeling the manufacturer indicates compliance with appropriate standards or performance in a specified manner.
NFPA 99, 1999 Edition. 2-1-Definitions- Listed. Equipment, materials, or services included in a list published by an organization that is acceptable to the authority having jurisdiction and concerned with evaluation of products or services, that maintains periodic inspection of production of listed equipment or materials or periodic evaluation of services, and whose listing states that either the equipment, material, or service meets identified standards or has been tested and found suitable for a specified purpose.

NFPA 99, 1999 3-3.2.1.2, All patient care areas. (d)(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters. NFPA 70, 1999 110-3 Examination, Identification, Installation and use of Equipment
(b) Installation and use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.
NFPA 70, 1999 400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.
400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

363-9. Splices shall be made in listed junction boxes.

370-25. Covers and canopies. In complete installations, each box shall have a cover, face plate, or fixture canopy.

Findings:

Sutter General Hospital
During a tour of the facility with Staff, electrical wiring and equipment were observed.

1. On 1/14/13, at 11:05 a.m., there were two open junction boxes on the wall opposite the door in the Information Technology Room 4D102. One box was a four inch square and the other was a two by four inch square. Both boxes had green wires cut and exposed at the box.

2. On 1/14/13, at 11:20 a.m., there was an air conditioning machine at the front lobby entrance that was plugged into an extension cord that was taped to the floor. This air conditioner was rated at 11 amps. When asked, Engineering Staff stated that it was to prevent cold air from coming into the Main Lobby.

3. On 1/14/13, at 11:25 a.m., there was a two by four inch outlet box at the Radiology Nurses' Station that had the cover removed.

4. On 1/14/13, at 11:30 a.m., there was a two by four inch outlet box in the MRI Storage Room that had the cover removed.

5. On 1/14/13, at 11:45 a.m., there was a power strip plugged into another power strip under a desk in Room 1137D.

6. On 1/14/13, at 11:55 a.m., there was a two by four inch outlet box in the Film Fill Room that had the cover removed.

7. On 1/14/13, at 11:57 a.m., there was a two by four inch outlet box in the Radiology Tech Room that had the cover removed.

When IT Staff 1 was asked about the open junction boxes, Staff stated that they were installing new fiber optic cables and that the work would be finished within a week

Capital Pavilion-Ambulatory Surgery at Sutter
8. On 1/14/13, at 2:40 p.m., there was a APC brand non hospital grade power strip in Operating Room 5. This power strip was mounted to the pedestal of a computer stand.


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9. On 1/14/13 at 10:15 a.m., two IV pump machines and feeding pump were plugged into a non-hospital grade surge protector. The surge protector was strapped on a computer cart, in Room 5B44 (203).

10. On 1/14/13 at 10:18 a.m., by 5th floor Intensive Care Unit (ICU) by stairway 2 corridor, an ultra sound scanner rated at 5 amperage, a battery charger rated at 13 amperage, and a defibrillator machine were plugged into a 15 amps non-hospital grade 15 amperage surge protector. The items used exceeded the required amperage.

11. On 1/14/13 at 10:40 a.m., a surge protector with items plugged into it was hanging suspended off the floor, adding tension to the cord, in east nurse station 5.

12. On 1/14/13 at 11:16 a.m., a water dispenser rated at 5.5 amperage, a coffee machine rated at 1425 watts, and a refrigerator rated at 1.5 amperage were plugged into a non-hospital grade 15 amperage surge protector. The items used exceed the required amperage, in Room 207.

Fort Sutter
13. On 1/14/13 at 2:25 p.m., four stations had electric heater chairs, vital sign machines, and IV pump machines plugged into a non-hospital grade power strip. Engineer staff 6 stated he checked the machines and outlets, but not the power strip.

14. On 1/14/13 at 2:27 p.m., a surge protector with items plugged into it was hanging suspended off the floor, adding tension to the cord, in front desk area.


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15. On 1/14/13 at 10:08 a.m., a 32 inch by 18 inch by 34 inch tool cart obstructed access to Electrical Panel 3LQ1 (inside the Electrical Room), near the Surgery Waiting Room.

16. On 1/14/13 at 10:23 a.m., there were two surge protectors aboard a crash cart in the Post Acute Care Unit. A defibrillator and a suction machine were plugged into Surge Protector 1. A monitor, defibrillator, and an Uninterrupted Power Source were plugged into Surge Protector 2. Surge Protector 1 was connected to Surge Protector 2.

17. On 1/14/13 at 1:45 p.m., there were three surge protectors and one extension cord in use in the "MDF Room." A charger for the automatic line transfer switch and a black multi-outlet extension cord with a laptop power supply connected to it were plugged into Surge Protector 1. The overhead paging system, of which five of the six outlets were used, was plugged into Surge Protector 2. A printer and the overhead paging system (which occupied two of the six outlets) were plugged into Surge Protector 3. Surge Protector 3 was connected to Surge Protector 2.

18. On 1/14/13 at 3:25 p.m., in Electrical Room BD51, a utility cart with a tool chest, cleaning solution, and an on-board five foot ladder obstructed access to Electrical Panel BL4-Section 2.

Sutter Memorial Hospital
19. On 1/17/13, at 9:26 a.m., there were six wires that had been cut off that were protruding out of and old x-ray machine. These wires were near the ceiling in the the Old X-Ray Room
Engineering Staff 2 stated that the machine was no longer in use.

20. On 1/17/13, at 9:35 a.m., in Radiology Room R148, there was a four inch square junction box on the floor that had a flexible cord attached to it making it a multiple outlet extension cord with no over-current protection.

21. On 1/17/13, at 9:35 a.m., in Radiology Control Room, there was a four inch square junction box on the floor that had a flexible cord attached to it making it a multiple outlet extension cord with no over-current protection. The metal cover to this junction box was also separated on one side partially exposing the wires.




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22. On 1/17/13 at 8:35 a.m., a 10 amperage laser printer and a 4.7 amperage water cooler machine were plugged into a non-hospital grade 15 amperage surge protector. The items used exceeded the required amperage, in Room C708.

23. On 1/17/13 at 8:47 a.m., a 1.7 amperage monitor, 8 amperage printer/fax machine, and a 1.7 amperage battery charger were plugged into a non-hospital grade 15 amperage surge protector. The items used exceeded the required amperage, in Room E706.

24. On 1/17/13 at 9:10 a.m., a 10.7 amperage laser printer, a 2.4 amperage laptop machine, 1.7 amperage monitor were plugged into a power strip. The items used exceeded the required amperage, in Room N604.

25. On 1/17/13 at 10:20 a.m., a 2 amperage label printer and an 11 amperage laser printer were plugged into a non-hospital grade 15 amp surge protector. The items used exceed the required amperage, in Room E011.