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 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.

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 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.

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.

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 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, 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.