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Based on observation and interview, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations observed in the fire-rated sheeting. This deficient practice affected staff and residents on three of four total floors in two of three buildings and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

Findings:

Main Hospital Building
First Floor
During a tour of the facility with the Director of Infection Control on 4/12/11, a penetration was observed in the gypsum wallboard which could potentially result in the spread of smoke and/or fire.

1. At 10:10 p.m., the First Floor Gurney Storage Room had a one-by-two inch unsealed penetration in the wall located to the left of the door on the southwest wall approximately 36 inches from the floor. Staff confirmed the penetration.




27893

Findings:

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

Main Hospital:

1. On 4/12/11 at 9:52 a.m., there were four approximately half inch diameter unsealed penetrations in the wall of patient room 234. The penetrations were located in the wall below the television in that room.

2. On 4/12/11 at 9:56 a.m., there was one approximately nineteen inch by five inch unsealed penetration in the wall of the storage room in the Nurse Documentation Room. The Nurse Documentation Room was located on the 2nd floor. Air flow could be felt coming out of the wall penetration. Engineer Staff 1 was interviewed at that time. Engineering Staff 1 indicated a sink was recently removed from that wall. Engineering Staff 1 indicated he was unaware that the wall penetration had not been sealed.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:52 p.m., there was one approximately ten inch by two inch unsealed penetration in the wall of the equipment storage room. The penetration was located in the north wall.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients on four of four total floors in three of three buildings.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, the following corridor doors did not positive latch when tested by releasing the door from an open position:

1. At 2:05 p.m., the door to the Housekeeping Closet in the Infusion Center did not positive latch when tested.
2. At 2:22 p.m., the door to the Tub Room in the Infusion Center did not positive latch when tested.
3. At 2:30 p.m., the door the the Conference Room near the Nurses' Station did not positive latch when tested.
4. At 3:00 p.m., the Large Conference Room door did not positive latch when tested.
5. At 3:05 p.m., the door to the Storage Room near Accounting Service did not positive latch when tested.
6. At 3:18 p.m., the door to the Finance Room near the Lobby identified on the facility drawings as the "Assistant Controller's Office" did not positive latch when tested.
7. At 3:20 p.m., the door to Administration near the area identified on the facility's drawings as the "Case Manager's Office" did not positive latch when tested.
8. At 3:42 p.m., the door to the Assistant Director's Office in Physical Therapy did not positive latch when tested.
9. At 3:43 p.m., the door to Speech Therapy in Physical Therapy did not positive latch when tested.

Main Hospital Building
First Floor
10. At 9:58 a.m., the corridor door to Admitting did not positive latch when tested.
11. At 10:15 a.m., the corridor door to Radiology 1156 did not positive latch when tested.
12. At 10:35 a.m., the one-hour fire-rated corridor door to the Pathology Laboratory did not positive latch when tested.
13. At 10:55 a.m., the corridor door to Gastro-intestinal Laboratory 1384 did not positive latch when tested.
14. At 11:00 a.m., the one-hour fire-rated corridor doors to Endoscopy did not positive latch when tested.
15. At 2:57 p.m., the corridor doors to the Dictation Room did not positive latch when tested
16. At 3:47 p.m., the doors to the Formula Room did not positive latch when tested.
17. At 3:55 p.m., the doors to the Breast Feeding Room had the striker plate taped, preventing the door from positive latching.
18. At 4:00 p.m., the door to the Treatment Room in the Birthing Center did not positive latch when tested.


27893

Findings:

Main Hospital:

1. On 4/11/11 at 4:19 p.m., the corridor door to patient room 219 failed to latch. The door was obstructed from latching by the door frame.

2. On 4/12/11 at 10:44 a.m., the corridor door to the Housekeeping Closet near the Engineering Department 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 4/12/11 at 4:08 p.m., the corridor door to the Doctor's Dictation Room near patient room 112 failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:23 p.m., the corridor doors to the Waiting Room were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs failed to latch. The door was obstructed from latching due to air pressure difference.

2. On 4/11/11 at 3:43 p.m., the corridor door to the Laser Room was obstructed from closing by a gurney placed directly in the swing path of the door. The room was unoccupied at the time of observation.

Based on observation, the facility failed to maintain a fire-rated shaft wall. This was evidenced by an unsealed penetration in a shaft wall. This affected two of four total floors in one of three buildings and could result in the spread of smoke or fire from one floor to another.

Findings:

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

Main Hospital:

1. On 4/13/11 at 9:09 a.m., there was on approximately two foot by two foot unsealed penetration in the shaft wall across from patient room 260. The shaft wall was a 2-hour fire-rated wall. The penetration was observed in the corridor wall located above the suspended ceiling.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of their fire barrier walls in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the fire-rated walls above the drop down ceiling. This deficient practice affected three of four total floors in three of three buildings and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

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.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

South Building
During an inspection of the facility's smoke barrier walls with the Senior Plant Engineer on 4/13/11, at 9:20 a.m., an unsealed penetration was observed in a one-hour fire-rated wall. This penetration was located above the drop down ceiling and was caused by an electrical conduit traveling through the wall between the Staff Lounge and the corridor leading to the Engineering Shop. The size of the penetration through the corridor side of the fire wall was approximately one-half inch wide around the outside of the approximately two inch 90 degree electrical conduit fitting. On the other side of the barrier wall in the Lounge area, the penetration was approximately one quarter inch larger in size than the same electrical conduit.




27893


Findings:

During a facility tour with staff, the facility's smoke barrier walls were observed.

Main Hospital:

1. On 4/13/11 at 9:32 a.m., there was an approximately quarter inch wide unsealed penetration in a smoke barrier wall surrounding an approximately one and one half inch diameter metal conduit. The penetration was located in the smoke barrier wall located near the Family Birthing Center elevator. Fire-rated caulking appeared to have come loose from that area and was surrounding a portion of the metal conduit. The fire-rated caulking was not sealing the penetration in the smoke barrier wall.

Ambulatory Surgery Center:

1. On 4/13/11 at 8:31 a.m., there was one approximately two and one half inch diameter unsealed penetration in the smoke barrier wall near the Waiting Room. The smoke barrier wall separated the Lobby from the Waiting Room.

Based on observation, the facility failed to maintain cross-corridor doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire as evidenced by cross-corridor doors that failed to close and/or latch. This deficient practice affected all staff and residents in two of four total floors in two of three buildings and could potentially result in the spread of smoke and/or fire.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, cross-corridor doors were observed in the following locations:

1. At 2:10 p.m., the left leaf facing north of the cross-corridor doors located near Patient Room 41 did not positive latch when tested by releasing the doors from an open position.

Main Hospital Building
First Floor
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, cross-corridor doors were observed in the following locations:

1. At 9:45 a.m., the east leaf facing south of the one-hour fire door separating the Lobby from the Quiet Room did not positive latch when tested by releasing it from an open position.
2. At 10:12 a.m., the right leaf facing south of the cross corridor door near Nuclear Medicine Room 1133 did not positive latch when tested by releasing the door from an open position.
3. At 10:22 a.m., the cross-corridor doors by Diagnostic Imaging Room 1204 did not positive latch when tested by releasing them from an open position.
4. During fire alarm testing, the Post Anesthesia Care Unit cross-corridor door number 1182 did not positive latch upon activation of the fire alarm system. The gap between the doors and the frame was approximately two inches. The bottom of the door moulding was bent. Engineering Staff 1 stated that the doors had been damaged earlier in the day.




27893

Findings:

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

South Building:

1. On 4/12/11 at 2:13 p.m., the smoke barrier doors near the Pharmacy Storage Room were equipped with self-closing devices and magnetic hold-open devices. The fire alarm was activated and the doors released from their magnetic hold-open devices. One of the two door leafs of the smoke barrier doors failed to close and latch. The door was obstructed from closing and latching due to circulating air pressure.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by unsealed penetrations in a hazardous area wall and one door to a hazardous area that was obstructed from latching. This affected two of four total floors in two of three buildings and could result in the spread of smoke or fire to other locations in the facility.

Findings:

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

Main Hospital:

1. On 4/12/11 at 10:47 a.m., there were four unsealed wall punctures in the north-east wall of the Purchasing Store Room. One puncture was approximately two inches by one half inch in size. The three other punctures were approximately one quarter inch in diameter. The Purchasing Store Room was greater that fifty square feet in area and housed combustible items.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:16 p.m., the corridor doors to the Boiler Room were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs failed to latch. The door was obstructed from latching by the door frame.

Based on observation and interview, the facility failed to properly store flammable liquids as evidenced by flammable liquids which were stored in an exit passageway. This deficient practice affected one of three exits in the Pathology Laboratory and could potentially result in the exit being unusable in the event of a fire.

NFPA 99, 1999 edition, 10-7.2.2 No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit.

Findings:

Main Hospital Building
During a tour of the Pathology Laboratory with with the Director of Plant Operations on 4/13/11, between 10:15 and 10:30 a.m., the flammable liquids storage cabinet was located in the path of egress within approximately four feet of the Laboratory exit door. Engineering Staff 1 stated that the cabinet had been temporarily placed in that location during construction in the Laboratory.

Surveyor: Compton, Robert S
Based on observation and interview, the facility failed to maintain all exit and directional signs, as evidenced by exit signs which were not properly illuminated or tested. It is essential that all exit signs are properly illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected three of four total floors in three of three buildings and could potentially result in a delayed evacuation in the event of an emergency.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, exit signs were observed in the following locations which were not illuminated:

1. At 2:17 p.m., the exit sign located in the Day Room near the Infusion Center was not illuminated.
2. At 2:40 p.m., the two exit signs in the Staff Lounge in Physical Therapy were not illuminated.



27893

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 facility tour with staff, the exit signs in the facility were observed.

Main Hospital:

1. On 4/13/11 at 10:30 p.m., the Pathology Laboratory was observed to have exit signs equipped with battery back-up. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that the exit signs are not tested monthly for thirty seconds. Engineering Staff 1 indicated that the exit signs are not tested annually for ninety minutes. Engineering Staff 1 indicated that he was unaware of those requirements. There were approximately three exit signs in the Pathology Laboratory.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:17 p.m., the facility was observed to have exit signs equipped with battery back-up. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that the exit signs are not tested monthly for thirty seconds. Engineering Staff 1 indicated that the exit signs are not tested annually for ninety minutes. Engineering Staff 1 indicated that he was unaware of those requirements. There were approximately eighteen exit signs in the Ambulatory Surgery Center.

Based on observation, the facility failed to maintain their fire alarm system components. This was evidenced by two fire alarm strobes and two fire alarm chimes that failed to function. This affected two of four total floors in two of three buildings and could result in a delayed notification of a fire.

Findings:

During a facility tour with staff, the fire alarm strobes and chimes were observed.

Main Hospital:

1. On 4/12/11 at 1:11 p.m., the strobe on the fire alarm chime/strobe device near the Diablo Nurse Station failed to flash when the fire alarm system was activated.

2. On 4/12/11 at 1:20 p.m., the strobe on the fire alarm chime/strobe device in the Penthouse Riser Room failed to flash when the fire alarm system was activated. The chime/strobe device was located near the back of the room near the automatic fire sprinkler test valves.

South Building:

1. On 4/12/11 at 2:08 p.m., the chime on the fire alarm chime/strobe device near the Infusion Nurse Station failed to emit an audible sound when the fire alarm system was activated. The chime/strobe device was located in the corridor near a soiled utility room in that area.

2. On 4/12/11 at 2:20 p.m., the chime on the fire alarm chime/strobe device near room 3 failed to emit an audible sound when the fire alarm system was activated.

Based on record review, observation, and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to maintain a hydraulic nameplate on an automatic fire sprinkler riser and one sprinkler that was missing an escutcheon fitting. This affected two of four total floors in one of three buildings and could result in a delay to address a malfunctioning fire sprinkler system or a delay to extinguish a fire due absent sprinkler fittings.

NFPA 13, 1999 edition
10-5 Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. the sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

NFPA 25, 1998 edition
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 record review and a facility tour with staff, the facility's automatic fire sprinkler system was observed.

Main Hospital:

1. On 4/11/11 at 10:26 a.m., the facility's five year sprinkler system certification report was reviewed. The report was dated 10/26/10 and indicated that five of five automatic sprinkler system risers were missing hydraulic nameplates. The five automatic fire sprinkler system risers were observed. Four of five risers were equipped with hydraulic nameplates. The riser located near the Loading Dock was not equipped with a hydraulic nameplate. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that the facility was in the process of obtaining the hydraulic nameplates for all their risers. Engineering Staff 1 indicated that the riser near the Loading Dock was the last riser that needed a hydraulic nameplate created.

2. On 4/12/11 at 11:04 a.m., the sprinkler located in the storage closet in the Purchasing Office was missing an escutcheon fitting. An unsealed penetration in the ceiling was observed surrounding the sprinkler pipe.

Surveyor: Compton, Robert S
Based on observation, the facility failed to protect its smoking areas, in accordance with 2000 NFPA 101 19.7.4, as evidenced by failure to provide safety-type ash trays and proper containers to dispose of cigarette butts where smoking is allowed. This deficient practice affected one of one smoking area outside of the facility and could potentially result in the ignition of fire.

Findings:

Main Hospital Building

During a tour of the facility with the S1 and the S3 on 4/11/11, the designated smoking area located outside of the Hospital Cafeteria did not have a safety-type ash tray or a container which ash trays could be emptied. The ash tray that was in the smoking area was an open-top ash tray that was built into the top of a trash can

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in non-sleeping staff areas. This deficient practice affected all staff and residents on one of two floors at the Main Hospital Building and could potentially result in the ignition of fire.

Findings:

Main Hospital Building
1. At 9:51 a.m., there was a portable electric heater in the Emergency Department Shift Supervisor's Office
2. At 9:53 a.m., there was a portable electric heater in the Admitting Manager's Office.
3. At 10:16 a.m., there was a portable electric heater in the X-Ray Room.
4. At 10:28 a.m., there was a portable electric heater in the Administration Office.
5. At 10:33 a.m., there was a portable electric heater in the Pathology Director's Office which was being used to dry pathology slides in a cabinet. The heater was approximately three inches from the slides. Maintenance Staff removed the heater at that time.
6. 10:41 a.m., there was a portable electric heater in the Pathology Office.
7. At 3:05 p.m., there were two portable electric heaters in the Nuclear Medicine Control Room.
8. At 4:08 p.m., there was a portable electric heater in the Doctors' Sleep Room.
9. At 4:30 p.m., there was a portable electric heater in the Pharmacy Director's Office.

These heaters had labels stating "3 feet clearance from combustibles required".

The above heaters did not have a facility testing or acceptance tag indicating that the heaters were approved for use in the facility.

When Engineering Staff 2 was asked if the above heaters were approved or tested by the facility, Staff stated that they were not.


27893

Findings:

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

Main Hospital:

1. On 4/12/11 at 10:58 a.m., a portable space heater was observed in the Clinical Nutrition Manager's Office. The space heater was not running but was plugged to a surge protected multi-outlet extension cord. The space heater was located below the desk in that office within one feet of combustible items and furniture. The room was unoccupied at the time of observation.

Surveyor: Compton, Robert
Based on observation and interview, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items that were stored in the path of egress. This deficient practice had the potential to affect all staff and patients in the Endoscopy Department on the first floor of the Main Hospital Building and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

Main Hospital
First Floor

During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, at 11:00 a.m., egress was impeded at the exit near the Soiled Linen Room in Endoscopy. This exit had a food cart and two wheelchairs stored near the exit doors. During fire alarm testing at 1:47 p.m., this surveyor observed the food tray and wheelchairs stored in the same locations. Engineering Staff 2 confirmed the location of the stored items and stated that they were in the same location.

Based on observation and interview, the facility failed to protect its piped medical compressed gas storage area, in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored secured together instead of individually and cylinders that were not secured against accidental damage. This deficient practice affected three of three compressed gas storage areas located outside of the facility and could potentially result in damage to the cylinders or the piped gas system if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Findings:

South Building

During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, the Oxygen Storage area located on the west end of the south building had a gas manifold with approximately 16 cylinders attached to the manifold. There were two groups of seven cylinders which were chained together with a single chain for a total of 14 H size cylinders. Engineering Staff 2 stated that the manifold piped gas system was no longer being used and that the piped gas was now supplied from the bulk tank at the Main Hospital Building.


27893

NFPA 99, 1999 edition
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 storage locations were observed.

Main Hospital:

1. On 4/11/11 at 2:31 p.m., the bulk oxygen storage location located near the Loading Dock was observed. Two oxygen E cylinders located at the location were free standing and unsecured. A group of two oxygen E cylinders and a group of five oxygen E cylinders had a single chain loosely draped across the neck of the cylinders. There was no other rack or fastening that would prevent those cylinders from being dislodged and damaged.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:11 p.m., the medical gas storage and manifold area located near the north side of the building was observed. A group of sixteen medical gas H tanks and a group of thirty-one medical gas H tanks had a chain loosely draped across the upper half of the tanks. The H tanks had a second chain loosely draped across the very bottom of the tanks such that the chain touched the floor. There was no other racks or fastenings that would prevent those H tanks from being dislodged and damaged.

Based on record review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to adopt and have a documented policy and procedure for monitoring the relative humidity levels at their anesthetizing location and the facility's failure to maintain the relative humidity level at thirty-five percent or above. This affected ten of ten anesthetizing locations in two of three buildings and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

1. From 4/11/11 to 4/13/11, the relative humidity logs for the facility's anesthetizing locations were observed. Six of six anesthetizing locations had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.
Operating Room 1 had recorded a relative humidity level below thirty-five percent on forty-three days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on twenty-six days during the past twelve months.

Operating Room 3 had recorded a relative humidity level below thirty-five percent on twenty days during the past twelve months.

Operating Room 4 had recorded a relative humidity level below thirty-five percent on thirty-three days during the past twelve months.

Labor and Delivery Room 1 had recorded a relative humidity level below thirty-five percent on seventy-four days during the past twelve months.

Labor and Delivery Room 2 had recorded a relative humidity level below thirty-five percent on fifty days during the past twelve months.

Review of the facility's policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing locations indicated that the humidity would be maintained between twenty and sixty percent. Engineering Staff 1 was interviewed on 4/11/11 at approximately 11:30 a.m. Engineering Staff 1 indicated that he was unaware that relative humidity in anesthetizing locations needed to be maintained at thirty-five percent or above.

Ambulator Surgery Center:

1. On 4/11/11 at 11:30 a.m., the relative humidity logs for the facility's anesthetizing locations were observed. Four of four anesthetizing locations had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.

Operating Room 1 had recorded a relative humidity level below thirty-five percent on thirty-five days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on thirty days during the past twelve months.

Operating Room 3 had recorded a relative humidity level below thirty-five percent on thirty-one days during the past twelve months.

Operating Room 4 had recorded a relative humidity level below thirty-five percent on thirty-three days during the past twelve months.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords, extension cords plugged into other extension cords, and faceplates that were missing. This deficient practice affected all staff and residents on three of four total floors in two of three buildings and could potentially result in the ignition of fire.

NEC 1999 Edition, 370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, electrical wiring and equipment were observed in the following locations:

1. At 2:25 p.m., there was a power strip suspended above the floor in the Admission Liaison Nurses Office.
2. At 2:35 p.m., the Medical Records Office had toaster and a microwave oven plugged into a power strip.
3. At 2:55 p.m., there was a fire extinguisher that was attached to the electrical panel in the Electrical Room.
4. At 3:36 p.m., there was a power strip suspended above the floor in the Physical Therapy-Hand Therapy Area.
5. At 3:47 p.m., there was an extension cord traveling along the north wall of physical Therapy.

During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, electrical wiring and equipment were observed in the following locations:

Main Hospital Building
First Floor
6. At 10:00 a.m., there were a coffee pot and refrigerator plugged into a power strip in the Information Systems Office.
7. At 10:04 a.m., there was a 15 foot extension cord being used on a permanent basis in the Technology Room near Radiation Transcription.
8. At 10:10 a.m., there was a plate cover missing on an electrical outlet to the left inside the exit door from the Gurney Storage Room
9. At 10:55 a.m., the Gastro-intestinal Lab Breakroom had a microwave oven and a toaster plugged into a power strip
10. At 3:47 p.m., there were a toaster and coffee pot plugged into a power strip in the Birth Center Staff Breakroom.
11. At 4:03 p.m., there was an electrical cord traveling along the wall under a desk in the office near Patient Room 128 in the Birth Center. This cord had papers which were stored under the desk lying on top of the cord.




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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.

Main Hospital:

1. On 4/11/11 at 4:22 p.m., computer equipment at the 2nd floor Sub-Station was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

2. On 4/12/11 at 10:06 a.m., an electrical wall receptacle in the Physician's Dictation Room located near the Diablo Nurse Station was missing a faceplate. Electrical wiring was exposed.

3. On 4/12/11 at 10:14 a.m., a microwave oven in the Diablo Staff Lounge was plugged into a surge protected multi-outlet extension cord. That surge protected multi-outlet extension cord and a refrigerator were both plugged into another surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

4. On 4/12/11 at 10:21 a.m., computer equipment in the Diablo Case Management Office was plugged into a surge protected multi-outlet extension cord that was plugged into a non-surge protected extension cord which was plugged into an electrical wall receptacle.

5. On 4/12/11 at 10:50 a.m., stereo equipment in the Purchasing Store Room was plugged into an orange non-surge protected extension cord. The orange extension cord, a microwave oven, and a miniature refrigerator were all plugged into the same surge protected multi-outlet extension cord that was plugged into a second orange non-surge protected extension cord. The second orange extension cord and a full size refrigerator were both plugged into a third orange non-surge protected extension cord that was plugged into a surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

6. On 4/12/11 at 11:09 a.m., the Diet Office located in the Dietary Storage Room was observed. Computer equipment was plugged into an orange non-surge protected extension cord and a surge protected multi-outlet extension cord. Both extension cords were plugged into the same surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

Findings:

Main Hospital Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, Alcohol Based Hand Rub (ABHR) dispensers were observed near potential ignition sources in the following locations:

First Floor
1. At 2:47 p.m., the Cath-lab Control Room had an ABHR dispenser located above a light switch.
2. At 3:26 p.m., Operating Room 1 had an ABHR dispenser located above a light switch.
3. At 3:27 p.m., the Quiet Room in Recovery had an ABHR dispenser above a light switch.





27893

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

Findings:

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

Main Hospital:

1. On 4/12/11 at 10:08 a.m., an alcohol based hand rub dispenser in patient room 252 was mounted on the wall approximately three inches to the right of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

2. On 4/12/11 at 11:02 a.m., an alcohol based hand rub dispenser near the west corridor door to the Purchasing Store Room was mounted on the wall approximately five inches above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

3. On 4/12/11 at 4:10 p.m., an alcohol based hand rub dispenser in the corridor near patient room 112 was mounted on the wall approximately thirty-eight inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:27 p.m., an alcohol based hand rub dispenser in the Pre-Op Testing Room was mounted on the wall approximately twenty-seven inches above an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

Based on observation and interview, the facility failed to maintain the walls of the building in a condition that would resist the passage of smoke and fire as evidenced by unsealed penetrations observed in the fire-rated sheeting. This deficient practice affected staff and residents on three of four total floors in two of three buildings and could potentially result in the spread of smoke and/or fire from one smoke compartment to another.

Findings:

Main Hospital Building
First Floor
During a tour of the facility with the Director of Infection Control on 4/12/11, a penetration was observed in the gypsum wallboard which could potentially result in the spread of smoke and/or fire.

1. At 10:10 p.m., the First Floor Gurney Storage Room had a one-by-two inch unsealed penetration in the wall located to the left of the door on the southwest wall approximately 36 inches from the floor. Staff confirmed the penetration.




27893

Findings:

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

Main Hospital:

1. On 4/12/11 at 9:52 a.m., there were four approximately half inch diameter unsealed penetrations in the wall of patient room 234. The penetrations were located in the wall below the television in that room.

2. On 4/12/11 at 9:56 a.m., there was one approximately nineteen inch by five inch unsealed penetration in the wall of the storage room in the Nurse Documentation Room. The Nurse Documentation Room was located on the 2nd floor. Air flow could be felt coming out of the wall penetration. Engineer Staff 1 was interviewed at that time. Engineering Staff 1 indicated a sink was recently removed from that wall. Engineering Staff 1 indicated he was unaware that the wall penetration had not been sealed.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:52 p.m., there was one approximately ten inch by two inch unsealed penetration in the wall of the equipment storage room. The penetration was located in the north wall.

Based on observation, the facility failed to maintain corridor doors free from obstructions to closing as evidenced by corridor doors that failed to close and latch when tested. It is critical that corridor doors can be closed and latched to prevent the spread of smoke and/or fire into other areas of the facility. This deficient practice affected staff and patients on four of four total floors in three of three buildings.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, the following corridor doors did not positive latch when tested by releasing the door from an open position:

1. At 2:05 p.m., the door to the Housekeeping Closet in the Infusion Center did not positive latch when tested.
2. At 2:22 p.m., the door to the Tub Room in the Infusion Center did not positive latch when tested.
3. At 2:30 p.m., the door the the Conference Room near the Nurses' Station did not positive latch when tested.
4. At 3:00 p.m., the Large Conference Room door did not positive latch when tested.
5. At 3:05 p.m., the door to the Storage Room near Accounting Service did not positive latch when tested.
6. At 3:18 p.m., the door to the Finance Room near the Lobby identified on the facility drawings as the "Assistant Controller's Office" did not positive latch when tested.
7. At 3:20 p.m., the door to Administration near the area identified on the facility's drawings as the "Case Manager's Office" did not positive latch when tested.
8. At 3:42 p.m., the door to the Assistant Director's Office in Physical Therapy did not positive latch when tested.
9. At 3:43 p.m., the door to Speech Therapy in Physical Therapy did not positive latch when tested.

Main Hospital Building
First Floor
10. At 9:58 a.m., the corridor door to Admitting did not positive latch when tested.
11. At 10:15 a.m., the corridor door to Radiology 1156 did not positive latch when tested.
12. At 10:35 a.m., the one-hour fire-rated corridor door to the Pathology Laboratory did not positive latch when tested.
13. At 10:55 a.m., the corridor door to Gastro-intestinal Laboratory 1384 did not positive latch when tested.
14. At 11:00 a.m., the one-hour fire-rated corridor doors to Endoscopy did not positive latch when tested.
15. At 2:57 p.m., the corridor doors to the Dictation Room did not positive latch when tested
16. At 3:47 p.m., the doors to the Formula Room did not positive latch when tested.
17. At 3:55 p.m., the doors to the Breast Feeding Room had the striker plate taped, preventing the door from positive latching.
18. At 4:00 p.m., the door to the Treatment Room in the Birthing Center did not positive latch when tested.


27893

Findings:

Main Hospital:

1. On 4/11/11 at 4:19 p.m., the corridor door to patient room 219 failed to latch. The door was obstructed from latching by the door frame.

2. On 4/12/11 at 10:44 a.m., the corridor door to the Housekeeping Closet near the Engineering Department 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 4/12/11 at 4:08 p.m., the corridor door to the Doctor's Dictation Room near patient room 112 failed to latch. The door was obstructed from latching due to misalignment of the latching barrel and striker plate.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:23 p.m., the corridor doors to the Waiting Room were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs failed to latch. The door was obstructed from latching due to air pressure difference.

2. On 4/11/11 at 3:43 p.m., the corridor door to the Laser Room was obstructed from closing by a gurney placed directly in the swing path of the door. The room was unoccupied at the time of observation.

Based on observation, the facility failed to maintain a fire-rated shaft wall. This was evidenced by an unsealed penetration in a shaft wall. This affected two of four total floors in one of three buildings and could result in the spread of smoke or fire from one floor to another.

Findings:

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

Main Hospital:

1. On 4/13/11 at 9:09 a.m., there was on approximately two foot by two foot unsealed penetration in the shaft wall across from patient room 260. The shaft wall was a 2-hour fire-rated wall. The penetration was observed in the corridor wall located above the suspended ceiling.

Based on observation and staff interview, the facility failed to maintain the fire-rated construction of their fire barrier walls in accordance with 2000 NFPA 101. This was evidenced by unsealed penetrations observed in the fire-rated walls above the drop down ceiling. This deficient practice affected three of four total floors in three of three buildings and could potentially result in smoke and/or fire spreading from one smoke compartment to another.

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.
b It shall be protected by an approved device that is designed for the specific purpose.
3. Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

South Building
During an inspection of the facility's smoke barrier walls with the Senior Plant Engineer on 4/13/11, at 9:20 a.m., an unsealed penetration was observed in a one-hour fire-rated wall. This penetration was located above the drop down ceiling and was caused by an electrical conduit traveling through the wall between the Staff Lounge and the corridor leading to the Engineering Shop. The size of the penetration through the corridor side of the fire wall was approximately one-half inch wide around the outside of the approximately two inch 90 degree electrical conduit fitting. On the other side of the barrier wall in the Lounge area, the penetration was approximately one quarter inch larger in size than the same electrical conduit.




27893


Findings:

During a facility tour with staff, the facility's smoke barrier walls were observed.

Main Hospital:

1. On 4/13/11 at 9:32 a.m., there was an approximately quarter inch wide unsealed penetration in a smoke barrier wall surrounding an approximately one and one half inch diameter metal conduit. The penetration was located in the smoke barrier wall located near the Family Birthing Center elevator. Fire-rated caulking appeared to have come loose from that area and was surrounding a portion of the metal conduit. The fire-rated caulking was not sealing the penetration in the smoke barrier wall.

Ambulatory Surgery Center:

1. On 4/13/11 at 8:31 a.m., there was one approximately two and one half inch diameter unsealed penetration in the smoke barrier wall near the Waiting Room. The smoke barrier wall separated the Lobby from the Waiting Room.

Based on observation, the facility failed to maintain cross-corridor doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire as evidenced by cross-corridor doors that failed to close and/or latch. This deficient practice affected all staff and residents in two of four total floors in two of three buildings and could potentially result in the spread of smoke and/or fire.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, cross-corridor doors were observed in the following locations:

1. At 2:10 p.m., the left leaf facing north of the cross-corridor doors located near Patient Room 41 did not positive latch when tested by releasing the doors from an open position.

Main Hospital Building
First Floor
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, cross-corridor doors were observed in the following locations:

1. At 9:45 a.m., the east leaf facing south of the one-hour fire door separating the Lobby from the Quiet Room did not positive latch when tested by releasing it from an open position.
2. At 10:12 a.m., the right leaf facing south of the cross corridor door near Nuclear Medicine Room 1133 did not positive latch when tested by releasing the door from an open position.
3. At 10:22 a.m., the cross-corridor doors by Diagnostic Imaging Room 1204 did not positive latch when tested by releasing them from an open position.
4. During fire alarm testing, the Post Anesthesia Care Unit cross-corridor door number 1182 did not positive latch upon activation of the fire alarm system. The gap between the doors and the frame was approximately two inches. The bottom of the door moulding was bent. Engineering Staff 1 stated that the doors had been damaged earlier in the day.




27893

Findings:

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

South Building:

1. On 4/12/11 at 2:13 p.m., the smoke barrier doors near the Pharmacy Storage Room were equipped with self-closing devices and magnetic hold-open devices. The fire alarm was activated and the doors released from their magnetic hold-open devices. One of the two door leafs of the smoke barrier doors failed to close and latch. The door was obstructed from closing and latching due to circulating air pressure.

Based on observation, the facility failed to maintain their hazardous areas. This was evidenced by unsealed penetrations in a hazardous area wall and one door to a hazardous area that was obstructed from latching. This affected two of four total floors in two of three buildings and could result in the spread of smoke or fire to other locations in the facility.

Findings:

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

Main Hospital:

1. On 4/12/11 at 10:47 a.m., there were four unsealed wall punctures in the north-east wall of the Purchasing Store Room. One puncture was approximately two inches by one half inch in size. The three other punctures were approximately one quarter inch in diameter. The Purchasing Store Room was greater that fifty square feet in area and housed combustible items.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:16 p.m., the corridor doors to the Boiler Room were equipped with self-closing devices. The doors were held open to the fullest extent and allowed to close. One of the two door leafs failed to latch. The door was obstructed from latching by the door frame.

Based on observation and interview, the facility failed to properly store flammable liquids as evidenced by flammable liquids which were stored in an exit passageway. This deficient practice affected one of three exits in the Pathology Laboratory and could potentially result in the exit being unusable in the event of a fire.

NFPA 99, 1999 edition, 10-7.2.2 No flammable or combustible liquid shall be stored or transferred from one vessel to another in any exit corridor or passageway leading to an exit.

Findings:

Main Hospital Building
During a tour of the Pathology Laboratory with with the Director of Plant Operations on 4/13/11, between 10:15 and 10:30 a.m., the flammable liquids storage cabinet was located in the path of egress within approximately four feet of the Laboratory exit door. Engineering Staff 1 stated that the cabinet had been temporarily placed in that location during construction in the Laboratory.

Surveyor: Compton, Robert S
Based on observation and interview, the facility failed to maintain all exit and directional signs, as evidenced by exit signs which were not properly illuminated or tested. It is essential that all exit signs are properly illuminated in order to identify the location of exits in an emergency situation. This deficient practice affected three of four total floors in three of three buildings and could potentially result in a delayed evacuation in the event of an emergency.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, exit signs were observed in the following locations which were not illuminated:

1. At 2:17 p.m., the exit sign located in the Day Room near the Infusion Center was not illuminated.
2. At 2:40 p.m., the two exit signs in the Staff Lounge in Physical Therapy were not illuminated.



27893

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 facility tour with staff, the exit signs in the facility were observed.

Main Hospital:

1. On 4/13/11 at 10:30 p.m., the Pathology Laboratory was observed to have exit signs equipped with battery back-up. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that the exit signs are not tested monthly for thirty seconds. Engineering Staff 1 indicated that the exit signs are not tested annually for ninety minutes. Engineering Staff 1 indicated that he was unaware of those requirements. There were approximately three exit signs in the Pathology Laboratory.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:17 p.m., the facility was observed to have exit signs equipped with battery back-up. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that the exit signs are not tested monthly for thirty seconds. Engineering Staff 1 indicated that the exit signs are not tested annually for ninety minutes. Engineering Staff 1 indicated that he was unaware of those requirements. There were approximately eighteen exit signs in the Ambulatory Surgery Center.

Based on observation, the facility failed to maintain their fire alarm system components. This was evidenced by two fire alarm strobes and two fire alarm chimes that failed to function. This affected two of four total floors in two of three buildings and could result in a delayed notification of a fire.

Findings:

During a facility tour with staff, the fire alarm strobes and chimes were observed.

Main Hospital:

1. On 4/12/11 at 1:11 p.m., the strobe on the fire alarm chime/strobe device near the Diablo Nurse Station failed to flash when the fire alarm system was activated.

2. On 4/12/11 at 1:20 p.m., the strobe on the fire alarm chime/strobe device in the Penthouse Riser Room failed to flash when the fire alarm system was activated. The chime/strobe device was located near the back of the room near the automatic fire sprinkler test valves.

South Building:

1. On 4/12/11 at 2:08 p.m., the chime on the fire alarm chime/strobe device near the Infusion Nurse Station failed to emit an audible sound when the fire alarm system was activated. The chime/strobe device was located in the corridor near a soiled utility room in that area.

2. On 4/12/11 at 2:20 p.m., the chime on the fire alarm chime/strobe device near room 3 failed to emit an audible sound when the fire alarm system was activated.

Based on record review, observation, and interview, the facility failed to maintain their automatic fire sprinkler system. This was evidenced by the facility's failure to maintain a hydraulic nameplate on an automatic fire sprinkler riser and one sprinkler that was missing an escutcheon fitting. This affected two of four total floors in one of three buildings and could result in a delay to address a malfunctioning fire sprinkler system or a delay to extinguish a fire due absent sprinkler fittings.

NFPA 13, 1999 edition
10-5 Hydraulic Design Information Sign. The installing contractor shall identify a hydraulically designed sprinkler system with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other approved means. Such signs shall be placed at the alarm valve, dry pipe valve, preaction valve, or deluge valve supplying the corresponding hydraulically designed area. the sign shall include the following information:
(1) Location of the design area or areas
(2) Discharge densities over the design area or areas
(3) Required flow and residual pressure demand at the base of the riser
(4) Occupancy classification or commodity classification and maximum permitted storage height and configuration
(5) Hose stream demand included in addition to the sprinkler demand

NFPA 25, 1998 edition
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 record review and a facility tour with staff, the facility's automatic fire sprinkler system was observed.

Main Hospital:

1. On 4/11/11 at 10:26 a.m., the facility's five year sprinkler system certification report was reviewed. The report was dated 10/26/10 and indicated that five of five automatic sprinkler system risers were missing hydraulic nameplates. The five automatic fire sprinkler system risers were observed. Four of five risers were equipped with hydraulic nameplates. The riser located near the Loading Dock was not equipped with a hydraulic nameplate. Engineering Staff 1 was interviewed at that time. Engineering Staff 1 indicated that the facility was in the process of obtaining the hydraulic nameplates for all their risers. Engineering Staff 1 indicated that the riser near the Loading Dock was the last riser that needed a hydraulic nameplate created.

2. On 4/12/11 at 11:04 a.m., the sprinkler located in the storage closet in the Purchasing Office was missing an escutcheon fitting. An unsealed penetration in the ceiling was observed surrounding the sprinkler pipe.

Surveyor: Compton, Robert S
Based on observation, the facility failed to protect its smoking areas, in accordance with 2000 NFPA 101 19.7.4, as evidenced by failure to provide safety-type ash trays and proper containers to dispose of cigarette butts where smoking is allowed. This deficient practice affected one of one smoking area outside of the facility and could potentially result in the ignition of fire.

Findings:

Main Hospital Building

During a tour of the facility with the S1 and the S3 on 4/11/11, the designated smoking area located outside of the Hospital Cafeteria did not have a safety-type ash tray or a container which ash trays could be emptied. The ash tray that was in the smoking area was an open-top ash tray that was built into the top of a trash can

Based on observation and interview, the facility failed to comply with the regulations regarding portable space heating devices as evidenced by unapproved portable heaters in non-sleeping staff areas. This deficient practice affected all staff and residents on one of two floors at the Main Hospital Building and could potentially result in the ignition of fire.

Findings:

Main Hospital Building
1. At 9:51 a.m., there was a portable electric heater in the Emergency Department Shift Supervisor's Office
2. At 9:53 a.m., there was a portable electric heater in the Admitting Manager's Office.
3. At 10:16 a.m., there was a portable electric heater in the X-Ray Room.
4. At 10:28 a.m., there was a portable electric heater in the Administration Office.
5. At 10:33 a.m., there was a portable electric heater in the Pathology Director's Office which was being used to dry pathology slides in a cabinet. The heater was approximately three inches from the slides. Maintenance Staff removed the heater at that time.
6. 10:41 a.m., there was a portable electric heater in the Pathology Office.
7. At 3:05 p.m., there were two portable electric heaters in the Nuclear Medicine Control Room.
8. At 4:08 p.m., there was a portable electric heater in the Doctors' Sleep Room.
9. At 4:30 p.m., there was a portable electric heater in the Pharmacy Director's Office.

These heaters had labels stating "3 feet clearance from combustibles required".

The above heaters did not have a facility testing or acceptance tag indicating that the heaters were approved for use in the facility.

When Engineering Staff 2 was asked if the above heaters were approved or tested by the facility, Staff stated that they were not.


27893

Findings:

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

Main Hospital:

1. On 4/12/11 at 10:58 a.m., a portable space heater was observed in the Clinical Nutrition Manager's Office. The space heater was not running but was plugged to a surge protected multi-outlet extension cord. The space heater was located below the desk in that office within one feet of combustible items and furniture. The room was unoccupied at the time of observation.

Surveyor: Compton, Robert
Based on observation and interview, the facility failed to ensure that all means of egress are continuously maintained free of obstructions to full, instant use in the case of fire or other emergency in accordance with 2000 NFPA 101. This was evidenced by items that were stored in the path of egress. This deficient practice had the potential to affect all staff and patients in the Endoscopy Department on the first floor of the Main Hospital Building and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

Main Hospital
First Floor

During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, at 11:00 a.m., egress was impeded at the exit near the Soiled Linen Room in Endoscopy. This exit had a food cart and two wheelchairs stored near the exit doors. During fire alarm testing at 1:47 p.m., this surveyor observed the food tray and wheelchairs stored in the same locations. Engineering Staff 2 confirmed the location of the stored items and stated that they were in the same location.

Based on observation and interview, the facility failed to protect its piped medical compressed gas storage area, in accordance with 1999 NFPA 99. This was evidenced by cylinders which were stored secured together instead of individually and cylinders that were not secured against accidental damage. This deficient practice affected three of three compressed gas storage areas located outside of the facility and could potentially result in damage to the cylinders or the piped gas system if they were to fall.

4-3.1.1.1 "Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over."

Findings:

South Building

During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, the Oxygen Storage area located on the west end of the south building had a gas manifold with approximately 16 cylinders attached to the manifold. There were two groups of seven cylinders which were chained together with a single chain for a total of 14 H size cylinders. Engineering Staff 2 stated that the manifold piped gas system was no longer being used and that the piped gas was now supplied from the bulk tank at the Main Hospital Building.


27893

NFPA 99, 1999 edition
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 storage locations were observed.

Main Hospital:

1. On 4/11/11 at 2:31 p.m., the bulk oxygen storage location located near the Loading Dock was observed. Two oxygen E cylinders located at the location were free standing and unsecured. A group of two oxygen E cylinders and a group of five oxygen E cylinders had a single chain loosely draped across the neck of the cylinders. There was no other rack or fastening that would prevent those cylinders from being dislodged and damaged.

Ambulatory Surgery Center:

1. On 4/11/11 at 3:11 p.m., the medical gas storage and manifold area located near the north side of the building was observed. A group of sixteen medical gas H tanks and a group of thirty-one medical gas H tanks had a chain loosely draped across the upper half of the tanks. The H tanks had a second chain loosely draped across the very bottom of the tanks such that the chain touched the floor. There was no other racks or fastenings that would prevent those H tanks from being dislodged and damaged.

Based on record review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations. This was evidenced by the facility's failure to adopt and have a documented policy and procedure for monitoring the relative humidity levels at their anesthetizing location and the facility's failure to maintain the relative humidity level at thirty-five percent or above. This affected ten of ten anesthetizing locations in two of three buildings and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During record review, the facility's relative humidity logs for their anesthetizing locations were observed.

Main Hospital:

1. From 4/11/11 to 4/13/11, the relative humidity logs for the facility's anesthetizing locations were observed. Six of six anesthetizing locations had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.
Operating Room 1 had recorded a relative humidity level below thirty-five percent on forty-three days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on twenty-six days during the past twelve months.

Operating Room 3 had recorded a relative humidity level below thirty-five percent on twenty days during the past twelve months.

Operating Room 4 had recorded a relative humidity level below thirty-five percent on thirty-three days during the past twelve months.

Labor and Delivery Room 1 had recorded a relative humidity level below thirty-five percent on seventy-four days during the past twelve months.

Labor and Delivery Room 2 had recorded a relative humidity level below thirty-five percent on fifty days during the past twelve months.

Review of the facility's policy and procedure for monitoring and maintaining relative humidity levels for their anesthetizing locations indicated that the humidity would be maintained between twenty and sixty percent. Engineering Staff 1 was interviewed on 4/11/11 at approximately 11:30 a.m. Engineering Staff 1 indicated that he was unaware that relative humidity in anesthetizing locations needed to be maintained at thirty-five percent or above.

Ambulator Surgery Center:

1. On 4/11/11 at 11:30 a.m., the relative humidity logs for the facility's anesthetizing locations were observed. Four of four anesthetizing locations had recorded relative humidity levels below thirty-five percent on multiple instances during the past twelve months.

Operating Room 1 had recorded a relative humidity level below thirty-five percent on thirty-five days during the past twelve months.

Operating Room 2 had recorded a relative humidity level below thirty-five percent on thirty days during the past twelve months.

Operating Room 3 had recorded a relative humidity level below thirty-five percent on thirty-one days during the past twelve months.

Operating Room 4 had recorded a relative humidity level below thirty-five percent on thirty-three days during the past twelve months.

Based on observation, the facility failed to comply with the regulations regarding electrical wiring and utilities in accordance with 1999 NFPA 70. This was evidenced by power strips which were suspended above the floor, high wattage devices which were plugged into power strips, the permanent use of extension cords, extension cords plugged into other extension cords, and faceplates that were missing. This deficient practice affected all staff and residents on three of four total floors in two of three buildings and could potentially result in the ignition of fire.

NEC 1999 Edition, 370-25 Covers and Canopies. In completed installations, each box shall have a cover, faceplate, or fixture canopy.

400.8 Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors.

400-10 Flexible cords and cables shall be connected to devices and to fittings so that tension will not be transmitted to joints or terminals.

110-12 requires that electrical equipment be installed in a neat and workman like manner.

Findings:

South Building
During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/11/11, electrical wiring and equipment were observed in the following locations:

1. At 2:25 p.m., there was a power strip suspended above the floor in the Admission Liaison Nurses Office.
2. At 2:35 p.m., the Medical Records Office had toaster and a microwave oven plugged into a power strip.
3. At 2:55 p.m., there was a fire extinguisher that was attached to the electrical panel in the Electrical Room.
4. At 3:36 p.m., there was a power strip suspended above the floor in the Physical Therapy-Hand Therapy Area.
5. At 3:47 p.m., there was an extension cord traveling along the north wall of physical Therapy.

During a tour of the facility with the Senior Plant Engineer and the Director of Infection Control on 4/12/11, electrical wiring and equipment were observed in the following locations:

Main Hospital Building
First Floor
6. At 10:00 a.m., there were a coffee pot and refrigerator plugged into a power strip in the Information Systems Office.
7. At 10:04 a.m., there was a 15 foot extension cord being used on a permanent basis in the Technology Room near Radiation Transcription.
8. At 10:10 a.m., there was a plate cover missing on an electrical outlet to the left inside the exit door from the Gurney Storage Room
9. At 10:55 a.m., the Gastro-intestinal Lab Breakroom had a microwave oven and a toaster plugged into a power strip
10. At 3:47 p.m., there were a toaster and coffee pot plugged into a power strip in the Birth Center Staff Breakroom.
11. At 4:03 p.m., there was an electrical cord traveling along the wall under a desk in the office near Patient Room 128 in the Birth Center. This cord had papers which were stored under the desk lying on top of the cord.




27893

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.

Main Hospital:

1. On 4/11/11 at 4:22 p.m., computer equipment at the 2nd floor Sub-Station was plugged into a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

2. On 4/12/11 at 10:06 a.m., an electrical wall receptacle in the Physician's Dictation Room located near the Diablo Nurse Station was missing a faceplate. Electrical wiring was exposed.

3. On 4/12/11 at 10:14 a.m., a microwave oven in the Diablo Staff Lounge was plugged into a surge protected multi-outlet extension cord. That surge protected multi-outlet extension cord and a refrigerator were both plugged into another surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

4. On 4/12/11 at 10:21 a.m., computer equipment in the Diablo Case Management Office was plugged into a surge protected multi-outlet extension cord that was plugged into a non-surge protected extension cord which was plugged into an electrical wall receptacle.

5. On 4/12/11 at 10:50 a.m., stereo equipment in the Purchasing Store Room was plugged into an orange non-surge protected extension cord. The orange extension cord, a microwave oven, and a miniature refrigerator were all plugged into the same surge protected multi-outlet extension cord that was plugged into a second orange non-surge protected extension cord. The second orange extension cord and a full size refrigerator were both plugged into a third orange non-surge protected extension cord that was plugged into a surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.

6. On 4/12/11 at 11:09 a.m., the Diet Office located in the Dietary Storage Room was observed. Computer equipment was plugged into an orange non-surge protected extension cord and a surge protected multi-outlet extension cord. Both extension cords were plugged into the same surge protected multi-outlet extension cord which was plugged into an electrical wall receptacle.