HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by one unsealed penetration in a facility wall. This affected one of four floors in the Main Hospital, and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff on 6/8/11 at 11:09 a.m., there was an approximately eight inch by five inch unsealed penetration in the wall of the Hazmat Spill Kit Room. The penetration had an approximately one inch diameter pipe running through it. The Hazmat Spill Kit Room was located on the First Floor, near the Nuclear Medicine department.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by nine corridor doors that were obstructed from closing or latching. This affected three of four floors in the Main Hospital, and could result in a delay to contain smoke or fire to a room.

Findings:

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

1. On 6/7/11 at 4:22 p.m., the corridor door to Room 225 was equipped with a self-closing device and a magnetic hold-open device. The door was released from its magnetic hold-open device and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

2. On 6/7/11 at 4:23 p.m., the corridor door to Room 227 was equipped with a self-closing device and a hold-open device. The door was released from its hold-open device and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

3. On 6/7/11 at 4:25 p.m., the corridor door to Room 231 was equipped with a self-closing device and a hold-open device. The door was released from its hold-open device and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

4. On 6/8/11 at 8:48 a.m., the corridor door to the Break Room near the Labor and Delivery Nurse Station was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door wedge placed under the door leaf.

5. On 6/8/11 at 9:07 a.m., the corridor door to the Doctor's Office near the Acute Care Unit Nurse Station was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door wedge placed under the door leaf.

6. On 6/8/11 at 9:10 a.m., the corridor door to the Employee Lounge in the Intensive Care Unit failed to latch when in the closed position. The door was obstructed from latching due to tape that had been placed over the striker plate, and over the latching barrel.

7. On 6/8/11 at 9:50 a.m., the corridor door to the Janitor's Closet near the First Floor freight elevator 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.

8. On 6/8/11 at 10:05 a.m., the corridor door to the Physical Therapy Department was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door wedge placed under the door leaf.

9. On 6/8/11 at 10:50 a.m., the corridor door to the Sonoma Valley Hospital Foundation Office was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door stop object placed in the swing path of the door.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by one smoke barrier door that failed to latch when the door was released from its hold-open device, and one smoke barrier door that was obstructed. This affected one of four floors in the Main Hospital, and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 6/8/11, the smoke barrier doors in the facility were observed.

1. At 10:27 a.m., the smoke barrier doors leading to the Skilled Nursing Unit were equipped with self-closing devices, and magnetic hold-open devices. The doors were released from their magnetic hold-open devices and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

2. At 11:19 a.m., the smoke barrier doors leading from the Emergency Department to the corridor were observed. One gurney and three portable vital monitors were located directly in front and to the side of the smoke barrier doors.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by two hazardous areas that were not equipped with self-closing doors. This affected one of four floors in the Main Hospital, and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff on 6/7/11, the hazardous areas in the facility were observed.

1. At 4:41 p.m., the Tub Room across from Room 225 was observed to be approximately sixty-five square feet in area. The room contained bed frames, mattresses, and other 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.

2. At 4:52 p.m., the Supply Room near Room 207 was observed to be over fifty square feet in area. The room contained storage of combustible items. 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.

Based on record review and interview, the facility failed to maintain their battery-powered emergency lighting units. This was evidenced by the facility's failure to perform annual ninety minute tests on their battery-powered emergency lighting units. This affected all patients, and could result in a delayed evacuation in the event of an emergency due to limited visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a record review on 6/7/11 at 1:27 p.m., the test records for the facility's battery-powered emergency lighting units were reviewed. The test records indicated that the battery-powered emergency lighting units are tested monthly for thirty seconds. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 indicated that the battery-powered emergency lighting units are also tested annually for thirty minutes. Engineering Staff 3 indicated that the battery-powered emergency lighting units are not tested annually for ninety minutes. Engineering Staff 3 indicated that they were unaware of that requirement.

Based on record review and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to perform annual ninety minute tests on their exit signs equipped with a battery-powered emergency power source. This affected all patients, and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a record review on 6/7/11 at 1:27 p.m., the test records for the facility's exit signs equipped with a battery-powered emergency power source were reviewed. The test records indicated that the exit signs are tested monthly for thirty seconds. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 indicated that the exit signs are not tested annually for ninety minutes. Engineering Staff 3 indicated that they were unaware of that requirement.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by one fire alarm manual pull station that was obstructed, and two fire alarm bells that failed to emit an audible sound. This affected two of four floors in the Main Hospital, and could result in a delayed notification of a fire.

NFPA 72, 1999 edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff on 6/8/11, the fire alarm system and components were observed.

1. At 11:14 a.m., the fire alarm manual pull station located in the Emergency Department near the ambulance entrance was observed. The manual pull station was physically and visually obstructed by a rolling shelving unit placed in front of it.

2. At 3:16 p.m., the fire alarm system was activated. The fire alarm bell near Room 229 and the fire alarm bell near Room 230 failed to emit an audible sound.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by two sprinkler heads that were missing escutcheon fittings, and one sprinkler head that was corroded. This affected two of four floors in the Main Hospital, and could result in a delayed response of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff, the facility's automatic sprinkler system was observed.

1. On 6/7/11 at 3:41 p.m., the sprinkler head in the Environmental Services Manager's Office was missing an escutcheon fitting. Sprinkler piping was exposed.

2. On 6/7/11 at 3:46 p.m., the sprinkler head in the Human Resources Director's Office was missing an escutcheon fitting. Sprinkler piping was exposed.

3. On 6/8/11 at 10:48 a.m., the sprinkler head in the Cardiopulmonary Unit above the staff break area was observed. The sprinkler head was green and heavily corroded.

Based on record review and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to conduct quarterly and annual automatic fire sprinkler system tests and inspections. This affected all patients in the Center for Women's Health and Wellness building, and could result in a malfunction of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler
2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is
attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.6 Main Drain Test. A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions.
9-3.4.1 Each control valve shall be operated annually through its full range and returned to its normal position. Post
indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.
9-3.4.2 A main drain test shall be conducted annually and any time the valve is closed at each system after the control valve has been closed to determine whether there has been a change in the condition of the water supply piping and control valves.
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved onefifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During record review on 6/8/11 at 2:44 p.m., the facility's automatic sprinkler system test records were requested. There was no record that indicated the facility had been conducting quarterly automatic fire sprinkler system tests and inspections. There was no record that indicated the facility had an annual inspection completed on their automatic fire sprinkler system. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that they would call the facility's sprinkler system vendor to obtain those missing inspections. Facilities Staff 1 indicated that the sprinkler system vendor did not have any records of a quarterly or annual test and inspection since the last 5-year certification of the sprinkler system. The last 5-year certification of the sprinkler system was completed on 10/31/08.

Based on record review and interview, the facility failed to maintain their fire/smoke dampers. This was evidenced by fifty-two fire/smoke dampers in the facility that had not been inspected due to obstructed access. This affected four of four floors in the Main Hospital, and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review, on 6/7/11 at 11:40 a.m., the facility's fire/smoke damper inspection records were reviewed. The facility last had their fire/smoke dampers inspected on 3/17/09. The fire/smoke damper inspection report indicated that fifty-two dampers in the facility were unable to be inspected because there was "No Access" to the dampers. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 confirmed that those fire/smoke dampers had not been inspected.

Based on observation and interview, the facility failed to maintain their use of portable space heaters. This was evidenced by the use of portable space heaters in staff areas that were not tested to ensure they did not exceed 212 degrees Fahrenheit, portable space heaters that did not have three feet clearance from furnishings and combustibles, and one portable space heater that was plugged into an extension cord. This affected two of four floors in the Main Hospital, 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.

1. On 6/7/11 at 3:46 p.m., a portable space heater was located in the Human Resources Director's Office. The portable space heater was located under a desk in that room, and did not have three feet of clearance from furnishings and combustibles. The portable space heater was plugged into a surge protected multi-outlet extension cord and not directly to a dedicated wall outlet. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the portable space heaters in the facility are not heat tested to ensure they do not exceed 212 degrees Fahrenheit.

2. On 6/8/11 at 9:21 a.m., a portable space heater was located in the Medical Imaging Manager's Office. The portable space heater was located under a desk in that room, and did not have three feet of clearance from furnishings and combustibles. Engineering staff had previously stated that portable space heaters in the facility are not heat tested to ensure they do not exceed 212 degrees Fahrenheit.

Based on record review, interview, and observation, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure have a policy and procedure for monitoring humidity, the facility's failure to monitor humidity in three of four anesthetizing locations, and the facility's incapability of adjusting humidity levels in two of four anesthetizing locations. This affected four of four anesthetizing locations in the Main Hospital, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

6/7/11:

During record review, at 1:45 p.m., the facility's humidity logs for their anesthetizing locations were requested. There were three Operation Rooms and one Labor and Delivery Room. The facility was able to locate humidity logs for the Labor and Delivery Room, but not for the three Operation Rooms. The humidity was logged for the Labor and Delivery Room by Labor and Delivery staff. No humidity logs were available prior to January, 2011.

At 2:31 p.m., Surgical Staff 1 was interviewed. Surgical Staff 1 indicated that the Surgery Department did not monitor humidity levels in there Operation Rooms. Surgical Staff 1 indicated that they believed engineering staff monitored the humidity levels. Surgical Staff 1 indicated that the facility does not have an adopted policy or procedure for monitoring humidity levels in their Operation Rooms.

At 2:52 p.m., Engineering Staff 1 was interviewed. Engineering Staff 1 indicated that engineering staff does not monitor humidity levels in the Operation Rooms.

At 3:03 p.m., the Surgery Department was observed. All three Operation Rooms had a wall mounted hygrometer displaying relative humidity levels at their respective locations. Operation Room 1 had a relative humidity of 86 percent. Operation Room 2 had a relative humidity of 88 percent. Operation Room 3 had a relative humidity level of 59 percent.

6/8/11:

At 9:01 a.m., the Labor and Delivery Room was observed. The Labor and Delivery Room had a wall mounted hygrometer displaying the relative humidity level at that location. The relative humidity was 72 percent.

At 2:35 p.m., Nurse Manager 1 was interviewed. Nurse Manager 1 indicated that Labor and Delivery staff observe the humidity levels daily. Nurse Manager 1 indicated that the relative humidity should be within the range of 45 to 60 percent. Nurse Manager 1 indicated that if humidity was observed to be outside the 45 to 60 percent range, then Labor and Delivery staff would contact the Engineering Department to adjust.

At 2:40 p.m., Engineering Staff 1 was interviewed. Engineering Staff 1 indicated that there is no way to adjust humidity levels in the Labor and Delivery Room or Operation Room 3. Engineering Staff 1 indicated that new air handling units were installed on 6/4/11 for Operation Rooms 1 and 2. Engineering Staff 1 said that the new air handling units could adjust humidity levels in those two Operation Rooms. Engineering Staff 1 indicated that prior to the new air handling units, there was no way to adjust relative humidity levels in Operation Rooms 1 and 2. Engineering Staff 1 indicated that there was no way for the facility to maintain the relative humidity at any specified range.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the use of extension cords plugged into other extension cords, electrical receptacles that were missing faceplates, electrical cords that were running through walls, and the use of non-surge protected extension cords as a substitute for permanent wiring. This affected three of four floors in the Main Hospital, and could result in an electrical fire to occur.

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.

1. On 6/7/11 at 3:44 p.m., computer equipment in the Human Resources Department was plugged into a surge protected multi-outlet extension cord. That surge protected multi-outlet extension cord and a miniature refrigerator were plugged into another surge protected multi-outlet extension cord, that was plugged into a yellow non-surge protected extension cord.

2. On 6/7/11 at 3:46 p.m., an electrical receptacle in the Human Resources Director's Office was missing a faceplate. Electrical wiring was exposed.

3. On 6/7/11 at 4:47 p.m., computer equipment cables at the Second Floor Nurse Station 2-North were running through a wall penetration into the adjacent Medication Room.

4. On 6/8/11 at 10:33 a.m., computer equipment in the Medical Records Office near the back office break room was plugged into a surge protected multi-outlet extension cord, that was plugged into another surge protected multi-outlet extension cord.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by the mounting of two alcohol based hand rub dispensers over ignition sources. This affected two of four floors in the Main Hospital, and could result in an alcohol based hand rub ignited fire.

Findings:

During a facility tour with staff on 6/8/11, the alcohol based hand rub dispensers were observed.

1. At 9:12 a.m., an alcohol based hand rub dispenser in Intensive Care Unit near the Employee Lounge was mounted on the wall approximately three feet above an electrical receptacle. The hand rub was seventy percent ethyl alcohol by volume.

2. At 9:32 a.m., an alcohol based hand rub dispenser in the Doctor's Reading Room near the Medical Imaging Department was mounted on the wall approximately three and a half feet above a surge protected multi-outlet extension cord. The hand rub was seventy percent ethyl alcohol by volume.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by one unsealed penetration in a facility wall. This affected one of four floors in the Main Hospital, and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff on 6/8/11 at 11:09 a.m., there was an approximately eight inch by five inch unsealed penetration in the wall of the Hazmat Spill Kit Room. The penetration had an approximately one inch diameter pipe running through it. The Hazmat Spill Kit Room was located on the First Floor, near the Nuclear Medicine department.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by nine corridor doors that were obstructed from closing or latching. This affected three of four floors in the Main Hospital, and could result in a delay to contain smoke or fire to a room.

Findings:

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

1. On 6/7/11 at 4:22 p.m., the corridor door to Room 225 was equipped with a self-closing device and a magnetic hold-open device. The door was released from its magnetic hold-open device and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

2. On 6/7/11 at 4:23 p.m., the corridor door to Room 227 was equipped with a self-closing device and a hold-open device. The door was released from its hold-open device and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

3. On 6/7/11 at 4:25 p.m., the corridor door to Room 231 was equipped with a self-closing device and a hold-open device. The door was released from its hold-open device and allowed to close. The door failed to latch. Pressure was applied to the door and the door failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

4. On 6/8/11 at 8:48 a.m., the corridor door to the Break Room near the Labor and Delivery Nurse Station was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door wedge placed under the door leaf.

5. On 6/8/11 at 9:07 a.m., the corridor door to the Doctor's Office near the Acute Care Unit Nurse Station was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door wedge placed under the door leaf.

6. On 6/8/11 at 9:10 a.m., the corridor door to the Employee Lounge in the Intensive Care Unit failed to latch when in the closed position. The door was obstructed from latching due to tape that had been placed over the striker plate, and over the latching barrel.

7. On 6/8/11 at 9:50 a.m., the corridor door to the Janitor's Closet near the First Floor freight elevator 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.

8. On 6/8/11 at 10:05 a.m., the corridor door to the Physical Therapy Department was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door wedge placed under the door leaf.

9. On 6/8/11 at 10:50 a.m., the corridor door to the Sonoma Valley Hospital Foundation Office was equipped with a self-closing device. The door was held in the open position, and was obstructed from closing by a door stop object placed in the swing path of the door.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by one smoke barrier door that failed to latch when the door was released from its hold-open device, and one smoke barrier door that was obstructed. This affected one of four floors in the Main Hospital, and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 6/8/11, the smoke barrier doors in the facility were observed.

1. At 10:27 a.m., the smoke barrier doors leading to the Skilled Nursing Unit were equipped with self-closing devices, and magnetic hold-open devices. The doors were released from their magnetic hold-open devices and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

2. At 11:19 a.m., the smoke barrier doors leading from the Emergency Department to the corridor were observed. One gurney and three portable vital monitors were located directly in front and to the side of the smoke barrier doors.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by two hazardous areas that were not equipped with self-closing doors. This affected one of four floors in the Main Hospital, and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff on 6/7/11, the hazardous areas in the facility were observed.

1. At 4:41 p.m., the Tub Room across from Room 225 was observed to be approximately sixty-five square feet in area. The room contained bed frames, mattresses, and other 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.

2. At 4:52 p.m., the Supply Room near Room 207 was observed to be over fifty square feet in area. The room contained storage of combustible items. 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.

Based on record review and interview, the facility failed to maintain their battery-powered emergency lighting units. This was evidenced by the facility's failure to perform annual ninety minute tests on their battery-powered emergency lighting units. This affected all patients, and could result in a delayed evacuation in the event of an emergency due to limited visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a record review on 6/7/11 at 1:27 p.m., the test records for the facility's battery-powered emergency lighting units were reviewed. The test records indicated that the battery-powered emergency lighting units are tested monthly for thirty seconds. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 indicated that the battery-powered emergency lighting units are also tested annually for thirty minutes. Engineering Staff 3 indicated that the battery-powered emergency lighting units are not tested annually for ninety minutes. Engineering Staff 3 indicated that they were unaware of that requirement.

Based on record review and interview, the facility failed to maintain their exit signs. This was evidenced by the facility's failure to perform annual ninety minute tests on their exit signs equipped with a battery-powered emergency power source. This affected all patients, and could result in a delayed evacuation due to limited exit sign visibility.

NFPA 101, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a record review on 6/7/11 at 1:27 p.m., the test records for the facility's exit signs equipped with a battery-powered emergency power source were reviewed. The test records indicated that the exit signs are tested monthly for thirty seconds. Engineering Staff 3 was interviewed at that time. Engineering Staff 3 indicated that the exit signs are not tested annually for ninety minutes. Engineering Staff 3 indicated that they were unaware of that requirement.

Based on observation, the facility failed to maintain their fire alarm system. This was evidenced by one fire alarm manual pull station that was obstructed, and two fire alarm bells that failed to emit an audible sound. This affected two of four floors in the Main Hospital, and could result in a delayed notification of a fire.

NFPA 72, 1999 edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff on 6/8/11, the fire alarm system and components were observed.

1. At 11:14 a.m., the fire alarm manual pull station located in the Emergency Department near the ambulance entrance was observed. The manual pull station was physically and visually obstructed by a rolling shelving unit placed in front of it.

2. At 3:16 p.m., the fire alarm system was activated. The fire alarm bell near Room 229 and the fire alarm bell near Room 230 failed to emit an audible sound.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by two sprinkler heads that were missing escutcheon fittings, and one sprinkler head that was corroded. This affected two of four floors in the Main Hospital, and could result in a delayed response of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.2 Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.

Findings:

During a facility tour with staff, the facility's automatic sprinkler system was observed.

1. On 6/7/11 at 3:41 p.m., the sprinkler head in the Environmental Services Manager's Office was missing an escutcheon fitting. Sprinkler piping was exposed.

2. On 6/7/11 at 3:46 p.m., the sprinkler head in the Human Resources Director's Office was missing an escutcheon fitting. Sprinkler piping was exposed.

3. On 6/8/11 at 10:48 a.m., the sprinkler head in the Cardiopulmonary Unit above the staff break area was observed. The sprinkler head was green and heavily corroded.

Based on record review and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to conduct quarterly and annual automatic fire sprinkler system tests and inspections. This affected all patients in the Center for Women's Health and Wellness building, and could result in a malfunction of the automatic fire sprinkler system.

NFPA 25, 1998 edition
2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
2-2.1.3 The supply of spare sprinklers shall be inspected annually for the following:
(a) The proper number and type of sprinklers
(b) A sprinkler wrench for each type of sprinkler
2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-2.7 Hydraulic Nameplate. The hydraulic nameplate, if provided, shall be inspected quarterly to verify that it is
attached securely to the sprinkler riser and is legible.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
9-2.6 Main Drain Test. A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves.
9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer ' s instructions.
9-3.4.1 Each control valve shall be operated annually through its full range and returned to its normal position. Post
indicator valves shall be opened until spring or torsion is felt in the rod, indicating that the rod has not become detached from the valve. Post indicating and outside screw and yoke valves shall be backed a one-quarter turn from the fully open position to prevent jamming.
9-3.4.2 A main drain test shall be conducted annually and any time the valve is closed at each system after the control valve has been closed to determine whether there has been a change in the condition of the water supply piping and control valves.
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve ' s normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved onefifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.
9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken
9-5.2.1 All valves shall be inspected quarterly. The inspection shall verify the following:
(a) The handwheel is not broken or missing.
(b) The outlet hose threads are not damaged.
(c) There are no leaks.
(d) The reducer and the cap are not missing.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During record review on 6/8/11 at 2:44 p.m., the facility's automatic sprinkler system test records were requested. There was no record that indicated the facility had been conducting quarterly automatic fire sprinkler system tests and inspections. There was no record that indicated the facility had an annual inspection completed on their automatic fire sprinkler system. Facilities Staff 1 was interviewed at that time. Facilities Staff 1 indicated that they would call the facility's sprinkler system vendor to obtain those missing inspections. Facilities Staff 1 indicated that the sprinkler system vendor did not have any records of a quarterly or annual test and inspection since the last 5-year certification of the sprinkler system. The last 5-year certification of the sprinkler system was completed on 10/31/08.

Based on record review and interview, the facility failed to maintain their fire/smoke dampers. This was evidenced by fifty-two fire/smoke dampers in the facility that had not been inspected due to obstructed access. This affected four of four floors in the Main Hospital, and could result in the spread of smoke or fire to other locations of the facility due to a malfunctioning fire/smoke damper.

NFPA 90A, 1999 edition
2-1.1 Equipment shall be arranged to afford access for inspection, maintenance, and repair.
3-4.7 At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they fully close; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During record review, on 6/7/11 at 11:40 a.m., the facility's fire/smoke damper inspection records were reviewed. The facility last had their fire/smoke dampers inspected on 3/17/09. The fire/smoke damper inspection report indicated that fifty-two dampers in the facility were unable to be inspected because there was "No Access" to the dampers. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 confirmed that those fire/smoke dampers had not been inspected.

Based on observation and interview, the facility failed to maintain their use of portable space heaters. This was evidenced by the use of portable space heaters in staff areas that were not tested to ensure they did not exceed 212 degrees Fahrenheit, portable space heaters that did not have three feet clearance from furnishings and combustibles, and one portable space heater that was plugged into an extension cord. This affected two of four floors in the Main Hospital, 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.

1. On 6/7/11 at 3:46 p.m., a portable space heater was located in the Human Resources Director's Office. The portable space heater was located under a desk in that room, and did not have three feet of clearance from furnishings and combustibles. The portable space heater was plugged into a surge protected multi-outlet extension cord and not directly to a dedicated wall outlet. Engineering Staff 2 was interviewed at that time. Engineering Staff 2 indicated that the portable space heaters in the facility are not heat tested to ensure they do not exceed 212 degrees Fahrenheit.

2. On 6/8/11 at 9:21 a.m., a portable space heater was located in the Medical Imaging Manager's Office. The portable space heater was located under a desk in that room, and did not have three feet of clearance from furnishings and combustibles. Engineering staff had previously stated that portable space heaters in the facility are not heat tested to ensure they do not exceed 212 degrees Fahrenheit.

Based on record review, interview, and observation, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure have a policy and procedure for monitoring humidity, the facility's failure to monitor humidity in three of four anesthetizing locations, and the facility's incapability of adjusting humidity levels in two of four anesthetizing locations. This affected four of four anesthetizing locations in the Main Hospital, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

6/7/11:

During record review, at 1:45 p.m., the facility's humidity logs for their anesthetizing locations were requested. There were three Operation Rooms and one Labor and Delivery Room. The facility was able to locate humidity logs for the Labor and Delivery Room, but not for the three Operation Rooms. The humidity was logged for the Labor and Delivery Room by Labor and Delivery staff. No humidity logs were available prior to January, 2011.

At 2:31 p.m., Surgical Staff 1 was interviewed. Surgical Staff 1 indicated that the Surgery Department did not monitor humidity levels in there Operation Rooms. Surgical Staff 1 indicated that they believed engineering staff monitored the humidity levels. Surgical Staff 1 indicated that the facility does not have an adopted policy or procedure for monitoring humidity levels in their Operation Rooms.

At 2:52 p.m., Engineering Staff 1 was interviewed. Engineering Staff 1 indicated that engineering staff does not monitor humidity levels in the Operation Rooms.

At 3:03 p.m., the Surgery Department was observed. All three Operation Rooms had a wall mounted hygrometer displaying relative humidity levels at their respective locations. Operation Room 1 had a relative humidity of 86 percent. Operation Room 2 had a relative humidity of 88 percent. Operation Room 3 had a relative humidity level of 59 percent.

6/8/11:

At 9:01 a.m., the Labor and Delivery Room was observed. The Labor and Delivery Room had a wall mounted hygrometer displaying the relative humidity level at that location. The relative humidity was 72 percent.

At 2:35 p.m., Nurse Manager 1 was interviewed. Nurse Manager 1 indicated that Labor and Delivery staff observe the humidity levels daily. Nurse Manager 1 indicated that the relative humidity should be within the range of 45 to 60 percent. Nurse Manager 1 indicated that if humidity was observed to be outside the 45 to 60 percent range, then Labor and Delivery staff would contact the Engineering Department to adjust.

At 2:40 p.m., Engineering Staff 1 was interviewed. Engineering Staff 1 indicated that there is no way to adjust humidity levels in the Labor and Delivery Room or Operation Room 3. Engineering Staff 1 indicated that new air handling units were installed on 6/4/11 for Operation Rooms 1 and 2. Engineering Staff 1 said that the new air handling units could adjust humidity levels in those two Operation Rooms. Engineering Staff 1 indicated that prior to the new air handling units, there was no way to adjust relative humidity levels in Operation Rooms 1 and 2. Engineering Staff 1 indicated that there was no way for the facility to maintain the relative humidity at any specified range.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by the use of extension cords plugged into other extension cords, electrical receptacles that were missing faceplates, electrical cords that were running through walls, and the use of non-surge protected extension cords as a substitute for permanent wiring. This affected three of four floors in the Main Hospital, and could result in an electrical fire to occur.

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.

1. On 6/7/11 at 3:44 p.m., computer equipment in the Human Resources Department was plugged into a surge protected multi-outlet extension cord. That surge protected multi-outlet extension cord and a miniature refrigerator were plugged into another surge protected multi-outlet extension cord, that was plugged into a yellow non-surge protected extension cord.

2. On 6/7/11 at 3:46 p.m., an electrical receptacle in the Human Resources Director's Office was missing a faceplate. Electrical wiring was exposed.

3. On 6/7/11 at 4:47 p.m., computer equipment cables at the Second Floor Nurse Station 2-North were running through a wall penetration into the adjacent Medication Room.

4. On 6/8/11 at 10:33 a.m., computer equipment in the Medical Records Office near the back office break room was plugged into a surge protected multi-outlet extension cord, that was plugged into another surge protected multi-outlet extension cord.