HospitalInspections.org

Based on observation, the Hospital failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in walls in the Pacific Building in one of eleven floors and on the wall to a room at the California West Campus, affecting 1 of 7 Floors. This could result in the spread of fire and smoke.

Findings:

Pacific Building
During a tour of the facility with a staff member on 10/12/11, the facility's walls and ceilings were observed.

1. At 10:40 a.m., on Level B in the Oncology Treatment Room 2 (#0279), the 3 inch pipe conduit from the treatment room to the control room was not sealed on either end. The pipe conduit ran across a concrete wall and was located in a cabinet in the treatment room and under the desk of the control room. Engineering Staff 5 confirmed that the pipe conduit was not sealed.

2. At 10:46 a.m., on Level B, in the Oncology Treatment Room 1 (#0280), the 3 inch pipe conduit from the treatment room to the control room was not sealed on either end. The pipe conduit ran across a concrete wall and was located in a cabinet in the treatment room and under the desk of the control room. Engineering Staff 5 confirmed that the pipe conduit was not sealed.

West California Campus
3. On 10/13/11, at 11:11 a.m., during a tour of the facility with Support Services Staff 1 and Engineering Staff 4, the facility's walls and ceilings were observed.
There were four penetrations through the wall in the IT Room 3312 on the 1st floor. The penetrations measured approximately 1/4-inch each.

Based on observation, the Hospital failed to maintain their corridor doors. This was evidenced by corridor doors that were obstructed from closing or latching, a dutch door that was not equipped with a top leaf latching device, and a self-closing device that was non-functioning. This affected three of eleven floors in the Pacific Building, one of two surveyed floors in the Stanford Building and
one of seven floors at the West California Campus and could result in a delay to contain smoke or fire to a room.

NFPA 101, Life Safety Code, 2000 edition
19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3 In addition, both the upper and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

Findings:

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

Pacific Building:
1. On 10/11/11 at 11:36 a.m., on the 6th floor, the corridor door to Patient Room 624 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 10/11/11 at 11:38 a.m., on the 6th floor, the corridor door to Patient Room 626 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 10/11/11 at 11:40 a.m., on the 6th floor, the corridor door to Medication Room 6807 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch.

4. On 10/11/11 at 12:07 p.m., on the 6th floor, corridor door to Patient Room 656 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

5. On 10/11/11 at 12:15 p.m., on the 6th floor, the corridor door to Patient Room 669 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

6. On 10/11/11 at 12:19 p.m., on the 6th floor, the corridor door to the Information Technology Closet, near the elevators, was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

7. On 10/11/11 at 12:37 p.m., on the 5th floor, the corridor door to the Nutrition Kitchen Room 5806 was equipped with an automatic closing device. The door was obstructed from closing by a trash bin positioned directly in the swing path of the door.

8. On 10/11/11 at 12:53 p.m., on the 5th floor, the corridor door to Equipment Room B (Room 5838) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

9. On 10/11/11 at 12:55 p.m., on the 5th floor, the corridor door to Patient Room 567 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

10. On 10/11/11 at 2:34 p.m., on the 5th floor, the corridor door to Patient Room 561 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

11. On 10/12/11 at 9:54 a.m., on the 3rd floor, the corridor dutch door to the Front Desk Room 3141 was observed. The top leaf of the dutch door was not equipped with a latching device.

Stanford Building:
12. On 10/12/11 at 11:16 a.m., on the 6th floor, the corridor door to the Telephone Room 622 was equipped with a self-closing device. The self-closing device was partially disassembled. The door was held open to the fullest extent and allowed to close. The door failed to close and remained in the open position.

13. On 10/12/11 at 11:29 a.m., on the 6th floor, the corridor door to Mechanical Room 639 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

14. On 10/12/11 at 11:31 a.m., on the 6th floor, the ACU side corridor door to the central elevators was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close and latch. The door was obstructed by air pressure differences.

West California Campus
15. On 10/13/11 at 11:15 a.m., the corridor door to the Pediatrics Holding Room 3505 on the 3rd floor, was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a table positioned in the swing path of the door.

Based on observation and interview, the Hospital failed to maintain their vertical openings. This was evidenced by two corridor doors to a vertical opening that were not equipped with a self-closing devices. This affected two of eleven floors in the Pacific Building and could result in the passage of smoke or fire from one floor to another.

Findings:

During a facility tour with staff, the vertical openings in the facility were observed.

Pacific Building:
1. On 10/11/11 at 12:22 p.m., on the 6th floor, the corridor door to the Sixth Floor pipe chase was not equipped with a self-closing device. The pipe chase was located near the elevator bank. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the pipe chase extended from the B-Level to the Sixth Floor.



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Pacific Building
2. On 10/12/11, at 10:30 a.m., on Level B, the door to the pipe chase near the elevator lobby was not equipped with a self-closing device. The pipe chase extended from the floor to Level B. Engineering Staff 5 stated that some doors were equipped with self closing devices.

Based on observation, the Hospital failed to install exit signs and directional signs on or by doors designated as emergency exit routes. This was evidenced by one missing exit sign in the Pacific Building that affected 1 of 11 floors, and no exit sign posted at the Stanford Building that affected 1 of 2 surveyed floors and
no directional sign posted at the West California Campus that affected 1 of 7 floors. This could have the potential for delaying evacuation of patients and incorrectly directing evacuees during an emergency.

Findings:

During a tour of the facility with Staff, the exits and signage in the facility were observed.

Pacific Building
1. On October 12, 2011, at 11:13 a.m., on Level A, there was no exit sign present over or near the exit door in the hallway by Room A143. The facility's evacuation map indicated that its evacuation route to the exit was through the door and the exit was not readily apparent.


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Stanford Building
2. On 10/12/11 at 11:58 a.m., the EEG Suite 141 on the first floor was observed. The exit door leading from Room 143 to the corridor had an exit sign placed above the door. There was no additional sign in the EEG Suite that indicated a possible exit was through Room 143. The exit through Room 143 was one of two unobstructed exits from the suite.

West California Campus
3. On 10/13/11, at 9:38 a.m., there was no directional sign present in the exit discharge area by Stairwell #6 on the 1st Floor. The facility's evacuation map indicated that its evacuation route to the public way was through the exit discharge. The public way was not readily apparent.

Based on observation, the Hospital failed to maintain the integrity of smoke barrier walls. This was evidenced by penetrations in smoke barrier wall on the 4th Floor and on the 1st Floor, affecting 2 of 11 Floors at the Pacific Building. This had the potential to allow the spread of smoke from one smoke compartment to the other smoke compartment in the event of a fire.

Findings:

During a tour of the facility with Administrative Services Staff 1, Support Services Staff 1, Engineering Staff 2, Engineering Staff 6, and Engineering Staff 7, the smoke barrier walls were observed.

Pacific Building
1. On 10/11/11, at 12:54 p.m., the 1-hour rated smoke barrier wall in the corridor by Room 4815 had a penetration in the atrium space above the fire doors on the 4th Floor. The penetration was located directly above a duct that measured approximately 5-inches by 2-inches.

Pacific Building
2. On October 12, 2011, at 10:45 a.m., the 2-hour rated smoke barrier wall in the corridor by Cath Lab 4 in Room 1504 on the 1st Floor had a penetration in the atrium space above the fire doors. The penetration was located directly below a treated beam that measured approximately 4-inches by 1/4-inch.

Based on observation and interview, the Hospital failed to maintain their fire doors as evidenced by fire doors that did not fully close and latch. This deficient condition affected two of eleven floors in the Pacific Building and could result in the spread of smoke in the event of a fire.

Findings
During a tour of the facility with a staff member on 10/14/11, the facility fire doors were observed.

Pacific Building
1. At 11:17 a.m., on the 4th floor, the door to elevator bank did not close upon smoke detector activation. The other two doors did close.

2. At 11:32 a.m., on the 2nd floor of the Pacific Campus, when the fire alarm was activated, the double fire doors to Nuclear Medicine were released. The double doors failed to fully close and latch. Engineering Staff 5 stated that the draft from the vents prevented the doors from fully closing.

Based on observation, the Hospital failed to maintain their hazardous areas. This was evidenced by three hazardous areas that were not equipped with self-closing doors and the laboratory that was not safeguarded by a 1-hour fire barrier. This affected two of eleven floors in the Pacific Building and two of two surveyed floors in the Stanford Building and one of seven floors at the West California Campus and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Pacific Building
1. On 10/12/11 at 9:39 a.m., the Anesthesia Work Room 3124 on the 3rd floor was observed to be over fifty square feet in area. The room contained combustible items in storage. The door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Stanford Building
2. On 10/12/11 at 11:21 a.m., the corridor door to the Soiled Utility Room 641 on the 6th floor was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.
3. On 10/12/11 at 12:01 p.m., the corridor door to the Soiled Utility Room, near Exam Room 5 in Suite 134 on the 1st floor, was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.


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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.

Pacific Building
3. On 10/11/11, at 3:30 p.m., it was observed that the wall to the North and North-West section of Corridor 2C9 on the 2nd Floor did not extend up through the atrium space. The North Wing section of this floor had a Clinical Laboratory that was not equipped with an automatic sprinkler system. The laboratory contained combustible materials and flammable liquids. The Nuclear Medicine Exam Rooms, Corridor 2C9, and Corridor 2C8 were located adjacent to the laboratory and had an open connection through the atrium space. Engineering Staff 2 confirmed that the floor plans marked in blue had a 1-hour wall that did not extend through the atrium space up to the rated deck. The surveyor was presented a document from an Engineer that stated that the corridor walls that terminate at the ceiling were constructed to meet the one-hour fire rating, forming a fire rated tunnel construction within the corridor. Engineering Staff 2 stated that he believed that the tiled ceiling above the laboratory area had one layer of 5/8-inch thick gypsum board; thus, 30-minute fire rating. No other evidence was presented to show that the laboratory was safeguarded by a 1-hour fire resistance barrier.

West California Campus
4. On 10/13/11 at 10:35 a.m., on the 4th floor, the corridor door to the Pathology Room 4409 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the Hospital failed to maintain egress passageways as evidenced by a gurney and bed that blocked the opening of an egress door. This deficient practice affected one of seven floors at the West California Campus and could result in a delay of egress in the event of an emergency evacuation.

Findings

During a tour of the facility with a staff member on 10/13/11, the facility egress passageways were observed.

West California Campus
1. On 10/13/11, at 10:28 a.m., the corridor in the Surgical Suite by the Neonatal Intensive Care Unit (NICU) on the 2nd Floor was obstructed by a patient bed and gurney. The bed prevented the door to the NICU from fully opening and obstructed the exit access through this passageway that is part of the facility's evacuation route.

Based on observation, the Hospital failed to maintain the fire alarm system as evidenced by strobes and horns that did not function during the fire alarm testing affecting two of eleven floors in the Pacific Building, one battery powered smoke detector door holder that failed to activate, affecting 1 of 7 Floors in the West California Campus and by strobes that did not function during fire alarm testing and by blocked pull stations at the East California Campus affecting three of seven floors. These deficient practices could result in the failure of alarm notification in the event of a fire
Findings
Pacific Building
1. At 11:13 a.m., on the 4th floor, the strobe on the strobe/horn combo #442 did not function during dire alarm testing.
2. At 11:20 a.m., in Pathology area, the horn/strobe over room 2431, the strobe functioned, but the horn failed to sound. The suite door to Nuclear medicine was tested several times and failed to self-close and latch due to positive air flow current in the area
3. At 11:34 a.m., on the 2nd floor, the ITV and smoke detector were tested at Nuclear Medicine. The ITV and the smoke detector failed to activate two of two horn/strobe devices.

East California Building
5. On 10/13/11, at 2:56 p.m., upon activation of the ITV valve on the second floor of CPMC East women ' s health center/breast cancer center, all 5 of 5 strobe horn combinations alarms failed to emit flash strobes. The horns sounded in all five alarms but there was no strobe. The alarms were located near rooms 272, 285, 289, and 293. The PAFA technician acknowledged the deficiency as well as the CPMC engineering staff.
6. On 10/13/11, at 2:57 p.m., in the Breast Health Center, five out of five horn/strobe combos could only be heard. The strobe on the combos did not function during the activation of the fire alarm.
7. On 10/13/11, at 3:05 p.m., the manual pull station in the front lobby nearest to California Street was blocked and not visible or accessible by a large upright blue hospital sign placed directly in front of the sign.
8. On 10/13/11, at 3:12 p.m., in the First floor lobby area, the pull station near the front entrance was blocked by a sign that was placed in front of the pull station. The sign blocked the accessibility and visibility of the pull station near the main entrance door.
9. On 10/13/11, at 3:12 p.m., on the first floor of CPMC East, 3 of 3 strobes failed to emit the flashing strobe light when the smoke detector was activated. The strobes were located along the corridor near room 1700, 1895, and 1893.
10. On 10/13/11, at 3:20 p.m., in the Operating Room area, the pull station was blocked by a supply cart and an IV stand was in front of the pull station. Accessibility to the pull station was blocked.
11. On 10/13/11, at 3:26 p.m., in the First floor hallway area by the elevators, three strobes failed to function during fire alarm testing. The strobes were part of a horn/strobe combo and only the horn was functioning.
12. On 10/13/11, at 3:30 p.m., the manual pull station in the OR suite nearest to room #1842 was partially obstructed by a supply cart and medical device. The pull station was no accessible. The OR nurse, manager acknowledged the presence of the supply cart and medical device.
13. On 10/13/11, at 3:32 p.m., in the Women ' s Health Resource Center, the door to the Library/Computer room (#1840) did not latch. The latch would not catch in the latch plate in the door frame.

West California Campus
4. On 10/13/11, at 2:50 p.m., on the 1st floor, the stand alone smoke detector door holder in the Gift Shop failed to activate upon spraying canned smoke. The smoke detector was battery operated and was not interconnected to the fire alarm system. Support Services Staff 1 stated that there was no current maintenance program in place for that device.

Based on observation, interview and record review the Hospital failed to maintain the kitchen hood as evidenced by failing to maintain the semi-annual cleaning of the kitchen hood. This deficient condition affected one of six floors in the Pacific building and could result in the ignition of a hood fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 editions
8-2 Inspection - An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations monthly
Systems serving high-volume cooking operations quarterly
(such as 24-hr cooking, charbroiling or wok cooking)
Systems serving moderate-volume cooking semiannually
Systems serving low-volume cooking operations,
(such as churches, day camps, seasonal businesses,
or senior centers) annually
8-3.1.2 - When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the service company. It shall also indicate areas not cleaned.

Findings:

During document review, the documents for the cleaning of the kitchen hood were observed.

Pacific Building
1. On 10/11/11, the documents for the cleaning of the kitchen hood were requested. The documents provided stated that the last cleaning of the kitchen hood was on 3/10/11. There were no other documents provided that the hood had been cleaned six months later. During a tour of the kitchen, the sticker on the kitchen hood had a date of 3/10/11 for the date that the hood was last cleaned.

Based on observation, the Hospital failed to ensure the safe use of portable space heating devices. This was evidenced by five portable space heaters that were not used according to manufacturer specifications. This affected two of two surveyed floors in the Stanford Building and one of seven floors in the West California Campus and could result in a portable space heater ignited fire emergency.

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

Stanford Building
1. On 10/12/11 at 11:33 a.m., a portable space heater was observed in a Staff Office Room 600B on the 6th floor. The portable space heater was not in use but was plugged into an electrical wall receptacle. The portable space heater was located under a desk and within three feet of combustibles and furnishings. The room was unoccupied at the time of observation.

2. On 10/12/11 at 12:11 p.m., a portable space heater was observed in the Radiology Reading Room on the 1st floor. The portable space heater was not in use but was plugged into a surge protected multi-outlet extension cord. The portable space heater was not plugged directly to an electrical wall receptacle. The portable space heater was located under a desk and within three feet of combustibles and furnishings.

West California Campus
3. On 10/13/11 at 9:36 a.m., a portable space heater was observed in the Genetic Counselor's Office 4330 on the 4th floor. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 verified with a department head and confirmed that the room is sometimes occupied by patients.

4. On 10/13/11 at 9:41 a.m., a portable space heater was observed in the Genetic Counselor's Office 4324 on the 4th floor. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 verified with a department head and confirmed that the room is sometimes occupied by patients.

5. On 10/13/11 at 10:32 a.m., a portable space heater was observed in Pathology Office 4417 on the 4th floor. The portable space heater was plugged into a surge protected multi-outlet extension cord instead of directly to an electrical wall receptacle. The portable space heater was located under a desk and within three feet of combustibles and furnishings. There were no facility labels observed on the portable space heater. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 indicated that the portable space heater does not look like one of the facility's approved portable space heater. Engineering Staff 3 could not confirm the portable space heater would not exceed 212 degrees Fahrenheit.

Based on observation, the Hospital failed to maintain safe storage of oxygen gas cylinders. This was evidenced by one oxygen E cylinder that was free standing and unsecured. This affected one of two surveyed floors in the Stanford Building and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the facility's oxygen gas cylinder storage locations were observed.

Stanford Building
1. On 10/12/11 at 11:25 a.m., there was one oxygen E cylinder located in the Ambulatory Care Unit Clinical Manager's Office (Room 643) on the 6th floor. The oxygen cylinder was free standing and unsecured.

Based on observation, the Hospital failed to maintain the relative humidity at equal to or greater than 35% as evidenced by 38 days in the past year that the humidity level in the Operating rooms in the Pacific Building dropped below 35%. This deficient practice affected all 9 of 11 operating rooms in the Operating Suite and five of five procedure/operating rooms in the ASU located at the East California Campus. This deficient practice could lead to an electrical fire in the operating room. A possible waiver to maintain the the humidity levels below the required 35% range was discussed with the maintenance/engineering staff.

Findings

During document review on 10/12/11, the Operating Room Humidity reports were reviewed.

The records provided indicated that the humidity dropped below 35%. The following Nine operating rooms in the Operating Suite dropped below 35% at least one time in the past year.

Pacific Building
1. Saenz: In January 2011 the humidity dropped below 35% 13 times. In February 2011, the humidity dropped below 35% 5 times. In March 2011, the humidity dropped below 30% 6 times. The humidity in this operating room dropped as low as 30%.

2. Jewett: In January 2011 the humidity dropped below 35% 1 time. The humidity in this operating room dropped as low as 22%.

3. Waterhouse: In January 2011 the humidity dropped below 35% 3 times. In February 2011, the humidity dropped below 35% 2 times. In March 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 32%.

4. Yates: In January 2011 the humidity dropped below 35% 8 times. In February 2011, the humidity dropped below 35% 8 times. In March 2011, the humidity dropped below 35% 8 times. In November 2010, the humidity dropped below 35% 3 times. The humidity in this operating room dropped as low as 30%.

5. Sampson: In January 2011 the humidity dropped below 35% 1 time. In February 2011, the humidity dropped below 35% 3 times. The humidity in this operating room dropped as low as 20%.

6. D: In January 2011 the humidity dropped below 35% 3 times. In February 2011, the humidity dropped below 35% 4 times. In March 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 30%.

7. Howard: In January 2011 the humidity dropped below 35% 3 times. In February 2011, the humidity dropped below 35% 1 times. In March 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 30%.

8. Kresge: In January 2011 the humidity dropped below 35% 10 times. In February 2011, the humidity dropped below 35% 2 times. In March 2011, the humidity dropped below 35% 1 time. The humidity in this operating room dropped as low as 15%.

9. Taylor: In January 2011 the humidity dropped below 35% 4 times. In February 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 30%.

East California Campus
10. OR11: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 25%.

11. OR12: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 23%.

12. OR14: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 29%.

13. OR15: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 28%.

14. OR16: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 28%.

Based on interview and document review, the Hospital failed to maintain the generator as evidenced by no alarm annunciator panel at the Pacific Campus and at the Mental Health Center, by not providing a back up or alternative fuel source for the natural gas generator at the Mental Health Center, by not providing any battery back up lighting for the generator area, and by the generator not transferring power under 10 seconds.
These deficient practices affected the eleven floors in the Pacific Campus and 1 of 1 surveyed floor in the Mental Health Center and could result in the malfunctioning of the generator in the event of a primary emergency power loss without staff knowledge.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
3-4.1.1.8 Load Pickup. The generator set(s)shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
3-4.1.1.15 Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

NFPA 110, 1999 Edition
6-3 Maintenance and Operational Testing.
6-3.4 A written record for the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:

(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.

6-4 Operational Inspection and Testing.
6-4.1* Level 1 and 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Findings:

During a tour of the facility with staff members, the generator area and the maintenance records were reviewed.

Pacific Building
1) On 10/12/11, at 10:00 a.m., the generator on Level C of the Pacific Campus was observed. No remote annunciator panel was observed in the Hospital.
Upon interview with Engineering Staff 5, staff acknowledged no remote annunciator was installed in the Hospital Pacific campus. A time limited waiver was discussed with the engineering staff concerning the installation for the remote annunciator panel.

Mental Health Center - 2323 Sacramento
During a tour of the facility with a staff member on 10/13/11, the generator area was inspected.
2) At 11:20 a.m., during document review with staff, on 10/11/11, the generator maintenance records were reviewed. The documents provided for the weekly inspections of the generator for the past year indicated that the generator had a transfer time between 11 seconds and 12 seconds. Engineering Staff 5 stated that the transfer time for the generator is not being timed.

3) At 11:25 a.m., there was no generator annunciator panel provided for the generator.

4) At 11:30 a.m., there was also no battery back up light for the generator area.

5) At 11:35 a.m., there was no secondary or alternative fuel source back up for the natural gas generator. In the event of an earthquake there could be a break in the natural gas line and the generator would not function.
Staff acknowledged that there was no annunciator panel. A possible waiver was discussed.

Based on observation, the Hospital failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances plugged into extension cords, extension cords plugged into other extension cords, and electrical receptacles that were missing faceplates. This affected six of eleven floors in the Pacific Building and one of two surveyed floors in the Stanford Building and three floors in the California West Campus. This could result in an electrical fire.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Pacific Building
1. On 10/11/11 at 11;55 a.m., a refrigerator in the Staff Lounge 6814 on the 6th floor, was plugged into a surge protected multi-outlet extension cord.

2. On 10/11/11 at 2:48 p.m., computer equipment in the G.I. Lab Entrance on the 5th floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

3. On 10/11/11 at 3:14 p.m., computer equipment in the Case Manager's Office 4802 on the 4th floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

4. On 10/11/11 at 3:34 p.m., office equipment in the Clinical Manager's Office 4224 on the 4th floor, was plugged into an orange non-surge protected multi-outlet extension cord that was plugged into a surge protected multi-outlet extension cord.

5. On 10/12/11 at 10:35 a.m., a miniature refrigerator in the Anesthesia Locker Room 3M10 on the 3rd floor Mezzanine level, was plugged into a surge protected multi-outlet extension cord.

6. On 10/12/11 at 9:45 a.m., a miniature refrigerator in the Circulatory Support Systems Room 3148 on the 3rd floor, was plugged into a surge protected multi-outlet extension cord.

7. On 10/12/11 at 9:51 a.m., a miniature refrigerator in the O.R. Office Room 3138 on the 3rd floor, was plugged into a surge protected multi-outlet extension cord.

8. On 10/12/11 at 10:43 a.m., a miniature refrigerator in the Clinical Nurse Manager's Office 3390 on the 3rd floor, was plugged into a surge protected multi-outlet extension cord.

9. On 10/12/11 at 11:08 a.m., a junction box in the Nurse Practitioner's Office 3445 on the 3rd floor, was missing a protective faceplate. Electrical wiring was exposed.




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Pacific Campus
10. On 10/12/11, at 10:21 a.m., on Level B, the 3D Transar system was plugged into a power strip instead of directly into the wall outlet. The 3D Transar is a chemical cooling system. Engineering Staff 5 confirmed that the cooling system was plugged into a power strip instead of directly into the wall outlet.

11. On 10/12/11, at 10:27 a.m., on Level B in the Radiology Department in room B233I, a lamp was plugged into an extension cord instead of directly into the wall outlet.

Stanford Building:
12. On 10/12/11 at 12:06 p.m., computer equipment at the MRI Reception Area on the 1st floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

West California Campus
13. On 10/12/11 at 2:59 p.m., office equipment in Staff Office 453 on the 4th floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

14. On 10/12/11 at 3:21 p.m., a miniature refrigerator in Staff Office 4567 on the 4th floor, was plugged into a surge protected multi-outlet extension cord.

15. On 10/12/11 at 3:27 p.m., a refrigerator in Staff Lounge 450 on the 4th floor, was plugged into a surge protected multi-outlet extension cord.

16. On 10/13/11 at 9:47 a.m., two of two refrigerators in the Conference Room 4361 on the f4th floor, were plugged into one surge protected multi-outlet extension cord.

17. On 10/13/11 at 9:50 a.m., a miniature refrigerator in Staff Office 409 on the 4th floor, was plugged into a surge protected multi-outlet extension cord.



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West California Campus
18. On 10/13/11, at 9:52 a.m., there was a refrigerator and a water dispenser plugged into a multi-outlet adapter in the staff lounge located in the Medical Records Room 1570 on the 1st Floor. The multi-outlet adapter was plugged into the receptacle wall outlet designed for two plugs.

19. On 10/ 13/11, at 9:55 a.m., there was a multi-outlet adapter interconnected to a second multi-outlet adapter with devices plugged into both adapters. This was located under the ASC Desk in the Medical Records Room 1570 on the 1st Floor. The multi-outlet adapter was plugged into the receptacle wall outlet designed for two plugs.

20. On 10/13/11, at 10:13 a.m., there was an electrical junction box mounted on the wall with no cover plate in patient Room 237 on the 2nd Floor. Engineering Staff 4 stated that the electrical cables within the junction box were low-voltage.

Based on observation, The Hospital failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of three alcohol based hand rub dispensers over ignition sources. This affected one of two surveyed floors in the Stanford Building, one of one surveyed floor in the Mental Health Center and one of seven floors in the West California Campus. This deficient practice could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff, the alcohol based hand rub dispensers in the facility were observed.

Stanford Building
1. On 10/12/11 at 11:40 a.m., an alcohol based hand rub dispenser located in Work Room 601/602 on the 6th floor, was mounted on the wall between and adjacent to two light switches The hand rub was seventy percent ethyl alcohol by volume.



27254

Mental Health Center
2. On 10/13/11, at 11:20 a.m., the alcohol based hand rub dispenser in Conference Room was mounted on the wall directly above a light switch. The hand rub was seventy percent ethyl alcohol by volume.

West California Campus
3. On 10/12/11 at 3:17 p.m., an alcohol based hand rub dispenser in Well Baby Nursery (Room 476, on the 4th floor) was mounted on the wall approximately four inches above an electrical receptacle. The hand rub was seventy percent ethyl alcohol by volume.

Based on observation, the Hospital failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in walls in the Pacific Building in one of eleven floors and on the wall to a room at the California West Campus, affecting 1 of 7 Floors. This could result in the spread of fire and smoke.

Findings:

Pacific Building
During a tour of the facility with a staff member on 10/12/11, the facility's walls and ceilings were observed.

1. At 10:40 a.m., on Level B in the Oncology Treatment Room 2 (#0279), the 3 inch pipe conduit from the treatment room to the control room was not sealed on either end. The pipe conduit ran across a concrete wall and was located in a cabinet in the treatment room and under the desk of the control room. Engineering Staff 5 confirmed that the pipe conduit was not sealed.

2. At 10:46 a.m., on Level B, in the Oncology Treatment Room 1 (#0280), the 3 inch pipe conduit from the treatment room to the control room was not sealed on either end. The pipe conduit ran across a concrete wall and was located in a cabinet in the treatment room and under the desk of the control room. Engineering Staff 5 confirmed that the pipe conduit was not sealed.

West California Campus
3. On 10/13/11, at 11:11 a.m., during a tour of the facility with Support Services Staff 1 and Engineering Staff 4, the facility's walls and ceilings were observed.
There were four penetrations through the wall in the IT Room 3312 on the 1st floor. The penetrations measured approximately 1/4-inch each.

Based on observation, the Hospital failed to maintain their corridor doors. This was evidenced by corridor doors that were obstructed from closing or latching, a dutch door that was not equipped with a top leaf latching device, and a self-closing device that was non-functioning. This affected three of eleven floors in the Pacific Building, one of two surveyed floors in the Stanford Building and
one of seven floors at the West California Campus and could result in a delay to contain smoke or fire to a room.

NFPA 101, Life Safety Code, 2000 edition
19.3.6.3.6 Dutch doors shall be permitted where they conform to 19.3.6.3 In addition, both the upper and lower leaf shall be equipped with a latching device, and the meeting edges of the upper and lower leaves shall be equipped with an astragal, a rabbet, or a bevel.

Findings:

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

Pacific Building:
1. On 10/11/11 at 11:36 a.m., on the 6th floor, the corridor door to Patient Room 624 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

2. On 10/11/11 at 11:38 a.m., on the 6th floor, the corridor door to Patient Room 626 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

3. On 10/11/11 at 11:40 a.m., on the 6th floor, the corridor door to Medication Room 6807 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch.

4. On 10/11/11 at 12:07 p.m., on the 6th floor, corridor door to Patient Room 656 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

5. On 10/11/11 at 12:15 p.m., on the 6th floor, the corridor door to Patient Room 669 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

6. On 10/11/11 at 12:19 p.m., on the 6th floor, the corridor door to the Information Technology Closet, near the elevators, was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

7. On 10/11/11 at 12:37 p.m., on the 5th floor, the corridor door to the Nutrition Kitchen Room 5806 was equipped with an automatic closing device. The door was obstructed from closing by a trash bin positioned directly in the swing path of the door.

8. On 10/11/11 at 12:53 p.m., on the 5th floor, the corridor door to Equipment Room B (Room 5838) was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

9. On 10/11/11 at 12:55 p.m., on the 5th floor, the corridor door to Patient Room 567 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

10. On 10/11/11 at 2:34 p.m., on the 5th floor, the corridor door to Patient Room 561 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

11. On 10/12/11 at 9:54 a.m., on the 3rd floor, the corridor dutch door to the Front Desk Room 3141 was observed. The top leaf of the dutch door was not equipped with a latching device.

Stanford Building:
12. On 10/12/11 at 11:16 a.m., on the 6th floor, the corridor door to the Telephone Room 622 was equipped with a self-closing device. The self-closing device was partially disassembled. The door was held open to the fullest extent and allowed to close. The door failed to close and remained in the open position.

13. On 10/12/11 at 11:29 a.m., on the 6th floor, the corridor door to Mechanical Room 639 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

14. On 10/12/11 at 11:31 a.m., on the 6th floor, the ACU side corridor door to the central elevators was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to close and latch. The door was obstructed by air pressure differences.

West California Campus
15. On 10/13/11 at 11:15 a.m., the corridor door to the Pediatrics Holding Room 3505 on the 3rd floor, was equipped with a self-closing device. The door was held in the open position and was obstructed from closing by a table positioned in the swing path of the door.

Based on observation and interview, the Hospital failed to maintain their vertical openings. This was evidenced by two corridor doors to a vertical opening that were not equipped with a self-closing devices. This affected two of eleven floors in the Pacific Building and could result in the passage of smoke or fire from one floor to another.

Findings:

During a facility tour with staff, the vertical openings in the facility were observed.

Pacific Building:
1. On 10/11/11 at 12:22 p.m., on the 6th floor, the corridor door to the Sixth Floor pipe chase was not equipped with a self-closing device. The pipe chase was located near the elevator bank. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the pipe chase extended from the B-Level to the Sixth Floor.



27254

Pacific Building
2. On 10/12/11, at 10:30 a.m., on Level B, the door to the pipe chase near the elevator lobby was not equipped with a self-closing device. The pipe chase extended from the floor to Level B. Engineering Staff 5 stated that some doors were equipped with self closing devices.

Based on observation, the Hospital failed to install exit signs and directional signs on or by doors designated as emergency exit routes. This was evidenced by one missing exit sign in the Pacific Building that affected 1 of 11 floors, and no exit sign posted at the Stanford Building that affected 1 of 2 surveyed floors and
no directional sign posted at the West California Campus that affected 1 of 7 floors. This could have the potential for delaying evacuation of patients and incorrectly directing evacuees during an emergency.

Findings:

During a tour of the facility with Staff, the exits and signage in the facility were observed.

Pacific Building
1. On October 12, 2011, at 11:13 a.m., on Level A, there was no exit sign present over or near the exit door in the hallway by Room A143. The facility's evacuation map indicated that its evacuation route to the exit was through the door and the exit was not readily apparent.


27893

Stanford Building
2. On 10/12/11 at 11:58 a.m., the EEG Suite 141 on the first floor was observed. The exit door leading from Room 143 to the corridor had an exit sign placed above the door. There was no additional sign in the EEG Suite that indicated a possible exit was through Room 143. The exit through Room 143 was one of two unobstructed exits from the suite.

West California Campus
3. On 10/13/11, at 9:38 a.m., there was no directional sign present in the exit discharge area by Stairwell #6 on the 1st Floor. The facility's evacuation map indicated that its evacuation route to the public way was through the exit discharge. The public way was not readily apparent.

Based on observation, the Hospital failed to maintain the integrity of smoke barrier walls. This was evidenced by penetrations in smoke barrier wall on the 4th Floor and on the 1st Floor, affecting 2 of 11 Floors at the Pacific Building. This had the potential to allow the spread of smoke from one smoke compartment to the other smoke compartment in the event of a fire.

Findings:

During a tour of the facility with Administrative Services Staff 1, Support Services Staff 1, Engineering Staff 2, Engineering Staff 6, and Engineering Staff 7, the smoke barrier walls were observed.

Pacific Building
1. On 10/11/11, at 12:54 p.m., the 1-hour rated smoke barrier wall in the corridor by Room 4815 had a penetration in the atrium space above the fire doors on the 4th Floor. The penetration was located directly above a duct that measured approximately 5-inches by 2-inches.

Pacific Building
2. On October 12, 2011, at 10:45 a.m., the 2-hour rated smoke barrier wall in the corridor by Cath Lab 4 in Room 1504 on the 1st Floor had a penetration in the atrium space above the fire doors. The penetration was located directly below a treated beam that measured approximately 4-inches by 1/4-inch.

Based on observation and interview, the Hospital failed to maintain their fire doors as evidenced by fire doors that did not fully close and latch. This deficient condition affected two of eleven floors in the Pacific Building and could result in the spread of smoke in the event of a fire.

Findings
During a tour of the facility with a staff member on 10/14/11, the facility fire doors were observed.

Pacific Building
1. At 11:17 a.m., on the 4th floor, the door to elevator bank did not close upon smoke detector activation. The other two doors did close.

2. At 11:32 a.m., on the 2nd floor of the Pacific Campus, when the fire alarm was activated, the double fire doors to Nuclear Medicine were released. The double doors failed to fully close and latch. Engineering Staff 5 stated that the draft from the vents prevented the doors from fully closing.

Based on observation, the Hospital failed to maintain their hazardous areas. This was evidenced by three hazardous areas that were not equipped with self-closing doors and the laboratory that was not safeguarded by a 1-hour fire barrier. This affected two of eleven floors in the Pacific Building and two of two surveyed floors in the Stanford Building and one of seven floors at the West California Campus and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff, the hazardous areas in the facility were observed.

Pacific Building
1. On 10/12/11 at 9:39 a.m., the Anesthesia Work Room 3124 on the 3rd floor was observed to be over fifty square feet in area. The room contained combustible items in storage. The door to the room was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.

Stanford Building
2. On 10/12/11 at 11:21 a.m., the corridor door to the Soiled Utility Room 641 on the 6th floor was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.
3. On 10/12/11 at 12:01 p.m., the corridor door to the Soiled Utility Room, near Exam Room 5 in Suite 134 on the 1st floor, was not equipped with a self-closing or automatic closing device. The door was held open to the fullest extent and remained in the open position.


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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.

Pacific Building
3. On 10/11/11, at 3:30 p.m., it was observed that the wall to the North and North-West section of Corridor 2C9 on the 2nd Floor did not extend up through the atrium space. The North Wing section of this floor had a Clinical Laboratory that was not equipped with an automatic sprinkler system. The laboratory contained combustible materials and flammable liquids. The Nuclear Medicine Exam Rooms, Corridor 2C9, and Corridor 2C8 were located adjacent to the laboratory and had an open connection through the atrium space. Engineering Staff 2 confirmed that the floor plans marked in blue had a 1-hour wall that did not extend through the atrium space up to the rated deck. The surveyor was presented a document from an Engineer that stated that the corridor walls that terminate at the ceiling were constructed to meet the one-hour fire rating, forming a fire rated tunnel construction within the corridor. Engineering Staff 2 stated that he believed that the tiled ceiling above the laboratory area had one layer of 5/8-inch thick gypsum board; thus, 30-minute fire rating. No other evidence was presented to show that the laboratory was safeguarded by a 1-hour fire resistance barrier.

West California Campus
4. On 10/13/11 at 10:35 a.m., on the 4th floor, the corridor door to the Pathology Room 4409 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the Hospital failed to maintain egress passageways as evidenced by a gurney and bed that blocked the opening of an egress door. This deficient practice affected one of seven floors at the West California Campus and could result in a delay of egress in the event of an emergency evacuation.

Findings

During a tour of the facility with a staff member on 10/13/11, the facility egress passageways were observed.

West California Campus
1. On 10/13/11, at 10:28 a.m., the corridor in the Surgical Suite by the Neonatal Intensive Care Unit (NICU) on the 2nd Floor was obstructed by a patient bed and gurney. The bed prevented the door to the NICU from fully opening and obstructed the exit access through this passageway that is part of the facility's evacuation route.

Based on observation, the Hospital failed to maintain the fire alarm system as evidenced by strobes and horns that did not function during the fire alarm testing affecting two of eleven floors in the Pacific Building, one battery powered smoke detector door holder that failed to activate, affecting 1 of 7 Floors in the West California Campus and by strobes that did not function during fire alarm testing and by blocked pull stations at the East California Campus affecting three of seven floors. These deficient practices could result in the failure of alarm notification in the event of a fire
Findings
Pacific Building
1. At 11:13 a.m., on the 4th floor, the strobe on the strobe/horn combo #442 did not function during dire alarm testing.
2. At 11:20 a.m., in Pathology area, the horn/strobe over room 2431, the strobe functioned, but the horn failed to sound. The suite door to Nuclear medicine was tested several times and failed to self-close and latch due to positive air flow current in the area
3. At 11:34 a.m., on the 2nd floor, the ITV and smoke detector were tested at Nuclear Medicine. The ITV and the smoke detector failed to activate two of two horn/strobe devices.

East California Building
5. On 10/13/11, at 2:56 p.m., upon activation of the ITV valve on the second floor of CPMC East women ' s health center/breast cancer center, all 5 of 5 strobe horn combinations alarms failed to emit flash strobes. The horns sounded in all five alarms but there was no strobe. The alarms were located near rooms 272, 285, 289, and 293. The PAFA technician acknowledged the deficiency as well as the CPMC engineering staff.
6. On 10/13/11, at 2:57 p.m., in the Breast Health Center, five out of five horn/strobe combos could only be heard. The strobe on the combos did not function during the activation of the fire alarm.
7. On 10/13/11, at 3:05 p.m., the manual pull station in the front lobby nearest to California Street was blocked and not visible or accessible by a large upright blue hospital sign placed directly in front of the sign.
8. On 10/13/11, at 3:12 p.m., in the First floor lobby area, the pull station near the front entrance was blocked by a sign that was placed in front of the pull station. The sign blocked the accessibility and visibility of the pull station near the main entrance door.
9. On 10/13/11, at 3:12 p.m., on the first floor of CPMC East, 3 of 3 strobes failed to emit the flashing strobe light when the smoke detector was activated. The strobes were located along the corridor near room 1700, 1895, and 1893.
10. On 10/13/11, at 3:20 p.m., in the Operating Room area, the pull station was blocked by a supply cart and an IV stand was in front of the pull station. Accessibility to the pull station was blocked.
11. On 10/13/11, at 3:26 p.m., in the First floor hallway area by the elevators, three strobes failed to function during fire alarm testing. The strobes were part of a horn/strobe combo and only the horn was functioning.
12. On 10/13/11, at 3:30 p.m., the manual pull station in the OR suite nearest to room #1842 was partially obstructed by a supply cart and medical device. The pull station was no accessible. The OR nurse, manager acknowledged the presence of the supply cart and medical device.
13. On 10/13/11, at 3:32 p.m., in the Women ' s Health Resource Center, the door to the Library/Computer room (#1840) did not latch. The latch would not catch in the latch plate in the door frame.

West California Campus
4. On 10/13/11, at 2:50 p.m., on the 1st floor, the stand alone smoke detector door holder in the Gift Shop failed to activate upon spraying canned smoke. The smoke detector was battery operated and was not interconnected to the fire alarm system. Support Services Staff 1 stated that there was no current maintenance program in place for that device.

Based on observation, interview and record review the Hospital failed to maintain the kitchen hood as evidenced by failing to maintain the semi-annual cleaning of the kitchen hood. This deficient condition affected one of six floors in the Pacific building and could result in the ignition of a hood fire.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 editions
8-2 Inspection - An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.
Table 8-3.1 Exhaust System Inspection Schedule
Type or Volume of Cooking Frequency Frequency
Systems serving solid fuel cooking operations monthly
Systems serving high-volume cooking operations quarterly
(such as 24-hr cooking, charbroiling or wok cooking)
Systems serving moderate-volume cooking semiannually
Systems serving low-volume cooking operations,
(such as churches, day camps, seasonal businesses,
or senior centers) annually
8-3.1.2 - When a vent cleaning service is used, a certificate showing date of inspection or cleaning shall be maintained on the premises. After cleaning is completed, the vent cleaning contractor shall place or display within the kitchen area a label indicating the date cleaned and the name of the service company. It shall also indicate areas not cleaned.

Findings:

During document review, the documents for the cleaning of the kitchen hood were observed.

Pacific Building
1. On 10/11/11, the documents for the cleaning of the kitchen hood were requested. The documents provided stated that the last cleaning of the kitchen hood was on 3/10/11. There were no other documents provided that the hood had been cleaned six months later. During a tour of the kitchen, the sticker on the kitchen hood had a date of 3/10/11 for the date that the hood was last cleaned.

Based on observation, the Hospital failed to ensure the safe use of portable space heating devices. This was evidenced by five portable space heaters that were not used according to manufacturer specifications. This affected two of two surveyed floors in the Stanford Building and one of seven floors in the West California Campus and could result in a portable space heater ignited fire emergency.

Findings:

During a facility tour with staff, the portable space heaters in the facility were observed.

Stanford Building
1. On 10/12/11 at 11:33 a.m., a portable space heater was observed in a Staff Office Room 600B on the 6th floor. The portable space heater was not in use but was plugged into an electrical wall receptacle. The portable space heater was located under a desk and within three feet of combustibles and furnishings. The room was unoccupied at the time of observation.

2. On 10/12/11 at 12:11 p.m., a portable space heater was observed in the Radiology Reading Room on the 1st floor. The portable space heater was not in use but was plugged into a surge protected multi-outlet extension cord. The portable space heater was not plugged directly to an electrical wall receptacle. The portable space heater was located under a desk and within three feet of combustibles and furnishings.

West California Campus
3. On 10/13/11 at 9:36 a.m., a portable space heater was observed in the Genetic Counselor's Office 4330 on the 4th floor. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 verified with a department head and confirmed that the room is sometimes occupied by patients.

4. On 10/13/11 at 9:41 a.m., a portable space heater was observed in the Genetic Counselor's Office 4324 on the 4th floor. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 verified with a department head and confirmed that the room is sometimes occupied by patients.

5. On 10/13/11 at 10:32 a.m., a portable space heater was observed in Pathology Office 4417 on the 4th floor. The portable space heater was plugged into a surge protected multi-outlet extension cord instead of directly to an electrical wall receptacle. The portable space heater was located under a desk and within three feet of combustibles and furnishings. There were no facility labels observed on the portable space heater. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 indicated that the portable space heater does not look like one of the facility's approved portable space heater. Engineering Staff 3 could not confirm the portable space heater would not exceed 212 degrees Fahrenheit.

Based on observation, the Hospital failed to maintain safe storage of oxygen gas cylinders. This was evidenced by one oxygen E cylinder that was free standing and unsecured. This affected one of two surveyed floors in the Stanford Building and could result in an oxygen tank initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During a facility tour with staff, the facility's oxygen gas cylinder storage locations were observed.

Stanford Building
1. On 10/12/11 at 11:25 a.m., there was one oxygen E cylinder located in the Ambulatory Care Unit Clinical Manager's Office (Room 643) on the 6th floor. The oxygen cylinder was free standing and unsecured.

Based on observation, the Hospital failed to maintain the relative humidity at equal to or greater than 35% as evidenced by 38 days in the past year that the humidity level in the Operating rooms in the Pacific Building dropped below 35%. This deficient practice affected all 9 of 11 operating rooms in the Operating Suite and five of five procedure/operating rooms in the ASU located at the East California Campus. This deficient practice could lead to an electrical fire in the operating room. A possible waiver to maintain the the humidity levels below the required 35% range was discussed with the maintenance/engineering staff.

Findings

During document review on 10/12/11, the Operating Room Humidity reports were reviewed.

The records provided indicated that the humidity dropped below 35%. The following Nine operating rooms in the Operating Suite dropped below 35% at least one time in the past year.

Pacific Building
1. Saenz: In January 2011 the humidity dropped below 35% 13 times. In February 2011, the humidity dropped below 35% 5 times. In March 2011, the humidity dropped below 30% 6 times. The humidity in this operating room dropped as low as 30%.

2. Jewett: In January 2011 the humidity dropped below 35% 1 time. The humidity in this operating room dropped as low as 22%.

3. Waterhouse: In January 2011 the humidity dropped below 35% 3 times. In February 2011, the humidity dropped below 35% 2 times. In March 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 32%.

4. Yates: In January 2011 the humidity dropped below 35% 8 times. In February 2011, the humidity dropped below 35% 8 times. In March 2011, the humidity dropped below 35% 8 times. In November 2010, the humidity dropped below 35% 3 times. The humidity in this operating room dropped as low as 30%.

5. Sampson: In January 2011 the humidity dropped below 35% 1 time. In February 2011, the humidity dropped below 35% 3 times. The humidity in this operating room dropped as low as 20%.

6. D: In January 2011 the humidity dropped below 35% 3 times. In February 2011, the humidity dropped below 35% 4 times. In March 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 30%.

7. Howard: In January 2011 the humidity dropped below 35% 3 times. In February 2011, the humidity dropped below 35% 1 times. In March 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 30%.

8. Kresge: In January 2011 the humidity dropped below 35% 10 times. In February 2011, the humidity dropped below 35% 2 times. In March 2011, the humidity dropped below 35% 1 time. The humidity in this operating room dropped as low as 15%.

9. Taylor: In January 2011 the humidity dropped below 35% 4 times. In February 2011, the humidity dropped below 35% 2 times. The humidity in this operating room dropped as low as 30%.

East California Campus
10. OR11: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 25%.

11. OR12: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 23%.

12. OR14: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 29%.

13. OR15: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 28%.

14. OR16: In November 2010, the humidity dropped below 35% 1 time. The humidity dropped as low as 28%.

Based on interview and document review, the Hospital failed to maintain the generator as evidenced by no alarm annunciator panel at the Pacific Campus and at the Mental Health Center, by not providing a back up or alternative fuel source for the natural gas generator at the Mental Health Center, by not providing any battery back up lighting for the generator area, and by the generator not transferring power under 10 seconds.
These deficient practices affected the eleven floors in the Pacific Campus and 1 of 1 surveyed floor in the Mental Health Center and could result in the malfunctioning of the generator in the event of a primary emergency power loss without staff knowledge.

NFPA 99, Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.
3-4.1.1.8 Load Pickup. The generator set(s)shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power.
3-4.1.1.15 Alarm Annunciator. A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical code, Section 700-12.)

The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15 (a) and (b) occur, but need not display these conditions individually. [110: 3-5.5.2]

NFPA 110, 1999 Edition
6-3 Maintenance and Operational Testing.
6-3.4 A written record for the EPSS inspections, tests, exercising, operation, and repairs shall be maintained on the premises. The written record shall include the following:

(a) The date of the maintenance report
(b) Identification of the servicing personnel
(c) Notation of any unsatisfactory condition and the corrective action taken, including parts replaced
(d) Testing of any repair for the appropriate time as recommended by the manufacturer.

6-4 Operational Inspection and Testing.
6-4.1* Level 1 and 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.
Exception: If the generator set is used for standby power or for peak load shaving, such use shall be recorded and shall be permitted to be substituted for scheduled operations and testing of the generator set, provided the appropriate data are recorded.

Findings:

During a tour of the facility with staff members, the generator area and the maintenance records were reviewed.

Pacific Building
1) On 10/12/11, at 10:00 a.m., the generator on Level C of the Pacific Campus was observed. No remote annunciator panel was observed in the Hospital.
Upon interview with Engineering Staff 5, staff acknowledged no remote annunciator was installed in the Hospital Pacific campus. A time limited waiver was discussed with the engineering staff concerning the installation for the remote annunciator panel.

Mental Health Center - 2323 Sacramento
During a tour of the facility with a staff member on 10/13/11, the generator area was inspected.
2) At 11:20 a.m., during document review with staff, on 10/11/11, the generator maintenance records were reviewed. The documents provided for the weekly inspections of the generator for the past year indicated that the generator had a transfer time between 11 seconds and 12 seconds. Engineering Staff 5 stated that the transfer time for the generator is not being timed.

3) At 11:25 a.m., there was no generator annunciator panel provided for the generator.

4) At 11:30 a.m., there was also no battery back up light for the generator area.

5) At 11:35 a.m., there was no secondary or alternative fuel source back up for the natural gas generator. In the event of an earthquake there could be a break in the natural gas line and the generator would not function.
Staff acknowledged that there was no annunciator panel. A possible waiver was discussed.

Based on observation, the Hospital failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances plugged into extension cords, extension cords plugged into other extension cords, and electrical receptacles that were missing faceplates. This affected six of eleven floors in the Pacific Building and one of two surveyed floors in the Stanford Building and three floors in the California West Campus. This could result in an electrical fire.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code
410-56(e) After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.015 in. (0.381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Findings:

During a facility tour with staff, the facility's electrical equipment and wiring were observed.

Pacific Building
1. On 10/11/11 at 11;55 a.m., a refrigerator in the Staff Lounge 6814 on the 6th floor, was plugged into a surge protected multi-outlet extension cord.

2. On 10/11/11 at 2:48 p.m., computer equipment in the G.I. Lab Entrance on the 5th floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

3. On 10/11/11 at 3:14 p.m., computer equipment in the Case Manager's Office 4802 on the 4th floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

4. On 10/11/11 at 3:34 p.m., office equipment in the Clinical Manager's Office 4224 on the 4th floor, was plugged into an orange non-surge protected multi-outlet extension cord that was plugged into a surge protected multi-outlet extension cord.

5. On 10/12/11 at 10:35 a.m., a miniature refrigerator in the Anesthesia Locker Room 3M10 on the 3rd floor Mezzanine level, was plugged into a surge protected multi-outlet extension cord.

6. On 10/12/11 at 9:45 a.m., a miniature refrigerator in the Circulatory Support Systems Room 3148 on the 3rd floor, was plugged into a surge protected multi-outlet extension cord.

7. On 10/12/11 at 9:51 a.m., a miniature refrigerator in the O.R. Office Room 3138 on the 3rd floor, was plugged into a surge protected multi-outlet extension cord.

8. On 10/12/11 at 10:43 a.m., a miniature refrigerator in the Clinical Nurse Manager's Office 3390 on the 3rd floor, was plugged into a surge protected multi-outlet extension cord.

9. On 10/12/11 at 11:08 a.m., a junction box in the Nurse Practitioner's Office 3445 on the 3rd floor, was missing a protective faceplate. Electrical wiring was exposed.




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Pacific Campus
10. On 10/12/11, at 10:21 a.m., on Level B, the 3D Transar system was plugged into a power strip instead of directly into the wall outlet. The 3D Transar is a chemical cooling system. Engineering Staff 5 confirmed that the cooling system was plugged into a power strip instead of directly into the wall outlet.

11. On 10/12/11, at 10:27 a.m., on Level B in the Radiology Department in room B233I, a lamp was plugged into an extension cord instead of directly into the wall outlet.

Stanford Building:
12. On 10/12/11 at 12:06 p.m., computer equipment at the MRI Reception Area on the 1st floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

West California Campus
13. On 10/12/11 at 2:59 p.m., office equipment in Staff Office 453 on the 4th floor, was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord.

14. On 10/12/11 at 3:21 p.m., a miniature refrigerator in Staff Office 4567 on the 4th floor, was plugged into a surge protected multi-outlet extension cord.

15. On 10/12/11 at 3:27 p.m., a refrigerator in Staff Lounge 450 on the 4th floor, was plugged into a surge protected multi-outlet extension cord.

16. On 10/13/11 at 9:47 a.m., two of two refrigerators in the Conference Room 4361 on the f4th floor, were plugged into one surge protected multi-outlet extension cord.

17. On 10/13/11 at 9:50 a.m., a miniature refrigerator in Staff Office 409 on the 4th floor, was plugged into a surge protected multi-outlet extension cord.



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West California Campus
18. On 10/13/11, at 9:52 a.m., there was a refrigerator and a water dispenser plugged into a multi-outlet adapter in the staff lounge located in the Medical Records Room 1570 on the 1st Floor. The multi-outlet adapter was plugged into the receptacle wall outlet designed for two plugs.

19. On 10/ 13/11, at 9:55 a.m., there was a multi-outlet adapter interconnected to a second multi-outlet adapter with devices plugged into both adapters. This was located under the ASC Desk in the Medical Records Room 1570 on the 1st Floor. The multi-outlet adapter was plugged into the receptacle wall outlet designed for two plugs.

20. On 10/13/11, at 10:13 a.m., there was an electrical junction box mounted on the wall with no cover plate in patient Room 237 on the 2nd Floor. Engineering Staff 4 stated that the electrical cables within the junction box were low-voltage.