HospitalInspections.org

685 Building on 7/19/10:

4. At 11:40 a.m., in the first floor Radiology Suite, the Electrical Panel Room had a unsealed conduit and a 1/2 inch unsealed penetration in the ceiling next to the sprinkler escutcheon ring.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings at the San Antonio Community Hospital (SACH). This could result in faster spread of fire and smoke through compartments and harm to patients and staff in the event of a fire. This affected 2 of 20 smoke compartments on the first floor, 1 of 6 smoke compartments on the second floor and 1 smoke compartment at the 685 Building.

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and the Facility Safety Officer on July 19, through July 22, 2010, the facility walls and ceilings were observed.

SACH on July 20, 2010:
1. At 10:07 a.m., in the Critical Care Education room on the 2nd floor there were two, ½ inch round penetrations in the wall behind the door.

2. At 11:10 a.m., in the Radiology Storage Room next to the CT-1 control room on the 1st floor there was a 7 inch long x 1 ½ inch wide penetration in the left wall and a 1 inch round penetration in the right wall.

3. At 1:18 p.m., in the Communication Room on the 1st floor there was a ½ inch wide penetration around the sprinkler in the ceiling.

Based on observation, the facility failed to maintain the integrity of the corridor doors by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke. This failure could result in the spread of fire and smoke throughout the suite causing potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the corridor doors were observed.

Sierra San Antonio Medical Plaza, Suite 105:

1. At 1:25 p.m., the door to the x-ray dark room failed to latch.

2. At 1:29 p.m., the corridor door next to the kitchen was held open by a magnetic device that was not connected to the fire alarm control panel so that the door would automatically close in the event the fire alarm system was activated.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

11. At 2:42 p.m., the door self -closure to the ultra sound room was removed.

12. At 2:55 p.m., 2 of 2 corridor door self - closures in the Radiology workroom area were removed.

13. At 2:58 p.m., the door self - closure to x-ray room 1 was removed.

14. At 3:01 p.m., the door self - closure to x-ray room 2 was removed.

Based on observation, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to positive latch upon closure. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to patients and staff in the event of a fire. This affected 4 of 20 smoke compartments on the first floor, 2 of 6 smoke compartments on the second floor, 1 of 3 smoke compartments on the third floor and one smoke compartment at the Rancho San Antonio Medical Plaza.

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and Safety Officer on July 19 - July 22, 2010, the facility doors were observed.

SACH on July 19, 2010:

1. At 11:20 a.m., the door to the Managers Office across from the nurse ' s station on the 3rd floor was held open by a door wedge.

SACH on July 20, 2010:

2. At 9:38 a.m., the door to the Clean Utility Room in ICU on the 2nd floor failed to latch upon self closure.

3. At 9:53 a.m., the door to the Storage across from Nursing Station East on the 2nd floor failed to self-close and latch.

4. At 10:34 a.m., the door to the ED Staff Lounge on the 1st floor failed to latch.

5. At 10:40 a.m., the door to the Infectious Waste storage room in ED on the 1st floor failed to self close and latch. Part of the self closing mechanism had been removed.



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SACH on July 20, 2010:

6. At 9:45 a.m., the corridor door next to the first floor EVS Lead offices did not have door hardware to keep the door close. The room is used for storage.

7. At 10:15 a.m., the corridor door to patient room 133 in the first floor Latimer Unit failed to latch.

8. At 10:55 a.m., the corridor door to patient room 146 in the first floor Maternity Unit failed to latch.

9. At 10:58 a.m., there was no latching device for patient rooms 141, 142 and 143, corridor doors in the first floor Maternity Unit.

10. At 11:00 a.m., the corridor door to patient room 140 failed to latch in the first floor Maternity Unit.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by a smoke barrier door that failed to latch. This creates the potential for the spread of smoke and fire and harm to residents and staff in the event of fire. This affected 2 of 20 smoke compartments on the first floor.

NFPA 101, 2000 Edition, Section 8.3 Smoke Barriers
8.3.4.3 Doors in smoke barriers shall be self-closing or automatic closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Findings:

During the facility tour with the Facilities Manger and Safety Officer on July 19, through July 22, 2010, the smoke barrier doors were observed.

SACH on July 20, 2010:

1. At 3:49 p.m., the smoke barrier door by the West Wing Conference Room on the 1st floor failed to positive latch on the left side upon release from the magnetic device during testing of the fire alarm system.



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SACH on July 21, 2010:

2. At 10:35 a.m., in the first floor Latimer Pavilion the smoke barrier double doors leaf next to room 114 failed to latch during the testing of the fire alarm system and devices.

Based on observation, the facility failed to ensure that corridor doors to all hazardous areas are automatically self-closing and latching in accordance with 19.3.2.1, as evidenced by failure to have a door closure for a hazardous area exceeding 50 sq. feet. This failure affected one smoke compartment at the Rancho San Antonio Medical Plaza.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the corridor doors were observed.

Rancho San Antonio Medical Plaza - 7777A:

1. At 2:48 p.m., the Environmental Services Storage room door closure was removed.

Based on observation, the facility failed to provide readily accessible exits at all times as evidenced by obstruction in 1 of 3 exit accesses in a smoke compartment which would delay the evacuation of patients in the event of a fire or other emergency resulting in potential harm.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the exit accesses were observed.

Rancho San Antonio Medical Plaza - 7777B:

1. At 3:35 p.m., the access to the Rehab Kitchen exit was obstructed by box's that were stored by the door so that the door could not be opened.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

11. At 3:05 p.m., the exit sign above the exit door entering into the waiting/lobby area only had 1 of 2 light bulbs working.

12. At 3:07 p.m., the exit sign next to the Ultra Sound room and the Radiology workroom area only had 1 of two light bulbs working.

Based on observation, the facility failed to maintain the exit signs in 4 of 20 smoke compartments on the first floor, 2 of 6 smoke compartments on the second floor and a suite at the Rancho San Antonio Medical Plaza as evidenced by exit signs that were not illuminated. This has the potential for confusion and the delay of evacuation in the event of a fire or other emergency causing potential harm to residents and staff.

Findings:

During the tour of the facility with the Facilities Manager and Maintenance Supervisor on July 19 through July 22, 2010, the exit signs were observed.

SACH on July 20, 2010:

1. At 9:26 a.m., the Exit sign by Room 232 in the CCU on the 2nd floor failed to illuminate.

2. At 3:26 p.m., the Exit sign #215 by Room 260 on the 2nd floor failed to illuminate.



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SACH on July 20, 2010:
First Floor Latimer Pavilion:

3. At 10:18 a.m., the north exit sign next to patient room 132 was not fully illuminated, 1 of 2 light bulbs were not working.

4. At 10:30 a.m., the south exit sign next to patient room 133 was not fully illuminated, 1 of 2 light bulbs were not working.

SACH on July 21, 2010:

5. At 9;45 a.m., the north east exit sign next to the frist floor Sterile Processing Department was not fully illuminated, 1 of 2 light bulbs were not working.

6. At 9:48 a.m., the exit sign next to OR 6 was not illuminated, both light bulbs were not working.

7. At 9:50 a.m., the exit sign next to OR 1 was not illuminated, both light bulbs were not working.

8. At 10:03 a.m., the exit sign in the corridor next to the surgery storage room was not fully illuminated, 1 of 2 light bulbs were not working.

9. At 10: 05 a.m., the corridor exit sign next to the OR recovery room was not fully illuminated.

10. At 1:20 p.m., the east exit sign in the first floor Laboratory was not illuminated, both light bulbs were not working.

Based on document review and interview, the facility failed to ensure staff were trained with respect to their duties and emergency procedures as evidenced by failure to provide written documentation of conducting an annual drill at the Sierra San Antonio Medical Plaza out patient clinics. This failure could delay staff initiating emergency procedures creating the potential for harm to patients if staff become confused and fail to follow or understand the emergency fire evacuation plan.

Findings:

During document review with the Director of Facilities on July 19, through July 21, 2010, the fire drill records were requested.

Sierra San Antonio Medical Plaza - Suite 105:

1. At 4:30 p.m., on July 21, during interview the Director of Facilities stated there were no records of conducting a fire drill for review.

Based on document review, the facility failed to conduct fire drills at least quarterly for each shift of personnel as evidence by missing one AM shift fire drill and missing one NOC shift fire drill. This failure could result in staff's inability to respond to a fire causing potential harm to patients and visitors in the event of a fire. This affected the entire facility.

Findings:

During document review with the Facilities Manager on July 19 through July 22, 2010, the facilities fire drill records were reviewed.

SACH on July 20, 2010 :

1. At 9:30 a.m., the fire drill records indicate that the facility failed to conduct fire drills for 2nd quarter 2010 April May and June AM and NOC shift.

901 Building on July 21, 2010:

7. At 2:34 p.m., the strobe and chime above the fire extinguisher and by the blanket warmer in Suite 301 failed to work during testing of the fire alarm system.

Rancho San Antonio Medical Plaza - 7777B July 19, 2010:

8. At 3:10 p.m., the manual pull box located in Rehabilitation waiting area failed to activate the audibles and visual strobes in the facility.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by failing to keep impediments from obstructing the manual fire alarm pull station devices from view and access, by failure of a manual pull station and the failures of audible devices. This could delay in the activation the fire alarm system and cause potential harm to patients, staff and visitors in the event of a fire. This affected 4 of 20 smoke compartments on the first floor, 1 of 2 smoke compartments on the fourth floor, one smoke compartment at the Rancho San Antonio Medical Plaza and one smoke compartment at the 901 Building.

Findings:

During the testing of the fire alarm system with the Facilities Manager, Safety Officer and Fire Alarm Technician on July 19 through July 22, 2010, the pull stations and the chimes and strobes were observed.

SACH on July 20, 2010:

1. At 9:41 a.m., in the OR on the 1st floor across from the Education Office there was a pull station blocked by a 5 shelf metal cart containing supplies.

2. At 2:48 p.m., the Chime next to the Infectious Waste storage area on the 4th floor failed during testing of the fire alarm system.

3. At 1:20 p.m., in the Laboratory on the 1st floor, 1 of 2 chimes in the Lab area and 1 chime in the break room located in the Lab failed to during testing of the fire alarm system.





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SACH on July 21, 2010:
4. At 10:45 a.m., the chime located across from the non stress test room located on the first floor failed to activate an audible during the testing of the fire alarms.

5. At 1:05 p.m., the chime next to the Radiology Film file room failed to activate an audible during fire alarm testing.

6. At 1:10 p.m., the chime located next to emergency rooms 17,18 and 19, failed to activate an audible during fire alarm testing.

901 Building on July 21 2010:

14. At 3:45 p.m., during the testing of the fire alarm system and sprinkler system the riser had a five year sticker with the dates 6/23/2004 as the last inspection date. During interview, the Directors of Facilities stated there were no records of a current five year inspection for the building.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by missing escutcheon rings, sprinklers with paint on them and expired automatic sprinkler system five (5) year certification. This failure affected SACH and 901 Building. This could result in the automatic sprinkler system not functioning as designed in the event of a fire, resulting in the spread of fire and putting patients and staff at risk.

Findings:

During a tour of the facility with the Facilities Manager and Maintenance Supervisor on July 19 through July 22, 2010, the facilities sprinkler system was observed.

SACH on July 20, 2010:

1. At 9:47 a.m., the sprinkler by the Rechargeable Equipment Room on the 2nd floor was ¼ covered in white paint.

2. At 10:59 a.m., in the Lab, Central Processing area on the 1st floor there was a sprinkler missing an escutcheon ring.

3. At 11:12 a.m., in the Radiology Work Room on the 1st floor there three sprinklers missing an escutcheon ring.

4. At 11:21 a.m., in the corridor outside of the MRI on the 1st floor there was a sprinkler missing an escutcheon ring.

SACH on July 22, 2010:

5. At 1:25 p.m., the automatic sprinkler five (5) year certificate on the riser was dated 6/23/04. When interviewed on July 19, 2010 and July 22, 2010, Staff 1 stated that the vendor had been out to the facility on September 21, 2009 but, the facility failed to pass inspection and the paperwork provided by the vendor dated 9/21/09 did not specify why. No other paperwork or certification for the sprinkler system was provided by the facility.




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SACH on July 20, 2010 - First Floor:

6. At 9:20 a.m., the sprinkler escutcheon ring was missing in the Administration West Wing bathroom.

7. At 9:48 a.m., the Environmental services storage room was missing 2 of 3 sprinkler escutcheon rings.

8. At 9:49 a.m., the sprinkler escutcheon ring was missing in the Environmental services equipment room.

9. At 9:52 a.m., the sprinkler escutcheon ring was missing in the Environmental employee break room.

10. At 9:55 a.m., the sprinkler escutcheon rings was missing in the Environmental laundry room.

11. At 1:05 p.m., the sprinkler escutcheon rings was missing in Labor delivery operating room one.

12. At 1:22 p.m., the sprinkler escutcheon ring was missing in the cafeteria corridor.

13. At 1:50 p.m., the sprinkler escutcheon rings was missing in the corridor next to the Information Services room.

Based on observation, the facility failed to maintain the portable fire extinguishers as evidenced by a fire extinguisher that was blocked from access, a fire extinguisher that was not secured and fire extinguishers that were missing monthly visual inspections. This failure has the potential for inaccessibility to the fire extinguisher in the event of a fire, which could cause potential harm to patients and staff.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
1-6 General Requirements.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanker or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled typed fire extinguishers shall be located in a designated location.
1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage (e.g. from impact, vibrations, the environment) shall be adequately protected.

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and Safety Officer on July 19, through July 21, 2010, the fire extinguishers were observed.

SACH on July 20, 2010:

1. At 1:15 p.m., on 7/20/10 the Kitchen ABC fire extinguisher was observed to be block by a clean linen cart and was not mounted and placed on the floor.

SACH on July 21, 2010:

2. At 1:00 p.m., on 7/21/10 the Kitchen ABC fire extinguisher was observed again to be block by a clean linen cart and was not mounted and free standing on the floor.




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SACH on July 21, 2010:

3. At 10:23 a.m., in Respiratory Care on the 1st floor there was a fire extinguisher blocked by a trash can and a rolling medical cart.

Based on observation, and interview, the facility failed to maintain the integrity of the portable fire extinguishers in the facility by failing to document monthly visual inspections of the extinguishers at approximately 30 day intervals in accordance with NFPA 10. This failure could result in the fire extinguisher not functioning as designed in the event of a fire causing potential harm to patients and staff.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
4-3.4 Inspection Recordkeeping.

4-3.4.1 Personnel making inspections shall keep records of all fire extinguisher inspected, including those found to require corrective action.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g. bar coding) that provides a permanent record.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the fire extinguishers were observed.

Sierra San Antonio Medical Plaza - Suite 105:

1. At 1:20 p.m., the fire extinguisher located next to the x-ray room failed to have monthly check for May and June 2010. During interview, the Maintenance Supervisor stated there was no further documentation other than the tags on the fire extinguisher.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

4. At 2:48 p.m., the fire extinguisher located in Environmental Services storage room failed to have monthly check for May and June 2010. During interview, the Maintenance Supervisor stated there was no further documentation for the monthly checks.

Based on observation, the facility failed to ensure that the storage of medical gas was in accordance with NFPA 99, as evidenced by oxygen tanks stored with combustible material, no self closures and no signs indicating the room was used for oxygen storage. This affected 3 of 20 smoke compartments on the first floor.

NFPA 99 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 1307F (547C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2.*Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with the Facilities Manager on July 19 through July 22, 2010, the oxygen storage areas were observed.

SACH on July 20, 2010:

1. At 9:30 a.m., in the Storage room by Room 232 in CCU there were 5 E-Oxygen Tanks stored approximately 10 inches from a shelf containing 12 reams of copy paper.

2. At 11:20 a.m., in the storage room by X-Ray #3 on the 1st floor there were 14 E-Oxygen Tanks in a room that was not labeled for oxygen storage, had no self closing device and had a light switch approximately 4 feet from the ground.

SACH on July 21, 2010:

3. At 10:04 a.m., in the Surgery/Oxygen Storage room on the 1st floor there were 2 E-Oxygen Tanks not individually secured, 3 H-Oxygen Tanks and 19 E-Oxygen tanks stored within 10 inches of IV poles and medical equipment that were covered in plastic wrap and a rubber container with traction equipment in it.

685 Building, First Floor on July 19, 2010:

10. At 11:45 a.m., the electrical cover plate was missing under the Picture, Archive, Communications Systems "PACS" desk.

11. At 11:48 a.m., the electrical cover plate was missing under the Kodak workstation located next to x-ray room 4.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

10. At 2:48 p.m., in the Environmental Services Room there was a power strip plugged into a power strip.

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets and broken or missing cover plates and the unauthorized use of power strips. This affected 4 of 20 smoke compartments on the first floor, 3 of 6 smoke compartments on the second floor, 1 of 3 smoke compartments on the third floor, a smoke compartment in the Basement, 1 smoke compartment at Rancho San Antonio Medical Plaza and 1 smoke compartment at the 685 building.

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and the Safety Officer on July 19 - July 22, 2010, the electrical system was observed.

SACH on July 19, 2010:

1. At 11:12 a.m., the Nurse ' s Lounge on the 3rd floor had a microwave plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

SACH on July 20, 1010:

2. At 9:46 a.m., in Room C by the " Cardiovascular Surgeon " office on the 2nd floor there was a microwave and refrigerator plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

3. At 9:55 a.m., there was a blue soiled linen cart in front of the electrical panel in the Environmental Services Laundry Room located on the first floor.

4. At 9:58 a.m., in the Nurses Lounge East across from room 255 on the 2nd floor there was a microwave and refrigerator plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

5. At 10:03 a.m., in the South Storage room by the elevators on the 2nd floor there was a broken electrical cover plate.

6. At 10:36 a.m., in the ED Lounge on the 1st floor there was a microwave plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

7. At 11:00 a.m., in the Radiology storage room next to the CT -1 control room on the 1st floor there was an electrical outlet cover missing on the right wall and on the left wall.

8. At 1:20 p.m., in the SPD office/Break room on the 1st floor there was a refrigerator plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

9. At 1:30 p.m., in the Dietary office located in the basement there was a power strip plugged into a power strip under the Dietician's desk.

685 Building on 7/19/10:

4. At 11:40 a.m., in the first floor Radiology Suite, the Electrical Panel Room had a unsealed conduit and a 1/2 inch unsealed penetration in the ceiling next to the sprinkler escutcheon ring.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings at the San Antonio Community Hospital (SACH). This could result in faster spread of fire and smoke through compartments and harm to patients and staff in the event of a fire. This affected 2 of 20 smoke compartments on the first floor, 1 of 6 smoke compartments on the second floor and 1 smoke compartment at the 685 Building.

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and the Facility Safety Officer on July 19, through July 22, 2010, the facility walls and ceilings were observed.

SACH on July 20, 2010:
1. At 10:07 a.m., in the Critical Care Education room on the 2nd floor there were two, ½ inch round penetrations in the wall behind the door.

2. At 11:10 a.m., in the Radiology Storage Room next to the CT-1 control room on the 1st floor there was a 7 inch long x 1 ½ inch wide penetration in the left wall and a 1 inch round penetration in the right wall.

3. At 1:18 p.m., in the Communication Room on the 1st floor there was a ½ inch wide penetration around the sprinkler in the ceiling.

Based on observation, the facility failed to maintain the integrity of the corridor doors by failing to provide doors with devices suitable for keeping the doors closed, failing to keep impediments from obstructing the closing of doors, and failing to provide doors that resist the passage of smoke. This failure could result in the spread of fire and smoke throughout the suite causing potential harm to patients, staff and visitors.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the corridor doors were observed.

Sierra San Antonio Medical Plaza, Suite 105:

1. At 1:25 p.m., the door to the x-ray dark room failed to latch.

2. At 1:29 p.m., the corridor door next to the kitchen was held open by a magnetic device that was not connected to the fire alarm control panel so that the door would automatically close in the event the fire alarm system was activated.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

11. At 2:42 p.m., the door self -closure to the ultra sound room was removed.

12. At 2:55 p.m., 2 of 2 corridor door self - closures in the Radiology workroom area were removed.

13. At 2:58 p.m., the door self - closure to x-ray room 1 was removed.

14. At 3:01 p.m., the door self - closure to x-ray room 2 was removed.

Based on observation, the facility failed to maintain the corridor doors as evidenced by corridor doors that failed to positive latch upon closure. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to patients and staff in the event of a fire. This affected 4 of 20 smoke compartments on the first floor, 2 of 6 smoke compartments on the second floor, 1 of 3 smoke compartments on the third floor and one smoke compartment at the Rancho San Antonio Medical Plaza.

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and Safety Officer on July 19 - July 22, 2010, the facility doors were observed.

SACH on July 19, 2010:

1. At 11:20 a.m., the door to the Managers Office across from the nurse ' s station on the 3rd floor was held open by a door wedge.

SACH on July 20, 2010:

2. At 9:38 a.m., the door to the Clean Utility Room in ICU on the 2nd floor failed to latch upon self closure.

3. At 9:53 a.m., the door to the Storage across from Nursing Station East on the 2nd floor failed to self-close and latch.

4. At 10:34 a.m., the door to the ED Staff Lounge on the 1st floor failed to latch.

5. At 10:40 a.m., the door to the Infectious Waste storage room in ED on the 1st floor failed to self close and latch. Part of the self closing mechanism had been removed.



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SACH on July 20, 2010:

6. At 9:45 a.m., the corridor door next to the first floor EVS Lead offices did not have door hardware to keep the door close. The room is used for storage.

7. At 10:15 a.m., the corridor door to patient room 133 in the first floor Latimer Unit failed to latch.

8. At 10:55 a.m., the corridor door to patient room 146 in the first floor Maternity Unit failed to latch.

9. At 10:58 a.m., there was no latching device for patient rooms 141, 142 and 143, corridor doors in the first floor Maternity Unit.

10. At 11:00 a.m., the corridor door to patient room 140 failed to latch in the first floor Maternity Unit.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by a smoke barrier door that failed to latch. This creates the potential for the spread of smoke and fire and harm to residents and staff in the event of fire. This affected 2 of 20 smoke compartments on the first floor.

NFPA 101, 2000 Edition, Section 8.3 Smoke Barriers
8.3.4.3 Doors in smoke barriers shall be self-closing or automatic closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.

Findings:

During the facility tour with the Facilities Manger and Safety Officer on July 19, through July 22, 2010, the smoke barrier doors were observed.

SACH on July 20, 2010:

1. At 3:49 p.m., the smoke barrier door by the West Wing Conference Room on the 1st floor failed to positive latch on the left side upon release from the magnetic device during testing of the fire alarm system.



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SACH on July 21, 2010:

2. At 10:35 a.m., in the first floor Latimer Pavilion the smoke barrier double doors leaf next to room 114 failed to latch during the testing of the fire alarm system and devices.

Based on observation, the facility failed to ensure that corridor doors to all hazardous areas are automatically self-closing and latching in accordance with 19.3.2.1, as evidenced by failure to have a door closure for a hazardous area exceeding 50 sq. feet. This failure affected one smoke compartment at the Rancho San Antonio Medical Plaza.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the corridor doors were observed.

Rancho San Antonio Medical Plaza - 7777A:

1. At 2:48 p.m., the Environmental Services Storage room door closure was removed.

Based on observation, the facility failed to provide readily accessible exits at all times as evidenced by obstruction in 1 of 3 exit accesses in a smoke compartment which would delay the evacuation of patients in the event of a fire or other emergency resulting in potential harm.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the exit accesses were observed.

Rancho San Antonio Medical Plaza - 7777B:

1. At 3:35 p.m., the access to the Rehab Kitchen exit was obstructed by box's that were stored by the door so that the door could not be opened.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

11. At 3:05 p.m., the exit sign above the exit door entering into the waiting/lobby area only had 1 of 2 light bulbs working.

12. At 3:07 p.m., the exit sign next to the Ultra Sound room and the Radiology workroom area only had 1 of two light bulbs working.

Based on observation, the facility failed to maintain the exit signs in 4 of 20 smoke compartments on the first floor, 2 of 6 smoke compartments on the second floor and a suite at the Rancho San Antonio Medical Plaza as evidenced by exit signs that were not illuminated. This has the potential for confusion and the delay of evacuation in the event of a fire or other emergency causing potential harm to residents and staff.

Findings:

During the tour of the facility with the Facilities Manager and Maintenance Supervisor on July 19 through July 22, 2010, the exit signs were observed.

SACH on July 20, 2010:

1. At 9:26 a.m., the Exit sign by Room 232 in the CCU on the 2nd floor failed to illuminate.

2. At 3:26 p.m., the Exit sign #215 by Room 260 on the 2nd floor failed to illuminate.



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SACH on July 20, 2010:
First Floor Latimer Pavilion:

3. At 10:18 a.m., the north exit sign next to patient room 132 was not fully illuminated, 1 of 2 light bulbs were not working.

4. At 10:30 a.m., the south exit sign next to patient room 133 was not fully illuminated, 1 of 2 light bulbs were not working.

SACH on July 21, 2010:

5. At 9;45 a.m., the north east exit sign next to the frist floor Sterile Processing Department was not fully illuminated, 1 of 2 light bulbs were not working.

6. At 9:48 a.m., the exit sign next to OR 6 was not illuminated, both light bulbs were not working.

7. At 9:50 a.m., the exit sign next to OR 1 was not illuminated, both light bulbs were not working.

8. At 10:03 a.m., the exit sign in the corridor next to the surgery storage room was not fully illuminated, 1 of 2 light bulbs were not working.

9. At 10: 05 a.m., the corridor exit sign next to the OR recovery room was not fully illuminated.

10. At 1:20 p.m., the east exit sign in the first floor Laboratory was not illuminated, both light bulbs were not working.

Based on document review and interview, the facility failed to ensure staff were trained with respect to their duties and emergency procedures as evidenced by failure to provide written documentation of conducting an annual drill at the Sierra San Antonio Medical Plaza out patient clinics. This failure could delay staff initiating emergency procedures creating the potential for harm to patients if staff become confused and fail to follow or understand the emergency fire evacuation plan.

Findings:

During document review with the Director of Facilities on July 19, through July 21, 2010, the fire drill records were requested.

Sierra San Antonio Medical Plaza - Suite 105:

1. At 4:30 p.m., on July 21, during interview the Director of Facilities stated there were no records of conducting a fire drill for review.

Based on document review, the facility failed to conduct fire drills at least quarterly for each shift of personnel as evidence by missing one AM shift fire drill and missing one NOC shift fire drill. This failure could result in staff's inability to respond to a fire causing potential harm to patients and visitors in the event of a fire. This affected the entire facility.

Findings:

During document review with the Facilities Manager on July 19 through July 22, 2010, the facilities fire drill records were reviewed.

SACH on July 20, 2010 :

1. At 9:30 a.m., the fire drill records indicate that the facility failed to conduct fire drills for 2nd quarter 2010 April May and June AM and NOC shift.

901 Building on July 21, 2010:

7. At 2:34 p.m., the strobe and chime above the fire extinguisher and by the blanket warmer in Suite 301 failed to work during testing of the fire alarm system.

Rancho San Antonio Medical Plaza - 7777B July 19, 2010:

8. At 3:10 p.m., the manual pull box located in Rehabilitation waiting area failed to activate the audibles and visual strobes in the facility.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by failing to keep impediments from obstructing the manual fire alarm pull station devices from view and access, by failure of a manual pull station and the failures of audible devices. This could delay in the activation the fire alarm system and cause potential harm to patients, staff and visitors in the event of a fire. This affected 4 of 20 smoke compartments on the first floor, 1 of 2 smoke compartments on the fourth floor, one smoke compartment at the Rancho San Antonio Medical Plaza and one smoke compartment at the 901 Building.

Findings:

During the testing of the fire alarm system with the Facilities Manager, Safety Officer and Fire Alarm Technician on July 19 through July 22, 2010, the pull stations and the chimes and strobes were observed.

SACH on July 20, 2010:

1. At 9:41 a.m., in the OR on the 1st floor across from the Education Office there was a pull station blocked by a 5 shelf metal cart containing supplies.

2. At 2:48 p.m., the Chime next to the Infectious Waste storage area on the 4th floor failed during testing of the fire alarm system.

3. At 1:20 p.m., in the Laboratory on the 1st floor, 1 of 2 chimes in the Lab area and 1 chime in the break room located in the Lab failed to during testing of the fire alarm system.





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SACH on July 21, 2010:
4. At 10:45 a.m., the chime located across from the non stress test room located on the first floor failed to activate an audible during the testing of the fire alarms.

5. At 1:05 p.m., the chime next to the Radiology Film file room failed to activate an audible during fire alarm testing.

6. At 1:10 p.m., the chime located next to emergency rooms 17,18 and 19, failed to activate an audible during fire alarm testing.

901 Building on July 21 2010:

14. At 3:45 p.m., during the testing of the fire alarm system and sprinkler system the riser had a five year sticker with the dates 6/23/2004 as the last inspection date. During interview, the Directors of Facilities stated there were no records of a current five year inspection for the building.

Based on observation, the facility failed to maintain the automatic sprinkler system as evidenced by missing escutcheon rings, sprinklers with paint on them and expired automatic sprinkler system five (5) year certification. This failure affected SACH and 901 Building. This could result in the automatic sprinkler system not functioning as designed in the event of a fire, resulting in the spread of fire and putting patients and staff at risk.

Findings:

During a tour of the facility with the Facilities Manager and Maintenance Supervisor on July 19 through July 22, 2010, the facilities sprinkler system was observed.

SACH on July 20, 2010:

1. At 9:47 a.m., the sprinkler by the Rechargeable Equipment Room on the 2nd floor was ¼ covered in white paint.

2. At 10:59 a.m., in the Lab, Central Processing area on the 1st floor there was a sprinkler missing an escutcheon ring.

3. At 11:12 a.m., in the Radiology Work Room on the 1st floor there three sprinklers missing an escutcheon ring.

4. At 11:21 a.m., in the corridor outside of the MRI on the 1st floor there was a sprinkler missing an escutcheon ring.

SACH on July 22, 2010:

5. At 1:25 p.m., the automatic sprinkler five (5) year certificate on the riser was dated 6/23/04. When interviewed on July 19, 2010 and July 22, 2010, Staff 1 stated that the vendor had been out to the facility on September 21, 2009 but, the facility failed to pass inspection and the paperwork provided by the vendor dated 9/21/09 did not specify why. No other paperwork or certification for the sprinkler system was provided by the facility.




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SACH on July 20, 2010 - First Floor:

6. At 9:20 a.m., the sprinkler escutcheon ring was missing in the Administration West Wing bathroom.

7. At 9:48 a.m., the Environmental services storage room was missing 2 of 3 sprinkler escutcheon rings.

8. At 9:49 a.m., the sprinkler escutcheon ring was missing in the Environmental services equipment room.

9. At 9:52 a.m., the sprinkler escutcheon ring was missing in the Environmental employee break room.

10. At 9:55 a.m., the sprinkler escutcheon rings was missing in the Environmental laundry room.

11. At 1:05 p.m., the sprinkler escutcheon rings was missing in Labor delivery operating room one.

12. At 1:22 p.m., the sprinkler escutcheon ring was missing in the cafeteria corridor.

13. At 1:50 p.m., the sprinkler escutcheon rings was missing in the corridor next to the Information Services room.

Based on observation, the facility failed to maintain the portable fire extinguishers as evidenced by a fire extinguisher that was blocked from access, a fire extinguisher that was not secured and fire extinguishers that were missing monthly visual inspections. This failure has the potential for inaccessibility to the fire extinguisher in the event of a fire, which could cause potential harm to patients and staff.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
1-6 General Requirements.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanker or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled typed fire extinguishers shall be located in a designated location.
1-6.8 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in brackets specifically designed to cope with this problem.
1-6.9 Fire extinguishers installed under conditions where they are subject to physical damage (e.g. from impact, vibrations, the environment) shall be adequately protected.

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and Safety Officer on July 19, through July 21, 2010, the fire extinguishers were observed.

SACH on July 20, 2010:

1. At 1:15 p.m., on 7/20/10 the Kitchen ABC fire extinguisher was observed to be block by a clean linen cart and was not mounted and placed on the floor.

SACH on July 21, 2010:

2. At 1:00 p.m., on 7/21/10 the Kitchen ABC fire extinguisher was observed again to be block by a clean linen cart and was not mounted and free standing on the floor.




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SACH on July 21, 2010:

3. At 10:23 a.m., in Respiratory Care on the 1st floor there was a fire extinguisher blocked by a trash can and a rolling medical cart.

Based on observation, and interview, the facility failed to maintain the integrity of the portable fire extinguishers in the facility by failing to document monthly visual inspections of the extinguishers at approximately 30 day intervals in accordance with NFPA 10. This failure could result in the fire extinguisher not functioning as designed in the event of a fire causing potential harm to patients and staff.

NFPA 10, Standard for Portable Fire Extinguishers (1998 Edition)
4-3.4 Inspection Recordkeeping.

4-3.4.1 Personnel making inspections shall keep records of all fire extinguisher inspected, including those found to require corrective action.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g. bar coding) that provides a permanent record.

Findings:

During a tour of the facility with the Maintenance Supervisor on July 19, 2010, the fire extinguishers were observed.

Sierra San Antonio Medical Plaza - Suite 105:

1. At 1:20 p.m., the fire extinguisher located next to the x-ray room failed to have monthly check for May and June 2010. During interview, the Maintenance Supervisor stated there was no further documentation other than the tags on the fire extinguisher.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

4. At 2:48 p.m., the fire extinguisher located in Environmental Services storage room failed to have monthly check for May and June 2010. During interview, the Maintenance Supervisor stated there was no further documentation for the monthly checks.

Based on observation, the facility failed to ensure that the storage of medical gas was in accordance with NFPA 99, as evidenced by oxygen tanks stored with combustible material, no self closures and no signs indicating the room was used for oxygen storage. This affected 3 of 20 smoke compartments on the first floor.

NFPA 99 1999 Edition
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a)* Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
1. Sources of heat in storage locations shall be protected or located so that cylinders or compressed gases shall not be heated to the activation point of integral safety devices. In no case shall the temperature of the cylinders exceed 1307F (547C). Care shall be exercised when handling cylinders that have been exposed to freezing temperatures or containers that contain cryogenic liquids to prevent injury to the skin.
2.*Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7].

Findings:

During a tour of the facility with the Facilities Manager on July 19 through July 22, 2010, the oxygen storage areas were observed.

SACH on July 20, 2010:

1. At 9:30 a.m., in the Storage room by Room 232 in CCU there were 5 E-Oxygen Tanks stored approximately 10 inches from a shelf containing 12 reams of copy paper.

2. At 11:20 a.m., in the storage room by X-Ray #3 on the 1st floor there were 14 E-Oxygen Tanks in a room that was not labeled for oxygen storage, had no self closing device and had a light switch approximately 4 feet from the ground.

SACH on July 21, 2010:

3. At 10:04 a.m., in the Surgery/Oxygen Storage room on the 1st floor there were 2 E-Oxygen Tanks not individually secured, 3 H-Oxygen Tanks and 19 E-Oxygen tanks stored within 10 inches of IV poles and medical equipment that were covered in plastic wrap and a rubber container with traction equipment in it.

685 Building, First Floor on July 19, 2010:

10. At 11:45 a.m., the electrical cover plate was missing under the Picture, Archive, Communications Systems "PACS" desk.

11. At 11:48 a.m., the electrical cover plate was missing under the Kodak workstation located next to x-ray room 4.

Rancho San Antonio Medical Plaza - 7777A on July 19, 2010:

10. At 2:48 p.m., in the Environmental Services Room there was a power strip plugged into a power strip.

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets and broken or missing cover plates and the unauthorized use of power strips. This affected 4 of 20 smoke compartments on the first floor, 3 of 6 smoke compartments on the second floor, 1 of 3 smoke compartments on the third floor, a smoke compartment in the Basement, 1 smoke compartment at Rancho San Antonio Medical Plaza and 1 smoke compartment at the 685 building.

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:

(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Facilities Manager, Maintenance Supervisor and the Safety Officer on July 19 - July 22, 2010, the electrical system was observed.

SACH on July 19, 2010:

1. At 11:12 a.m., the Nurse ' s Lounge on the 3rd floor had a microwave plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

SACH on July 20, 1010:

2. At 9:46 a.m., in Room C by the " Cardiovascular Surgeon " office on the 2nd floor there was a microwave and refrigerator plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

3. At 9:55 a.m., there was a blue soiled linen cart in front of the electrical panel in the Environmental Services Laundry Room located on the first floor.

4. At 9:58 a.m., in the Nurses Lounge East across from room 255 on the 2nd floor there was a microwave and refrigerator plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

5. At 10:03 a.m., in the South Storage room by the elevators on the 2nd floor there was a broken electrical cover plate.

6. At 10:36 a.m., in the ED Lounge on the 1st floor there was a microwave plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

7. At 11:00 a.m., in the Radiology storage room next to the CT -1 control room on the 1st floor there was an electrical outlet cover missing on the right wall and on the left wall.

8. At 1:20 p.m., in the SPD office/Break room on the 1st floor there was a refrigerator plugged into a multi-plug surge protection strip and not directly into the electrical outlet on the wall.

9. At 1:30 p.m., in the Dietary office located in the basement there was a power strip plugged into a power strip under the Dietician's desk.