HospitalInspections.org

Based on observation and interview, the facility failed to protect their hazardous areas. This was evidenced by one hazardous area door that was not equipped with a self-closer and was obstructed from closing. This was also evidenced by one hazardous area door that failed to latch. This affected one of five floors and the basement of the main hospital. This could result in the faster spread of smoke and fire and the increased risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, the hazardous areas were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 3:47 p.m., on 5/16/16, the self-closing fire-rated door to the soiled utility closet in Radiology failed to latch during four of four attempts. The closet contained multiple receptacles of trash.

MAIN HOSPITAL
BASEMENT

2. At 4:32 p.m., on 5/17/16, the trash room near Pharmacy contained two approximately 125-gallon trash receptacles. The door to the trash room was opened and not equipped with a self-closer. The door dragged on the floor and was obstructed from closing.

During an interview at 4:33 p.m., the Manager of Facilities (MF) stated that the door was not closing because its bottom hinge was broken.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by one fire alarm annunciator that failed to emit an audible signal. This was also evidenced by no fire alarm notification in the Pharmacy and pharmacy storage areas. This affected one of five floors and the basement of the main hospital. This could result in a delay in notification, and the increased risk of injury, in the event of a fire.

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

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

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

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

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.5.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, the fire alarm system was tested.

MAIN HOSPITAL
THIRD FLOOR

1. At 3:47 p.m., on 5/17/16, the smoke detector in Room 318 was tested by the Manager of Facilities (MF). The "Patient Room Smoke Detector Annunciator" at Nurses Station 1 exhibited a visual trouble light next to the Room 318 label but did not emit an audible signal. Scribe1 confirmed the finding.

Similar annunciators on the fourth and fifth floor nurses stations emitted both a visual and an audible trouble signal when tested.

During an interview at 3:48 p.m., MF stated that the annunciator should have emitted an audible signal.

MAIN HOSPITAL
BASEMENT

2. At 4:37 p.m., on 5/17/16, MF tested the fire alarm system and no alarms could be heard in Pharmacy Storage. This room was approximately 500 square feet and included a staff workstation.

During an interview at 4:37 p.m., Pharmacist1 stated that she could not hear the fire alarms.

3. At 4:38 p.m., on 5/17/16, MF tested the fire alarm system. There were no fire alarm notification devices inside the Pharmacy and the fire alarms could not be heard

During an interview at 4:38 p.m., Pharmacist2 stated that he could not hear the fire alarms because the fume hoods were loud.

29665

Based on observation, record review, and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the failure of the remote monitoring station to receive supervisory signals from closure of the sprinkler control valves. This could result in a delayed notification, in the event of tampered sprinkler control valves, and a delay in extinguishing a fire. This deficiency affected the entire main hospital and increased the potential for harm to patients, visitors, and staff.

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

19.3.5.3 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments and specifically reference this paragraph, the sprinkler system shall meet the following criteria:
(1) It shall be installed throughout the building in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
(4) It shall be equipped with listed quick-response or listed residential sprinklers throughout all smoke compartments containing patient sleeping rooms.
Exception No. 1: Standard response sprinklers shall be permitted to be continued to be used in existing approved sprinkler systems where quick-response and residential sprinklers were not listed for use in such locations at the time of installation.
Exception No. 2: Standard response sprinklers shall be permitted for use in hazardous areas protected accordance with 19.3.2.1

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

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water-Based Fire Protection Systems. 1998 Edition
1.4 Qualified. Having adequate knowledge of the installation, construction, or operations of apparatus and the hazards involved.
Supervision. A means of monitoring system status and indicating abnormal conditions.

NFPA 72 National Fire Alarm Code, 1999 Edition
1-4 Central Station. A supervising station that is listed for central station service.

1-5.4.3.2.2 Visible and audible supervisory signals and visible indication of their restoration to normal shall be indicated within 90 seconds at the following locations:
(1) Control unit (central equipment)for local fire alarm systems
(2) Building fire command center for emergency voice/alarm communication service
(3) Supervising station location for systems installed in compliance with Chapter 5.

5-2.5.1 The central station shall have sufficient personnel, but not less than two persons, on duty at the central station at all times to ensure disposition of signals in accordance with the requirements of 5-2.6.1.

5-2.5.2 Operation and supervision shall be the primary functions of the operators, and no other interest or activity shall take precedence over the protective service.

5-2.6.1.3 Upon receipt of a supervisory signal from a sprinkler system, other fire suppression system(s), or other equipment, the central station shall perform the following actions:
(1) Communicate immediately with the person(s) designated by the subscriber
(2) Dispatch a runner or maintenance person to arrive within 1 hour to investigate
Exception: Where the supervisory signal is cleared in accordance with a scheduled procedure determined by 5-2.6.1.3(1).
(3) Notify the fire department or law enforcement agency, or both, if required
(4) Notify the authority having jurisdiction when sprinkler systems or other fire suppression systems or equipment has been wholly or partially out of service for 8 hours
(5) When service has been restored, provide notice, if required, to the subscriber or the authority having jurisdiction,
or both, as to the nature of the signal, the time of occurrence, and the restoration of service when equipment has been out of service for 8 hours or more
Exception: If the supervisory signal results from a prearranged test, the actions specified by 5-2.6.1.3 (1), (3), and (5) shall not be required.

Findings:

During record review and facility tour with staff from 5/16/16 to 5/18/16, the sprinkler control valves were tested and documents were reviewed.

MAIN HOSPITAL

1. At 4:12 p.m., on 5/17/16, the tamper switch at the main post indicator valve (PIV) for the sprinkler system was activated and a supervisory signal was sent to the fire panel.

At 4:16 p.m., on 5/17/16, the tamper switch at the MRI PIV was activated and a supervisory signal was sent to the fire panel.

At 11:24 a.m., on 5/18/16, the monitoring report showed that the remote monitoring facility failed to receive the supervisory signals activated by the closure of the sprinkler control valves on 5/17/16.

During an interview at 12:05 p.m., on 5/18/16, the Manager of Facilities (MF) stated that the tamper switches at the two PIVs were tested again at 11:51 a.m. and 11:52 a.m. by staff. He confirmed that the remote monitoring station failed to receive the supervisory signals again. He said that a technician was called to troubleshoot the panel.

29665

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler and extinguishing systems. This was evidenced by a clean agent extinguishing system that failed an inspection, by a pendant sprinkler head in a room where the drop down ceiling was recently demolished, by the failure to conduct a complete five-year inspection, by one corroded sprinkler head, and by one sprinkler head with an obstructed spray pattern. This affected one of five floors and the basement of the main hospital. This also affected the Wound Care Clinic. These deficiencies could result in a delay in extinguishing a fire and the increased risk of injury to patients, staff, and visitors.

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

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

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

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

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

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

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

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

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

9-2.8.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-4.1.2 Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

9-4.2 Check Valves.
9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

9-5 Pressure Reducing Valves and Relief Valves.
9-5.1.2 A full flow test shall be conducted on each valve at 5-year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be made in accordance with the manufacturer's instructions.

10-2.2 Obstruction Prevention. Systems shall be examined internally for obstructions where conditions exist that could cause obstructed piping. If the condition has not been corrected or the condition is one that could result in obstruction of piping despite any previous flushing procedures that have been performed, the system shall be examined internally for obstructions every 5 years. This investigation shall be accomplished by examining the interior of a dry valve or preaction valve and by removing two cross main flushing connections.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition.
8-1.1 Working plans shall be submitted for approval to the authority having jurisdiction before any equipment is installed or remodeled. Deviation from approved plans shall require permission of the authority having jurisdiction.

8-1.1.1 Working plans shall be drawn to an indicated scale, on sheets of uniform size, with a plan of each floor, and shall show those items from the following list that pertain to the design of the system.
(4) Full height cross section or schematic diagram, including structural member information if required for clarity and including ceiling construction and method of protection for nonmetallic piping.
(5) Location of partitions.
(8) Location and size of concealed spaces, closets, attics, and bathrooms.

NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems, 2000 Edition.
4-5.1 These systems shall be maintained in full operating condition at all times. Actuation, impairment, and restoration of this protection shall be reported promptly to the authority having jurisdiction.

4-5.2 Any troubles or impairments shall be corrected in a timely manner consistent with the hazard protected.

4-6.2 Personnel working in an enclosure protected by a clean agent shall receive training regarding agent safety issues.

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, the extinguishing systems at all buildings were observed and maintenance records were requested.

MAIN HOSPITAL
BASEMENT

1. At 9:50 a.m., on 5/16/16, the drop ceiling in the old sterilizer room of Sterile Processing was removed and the attic space in the room was exposed. The two sprinkler heads in the room were pendant-type that previously hung below the drop down ceiling. Removal of the ceiling and exposure of the attic space may delay activation of these sprinkler heads, in the event of a fire.

The adjacent new sterilizer room of similar dimensions had no drop down ceiling and was protected by two upright sprinkler heads closer to the roof deck.

During an interview at 9:51 a.m., the Project Manager for Construction (PM) stated that the demolition of the ceiling was part of an emergency project (Project #S160649-19-00) approved by the Office of Statewide Health Planning and Development (OSHPD) to remove the old sterilizer. She stated that the old sterilizer was removed in March and the facility was still deciding whether to install a new sterilizer or reinstall the room partitions. She confirmed that plans for the room have not yet been drawn up or submitted to OSHPD.

The facility was granted permission by OSHPD to begin repairing damage to the old sterilizer room on 3/16/16 under the emergency project number above. The approval notice from the regional compliance officer stated "this authorization does not waive the plan approval and permit process." The memo also stated "in order to assure safety and code compliance, all work shall be inspected by an approved certified Inspector of Record (IOR)."

During an interview at 10:15 a.m., on 5/18/16, the IOR confirmed that the sprinkler heads in the room corresponded with the presence of a drop down ceiling. He stated that they may need to add heat collecting plates around the sprinkler heads until construction is completed.

WOUND CARE CLINIC (HYPERBARIC CENTER)

2. At 11:36 a.m., on 5/17/16, the sprinkler riser was tagged with an April 2016 annual inspection certification sticker by Vendor 1. The riser was not tagged with a five-year inspection sticker and records of a five-year inspection had not yet been provided.

During an interview at 11:37 a.m., the Facilities Consultant (FC) stated that only an annual inspection was performed at this building because the sprinkler system was only a "couple of years old."

Confirmation of the sprinkler system installation date was not provided.

At 8:14 a.m., on 5/18/16, FC provided a picture of the sprinkler riser with a May 2016 five-year certification sticker by Vendor 2.

During an interview at 8:15 a.m., FC stated that the a five-year inspection was conducted yesterday (5/17/16).

At 11:09 a.m., on 5/18/16, records of the five-year inspection were provided. Vendor 2 indicated that only a visual inspection was conducted on 5/17/16. The report stated "return trip required to test devices and backflush."

The facility failed to provide records of a complete five-year inspection at the Wound Care Clinic.

MAIN HOSPITAL
THIRD FLOOR

3. At 3:40 p.m., on 5/17/16, there was a portable air conditioner (AC) in the storage/data closet. Its exhaust duct was less than 7 inches away from an automatic sprinkler head and obstructed the sprinkler's spray pattern.

MAIN HOSPITAL
BASEMENT

4. At 4:52 p.m., on 5/17/16, the sprinkler head in the kitchen's walk-in refrigerator was corroded.

5. At 11:00 a.m., on 5/18/16, records of clean-agent and preaction system inspections in the Server and Telco Rooms were provided. Each system had its own subpanel. A vendor indicated that the Halon 1301 system outside the Server Room failed a visual inspection on 5/17/16. The vendor indicated that the bell and chime were "missing signage depicting the state of alarm." The vendor also stated "found EPO relay wires disconnected inside the panel. Not known why."

At 12:22 p.m., there were four alarm notification devices adjacent to each other in the front of the Server Room. There were three bells and one combination chime/strobe device. The Server Room was protected by a preaction system and a Halon system but the notification devices were not labeled.

During an interview at 12:23 p.m., the Manager of Facilities (MF) stated that each bell corresponded to one system and he will ask the vendor to label them accordingly.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) systems. This was a evidenced by a leaking water pump in the chiller room, by dampers that failed an inspection, and by the use of a portable air conditioner (AC) in lieu of mechanical ventilation. This affected the main hospital and could result in the faster spread of smoke and fire through the HVAC system, and the increased risk of injury to patients, visitors, and staff.

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

19.5.2.2 Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Exception No. 1: Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient sleeping areas, provided that such heaters are located high enough to be out of the reach of persons using the area and are equipped with the safety features required by 19.5.2.2.
Exception No. 2: Fireplaces shall be permitted and used only in areas other than patient sleeping areas, provided that such areas are separated from patient sleeping spaces by construction having not less than a 1-hour fire resistance rating and that such fireplaces comply with the provisions of 9.2.2. In addition, the fireplace shall be equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650°F (343°C) and constructed of heat-tempered glass or other approved material. If, in the opinion of the authority having jurisdiction, special hazards are present, a lock on the enclosure and other safety precautions shall be permitted to be required.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.

2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.

2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.

2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.

2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.

2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.

3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.

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

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, the HVAC systems were observed and maintenance records were reviewed.

MAIN HOSPITAL
FIRST FLOOR

1. At 2:19 p.m., on 5/16/16, records from a vendor inspection on 4/26/16 showed that the combination smoke/fire dampers (CSFD) in the Nursery Storage Room and Nursery Utility Room required repairs. The vendor wrote that the 1 foot by 1 foot access in the Nursery Storage Room was too small to allow access for inspection of the CSFD. He also wrote that CSFD 408, in the Nursery Utility Room, was "tweaked as if it was pried open" and needed a new assembly.

During an interview at 2:30 p.m., the Facilities Consultant (FC) stated that the vendor told him he was able to fix all dampers during the inspection except for #408 and the one in Nursery Storage.

MAIN HOSPITAL
CENTRAL PLANT

2. At 3:17 p.m., on 5/16/16, there was a leak at one of three water pumps in the chiller room. A hose was connected to the site of the leak that expelled water into a nearby drain.

During an interview at 3:18 p.m., Facilities Engineer (FE1) stated that the pump had been leaking for about one week.


MAIN HOSPITAL
THIRD FLOOR

3. At 3:37 p.m., on 5/17/16, there was a portable AC in the storage/data room that exhausted hot air into the room's return vent. This AC was observed to be in use during the March 2016 Life Safety Code survey.

During an interview at 3:38 p.m., FC and the Manager of Facilities (MF) stated that the portable AC is used because the room gets too hot from the all the data boxes. FC stated that the AC is only a temporary solution and the facility is looking into getting the room adequately ventilated and cooled.







29566

29665

Based on observation, record review, and interview, the facility failed to maintain their means of egress. This was evidenced by egress corridors that were not free of obstructions. This affected one of five floors at the main hospital. This could result in a delay in evacuation and staff response, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During tour of the facility with staff from 5/16/16 to 5/18/16, the means of egress were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 11:19 a.m., on 5/17/16, there were items blocking the egress corridor close to Operating Room (OR) 5 in the surgery department. There were exit signs marking exit doors on both sides of the corridor. The items in the corridor included five carts of supplies, three large plastic containers, and two large wheeled tables. On the wall above the tables were labels stating "Supply/Receiving" and "Broken Items."

During an interview at 11:20 a.m., the Director of Perioperative Services (DPS) stated that there was no other place to keep these supplies. She stated that staff are assigned to move these items during the evacuation and this is written into their evacuation policy.

At 11:25 a.m., under the "Procedure for Operating Room" section of the Surgery Department's evacuation policy, Part B stated "Transporters: Clear hallways of all equipment and supply carts to the closest vacant operating room."

2. At 4:18 p.m., on 5/17/16, there were five gurneys lined up against the wall of the egress corridor in the MRI building.

During an interview at 4:19 p.m., the Director of Radiology (DOR) acknowledged the finding and stated that they would look for a place to relocate the gurneys.

Based on observation, record review, and interview, the facility failed to ensure that equipment is installed in accordance with manufacturer's specifications and was approved by the authority having jurisdiction (AHJ). This was evidenced by pharmacy hoods that were not permanently installed, by one pharmacy hood that was not vented correctly, and by medication dispensers that were not seismically anchored. This affected the entire main hospital. This could result in the increased risk of hazardous conditions and injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
4.5.7 Maintenance. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

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

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 5 Environmental Systems
5-1 Scope. This chapter covers the performance, maintenance, and testing of the environmental systems used within health care facilities.
5-4.3.3 Fume hoods intended for use with radioactive isotopes
shall be constructed of stainless steel or other material suitable for the particular exposure.
5-4.3.5 Fume hoods shall be so designed that the face velocity ventilation is adequate to prevent the backflow of contaminants into the room, especially in the presence of cross drafts or the rapid movements of an operator working at the face of the hood.

Chapter 9 Manufacturer Requirements
9-1 Scope. This chapter covers the performance, maintenance, and testing, with regard to safety, required of manufacturers of equipment used within health care facilities.
9-2.1.1.2 Mechanical Stability. The appliance shall be mechanically stable in the position of normal use. If the appliance is intended for use in an anesthetizing location, 12-4.1 applies.
9-2.1.6.3 Chemical Agents. Electric appliances containing hazardous chemicals shall be designed to facilitate the replenishment of these chemicals without spillage to protect the patient, the operating personnel, and the safety features of the appliance from such chemicals.

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, potential hazards were observed.

MAIN HOSPITAL (THROUGHOUT EXCEPT MECHANICAL SECOND FLOOR)

1. During the Life Safety Code survey from 3/7/16 to 3/10/16, the facility was cited for OMNICells (medication dispensers) that were not seismically anchored for earthquake safety.

During an interview at 2:10 p.m., on 5/16/16, the Assistant Project Manager for Construction (PM2) stated that the medication dispensers had not yet been anchored. She stated that the facility was granted an emergency project (Project S160647-19-00) from the Office of Statewide Health Planning and Development (OSHPD) for "OMNICell Anchorage."

The 3/16/16 memo from the OSHPD regional compliance officer stated "you are hereby authorized to proceed with the damage repair and replacement prior to issuance of a Building Permit."

Between 11:49 a.m. and 11:53 a.m., on 5/18/16, OMNICells were observed throughout the hospital. There was one OMNICell across from a bed in the Post-Anesthesia Care Unit (PACU), there were three OMNICells in the clean utility room of the Intensive Care Unit (ICU), and there were four OMNICells in the medication room of the Emergency Care Center (ECC). All these OMNICells were more than six-feet tall and were not seismically anchored.

During an interview at 11:54 a.m., the Director of Pharmacy (DOP) stated that there were additional OMNICell towers on the third, fourth, and fifth floors. He stated that they were all not seismically anchored yet.


MAIN HOSPITAL
BASEMENT

2. During the Life Safety Code survey from 3/7/16 to 3/10/16, the facility was cited for using two pharmacy hoods that were not permanently installed or seismically anchored and for the exhausting the chemotherapy preparation (chemo prep) hood into a regular exhaust vent.

During an interview at 9:40 a.m., on 5/17/16, the Project Manager for Construction (PM) stated that repairs had not yet begun on the two pharmacy hoods. She stated that the repairs of the hoods fell under the OMNICell Anchorage project mentioned in Finding 2 above. She stated that plans are not yet completed for this project.

Partial blueprints for Project S160647-19-00 were provided. Anchorage of the OMNICells, pharmacy hoods, and exhaust of the two laminar flow hoods were included under the "Scope of Work" section. The plans were preliminary and only included architectural drawings for the basement and first floor.

During an interview at 9:43 a.m., PM confirmed that the plans were only partial and not ready for review by OSHPD. She stated that the mechanical drawings for exhausting the hoods were not yet ready.

At 11:45 a.m., on 5/18/16, the two pharmacy hoods were observed to be in the same condition as the last Life Safety Code survey in March 2016. Both hoods were on wheels and not seismically anchored. The chemo prep hood was exhausted into a regular return exhaust vent.







29566

Based on observation, the facility failed to maintain their electrical wiring. This was evidenced by the unapproved use of power strips and extension cords and by electrical fixtures with missing covers. This affected two of five floors of the main hospital and the Women's Care Center. This could result in the increased risk of an electrical fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
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 70, National Electrical Code, 1999 Edition.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

Table 210-21(b)(2). Maximum Cord- and Plug-Connected Load to Receptacle
Circuit Rating (Amperes): 20
Receptacle Rating (Amperes): 20
Maximum Load (Amperes): 16

210-23. Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified according to its size as specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.

370-25. Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Finding:

During a facility tour with staff from 5/16/16 to 5/18/16, the electrical wiring was observed.

MAIN HOSPITAL
THIRD FLOOR

1. At 3:38 p.m., on 5/17/16, there was a portable air conditioner (AC) in the storage/data room plugged into a 10-plug power strip equipped with an uninterupptable power source (UPS). The power strip's manufacturer's specifications indicated that it was intended for computer use to avoid data loss during a power failure. The power strip had a "Rated Input Current (Maximum Load)" of 10 amps. The portable AC had a "Current Consumption" rate of 11.9 amps and a "Recommended Fuse Size" of 15 Amps.

The facility failed to ensure that the maximum load of the power strip was not exceeded.

WOMEN'S CARE CENTER

2. At 8:59 a.m., on 5/18/16, there was a six-plug power strip plugged into an extension cord in the Consultation Room.

MAIN HOSPITAL
FIRST FLOOR

3. At 12:09 p.m., on 5/18/16, there were two 4 inch by 4 inch junction boxes with no covers in the "Full Oxygen Cylinders" Room.







29566

Based on document review and interview, the facility failed to maintain their elevators. This was evidenced by the failure to conduct monthly testing for all elevators equipped with Phase I and Phase II Firefighter service. This affected five of five elevators at the main hospital. This could result in the increased risk of malfunction of the elevator safety features, in the event of a fire, and could result in the increased risk of patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.

9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and test as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

Findings:

During record review with staff from 5/16/16 to 5/18/16, the elevator inspection records were requested.

1. At 4:15 p.m., on 5/16/16, a record titled "Elevator Fire Service Phase I and II Monthly Test Log for State # 1, 2, 3, 4" was reviewed. The log showed that the Phase I and Phase II Keyswitch tests were not conducted for more than a year between 10/9/14 to 12/4/15. The log also showed that there were no tests conducted in April 2016. The vendor indicated that, from December 2015 to March 2016, the monthly testing was only conducted for "Cars 2 to 4."

During an interview at 4:16 p.m., the Manager of Facilities (MF) and the Facilities Consultant (FC) stated that the hospital operated five elevators. MF stated that there were no other elevator maintenance records available.

Based on observation and interview, the facility failed to protect their hazardous areas. This was evidenced by one hazardous area door that was not equipped with a self-closer and was obstructed from closing. This was also evidenced by one hazardous area door that failed to latch. This affected one of five floors and the basement of the main hospital. This could result in the faster spread of smoke and fire and the increased risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a facility tour with staff from 5/16/16 to 5/18/16, the hazardous areas were observed.

MAIN HOSPITAL
FIRST FLOOR

1. At 3:47 p.m., on 5/16/16, the self-closing fire-rated door to the soiled utility closet in Radiology failed to latch during four of four attempts. The closet contained multiple receptacles of trash.

MAIN HOSPITAL
BASEMENT

2. At 4:32 p.m., on 5/17/16, the trash room near Pharmacy contained two approximately 125-gallon trash receptacles. The door to the trash room was opened and not equipped with a self-closer. The door dragged on the floor and was obstructed from closing.

During an interview at 4:33 p.m., the Manager of Facilities (MF) stated that the door was not closing because its bottom hinge was broken.

Based on document review and interview, the facility failed to maintain their elevators. This was evidenced by the failure to conduct monthly testing for all elevators equipped with Phase I and Phase II Firefighter service. This affected five of five elevators at the main hospital. This could result in the increased risk of malfunction of the elevator safety features, in the event of a fire, and could result in the increased risk of patients, staff, and visitors.

NFPA 101 Life Safety Code, 2000 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.

9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and test as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators.

Findings:

During record review with staff from 5/16/16 to 5/18/16, the elevator inspection records were requested.

1. At 4:15 p.m., on 5/16/16, a record titled "Elevator Fire Service Phase I and II Monthly Test Log for State # 1, 2, 3, 4" was reviewed. The log showed that the Phase I and Phase II Keyswitch tests were not conducted for more than a year between 10/9/14 to 12/4/15. The log also showed that there were no tests conducted in April 2016. The vendor indicated that, from December 2015 to March 2016, the monthly testing was only conducted for "Cars 2 to 4."

During an interview at 4:16 p.m., the Manager of Facilities (MF) and the Facilities Consultant (FC) stated that the hospital operated five elevators. MF stated that there were no other elevator maintenance records available.