HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the walls and ceilings. This affected two of two floors in the Main Hospital and could potentially result in the spread of fire and smoke to other areas of the facility.

Findings:

During a tour of the facility with Staff on 8/3/15, the walls and ceilings were observed.

Main Hospital

1. At 9:30 a.m., there were three approximately 1/4 inch penetrations in the north wall next to fire extinguisher 54 in the Lift Equipment Room.

2. At 9:35 a.m., in the South Mechanical Room wall, there was an approximately 1/4 inch penetration around a one inch pipe, an approximately 1/4 inch penetration around a 1/2 inch pipe, and an approximately 1/4 inch penetration around a cord in the wall.

3. At 9:50 a.m., in the Maternity Ward Storage Room, there was an approximately eight foot by eight foot area of the southwest wall that was missing the sheet rock. There was also an approximately eight foot by two foot area of the ceiling that was missing the sheet rock.

4. At 10:10 a.m., a data outlet plate cover was shifted to one side exposing an approximately 1/4 inch penetration in the wall below a desk in the Neurology Lab.

5. At 10:31 a.m., a sprinkler head was missing an escutcheon ring exposing an approximately 1/2 inch penetration in the ceiling in Janitor Closet 9.

6. At 11:20 a.m., a sprinkler head was missing an escutcheon ring exposing an approximately 1/4 inch penetration around the pipe in the X-ray Office.

7. At 11:33 a.m., a sprinkler escutcheon ring was not flush to the ceiling exposing an approximately 1/4 inch penetration in the Emergency Registration Office.

8. At 11:40 a.m., a sprinkler escutcheon ring was shifted to one side exposing an approximately 1/4 inch penetration in the ceiling in the Respiratory Break Room.

9. At 11:51 a.m., a sprinkler head was missing an escutcheon ring exposing an approximately 1/2 inch penetration in the ceiling in the Kitchen Serving Line.

10. At 12:57 p.m., a sprinkler head was missing an escutcheon ring exposing an approximately 1/4 inch penetration in Room 604 of Ambulatory Care Service (ACS).

Based on observation, the facility failed to maintain its corridor doors. This was evidenced by four doors that were obstructed and one door that failed to latch. This affected two of two floors in the Main Hospital and could potentially result in the inability to contain a fire to a room.

NFPA 101, 2000
19.3.6.3.7 Door frames shall be labeled, shall be of steel construction, or shall be other materials in compliance with the provisions of 8.2.3.2.1

8.2.3.2.1 Doors assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following: (a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, 1999
Door opening and the surrounding area shall be kept clear of anything that could obstruct or interfere with the free operation of the door.

Findings:

During a tour of the facility with Staff on 8/3/15, the corridor doors were observed.

Main Hospital

1. At 9:54 a.m., the roll down fire door at the Obstetrics and Gynecology (OB) Nurse's Station was obstructed from closing by a tissue box, a box of face masks, and a hole puncher.

2. At 10:23 a.m., the self-closing door to the State Office was held open by a rubber wedge.

3. At 11:07 a.m., the rolling down fire door in the Laboratory was obstructed by a tissue box, a brochure box, a bell, and a black basket.

4. At 11:16 a.m., the self-closing door to Micro Laboratory was held open by a piece of cardboard.

5. At 1 p.m., the self-closing door to the Unit 3 Overflow failed to latch.

Based on observation, the facility failed to mark access to exits. This was evidenced by the failure to provide visible exit signs at exit locations. This affected two of two floors in the Main Hospital, and had the potential to delay evacuation in the event of an emergency.

Findings:

During a tour of the facility with Staff on 8/3/15, the exit locations were observed.

Main Hospital

1. At 10:05 a.m., there was no exit sign above the exit door in the Obstetrics and Gynecology (OB) waiting room. There was a sign on the door identifying it as an emergency exit.

2. At 11 a.m., there was no exit sign above the exit stairway door on the second floor near the Dover elevator.

3. At 11:34 a.m., there was no exit sign above the Emergency Room (ER) waiting area door.

4. At 11:35 a.m., there was no exit sign above the ER patient registration door.

Based on observation, the facility failed to maintain the fire doors. This was evidenced by items that were stored in front of the fire doors. This affected two of two floors in the Main Hospital, and could result in a delay in egress in the event of an emergency.

NFPA 101, 2000
19.3.6.3.7 Door frames shall bed labeled, shall be of steel constructions, or shall be of other materials in compliance with the provision of 8.2.3.2.1
8.2.3.2.1 Door assemblies in fire barrier shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following: (A) the fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Window. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Test of Door Assemblies.

NFPA 80, 1999
2-4.1.4* All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.
15-1 This chapter covers the care and maintenance of fire doors and fire windows.
15-2.3 Prevention of Door Blockage.
15-2.3.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door.
15-2.3.3 Blocking or wedging of doors in the open position shall be prohibited.

Findings:

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

Main Hospital

1. On 8/3/15, at 9:26 a.m., the right leaf fire door 4-22 on the first floor was obstructed by a large, tall yellow bin. The yellow bin was stationed within one inch of the door handle when the door was closed.

2. On 8/3/15, at 10:26 a.m., the right leaf fire door 1-13 on the first floor was obstructed by a north cart. The north cart was stationed within one inch of the door handle when the door was closed.

3. On 8/4/15, at 9:22 a.m., the left leaf of fire door 26-11 on the second floor near Dover corridor failed to latch .

4. On 8/4/15, at 9:32 a.m., the right leaf of fire door 7-20 on the second floor failed to latch.

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Outpatient Services Building 2-2809 Olive Highway

3. On 8/5/15, at 10 a.m., the door to the Biohazard Room in Suite 230 was not equipped with a self-closing device.

Based on observation, the facility failed to maintain the emergency exit doors. This was evidenced by items that were stored in front of the emergency exit doors. This affected two of two floors in the Main Hospital and could result in a delayed egress in the event of an emergency.

Findings:

During a tour of the facility with Staff on 8/3/15, the emergency exit doors were observed.

Main Hospital

1. At 9:20 a.m., there was an exit sign above the emergency exit door in the Linen Storage Room on the first floor. The door was completely obstructed by a laundry cart, a large box, two step stools, and a walker.

2. At 11:31 a.m., the exit door that was adjacent to 14T in the Emergency Department was obstructed by a bed that was stationed within one inch of the left leaf push handle.

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Outpatient Services Building 2-2809 Olive Highway

2. On 8/5/15, at 1:20 p.m., there was one emergency light observed in Suite 110. No documentation was provided indicating that the 30 second monthly or 90 minute annual tests had been performed in the past 12 months. During an interview at 1:30 p.m., the Assistant Director of Plant Operations confirmed the finding.

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Outpatient Services Building 2-2809 Olive Highway

2. On 8/5/15, at 1:20 p.m., the facility was observed with exit signs with battery back up throughout the building. A review of the exit sign logs indicated no 90 minutes annual tests had been performed in the past 12 months. During an interview at 1:22 p.m., the Assistant Director of Plant Operations stated that the facility was not aware of the requirement for the 90 minutes annual test for the exit signs.

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Outpatient Services Building 2-2809 Olive Highway

2. On 8/6/15, at 9:10 a.m., three of five suites (Suite 110, 120, 230) failed to provide documentation for fire drills in the past 12 months. During an interview at 9:15 a.m., the Assistant Director of Plant Operations confirmed that there had been no drills.

3. On 8/6/15, at 1:20 p.m., in suit 120, one of four staff members did not know how to use a portable fire extinguisher.

Outpatient Building 3-2450 Oro Dam Blvd.

4. On 8/5/15, at 1:25 p.m., there was no fire drill documentation provided for the past 12 months. During an interview at 1:30 p.m., the Assistant Director Plant Operation confirmed that there had been no drills.

Based on observation and interview, the facility failed to maintain fire alarm system components. This was evidenced by one fire alarm chime that failed to emit an audible sound. This affected one of two floors at the Main Hospital and could potentially result in a delayed notification of fire.

NFPA 101, 2000
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

39.3.4.1 General. A fire alarm system in accordance with section 9.6 shall be provided in any business occupancy where any one of the following condition exists: (1) the building is two or more stories in height above the level of exit discharge. (2) the occupancy is subject to 100 or more occupants above or below the level of exit discharge. (3) The occupancy is subject to 1000 or more total occupants.

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 the occupancy.

Findings:

During a tour of the facility with Staff on 8/4/15, the fire alarm system was observed and Staff was interviewed.

Main Hospital

At 9:59 a.m., chime/strobe N13-4 in the Laboratory failed to chime during testing. During an interview at 10 a.m., the Assistant Director of Plant Operations confirmed that the device did not chime but made a clicking sound.

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Outpatient Services Building 2-2809 Olive Highway

3. On 8/5/15, at 1:20 p.m., the document titled, "Quarterly Fire Inspection Reports 2015," was incomplete. In the third quarter on 7/21/15, the document indicated that there was no access to two smoke detectors in the North and South Electrical Rooms on the second floor. The report also indicated that a duct detector on the third floor was not tested. Plant Operation Staff 1 confirmed a South Electrical Room duct detector on the third floor was not tested.

Based on document review and interview, the facility failed to maintain its smoke detectors. This was evidenced by incomplete documentation for smoke detector sensitivity testing and by the failure to have the smoke detectors tested for sensitivity by a certified and trained person. This affected two of two floors in the Main Hospital and could result in delayed notification of a fire due to a malfunctioning or dirty smoke detector.

NFPA 101, 2000
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.

NFPA 72, 1999
7-1.2.2 Service personnel shall be qualified and experienced in the inspection, testing, and maintenance of fire alarm systems. Examples of qualified personnel shall be permitted to include, but shall not be limited to, individuals with the following qualifications:
(1) Factory trained and certified
(2) National Institute for Certification in Engineering Technologies
fire alarm certified
(3) International Municipal Signal Association fire alarm
certified
(4) Certified by a state or local authority
(5) Trained and qualified personnel employed by an organization
listed by a national testing laboratory for the servicing
of fire alarm systems.

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

Findings:

During document review and interview with Staff on 8/4/15, the smoke detector sensitivity records were reviewed.

Main Hospital

1. At 1:26 p.m., the facility had approximately 166 smoke detectors. A review of the smoke detector sensitivity log indicated 11 of 166 smoke detectors were not tested for sensitivity. During an interview at 1:32 p.m., the Director of Plant Operations stated that some areas were not accessible.

2. At 1:32 p.m., a review of the smoke detector sensitivity log indicated that the facility performed in-house smoke detector sensitivity testing. During an interview at 1:35 p.m., Director of Plant Operations stated that Plant Operation Staff 2 was trained but not certified.

Based on observation, testing, and interview, the facility failed to ensure that the automatic sprinkler system had control valves that were supervised. This was evidenced by three sprinkler system backflow preventer-valve assemblies that were not supervised. This affected two of two floors in the Main Hospital and could potentially result in staff being unaware of a loss of sprinkler protection if the automatic sprinkler system water were shut off.

NFPA 101, 2000
19.3.5.2 Where this code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria: (1) it shall be in accordance with section 9.7. (2) it shall be electrically connected to the fire alarm system. (3) it shall be fully supervised. 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.

9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems 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.
9.7.2.2. Alarm Signal Transmission. Where supervision of the automatic sprinkler systems is provided in accordance with another provision of this code, waterflow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

Findings:

During a tour of the facility, testing, and interview with Staff 8/5/15, the automatic sprinkler system backflow shut off valves were observed and tested.

Main Hospital

1. At 9:01 a.m., the southwest sprinkler system backflow shut-off valve assembly was chained and locked in an open position. The valves were closed and there was no tamper alarm and/or supervisory signal that was initiated at the fire alarm control panel (FACP) room/Private Branch Exchange (PBX) office, or at an off site monitoring station. The control valve assembly was not equipped with a tamper switch. During an interview at 9:05 a.m., the Assistant Director of Plant Operations and Plant Operation Staff 1 confirmed that no signals were received at the FACP or PBX.

2. At 9:11 a.m., the northwest sprinkler system backflow shut-off valve assembly was chained and locked in an open position. The valves were closed and there was no tamper alarm and/or supervisory signal that was initiated at the FACP Room, the PBX office, or at an off site monitoring station. The control valve assembly did not have a tamper switch on it. During an interview at 9:12 a.m., the Assistant Director of Plant Operations and Plant Operation Staff 1 confirmed that there were no signals received at the FACP or PBX.

3. At 9:15 a.m., the northeast sprinkler system backflow shut-off valve assembly was chained and locked in an open position. The valves were closed and there was no tamper alarm and/or supervisory signal that was initiated at the FACP room, the PBX office, or at an off site monitoring station. The control valve assembly did not have a tamper switch on it. During an interview at 9:17 a.m., Assistant Director of Plant Operations and Plant Operation Staff 1 confirmed that there were no signals received at the FACP or PBX.

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Outpatient Services Building 2-2809 Olive Highway

6. On 8/5/15 at 9:46 a.m., a corridor sprinkler was observed with a green liquid substance on the deflector plate in Suite 110.

7. On 8/5/15 at 9:47 a.m., a sprinkler head in the Supply Closet in Suite 120 had a box that was within 12 inches of the deflector.

8. On 8/5/15 at 10:06 a.m., the Inspector Test Valve (ITV) on the first floor took longer than 90 seconds to alarm. The ITV took one minute and forty seconds to activate the fire alarm system. Plant Operations Staff 2 confirmed.

9. On 8/5/15 at 1:25 p.m., the facility was missing two quarterly sprinkler inspection tests for the third and fourth quarter of 2014. Assistant Director of Plant Operations and Plant Operation Staff 2 confirmed the findings.

Outpatient Building 3-2450 Oro Dam Blvd.

10. On 8/5/15, at 10:42 a.m., the spare sprinkler box that was located between the two Sprinkler Risers was missing the special sprinkler head wrench.

11. On 8/5/15, at 10:50 a.m., one of two Post Indicator Valves (PIV) was observed without a wrench to operate the valve and without a lock to prevent tampering. The valve was supervised and functioned properly when tested.

Based on observation, the facility failed to maintain its portable fire extinguishers. This was evidenced by fire extinguishers that were recessed into the wall that were obscured from view and by fire extinguishers that were obstructed from access. This affected two of two floors in the Main Hospital and could result in a delay in access to the fire extinguisher in the event of a fire.

NFPA 101, 2000
19.3.5.6 Portable Fire Extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1
9.7.4 Manual Extinguishing Equipment
9.7.4.1 Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguisher.

21.3.5.2 Portable fire extinguishers shall be provided in ambulatory health care facilities in accordance with 9.7.4.1
9.7.4.1 Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, 1998
1-6.6* Fire extinguishers shall not be obstructed or obscured from view. Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means all be provided to indicate the location.

1-6.12 Fire extinguishers mounted in cabinets or wall recesses shall be placed so that the fire extinguisher operating instructions face outward. The location of such fire extinguishers shall be marked conspicuously. (See 1 6.6.)

Findings:

During a tour of the facility with Staff on 8/3/15, the portable fire extinguishers were observed.

Main Hospital

1. At 9:25 a.m., recessed cabinet fire extinguisher number 46 on the first floor by the Linen Storage Room was obscured from view. There was no sign marking its location.

2. At 9:25 a.m., cabinet fire extinguisher 54 on the first floor in the South Mechanical Room was obstructed from access by a vacuum pump and other large equipment. The items were stationed within one inch of the fire extinguisher.

3. At 10:10 a.m., recessed cabinet fire extinguisher number 41 on the first floor by Elevator Door 4-16 was obscured from view. There was no sign marking its location.

4. At 10:16 a.m., recessed cabinet fire extinguisher number 43 on the first floor by Room 114 was obstructed by four wheelchairs that prevented direct access to the extinguisher.

5. At 10:20 a.m., recessed cabinet fire extinguisher number 44 on the first floor in Unit 1 was obscured from view and was also obstructed from access by a metal rolling ladder that was stationed within one inch in front of it. There was no sign marking its location.

6. At 10:21 a.m., recessed cabinet fire extinguisher number 45 on the first floor in Unit 1 was obscured from view. There was no sign marking its location.

7. At 10:24 a.m., recessed cabinet fire extinguisher number 42 on the first floor in Unit 1 was obscured from view. There was no sign marking its location. The fire extinguisher was also obstructed from access by a janitor's cart that was stationed within one inch of the front of it.

8. At 10:30 a.m., recessed cabinet fire extinguisher number 47 on the second floor behind elevator fire door 7-17 was obscured from view. There was no sign marking its location.

9. At 10:31 a.m., recessed cabinet fire extinguisher number 55 on the second floor in Unit 2 was obscured from view. There was no sign marking its location.

10. At 10:35 a.m., recessed cabinet fire extinguisher number 53 on the second floor in Unit 2 was obscured from view. There was no sign marking its location.

11. At 10:37 a.m., recessed cabinet fire extinguisher number 52 on the second floor in Unit 2 was obscured from view. There was no sign marking its location.

12. At 10:40 a.m., recessed cabinet fire extinguisher number 51 on the second floor in the Intensive Care Unit (ICU) was obscured from view. There was no sign marking its location.

13. At 10:41 a.m., recessed cabinet fire extinguisher number 50 on the second floor in ICU was obscured from view. There was no sign marking its location.

14. At 10:46 a.m., recessed cabinet fire extinguisher number 49 on the second floor in Surgery was obscured from view. There was no sign marking its location.

15. At 10:51 a.m., recessed cabinet fire extinguisher number 48 on the second floor in the Surgery was obscured from view. There was no sign marking its location.

16. At 11:02 a.m., recessed cabinet fire extinguisher number 79 on the second floor in the Lab was obstructed from access by a trash bin that was stationed within one inch of it. There was no sign marking its location.

17. At 11:40 a.m., recessed cabinet fire extinguisher number 12 on the second floor in the Emergency Department (ER) was obscured from view. There was no sign marking its location.

18. At 12:55 p.m., recessed cabinet fire extinguisher number 3 on the second floor in the Ambulatory Care Service (ACS) was obscured from view and was also obstructed by a tall IV pole that was stationed in front of it. There was no sign marking its location.

Based on observation, the facility failed to maintain its compressed gas cylinders. This was evidenced by an unsecured cylinder. This affected one of two floors in the Main Hospital and could result in an increased risk or acceleration of a fire.

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.
4-3.5.2.1 (27) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with Staff on 8/3/15, the non-flammable gas was observed.

Main Hospital

1. At 11:45 a.m., a carbon dioxide cylinder was observed freestanding on the floor in the Kitchen Dry Storage.

Based on observation, the facility failed to maintain access to its medical gas shut off valves. This was evidenced by equipment placed in front of emergency oxygen shut off valves. This affected one of two floors in the Main Hospital and could delay personnel from shutting off oxygen during an emergency.

NFPA 101, 2000
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99,1999
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with Staff 8/3/15, the piped-in medical gas shut off valves were observed.

Main Hospital

1. At 10:50 a.m., the shut off valve near Operation Room (OR) 2 in the Surgery Unit was obstructed by a cart, two instrument holders, a tall supply cart, and a stints cart. The items impeded access to the shut off valve.

2. At 10:55 a.m., the shut off valve by OR 1 in the Surgery Unit was obstructed by a metal supply cart.

3. At 11:37 a.m., the shut off valve in the Emergency Department (ER) was obstructed by a x-ray machine that was stationed within one inch of the front of it.

4. At 11:41 a.m., the shut off valve in the Respirator Care Workroom had a tool box that was stationed within one inch of the front of it.

Based on document review and interview, the facility failed to maintain and
provide a written policy for the relative humidity (RH). This was evidenced by failure to following the policy for the RH and failure to document the RH level. This affected one of two floors in the Main Hospital and could result in an increased risk of fire.

Findings:

During document review and interview, the RH policy was requested and reviewed.

Main Hospital

1. On 8/4/15, at 1:35 p.m., the Surgery Unit had five operating rooms. (OR). The relative humidity (RH) policy indicated that the RH would be maintained at 55%-65%." A review of the RH log indicated that in the last six month period (January-July 2015), the RH level went as low as 18% and as high at 76%. During an interview on 8/5/15 at 1:26 p.m., the Surgery Administrative Staff stated that Plant Operations personnel made the adjustments to the RH when needed. Staff further stated there was no log recording the adjustments that have been made. During an interview at 1:30 p.m., Director of Plant Operations stated that they do not make adjustments to the RH levels.

2. On 8/6/15, at 9:10 a.m., the Ambulatory Care Services Unit (ACS) had five Endoscopy Rooms (rooms 601, 603, 604, 606, and 607) and one eye laser procedure room. The ACS Unit failed to provide a written policy or maintain a log for RH levels. During an interview at 9:20 a.m., Director of Plant Operations stated they did not have a policy or a log for the RH.

Based on observation, the facility failed to maintain its smoke barrier walls free from penetrations. This was evidenced by penetrations in four walls. This affected two of two floors in the Main Hospital and could result in the spread of fire and/or smoke.

NFPA 101, 2000
19.3.7.3 Any required smoke barrier shall be constructed in accordance with section 8.3 and shall have a fire resistance rating of not less than 1/2 hours.

8.3.6.1: Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one following conditions:
(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
(b) It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:(a) It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier

Findings:

During a tour of the facility with Staff on 8/3/15, the smoke barrier walls were observed.

Main Hospital

1. At 1:26 p.m., there was an approximately four inch by four inch penetration with wires traveling through the smoke barrier wall in Unit 1 near fire door 2-14.

2. At 1:27 p.m., there was an approximately four inch by four inch penetration with wires traveling through the smoke barrier wall in the Unit 1 Conference Room by fire door 2-12.

3. At 1:40 p.m., there was an approximately three inch penetration with wires traveling through the wall in the west smoke barrier wall by Dietary.

4. At 1:43 p.m., there was an approximately two inch penetration with wires traveling through the wall in the east smoke barrier wall by Dietary.

Based on document review and interview, the facility failed to test its diesel generators. This was evidenced by missing documentation for three monthly full load tests in the past 12 months. This affected two of two smoke compartments and could potentially result in a generator failure during an emergency.

NFPA 101, 2000
19.7.6 Maintenance and Testing (see 4.6.12)
4.6.12 Maintenance and Testing. Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 110, 1999
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During document review and interview with Staff on 8/4/15, the generator records were requested.

1. At 11:30 a.m., the facility had two emergency diesel-powered generators. The north generator was rated for 250 kilowatts (KW) and the south generator was rated 200 KW. The north 250KW generator supplies emergency back-up power to Unit 3, Obstetrics and Gynecology (OB), Ambulance, Dietary, Emergency Department, X-ray, and Pharmacy. The south 200KW generator supplies emergency back-up power to Surgery, the Intensive Care Unit (ICU), and Unit 2 and Unit 1. The generator log titled, "Weekly Operational Test Exercise Log", did not indicate that a full load test was done in January 2015 and November 2014 for the north generator. There was no documentation provided indicating that the full load test was done for the south generator in August 2014. During an interview at 12 p.m., Assistant Director of Plant Operations confirmed the findings.

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Outpatient Services Building 2-2809 Olive Highway

27. On 8/5/15, at 9:50 a.m., in Suite 150 Infusion Room, there were three IV pumps and a patient monitor plugged into a power strip at Station A, two IV pumps were plugged into a power strip at Station B, two IV pumps and a patient monitor were plugged into a power strip at Station C, two IV poles were plugged into a power strip at Station D, and four IV pumps and a patient monitor were plugged into a power strip at Station E.

28. On 8/5/15, at 9:56 a.m., a computer charger was plugged into a extension card in the Suite 230 Break Room.

Based on observation, the facility failed to maintain the installation of its alcohol based hand rub dispensers (ABHR). This was evidenced by the mounting of an ABHR dispenser over or adjacent to an ignition source. This affected two of two floors in the Main Hospital. This could result in the ignition of fire.

Findings:

During a tour of the facility with Staff on 8/3/15, the alcohol based hand rub dispensers were observed.

Main Hospital

1. At 11:43 a.m., the ABHR dispenser in the Cardiology Treadmill Office was mounted 10 inches directly above a light switch.

2. At 12:58 p.m., the ABHR dispenser in Room 604 of the Ambulatory Care Service Unit (ACS) was mounted 10 inches directly above a light switch.

3. At 1:01 p.m., the ABHR dispenser in Unit 3 Overflow Storage was mounted 10 inches directly above a light switch.