HospitalInspections.org

Based on observation, the facility failed to maintain a two hour fire barrier, as evidenced by a fire barrier door that failed to fully close and latch. This could result in the spread of fire or smoke, in the event of a fire, affecting two floors in two buildings.

Findings:

During a facility tour with staff from 10/8/12 and 10/12/12, the facility two hour barriers were observed.

Trauma Building - 10/11/12
1st Floor
At 3:57 p.m., the two hour door by the Rotunda, failed to fully close and latch after activation of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair a penetration in the ceiling, in two areas. This could result in the spread of smoke in the event of a fire. This affected 1 of 5 floors in the 5 Story Building and 1 of 10 floors in the 10 Story Building.

Findings:

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the facility walls and ceilings were observed.

5 Story Building - 10/10/12
1st Floor -
1. At 11:42 a.m., there was an approximately one inch penetration in the ceiling of the Housekeeping Closet, near the double doors, in the Pulmonary Function Unit, 1 East.



29665

10-Story Building - 10/9/12
10th Floor -
2. At 2:30 p.m., there was an approximately 1 foot by 1 foot area, in the drop ceiling of Anteroom 1012, where a ceiling tile was removed. The area was covered with plastic and blue masking tape.

Based on observation and interview, the facility failed to ensure corridor walls were constructed to resist the passage of smoke. This was evidenced by penetrations in corridor walls and ceilings. These penetrations could allow the spread of smoke or fire in the event of a fire and affected two of seven floors in the Trauma Building and one of ten floors in the 10 Story Building.

Findings:

During a facility tour with staff from 10/08/12 to 10/12/12, the corridor walls and ceilings were observed.

Trauma Building - 10/09/12
5th Floor -
1. At 10:04 a.m., there was an approximately 1 to 1 1/2 inch penetration in the corridor wall above the Women's Locker Room, at door 5032A. The penetration was above the drop ceiling.

1st Floor -
2. At 2:30 p.m., there was an approximately 3/4 inch electrical conduit, around a bundle of blue and white wires, in the corridor wall above the drop ceiling, at door 1166B.

During an interview, Staff 5 reported that the wires were for the badge reader.


29665

10-Story Building - 10/9/12
8th Floor -
3. At 4:01 p.m., there was an approximately 1/2 inch penetration in the corridor wall, across from the door going into Stairwell C.

Based on observation and interview, the facility failed to maintain their corridor doors as evidenced by corridor doors that failed to latch, by self-closing doors that failed to latch when released, and by doors that were obstructed from closing. This could result in the spread of smoke and fire in the event of a fire. This affected 4 of 5 floors in the 5 Story Building, 3 of 7 floors in the Trauma Building, and 3 of 10 floors in the 10 Story Building.

Findings:

During the facility tour with Staff 4, 6, and 7 between 10/8/12 and 10/12/12, the facility doors were observed.

5 Story Building - 10/9/12
5th Floor -
1. At 2:05 p.m., the corridor door to Room 528 failed to latch when closed.

2. At 2:11 p.m., the corridor door to Room 504 was obstructed from closing, by a work station on wheels.

3. At 2:26 p.m., the self-closing door to the Stock Room failed to latch in two attempts. The room was located near Room 553. The door was held open to the fullest extent and released.

4. At 2:30 p.m., the self-closing door to the Mechanical Room failed to latch. The door was held open to the fullest extent and released. Two attempts were made to close and latch the door.

5 Story Building
3rd Floor -
5. At 3:48 p.m., the self-closing door to Patient Shower A failed to latch.
The shower room is located near Room 308.
6. At 3:59 p.m., the self-closing door 5S3/05 was obstructed by a wheelchair.

5 Story Building - 10/10/12
2nd Floor - Central
7. At 8:01 a.m., the self-closing door to the Utility Room 2 failed to latch.

8. At 8:08 a.m., the self-closing door to the Med Room near Nurses Station 2 failed to latch.

9. At 8:12 a.m., the self-closing door to Housekeeping, near Room 245, failed to latch.

10. At 8:35 a.m., the self-closing door to the Surgery Med Room failed to latch. The door was held open to the fullest extent and released two times.

11. At 8:40 a.m., the self-closing door to the Men's Locker Room 19 failed to latch.

12. At 9:06 a.m., the self-closing door to the Storage Room failed to latch. The room was located across from Room 220. The latch was covered with tape.

During an interview, Staff reported that the door handle was broken and that's why it was taped. "It's so we can get in and out of the door, it's been reported just hasn't been fixed yet."

5 Story Building
1st Floor -
13. At 9:45 a.m., the self-closing door to the P.A. Office 2 failed to latch.

14. At 10 a.m., the self-closing door to the Endoscopy Breakroom failed to latch. The latch was covered with tape.

15. At 10:06 a.m., the self-closing door to the Soiled Utility Room failed to latch. The room was located in the Endoscopy Unit.

16. At 11:21 a.m., the self-closing door to the Mechanical Room (south) failed to latch. The door bounced off the latch and exposed an approximately 1 inch gap. The door was held open to the fullest extent and released two times. Staff confirmed the door did not latch.

Med Surge - 5 Story Building
1st Floor
17. At 11:26 a.m., the self-closing door to Exam 1 was held open with a gurney. The room was located in the Neurodiagnostic Unit.

18. At 11:29 a.m., the self-closing door failed to latch, for H1525, in Pulmonary Function Lab 1.

19. At 11:32 a.m., the self-closing door was equipped with a magnetic hold open device, in Room 2 located in the Endoscopy Pre-OP Unit. The self-closing door was not engaged to the magnet. The door was held open with a hospital bed. The self-closing door failed to latch when released.

20. At 1:29 p.m., the interior self-closing door failed to latch, in the Chief Operating office. The latching device was loose.

Trauma Unit - Critical Care Building
2nd Floor
21. At 1:48 p.m., the door to the Surgical Administration office, 2147A, was held open with a small wooden table, holding a live plant. The table obstructed the door from closing.


28602

Trauma Building - 10/10/12
4th Floor -
22. At 10:35 a.m., the self-closing corridor door to room 4453A closed but failed to latch. The door was tested three times.

3rd Floor-
23. At 11:45 a.m., the self-closing corridor door to room 3466A failed to fully close and latch. The door was tested four times.

1st Floor -
24. At 4:28 p.m., the self-closing corridor door the restroom 1222A, failed to fully close and latch. The door was tested three times.


29665

10-Story Building - 10/10/12
5th Floor -
25. At 9:16 a.m., the door to the patient shower, across from Stairwell B, was equipped with a self-closing device. The door closed but failed to latch.

4th Floor -
26. At 9:54 a.m., the door to the housekeeping closet, next to Room H464 in the NICU Department, was equipped with a self-closing device. The door closed but failed to latch.

2nd Floor -
27. At 10:51 a.m., the door labeled H2044B, at the clean utility room, was equipped with a self-closing device. The door closed but failed to latch.

Trauma Center - 10/10/12
1st Floor -
28. At 4:19 p.m., the west door into the East Track was held open by a magnetic automatic-closing device. The door was obstructed from closing by a trash can and a WOW (wireless on wheels).


29752


Five Story - 10/11/12
4th Floor -
29. At 9:46 a.m., the corridor door for Patient Room 454 failed to self close and remained partially open. The door was equipped with a self closing mechanism that failed to engage and close the door.

Based on observation, the facility failed to maintain the construction of vertical openings between floors. This was evidenced by penetrations between floors in two areas. This affected two of seven floors in the Trauma Building and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 10/08/12 to 10/12/12, vertical openings were observed throughout the hospital buildings.

Trauma Building - 10/9/12
6th Floor
1. At 9:58 a.m., there was an approximately 2 inch unsealed conduit inside a 4 inch pipe sleeve in the elevator lobby ceiling.

During an interview, Staff 4 reported that this was an electrical conduit.

5th Floor
2. At 4:07 p.m., there was an approximately 3/4 inch unsealed electrical conduit inside a 2 inch conduit in the ceiling in Stairwell 3 (Rotunda 5th Floor).

Based on observation, the facility failed to ensure that smoke barrier doors closed when the fire alarm system was activated. This was evidenced by smoke barrier corridor doors that failed to release during fire alarm testing. This could result in the spread of smoke affecting one of five floors in the Five Story building.

Finding:

During fire alarm testing with Staff 4, on 10/11/12, the automatic and self closing corridor doors were observed.

Five Story Building - 10/11/12
1st Floor East
At 11:33 a.m., the double set of smoke barrier doors, near the east end of the reception/lobby area, failed to self close when the fire alarm system was activated. The doors were located in the corridor leading to Patient Rooms 157-166. The door closing hardware was equipped with a hold-open position that kept the doors from closing after activation of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of their smoke barrier partitions. This was evidenced by penetrations in the smoke barrier walls. This affected the Radiology Clinic, 2 of 7 floors in the Trauma Building and 3 of 10 floors in the Ten Story Building. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour from 10/8/12 to 10/12/12, the smoke barrier walls were observed.

Radiology Center - 10/11/12

1. At 9:19 a.m., the smoke barrier wall between the patient treatment area and the reception area was observed. There was an approximately 1 inch penetration in the center of the wall, around data cables.


28602

Trauma Building -10/9/12
2nd Floor
2. At 1:42 p.m., there was an approximately 1/2 penetration around a white wire, penetrating the wall at Smoke Barrier Door 2108A, in the West corridor.
During an interview, facility Staff 1 and Staff 5 reported that the penetrations was created during wiring for the security system (badge reader).

1st Floor
3. At 2 p.m., there was an approximately 1/2 unsealed pipe sleeve around a red wire penetrating the smoke barrier wall at Door 1102B.
During an interview, Staff 5 reported that the penetration was created during a repair to the fire alarm wiring a couple of months ago.


31070

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the smoke barriers were observed.

10 Story Building - 10/9/12
10th Floor -
4. At 9:37 a.m., there was an unsealed 2 inch by 2 inch penetration, around a pipe, in the smoke barrier above Doors 10S10/05, in the Step Down 1 Unit.
Staff 6 confirmed there was a penetration around the pipe.

5th Floor
5. At 10:56 a.m., there was an unsealed 1 1/2 inch penetration around a two inch pipe in the smoke barrier.

6. At 10:59 a.m., there was an unsealed 1 1/2 inch penetration, around a pipe, in the smoke barrier above the Case Management office.
Staff 6 confirmed there was a penetration around the pipe.

4th Floor -
7. At 11:13 a.m., there was an unsealed one inch penetration, around a pipe in the smoke barrier, above the Conference Room.
Staff 6 confirmed there was a penetration around the pipe.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by smoke barrier doors that failed to latch during fire alarm testing. This could result in the spread of fire and smoke in the event of a fire. This affected 3 of 5 floors of the 5 Story Building, 4 of 10 floors of the 10 Story Building, and 4 of 7 floors of the Trauma Building.

Findings:

During fire alarm testing with Staff 1 and 4 on 10/11/12, the facility smoke barrier doors were observed.

5 Story Building
1st Floor -
1. At 11:29 a.m., the Smoke Barrier Door 5S1/01 failed to latch when the fire alarm was activated. The 1 hour fire rated door was altered with a metal plate added to the lower half of the door. The actuator pin hardware was removed from the lower half. The door did not latch in the latching plate in the floor.

10 Story Building
2nd Floor -
2. At 1:29 p.m., the smoke barrier door to the Short Stay Surgery, on 2 West, failed to latch when the fire alarm was activated. The door latch was taped with a piece of cardboard.
During an interview, Staff stated that around 11:30 a.m., the security personnel taped the latch so patient's could enter.

10 Story Building
5th Floor -
3. At 2:13 p.m., the smoke barrier door 10S5/04, Orthopedics, failed to latch when the fire alarm was activated. The smoke barrier door bounced off the latch and failed to close completely. There was an exposed 1 inch gap.


28602

Five Story - 10/11/12
4th Floor
4. At 9:46 a.m., the left smoke barrier door 5S4/07 closed but failed to latch.

1st Floor
5. At 11:47 a.m., the right door of the smoke barrier by the "Charles and Ann Matoian," failed to latch.

Ten Story - 10/11/12
3rd Floor
6. At 1:45 p.m., the right smoke barrier door, by the elevator foyer, was obstructed from closing by a 50 gallon gray container. The container was directly in front of the door.
During an interview, facility staff reported that the container was for documents that need to be shredded.

5th Floor
7. At 2:17 p.m., the right smoke barrier door, by the elevator foyer, closed but failed to latch.

6th Floor
8. At 2:32 p.m., the right smoke barrier door, by the elevator foyer, closed but failed to latch.

Trauma Building - 10/11/12
1st Floor -
9. At 4:21 p.m., the left smoke barrier door, by the Fire Pump Room 021A, failed to fully close and latch.

Trauma Building -10/12/12
2nd Floor -
10. At 8:17 a.m., the right Smoke Barrier Door 2112A, at the entrance into OR suites 4 and 6, failed to fully close and latch.

4th Floor
11. At 9:09 a.m., the left Smoke Barrier Door 4028A, failed to fully close and latch. The door was tested twice.

5th Floor
12. At 9:26 a.m., the right Smoke Barrier Door 5026A, failed to fully close and latch.


29752

Ten Story Building - 10/11/12
2nd Floor
13. At 1:33 p.m., the left smoke barrier door (10S2/11), at the MOB bridge, failed to close completely during fire alarm testing. The door was obstructed from closing the last two inches by air flow coming from the Medical Office Building (MOB) bridge to the Ten Story.
During an interview, Staff 4 explained that "there was an air-imbalance that occurs when air handlers shut down during fire alarm testing."

14. At 2:32 p.m., the left smoke barrier door (10S6/04) at the MOB bridge failed to close completely during fire alarm testing. The door was obstructed from closing the last inch by air flow coming from the Medical Office Building (MOB) bridge to the Ten Story. Staff 4 explained that this was the same type of air-imbalance that occurs when air handlers shut down during fire alarm testing.

Based on observation, the facility failed to ensure that hazardous areas were separated from other spaces by smoke resisting partitions and self-closing doors. This was evidenced by one hazardous area with no self-closing doors. This affected the Clovis Dialysis Center and the Sierra Health Center. This could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour from 10/8/12 to 10/12/12, the hazardous areas were observed. Combustible storage rooms greater than 50 square feet in size, trash collection rooms, and water heater rooms, are considered hazardous areas.

Clovis Dialysis Center - 10/11/12 -
At 8:52 a.m., the door to the water heater room was not equipped with a self-closing device. The room contained combustible storage.

Sierra Health Center - 10/11/12
1st Floor
At 1:36 p.m., the dirty trash room of Suite 114 contained four full trash receptacles. The door to the trash room was not equipped with a self-closing device.

Based on observation, the facility failed to maintain their exits, as evidenced by exit doors that were obstructed. This affected one of ten floors of the 10-Story Building and one of seven floors of the Trauma Building and could result in a delay in evacuation, in the event of a fire.

Findings:

During a facility tour from 10/8/12 to 10/12/12, the exit paths were observed.

Ten Story Building - 10/10/12
1st floor
1. At 11:36 a.m., the Sequoia West Conference Room had two doors labeled as exits. One exit door was blocked by a table and more than 5 chairs.


28602

Trauma Building - 10/10/12
3rd Floor
2. At 2:32 p.m., one of two exit doors in the corridor exiting to the 4th floor, failed to open when the button was activated. Staff 1 made several attempts.
During an interview he reported that they have had problems with this door.

Based on observation, the facility failed to maintain their fire alarm system, as evidenced by pull stations that were obstructed, and by alarm notification devices that failed. This affected two of five floors in the 5 Story Building, and two of seven floors in the Trauma Building. This could result in a delay in notification, in the event of a fire.

Findings:

During record review and the facility tour with staff, from 10/8/12 to 10/12/12, the alarm testing records and the fire alarm system were observed.

Trauma Building - 10/8/12
1. During record review, at 2:55 p.m., the quarterly inspection of the fire alarm system, dated 7/20/12, indicated that the "Won" door (horizontal fire barrier) failed to work, in the Rotunda, 5th floor.
During an interview, the vendor reported that he is currently working with another vendor to get the door repaired.

Five Story Building - 10/11/12
1st Floor
2. At 11:25 a.m., the strobe light notification device at Endoscopy Recovery, failed to alarm upon activation of the fire alarm system.

3. At 11:26 a.m., the strobe light notification device at the endoscopy hallway, outside recovery, failed to alarm upon activation of the fire alarm system.

Trauma Building
10/12/12- 4th Floor
4. At 9:04 a.m.,the strobe light notification device inside the bathroom 4458A, was observed during fire alarm testing. The device failed to alarm upon activation of the fire alarm system.


31070

During the facility tour with Staff 4, 6, and 7 between 10/8/12 and 10/12/12, the manual fire alarm boxes were observed.

5 Story Building - 10/9/12
5th Floor -
5. At 2:20 p.m., the manual fire alarm box near Room 542 was obstructed by a work station on wheels.
Staff 6 confirmed the work station on wheels obstructed access to the manual fire alarm box.

Based on observation and record review, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was covered in tape, by no records for testing all smoke detectors, by smoke detectors that failed to activate the fire alarm system, and by no records for sensitivity testing of all smoke detectors. This affected the basement of the 10-Story Building, the CMP, the Radiology Clinic, and four of seven floors of the Trauma Building. This could result in a delay in notification, in the event of a fire.

NFPA 101, 2000 edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 National Fire Alarm Code 1999 Edition
7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
13. Initiating Devices
(g) Smoke Detectors - The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review and the facility tour from 10/8/12 to 10/12/12, the smoke detectors were observed and testing records were requested.

10/8/12
Record Review for the CMP
1. At 1:45 p.m., documentation for annual testing of the smoke detectors, dated 4/20/12, showed that six of six smoke detectors in the building were not tested. The comments indicated that they "need to be tested with the elevator company."

10 Story Building - 10/10/12
Basement
2. At 1:40 p.m., the smoke detector in the linen chute room was covered with blue masking tape.

Radiology Clinic - 10/11/12
3. At 9:25 a.m., smoke detectors were observed at the clinic. There were no records for detector sensitivity testing provided.


28602

Trauma Building - 10/11/12
1st Floor
4. At 3:53 p.m., the smoke detector in the corridor by Room 1289A was tested. The smoke detector failed to activate the fire alarm system. The smoke detector was tested five times with canned smoke.

10/12/12
2nd Floor
5. At 8:15 a.m., the smoke detector in the OR suites failed to activate the fire alarm system. The smoke detector was tested four times with canned smoke.

7th Floor
6. At 9:48 a.m., the smoke detector in the elevator lobby failed to activate the fire alarm system. The smoke detector was tested seven times with canned smoke.


29752

Trauma Building - 10/11/12
4th Floor
7. At 2:02 p.m., a smoke detector, in a corridor by the Electrical Room and Directors Office, activated the elevator smoke barrier curtain. The smoke barrier curtain dropped on one of the double set of elevators after the smoke detector was activated.
During an interview, Staff 4 explained that "some wiring may have crossed."

28602


Surveyor: Mills, Marie
Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by escutcheon rings that were corroded, by missing escutcheon rings or escutcheon rings that were not flush to the ceiling, by sprinklers covered with debris, and by sprinklers with less than 18 inch clearance. This could result in a malfunction of the sprinkler system, or an obstruction to the water spray pattern, which could delay extinguishing a fire. This affected the 5 Story Building, the 10 Story Building, the Trauma Building, the Radiology Center and the Fresno Dialysis Clinic.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems,1998 Edition
2-2 Inspection.
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.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
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.

4.3.1 Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.
5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 inch (457 mm) or greater.

Findings:

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the facility automatic sprinkler system was observed. Escutcheon rings are used to cover penetrations around sprinkler pipes and sprinkler heads. The sprinkler deflector diverts the water to create a spray pattern when the sprinkler is activated.

5 Story Building - 10/9/12
5th Floor -
1. At 2:16 p.m., the escutcheon ring was corroded, in the Room 503 bathroom.

2. At 2:31 p.m., the escutcheon ring was missing in Patient Shower A, located across from Room 548.

3. At 2:32 p.m., the escutcheon ring was corroded in Patient Shower B, located across from Room 548.

5 Story Building
4th Floor -
4. At 2:47 p.m., 1 of 8 sprinklers in Room 408 was covered with dust and/or dirt.

3rd Floor -
5. At 3:47 p.m., the escutcheon ring was corroded in Patient Shower A, located near Room 308.

6. At 4:02 p.m., the escutcheon ring was corroded in Patient Shower A, located across from Room 348.

7. At 4:03 p.m., the escutcheon ring was corroded in Patient Shower B, located across from Room 348.

5 Story Building - 10/10/12
2nd Floor -
8. At 8:05 a.m., the escutcheon ring was corroded in Patient Shower B, near Room 206.

9. At 8:21 a.m., the escutcheon ring was corroded in Patient Shower A, located across from Room 248.

10. At 8:36 a.m., there was a box of head covers on the top closet shelf in the closet next to Surgery Med Room 2 Central. The box was approximately 4 inches below the sprinkler deflector.

11. At 9:11 a.m., the escutcheon ring was corroded in the patient bath, located across from Room 230.

12. At 9:13 a.m., the escutcheon ring was corroded in the patient shower, located across from Room 230.

Med Surge - 5 Story Building
1st Floor -
13. At 1:12 p.m., 3 of 3 sprinklers in the kitchen pantry area were covered with dust and/or dirt.

14. At 1:30 p.m., the escutcheon ring was not flush to the ceiling in the Manager Support Services office. There was an approximately 2 inch gap. Staff 4 tried to push the escutcheon ring back up.

Surveyor: Rodriguez-Herrera, A
During record review on 10/8/12 and 10/9/12, the records for quarterly sprinkler inspection and testing were reviewed.

Five and Ten Story Buildings - 10/8/12
15. At 1:27 p.m., there were no testing records for the sprinkler system for the 1st quarter of 2012. The facility provided three testing records titled, "Inspection, Testing, Maintenance of Water Based Fire Protection Systems."
At 1:28 p.m., during an interview, Staff 2 reported that there was a change in vendors in May of this year. He reported that the previous vendor failed to perform the quarterly sprinklered testing for the first quarter.

5 Story Building - 10/9/12
16. At 8:45 a.m., the quarterly sprinkler system testing records dated 9/24/12, indicated the system "failed." The document reported "Risers 1 and 2 in 5 Story, risers 1/2 time valves are leaking. Recommend replace time valves with new."
At 8:46 a.m., during an interview, the vendor (technician) reported that the repair is currently taking place together with the 5 year certification.

Trauma Building - 10/9/12
17. At 8:52 a.m., the quarterly sprinkler system testing records dated 9/24/12, indicated the system "failed." The document reported "Loaded and painted fire sprinkler heads in various areas (see 5 year report)."
At 8:53 a.m., during an interview, the vendor (technician) reported that the repairs are currently taking place together with the 5 year certification.

10/10/12
5th Floor
18. At 8:07 a.m., the escutcheon ring was not flush to the ceiling in the Burn Unit OR. There was an approximately 1/2 inch gap between the escutcheon ring and the ceiling exposing an approximately 1/4 inch penetration around the sprinkler pipe.

Surveyor: Naser, Zeina
Record Review for Radiology Center
10/12/12
19. At 1:30 p.m., records indicated that the sprinkler system was tested on 10/11/12. There were no records for testing the sprinkler system during the first, second, and third quarters (January to September) of 2012.

Fresno Dialysis Clinic
10/8/12 -
20. During record review at 1:30 p.m., records indicated that the sprinkler system was tested on 1/5/12, 5/23/12, and 8/2/12. There were no records for testing the sprinkler system during the fourth quarter of 2011.

Based on an interview at 1:45 p.m., Engineering Staff 2 stated that the Fresno Dialysis Clinic sprinkler system was under contract for semi-annual testing with the previous vendor. The new vendor, which began their contract in May, started testing the system quarterly.





29665

Based on observation, the facility failed to maintain their portable ABC fire extinguishers. This was evidenced by one fire extinguisher that was overcharged, one fire extinguisher that was obstructed, and by one fire extinguisher that was missing the nozzle ring. This could result in a delay to extinguish a fire if the extinguisher was non-operable in the event of a fire. This affected 3 of 5 floors in the 5 story building.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of a least the following items:
(a) Location in designated Place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged
nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the fire extinguishers were observed.

5 Story Building - 10/9/12
5th Floor -
1. At 2:15 p.m., a portable ABC fire extinguisher was obstructed by a work station on wheels, located near Room 505.
Staff 6 confirmed the work station on wheels obstructed access to the fire extinguisher.

10/10/12
1st Floor
2. At 9:39 a.m., the fire extinguisher, in the Electrical Room in the Endoscopy Unit, was missing the nozzle ring. The fire extinguisher was mounted on the bracket backwards to prevent the hose from obstructing the door entrance.

5 Story Building Trauma Unit - Critical Care
2nd Floor -
3. At 2:23 p.m., the fire extinguisher located in Sterile Processing, next to the ETU vestibule, was overcharged. The needle pointed to the red zone marked overcharged.
Staff 6 confirmed the fire extinguisher was overcharged.

Based on record review, the facility failed to maintain their air duct fire protection system, as evidenced by no records for testing two of seventeen fire dampers in the Cancer Center. This affected one of two floors of the Cancer Center and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a facility tour and record review from 10/8/12 to 10/12/12, the fire dampers were observed and maintenance records were reviewed.

Cancer Center
10/11/12
At 11:46 a.m., the Fire Inspection Report indicated that the fire dampers were tested on 1/19/12. The report stated that Fire Link Damper 001, located in the library storage room, and Fire Link Damper 005, located in the hatch by the men's restroom in the lobby, were in-accessible and not tested. There were no documents showing that the dampers were made accessible for testing after the findings were identified.

Based on observation and interview, the facility failed to use portable space heaters in accordance with the manufacturer's recommendation. This was evidenced by space heaters with a maximum temperature above 212 degrees F, and by heaters placed adjacent to furnishings and under desks. This affected 2 of 5 floors in the 5 Story Building, in the Administration office areas and the Resident Call Room Unit. This could result in an increased risk of fire.

Findings:

During the facility tour with Staff 4, Staff 6 and Staff 7, on 10/9/12 and 10/10/12, the office areas were observed in the 5 Story Building.

3rd Floor
1. At 3:38 p.m., there was a gray portable space heater located inside the Perinatal/Newborn Manager's office, next to the desk. The Manager's office is located in a smoke compartment with resident rooms, across from Room 323.

Based on the manufacture's specification information, received from Staff 4, the brand of the heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear."

2. At 3:42 p.m., there was a gray portable space heater located inside the PNU/NBU Clinical Supervisor's office. The Clinical Supervisors office faces the corridor. The heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

3. At 4:27 p.m., there were 2 gray portable space heaters located inside the Resident Call Room Unit. There was one gray portable space heater located under the computer desk and one portable space heater sitting on a table near the couch. The heater was on. The room was empty and the gray portable space heater was left unattended. Both heaters were identified by Staff 4, as Dayton Oil-Filled Flat Panel Heaters. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear."

5 Story Building - 10/10/12
2nd Floor -
4. At 9:17 a.m., there was a gray portable space heater inside the Administration offices located under the desk of Executive Assistant 1.
During an interview, Staff 4 confirmed the heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear".

5. At 9:18 a.m., there were two heaters located in the Associate Administration office. There was a Dayton Oil-Filled Flat Panel Heater under the desk and a Dakota brand portable electric heater with a Oil-Filled Column in the office space.

Based on the manufactures heater specification information received from Staff 4, the Dakota brand portable electric heater is 120 Voltage and the Rated Maximum Power is 1500w.
The Dayton brand Oil-Filled Flat Panel Heater maximum Fahrenheit is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear".

6. At 9:22 a.m., the was a gray portable space heater inside the Administration offices located under the desk of Executive Assistant 2.
Staff 4 confirmed the heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear".

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions. This was evidenced by items that were stored in the path of egress in an exit access. This had the potential to affect all staff and patients on one of seven floors in the Trauma Building and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During the facility tour with staff from 10/8/12 to 10/12/12, the corridors were observed.

Trauma Building - 10/9/12
1st Floor
1. At 2:10 p.m., there were 2 gurneys with patients, lined up against the wall, in the Green Zone corridor, Rooms 16-21, next to Zone E.
At 2:11 p.m., during an interview, the patient next to Zone E reported she had been at this location for approximately 23 hours.

2. At 2:17 p.m., there were 2 gurneys with patients, lined up against the wall, in the Yellow "M" Zone by the Nurses Station.
At 2:18 p.m., during an interview, one patient reported he had been at this location since yesterday at approximately 6:30 p.m.

3. At 2:20 p.m., there were 2 gurneys with patients, lined up against the wall, in the Yellow Hall G and H.
At 2:21 p.m., during an interview, one patient reported he had been at this location since yesterday at approximately 7:30 p.m.

4. At 2:23 p.m., there was 1 gurney with a patient, lined up against the wall, in the Yellow J Hall, across room Yellow 8. There was an empty gurney across room Yellow 7.
At 2:24 p.m., during an interview, the patient reported she had been at this location since this morning, at approximately 9:30 a.m.

5. At 2:42 p.m., there was 1 gurney with a patient, lined up against the wall, in the Green Hall P.
At 2:43 p.m., during an interview, the patient reported he had been at this location for approximately 2 1/2 hours.

10/10/12
6. At 4:12 p.m., there was an empty gurney, lined up against the wall, in Red Hall A, against the wall, near an exit door.

7. At 4:22 p.m., there was a gurney with a patient in the Yellow Hall G. There were also privacy dividers blocking approximately 100% of the connecting corridor.

On 10/11/12, at 8:10 a.m., during an interview, the clinical supervisor reported that the gurney had to be pulled away from the wall as an additional nurse was needed to assist with the IV. She reported that this was not a usual occurrence, as the gurneys were always against the wall and that the privacy partitions were needed for patient privacy. She stated that the privacy partitions do not normally block the entire corridor.

Based on observation and interview, the facility failed to maintain their soiled linen and trash receptacles. This was evidenced by rooms storing more than 32 gallons of soiled linen, that were not protected as hazardous areas, and by soiled linen and trash receptacles with capacities greater than 32-gallons that were not stored in rooms protected as hazardous areas. This affected the basement of the 10-Story Building and one of two floors of the Ambulatory Care Center. This could result in the increased risk of a fire.

Findings:

During the facility tour from 10/8/12 to 10/12/12, soiled linen and trash receptacles were observed throughout the facility.

10-Story Building - 10/10/12
Basement
1. At 1:55 p.m., there was an approximately 100-gallon trash cart filled with cardboard, in the corridor outside the pharmacy.
During an interview at 1:56 p.m., the pharmacy buyer stated that the cart sometimes stays in the corridor for two or three days before housekeeping staff picks it up.

2. At 2:01 p.m., there was a soiled linen cart with more than 96 gallons of soiled linen, in the corridor leading to the ramp into the Trauma Center basement.
During an interview at 2:02 p.m., Engineering Staff 3 stated that the soiled linen stays in the corridor until it is picked up once a day.

Ambulatory Care Center - 10/12/12
2nd Floor
3. At 9:14 a.m., the special services soiled utility room contained three 32-gallon soiled linen bins. The door to the utility room was not equipped with a self-closing device.


28602

Trauma Building - 10/9/12
5th Floor
4. At 4:24 p.m., there was one 40 gallon soiled linen cart outside Rooms 53332A and 53333A, against the wall.
During an interview, nursing staff reported that the soiled linen container (cart) is always stored at the same location.

10/10/12
5. At 8:14 a.m., a 55 gallon and a 32 gallon trash container were lined up against the wall in the Burn Unit hallway. The carts were within a 64 square foot area.

6. At 8:22 a.m., a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin were lined up, side by side, against the wall in the Room T533. The carts were within a 64 square foot area.

7. At 8:24 a.m., there were a tan 23 gallon trash container, and one 18 gallon Biohazard bin lined up, side by side, against the wall in the Patient Room T531. The carts were within a 64 square foot area.

8. At 8:27 a.m., a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin were lined up, side by side, against the wall in the Patient Room T530. The carts were within a 64 square foot area.
At 8:28 a.m., during an interview, nursing staff reported that all the patient rooms in the Burn Unit contain the trash, linen and Biohazard containers.

9. At 8:30 a.m., a tan 23 gallon trash container, and one 18 gallon trash bin were lined up, side by side, against the wall in the ante room. The carts were within a 64 square foot area.

10. At 8:33 a.m., there were 2 tan 23 gallon trash containers lined up, side by side, against the wall in room 118A, Procedure Room of the Burn Unit. The carts were within a 64 square foot area.

11. At 8:47 a.m., there was a tan 23 gallon trash container, and one 18 gallon Biohazard bin lined up, side by side, against the wall in Patient Room 524, 5-ICU North Unit. The carts were within a 64 square foot area.

10/10/12
4th Floor
12. At 9:52 a.m., a tan 23 gallon trash container, and one 18 gallon Biohazard bin were lined up, side by side, against the wall in Room T432, in the Cardio Vascular Unit. The carts were within a 64 square foot area.

13. At 9:56 a.m., a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin were lined up, side by side, against the wall in the Patient Room 4131A. The carts were within a 64 square foot area.

14. At 10:10 a.m., there was a tan 23 gallon trash container, a 32 gallon soiled linen container, and one 18 gallon Biohazard bin lined up, side by side, against the wall in Room T413, in the ICU 4 North Unit. The carts were within a 64 square foot area.
During an interview, nursing staff reported that all rooms in the ICU 4 North (413 to 424) have these containers.

15. At 10:15 a.m., there were two tan 23 gallon trash containers, one 32 gallon soiled linen cart, and one 18 gallon Biohazard bin lined up, side by side, against the wall in Room 4428A. The carts were within a 64 square foot area.

10/10/12
3rd Floor
16. At 2:05 p.m., one tan 23 gallon trash container, and one 23 gallon Biohazard bin were lined up, side by side, against the wall in the X-Ray Room 5, in Radiology. The carts were within a 64 square foot area.

17. At 2:14 p.m., there were a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin lined up, side by side, against the wall in the X-Ray Room 6, in Radiology. The carts were within a 64 square foot area.

1st Floor
18. At 4:05 p.m., there was a 23 gallon trash container, and a 32 gallon soiled linen cart lined up, side by side, against the wall in the trauma area, Room 2. The carts were within a 64 square foot area.

19. At 4:08 p.m., there was a 23 gallon trash container and a 23 gallon Biohazard bin lined up, side by side, against the wall in the trauma area, Room 3. The carts were within a 64 square foot area.

20. At 4:10 p.m., there was a 23 gallon trash container and a 23 gallon Biohazard bin lined up, side by side, against the wall in X-Ray Room 3. The carts were within a 64 square foot area.

21. At 4:13 p.m., there was a 23 gallon trash container and an 18 gallon Biohazard bin lined up, side by side, against the wall in Room 113A, in the Red Zone in the emergency department.

Based on observation, the facility failed to maintain their medical gas storage areas. This was evidenced by an oxygen room with a self-closing door that failed to latch, by electrical fixtures in a medical gas supply room that were mounted less than 5 feet from the floor, and by oxygen cylinders that were not secured. This affected two of ten floors of the 10-Story Building, three of seven floors of the Trauma Building, and could result in damage to the medical gas cylinders.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a facility tour from 10/8/12 to 10/12/12, the medical gas storage areas were observed.

10-Story Building - 10/10/12
2nd Floor
1. At 11:04 a.m., there were six nitrogen H-tanks and two argon H-tanks in the medical gas storage room in the surgery corridor. There was a light switch approximately 4 feet from the floor, near the argon tanks. There was a four-plug receptacle outlet approximately 10 inches from the floor, near the nitrogen tanks.

Trauma Center - 10/10/12
Basement
2. At 2:31 p.m., the medical storage room contained more than 100 oxygen E-tanks. The door into the storage room was equipped with a self-closing device. The door closed but failed to latch.

Trauma Center
1st Floor
3. At 4:09 p.m., there were three oxygen E-tanks on the floor, unsecured, in the emergency department storage room (Room 1166 B).


28602

Trauma Building
3rd Floor
4. At 3:00 p.m., the oxygen storage room in the Hot Lab (Nuclear) had full and empty E sized cylinders stored in the same racks. There were two racks with full and empty cylinders in the racks. There was no sign indicating which cylinders were empty or which were full.
During an interview, lab staff reported that the oxygen cylinders are mixed storage and have always been stored this way.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by electrical panels that were not maintained with 36 inch clearance, by missing electrical box outlet/fixture and call light cover plates, by surge protected multi-outlet extension cords (surge protectors), connected to other surge protectors, by appliances that were plugged into a surge protector, and by the use of extension cords and adapters without overcurrent protection. This affected four of five floors in the 5 Story Building, two of ten in the 10 Story Building, and three of seven floors in the Trauma Building and could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

(a) Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of electrical equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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.

NFPA 99 Health Care Facilities 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During the facility tour with Staff 1, Staff 5, Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the electrical wiring and equipment were observed.

Trauma Building - 10/9/12
5th Floor
1. At 4:30 p.m., there was a six plug surge protector connected to another six plug surge protector in Room 5322A, Executive Secretary Burn Services Office. The surge protectors were used to connect computer and office equipment to the wall outlet.

10/10/12
5th Floor
2. At 8:05 a.m., there was a six plug surge protector connecting medical equipment, "Bovie," a "Fibrin Glue Sprayer," a bed plug and a SCD (Sequential Compression Device), to the wall outlet in the burn unit OR.

3. At 8:45 a.m., there was a six plug adapter, without overcurrent protection, connecting a mid size refrigerator, and office and computer equipment to the wall outlet in the Critical Care Director's Office 524, 5-ICU North Unit.

4th Floor
4. At 10:06 a.m., there was a six plug surge protector connecting a mid-size refrigerator to the wall outlet in Room 4158A, Manager's Office.

5. At 10:28 a.m., there was a six plug surge protector connected to another six plug surge protector, in Room 4254A, the Clinical Supervisor's Office.

3rd Floor
6. At 1:20 p.m., there was a black extension cord, without overcurrent protection, connecting a water cooler to the wall outlet in Room 3212A, Radiology Break Room.

7. At 2:20 p.m., there was a six plug surge protector connecting a mid size refrigerator, a microwave, an ultra sound machine and a phone charger to the wall outlet, in Room 3003, PICC. The surge protector was on a metal rack.

8. At 2:22 p.m., there was an eight plug surge protector connected to a six plug surge protector, connected to the wall outlet, in Room 3003A.

9. At 2:24 p.m., there was an orange heavy duty extension cord, without overcurrent protection, connected to a six plug surge protector in Room 3003A, underneath the desk.

10. At 2:38 p.m., there was a six plug surge protector connecting a microwave to the wall outlet in Room 3124B, Radiology Staff Lounge.


29665


10-Story Building - 10/9/12
10th Floor
11. At 2:28 p.m., there was an approximately 8 inch by 8 inch electrical box with no cover, in the Step Down 1 medication room.

12. At 2:55 p.m., there was an approximately 6 inch by 6 inch electrical box with no cover, in the Internal Medicine clinical pharmacy office.

10-Story Building - 10/10/12
1st Floor
13. At 11:26 a.m., there was a lamp plugged into an extension cord in the Critical Care/Trauma Fellows office. The extension cord was plugged into a six-plug surge protector.

Trauma Center
1st Floor
14. At 4:23 p.m., there was a refrigerator plugged into a six-plug surge protector, in the office across from the Behavioral Care Unit.


31070

5 Story Building - 10/9/12
4th Floor -
15. At 3:17 p.m., the electrical panel labeled 4E had no cover. The panel was located in the linen closet near Nurses Station 4 (east). The cover to the electrical panel was on the floor leaning against the wall.

16. At 3:33 p.m., the call light cover was missing above the door labeled Employee Only in the alcove next to Room 429.

3rd Floor
17. At 4:25 p.m., there was no cover on the light fixture, in the storage closet, located in the Resident Call Room Unit.

18. At 4:33 p.m., the electrical panel labeled 3D, located near Room 321, was obstructed by a weight scale and perinatal care stand.

5 Story Building - 10/10/12
2nd Floor -
19. At 8 a.m., the telephone outlet was not flush to the wall, in the storage room across from Room 201.

1st Floor
20. At 9:28 a.m., a microwave was plugged into a surge protector located in the Doctor's Lounge.

21. At 9:30 a.m., the computer port outlet, located in the Doctor's Lounge, was missing a cover.

22. At 9:34 p.m., a refrigerator and microwave were plugged into a surge protector, located in the Medical Records office.

23. At 9:38 a.m., a refrigerator, microwave, radio and a fan, were plugged into a surge protector located in the Endoscopy Scheduling room.

24. At 9:43 a.m., a refrigerator, coffee machine, microwave and a fan were plugged into a surge protector located in P.A. 1.

25. At 9:56 a.m., a refrigerator was plugged into a surge protector located in the Endoscopy scope storage room.

26. At 10:44 a.m., a refrigerator was plugged into a surge protector located in the Endoscopy Administration office H1756.

5 Story Building - Med Surge
1st Floor -
27. At 11:23 a.m., the electrical panels labeled XA and XB, located next to Exam 4 room, in the Neurodiagnostic Unit, were obstructed by a wheelchair.

29. At 11:38 a.m., a coffee maker was plugged into a gray extension cord, in the Employee Breakroom, located in the Pulmonary Function Unit.

30. At 11:47 a.m. the call light cover, above the door to the Nursing Administration office, was broken.

31. At 1:03 p.m., a radio was plugged into a surge protector located in the kitchen offices under the staff desk.

32. At 1:20 p.m., a microwave was plugged into a surge protector located in the Medical Staff office.

33. At 4:29 p.m., a refrigerator was plugged into a surge protector located in the ED Administrative Support office 1284A.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by alcohol based hand rub dispensers mounted over and adjacent to ignition sources. This affected three of seven floors in the Trauma Building, four of ten floors in the 10 Story Building, and two of five floors of the 5 Story Building. This could result in an increased risk of fire.

Findings:

During a facility tour with staff from 10/8/12 to 10/12/12, the alcohol based hand rub dispensers in the facility were observed.

Trauma Building
10/9/12-5th Floor
1. At 9:18 a.m., an alcohol based hand rub dispenser in the Rotunda Waiting Room was mounted on the wall over an electrical receptacle by the North entry door. The hand rub was sixty-two percent ethyl alcohol by volume.

10/10/12 - 5th Floor
2. At 9:10 a.m., an alcohol based hand rub dispenser in the Private Waiting Room 5-C was directly above a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

3. At 9:14 a.m., an alcohol based hand rub dispenser was mounted on the wall adjacent to the light switch in Room 5007A. The dispenser was within five inches from the light switch.

4. At 9:17 a.m., an alcohol based hand rub dispenser in 5A Private Waiting Room was mounted on the wall directly over two electrical wall outlets. The hand rub was sixty-two percent ethyl alcohol by volume.

4th Floor
5. At 10:13 a.m., an alcohol based hand rub dispenser was mounted on the corridor wall directly over an electrical receptacle in the 4 ICU South, between rooms T409 and T410. The hand rub was sixty-two percent ethyl alcohol by volume.

6. At 10:14 a.m., an alcohol based hand rub dispenser was mounted on the corridor wall directly over an electrical receptacle in the 4 ICU South, between rooms T407 and T408. The hand rub was sixty-two percent ethyl alcohol by volume.

7. At 10:22 a.m., an alcohol based hand rub dispenser was on the corridor wall directly over an electrical receptacle in 4 ICU North, across from Room 4212A. The hand rub was sixty-two percent ethyl alcohol by volume.

8. At 10:47 a.m., an alcohol based hand rub dispenser in the 4B Private Waiting Room, 4357A, was mounted on the wall adjacent to a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

9. At 2:50 p.m., an alcohol based hand rub dispenser in Nuclear Medicine Room 1, near door 3152A, was mounted on the wall directly over an electrical receptacle. The hand rub was sixty-two percent ethyl alcohol by volume.

10. At 2:52 p.m., an alcohol based hand rub dispenser in Thyroid Room 3159B, was mounted on the wall within approximately 2 inches of a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

1st Floor
11. At 3:52 p.m., an alcohol based hand rub dispenser, in Room 1107A, was mounted on the wall adjacent to a light switch. The hand rub was sixty-two percent ethyl alcohol by volume.

12. At 3:53 p.m., an alcohol based hand rub dispenser, in Registration Office Room 1159, was mounted on the wall adjacent to and over an electric wrist band machine printer.


29665

10-Story Building - 10/9/12
10th Floor
13. At 2:45 p.m., the ABHR dispenser was installed approximately 3 1/2 feet directly above an electrical outlet, outside the oxygen room, in the dialysis department.

10/10 - 6th Floor
14. At 8:35 a.m., the ABHR dispenser, across from Room 675, was installed directly above a data cable box.

10/10 - 2nd Floor
15. At 10:44 a.m., the ABHR dispenser, next to Room 265, was installed directly above a receptacle outlet.

10/10 - Basement
16. At 1:21 p.m., the ABHR dispenser installed directly over a light switch, near the mail boxes in the pharmacy.


31070

10/9/12
5th Floor - 5 Story Building

17. From 2:05 p.m., to 2:39 p.m., the 60% Alcohol Based Hand Rub (ABHR) dispensers were installed adjacent to the single unit light switches in the following rooms: 501, 502, 503, 504, 505, 506, 507, 508, 520, 521, 522, 523, 524, 525, 526, 527, 528, 529, 530, 540, 541, 542, 543, 544, 545, 546, 548, 550, 551, 552, 553, 554, 555, 556, 557, 558. The dispensers were within 1 inch of the light switches.

Some rooms could not be accessed but Staff 4 stated "all the rooms on the 5th floor have the Alcohol Based Hand Rub dispenser mounted next to the light switch, they are all in the same place".

Med Surge - 5 Story Building - 10/10/12
1st Floor -
18. At 10:53 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch, in the office next to the D.O.N. office.

19. At 10:57 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch in Room 160.

20. At 10:59 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch in Room 158.

21. At 11 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch in Room 162.

22. At 11:15 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch in Room 161.

23. At 11:16 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch in Room 159.

24. At 11:17 a.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the 3 unit light switch in Room 157.

Trauma Unit - Critical Care - 5 Story Building
1st Floor -
25. At 3:54 p.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the single unit light switch in 1148A (Red Zone).

26. At 3:58 p.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed 2 inches above the double unit light switch in Staff Lounge 1156A (Red Zone). One light switch was red.

27. At 4:06 p.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the single light switch in the Nurses Station (Green Zone).

28. At 4:07 p.m., the 60% Alcohol Based Hand Rub (ABHR) dispenser was installed adjacent to the double plug receptacle outlet in 1268A (Green Zone).

Based on observation, the facility failed to maintain a two hour fire barrier, as evidenced by a fire barrier door that failed to fully close and latch. This could result in the spread of fire or smoke, in the event of a fire, affecting two floors in two buildings.

Findings:

During a facility tour with staff from 10/8/12 and 10/12/12, the facility two hour barriers were observed.

Trauma Building - 10/11/12
1st Floor
At 3:57 p.m., the two hour door by the Rotunda, failed to fully close and latch after activation of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair a penetration in the ceiling, in two areas. This could result in the spread of smoke in the event of a fire. This affected 1 of 5 floors in the 5 Story Building and 1 of 10 floors in the 10 Story Building.

Findings:

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the facility walls and ceilings were observed.

5 Story Building - 10/10/12
1st Floor -
1. At 11:42 a.m., there was an approximately one inch penetration in the ceiling of the Housekeeping Closet, near the double doors, in the Pulmonary Function Unit, 1 East.



29665

10-Story Building - 10/9/12
10th Floor -
2. At 2:30 p.m., there was an approximately 1 foot by 1 foot area, in the drop ceiling of Anteroom 1012, where a ceiling tile was removed. The area was covered with plastic and blue masking tape.

Based on observation and interview, the facility failed to ensure corridor walls were constructed to resist the passage of smoke. This was evidenced by penetrations in corridor walls and ceilings. These penetrations could allow the spread of smoke or fire in the event of a fire and affected two of seven floors in the Trauma Building and one of ten floors in the 10 Story Building.

Findings:

During a facility tour with staff from 10/08/12 to 10/12/12, the corridor walls and ceilings were observed.

Trauma Building - 10/09/12
5th Floor -
1. At 10:04 a.m., there was an approximately 1 to 1 1/2 inch penetration in the corridor wall above the Women's Locker Room, at door 5032A. The penetration was above the drop ceiling.

1st Floor -
2. At 2:30 p.m., there was an approximately 3/4 inch electrical conduit, around a bundle of blue and white wires, in the corridor wall above the drop ceiling, at door 1166B.

During an interview, Staff 5 reported that the wires were for the badge reader.


29665

10-Story Building - 10/9/12
8th Floor -
3. At 4:01 p.m., there was an approximately 1/2 inch penetration in the corridor wall, across from the door going into Stairwell C.

Based on observation and interview, the facility failed to maintain their corridor doors as evidenced by corridor doors that failed to latch, by self-closing doors that failed to latch when released, and by doors that were obstructed from closing. This could result in the spread of smoke and fire in the event of a fire. This affected 4 of 5 floors in the 5 Story Building, 3 of 7 floors in the Trauma Building, and 3 of 10 floors in the 10 Story Building.

Findings:

During the facility tour with Staff 4, 6, and 7 between 10/8/12 and 10/12/12, the facility doors were observed.

5 Story Building - 10/9/12
5th Floor -
1. At 2:05 p.m., the corridor door to Room 528 failed to latch when closed.

2. At 2:11 p.m., the corridor door to Room 504 was obstructed from closing, by a work station on wheels.

3. At 2:26 p.m., the self-closing door to the Stock Room failed to latch in two attempts. The room was located near Room 553. The door was held open to the fullest extent and released.

4. At 2:30 p.m., the self-closing door to the Mechanical Room failed to latch. The door was held open to the fullest extent and released. Two attempts were made to close and latch the door.

5 Story Building
3rd Floor -
5. At 3:48 p.m., the self-closing door to Patient Shower A failed to latch.
The shower room is located near Room 308.
6. At 3:59 p.m., the self-closing door 5S3/05 was obstructed by a wheelchair.

5 Story Building - 10/10/12
2nd Floor - Central
7. At 8:01 a.m., the self-closing door to the Utility Room 2 failed to latch.

8. At 8:08 a.m., the self-closing door to the Med Room near Nurses Station 2 failed to latch.

9. At 8:12 a.m., the self-closing door to Housekeeping, near Room 245, failed to latch.

10. At 8:35 a.m., the self-closing door to the Surgery Med Room failed to latch. The door was held open to the fullest extent and released two times.

11. At 8:40 a.m., the self-closing door to the Men's Locker Room 19 failed to latch.

12. At 9:06 a.m., the self-closing door to the Storage Room failed to latch. The room was located across from Room 220. The latch was covered with tape.

During an interview, Staff reported that the door handle was broken and that's why it was taped. "It's so we can get in and out of the door, it's been reported just hasn't been fixed yet."

5 Story Building
1st Floor -
13. At 9:45 a.m., the self-closing door to the P.A. Office 2 failed to latch.

14. At 10 a.m., the self-closing door to the Endoscopy Breakroom failed to latch. The latch was covered with tape.

15. At 10:06 a.m., the self-closing door to the Soiled Utility Room failed to latch. The room was located in the Endoscopy Unit.

16. At 11:21 a.m., the self-closing door to the Mechanical Room (south) failed to latch. The door bounced off the latch and exposed an approximately 1 inch gap. The door was held open to the fullest extent and released two times. Staff confirmed the door did not latch.

Med Surge - 5 Story Building
1st Floor
17. At 11:26 a.m., the self-closing door to Exam 1 was held open with a gurney. The room was located in the Neurodiagnostic Unit.

18. At 11:29 a.m., the self-closing door failed to latch, for H1525, in Pulmonary Function Lab 1.

19. At 11:32 a.m., the self-closing door was equipped with a magnetic hold open device, in Room 2 located in the Endoscopy Pre-OP Unit. The self-closing door was not engaged to the magnet. The door was held open with a hospital bed. The self-closing door failed to latch when released.

20. At 1:29 p.m., the interior self-closing door failed to latch, in the Chief Operating office. The latching device was loose.

Trauma Unit - Critical Care Building
2nd Floor
21. At 1:48 p.m., the door to the Surgical Administration office, 2147A, was held open with a small wooden table, holding a live plant. The table obstructed the door from closing.


28602

Trauma Building - 10/10/12
4th Floor -
22. At 10:35 a.m., the self-closing corridor door to room 4453A closed but failed to latch. The door was tested three times.

3rd Floor-
23. At 11:45 a.m., the self-closing corridor door to room 3466A failed to fully close and latch. The door was tested four times.

1st Floor -
24. At 4:28 p.m., the self-closing corridor door the restroom 1222A, failed to fully close and latch. The door was tested three times.


29665

10-Story Building - 10/10/12
5th Floor -
25. At 9:16 a.m., the door to the patient shower, across from Stairwell B, was equipped with a self-closing device. The door closed but failed to latch.

4th Floor -
26. At 9:54 a.m., the door to the housekeeping closet, next to Room H464 in the NICU Department, was equipped with a self-closing device. The door closed but failed to latch.

2nd Floor -
27. At 10:51 a.m., the door labeled H2044B, at the clean utility room, was equipped with a self-closing device. The door closed but failed to latch.

Trauma Center - 10/10/12
1st Floor -
28. At 4:19 p.m., the west door into the East Track was held open by a magnetic automatic-closing device. The door was obstructed from closing by a trash can and a WOW (wireless on wheels).


29752


Five Story - 10/11/12
4th Floor -
29. At 9:46 a.m., the corridor door for Patient Room 454 failed to self close and remained partially open. The door was equipped with a self closing mechanism that failed to engage and close the door.

Based on observation, the facility failed to maintain the construction of vertical openings between floors. This was evidenced by penetrations between floors in two areas. This affected two of seven floors in the Trauma Building and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 10/08/12 to 10/12/12, vertical openings were observed throughout the hospital buildings.

Trauma Building - 10/9/12
6th Floor
1. At 9:58 a.m., there was an approximately 2 inch unsealed conduit inside a 4 inch pipe sleeve in the elevator lobby ceiling.

During an interview, Staff 4 reported that this was an electrical conduit.

5th Floor
2. At 4:07 p.m., there was an approximately 3/4 inch unsealed electrical conduit inside a 2 inch conduit in the ceiling in Stairwell 3 (Rotunda 5th Floor).

Based on observation, the facility failed to ensure that smoke barrier doors closed when the fire alarm system was activated. This was evidenced by smoke barrier corridor doors that failed to release during fire alarm testing. This could result in the spread of smoke affecting one of five floors in the Five Story building.

Finding:

During fire alarm testing with Staff 4, on 10/11/12, the automatic and self closing corridor doors were observed.

Five Story Building - 10/11/12
1st Floor East
At 11:33 a.m., the double set of smoke barrier doors, near the east end of the reception/lobby area, failed to self close when the fire alarm system was activated. The doors were located in the corridor leading to Patient Rooms 157-166. The door closing hardware was equipped with a hold-open position that kept the doors from closing after activation of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of their smoke barrier partitions. This was evidenced by penetrations in the smoke barrier walls. This affected the Radiology Clinic, 2 of 7 floors in the Trauma Building and 3 of 10 floors in the Ten Story Building. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour from 10/8/12 to 10/12/12, the smoke barrier walls were observed.

Radiology Center - 10/11/12

1. At 9:19 a.m., the smoke barrier wall between the patient treatment area and the reception area was observed. There was an approximately 1 inch penetration in the center of the wall, around data cables.


28602

Trauma Building -10/9/12
2nd Floor
2. At 1:42 p.m., there was an approximately 1/2 penetration around a white wire, penetrating the wall at Smoke Barrier Door 2108A, in the West corridor.
During an interview, facility Staff 1 and Staff 5 reported that the penetrations was created during wiring for the security system (badge reader).

1st Floor
3. At 2 p.m., there was an approximately 1/2 unsealed pipe sleeve around a red wire penetrating the smoke barrier wall at Door 1102B.
During an interview, Staff 5 reported that the penetration was created during a repair to the fire alarm wiring a couple of months ago.


31070

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the smoke barriers were observed.

10 Story Building - 10/9/12
10th Floor -
4. At 9:37 a.m., there was an unsealed 2 inch by 2 inch penetration, around a pipe, in the smoke barrier above Doors 10S10/05, in the Step Down 1 Unit.
Staff 6 confirmed there was a penetration around the pipe.

5th Floor
5. At 10:56 a.m., there was an unsealed 1 1/2 inch penetration around a two inch pipe in the smoke barrier.

6. At 10:59 a.m., there was an unsealed 1 1/2 inch penetration, around a pipe, in the smoke barrier above the Case Management office.
Staff 6 confirmed there was a penetration around the pipe.

4th Floor -
7. At 11:13 a.m., there was an unsealed one inch penetration, around a pipe in the smoke barrier, above the Conference Room.
Staff 6 confirmed there was a penetration around the pipe.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by smoke barrier doors that failed to latch during fire alarm testing. This could result in the spread of fire and smoke in the event of a fire. This affected 3 of 5 floors of the 5 Story Building, 4 of 10 floors of the 10 Story Building, and 4 of 7 floors of the Trauma Building.

Findings:

During fire alarm testing with Staff 1 and 4 on 10/11/12, the facility smoke barrier doors were observed.

5 Story Building
1st Floor -
1. At 11:29 a.m., the Smoke Barrier Door 5S1/01 failed to latch when the fire alarm was activated. The 1 hour fire rated door was altered with a metal plate added to the lower half of the door. The actuator pin hardware was removed from the lower half. The door did not latch in the latching plate in the floor.

10 Story Building
2nd Floor -
2. At 1:29 p.m., the smoke barrier door to the Short Stay Surgery, on 2 West, failed to latch when the fire alarm was activated. The door latch was taped with a piece of cardboard.
During an interview, Staff stated that around 11:30 a.m., the security personnel taped the latch so patient's could enter.

10 Story Building
5th Floor -
3. At 2:13 p.m., the smoke barrier door 10S5/04, Orthopedics, failed to latch when the fire alarm was activated. The smoke barrier door bounced off the latch and failed to close completely. There was an exposed 1 inch gap.


28602

Five Story - 10/11/12
4th Floor
4. At 9:46 a.m., the left smoke barrier door 5S4/07 closed but failed to latch.

1st Floor
5. At 11:47 a.m., the right door of the smoke barrier by the "Charles and Ann Matoian," failed to latch.

Ten Story - 10/11/12
3rd Floor
6. At 1:45 p.m., the right smoke barrier door, by the elevator foyer, was obstructed from closing by a 50 gallon gray container. The container was directly in front of the door.
During an interview, facility staff reported that the container was for documents that need to be shredded.

5th Floor
7. At 2:17 p.m., the right smoke barrier door, by the elevator foyer, closed but failed to latch.

6th Floor
8. At 2:32 p.m., the right smoke barrier door, by the elevator foyer, closed but failed to latch.

Trauma Building - 10/11/12
1st Floor -
9. At 4:21 p.m., the left smoke barrier door, by the Fire Pump Room 021A, failed to fully close and latch.

Trauma Building -10/12/12
2nd Floor -
10. At 8:17 a.m., the right Smoke Barrier Door 2112A, at the entrance into OR suites 4 and 6, failed to fully close and latch.

4th Floor
11. At 9:09 a.m., the left Smoke Barrier Door 4028A, failed to fully close and latch. The door was tested twice.

5th Floor
12. At 9:26 a.m., the right Smoke Barrier Door 5026A, failed to fully close and latch.


29752

Ten Story Building - 10/11/12
2nd Floor
13. At 1:33 p.m., the left smoke barrier door (10S2/11), at the MOB bridge, failed to close completely during fire alarm testing. The door was obstructed from closing the last two inches by air flow coming from the Medical Office Building (MOB) bridge to the Ten Story.
During an interview, Staff 4 explained that "there was an air-imbalance that occurs when air handlers shut down during fire alarm testing."

14. At 2:32 p.m., the left smoke barrier door (10S6/04) at the MOB bridge failed to close completely during fire alarm testing. The door was obstructed from closing the last inch by air flow coming from the Medical Office Building (MOB) bridge to the Ten Story. Staff 4 explained that this was the same type of air-imbalance that occurs when air handlers shut down during fire alarm testing.

Based on observation, the facility failed to ensure that hazardous areas were separated from other spaces by smoke resisting partitions and self-closing doors. This was evidenced by one hazardous area with no self-closing doors. This affected the Clovis Dialysis Center and the Sierra Health Center. This could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour from 10/8/12 to 10/12/12, the hazardous areas were observed. Combustible storage rooms greater than 50 square feet in size, trash collection rooms, and water heater rooms, are considered hazardous areas.

Clovis Dialysis Center - 10/11/12 -
At 8:52 a.m., the door to the water heater room was not equipped with a self-closing device. The room contained combustible storage.

Sierra Health Center - 10/11/12
1st Floor
At 1:36 p.m., the dirty trash room of Suite 114 contained four full trash receptacles. The door to the trash room was not equipped with a self-closing device.

Based on observation, the facility failed to maintain their exits, as evidenced by exit doors that were obstructed. This affected one of ten floors of the 10-Story Building and one of seven floors of the Trauma Building and could result in a delay in evacuation, in the event of a fire.

Findings:

During a facility tour from 10/8/12 to 10/12/12, the exit paths were observed.

Ten Story Building - 10/10/12
1st floor
1. At 11:36 a.m., the Sequoia West Conference Room had two doors labeled as exits. One exit door was blocked by a table and more than 5 chairs.


28602

Trauma Building - 10/10/12
3rd Floor
2. At 2:32 p.m., one of two exit doors in the corridor exiting to the 4th floor, failed to open when the button was activated. Staff 1 made several attempts.
During an interview he reported that they have had problems with this door.

Based on observation, the facility failed to maintain their fire alarm system, as evidenced by pull stations that were obstructed, and by alarm notification devices that failed. This affected two of five floors in the 5 Story Building, and two of seven floors in the Trauma Building. This could result in a delay in notification, in the event of a fire.

Findings:

During record review and the facility tour with staff, from 10/8/12 to 10/12/12, the alarm testing records and the fire alarm system were observed.

Trauma Building - 10/8/12
1. During record review, at 2:55 p.m., the quarterly inspection of the fire alarm system, dated 7/20/12, indicated that the "Won" door (horizontal fire barrier) failed to work, in the Rotunda, 5th floor.
During an interview, the vendor reported that he is currently working with another vendor to get the door repaired.

Five Story Building - 10/11/12
1st Floor
2. At 11:25 a.m., the strobe light notification device at Endoscopy Recovery, failed to alarm upon activation of the fire alarm system.

3. At 11:26 a.m., the strobe light notification device at the endoscopy hallway, outside recovery, failed to alarm upon activation of the fire alarm system.

Trauma Building
10/12/12- 4th Floor
4. At 9:04 a.m.,the strobe light notification device inside the bathroom 4458A, was observed during fire alarm testing. The device failed to alarm upon activation of the fire alarm system.


31070

During the facility tour with Staff 4, 6, and 7 between 10/8/12 and 10/12/12, the manual fire alarm boxes were observed.

5 Story Building - 10/9/12
5th Floor -
5. At 2:20 p.m., the manual fire alarm box near Room 542 was obstructed by a work station on wheels.
Staff 6 confirmed the work station on wheels obstructed access to the manual fire alarm box.

Based on observation and record review, the facility failed to maintain their smoke detectors. This was evidenced by one smoke detector that was covered in tape, by no records for testing all smoke detectors, by smoke detectors that failed to activate the fire alarm system, and by no records for sensitivity testing of all smoke detectors. This affected the basement of the 10-Story Building, the CMP, the Radiology Clinic, and four of seven floors of the Trauma Building. This could result in a delay in notification, in the event of a fire.

NFPA 101, 2000 edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72 National Fire Alarm Code 1999 Edition
7.2.2. Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2.
13. Initiating Devices
(g) Smoke Detectors - The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:

(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During record review and the facility tour from 10/8/12 to 10/12/12, the smoke detectors were observed and testing records were requested.

10/8/12
Record Review for the CMP
1. At 1:45 p.m., documentation for annual testing of the smoke detectors, dated 4/20/12, showed that six of six smoke detectors in the building were not tested. The comments indicated that they "need to be tested with the elevator company."

10 Story Building - 10/10/12
Basement
2. At 1:40 p.m., the smoke detector in the linen chute room was covered with blue masking tape.

Radiology Clinic - 10/11/12
3. At 9:25 a.m., smoke detectors were observed at the clinic. There were no records for detector sensitivity testing provided.


28602

Trauma Building - 10/11/12
1st Floor
4. At 3:53 p.m., the smoke detector in the corridor by Room 1289A was tested. The smoke detector failed to activate the fire alarm system. The smoke detector was tested five times with canned smoke.

10/12/12
2nd Floor
5. At 8:15 a.m., the smoke detector in the OR suites failed to activate the fire alarm system. The smoke detector was tested four times with canned smoke.

7th Floor
6. At 9:48 a.m., the smoke detector in the elevator lobby failed to activate the fire alarm system. The smoke detector was tested seven times with canned smoke.


29752

Trauma Building - 10/11/12
4th Floor
7. At 2:02 p.m., a smoke detector, in a corridor by the Electrical Room and Directors Office, activated the elevator smoke barrier curtain. The smoke barrier curtain dropped on one of the double set of elevators after the smoke detector was activated.
During an interview, Staff 4 explained that "some wiring may have crossed."

28602


Surveyor: Mills, Marie
Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by escutcheon rings that were corroded, by missing escutcheon rings or escutcheon rings that were not flush to the ceiling, by sprinklers covered with debris, and by sprinklers with less than 18 inch clearance. This could result in a malfunction of the sprinkler system, or an obstruction to the water spray pattern, which could delay extinguishing a fire. This affected the 5 Story Building, the 10 Story Building, the Trauma Building, the Radiology Center and the Fresno Dialysis Clinic.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems,1998 Edition
2-2 Inspection.
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.
2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
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.

4.3.1 Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.
5-5.6* Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 inch (457 mm) or greater.

Findings:

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the facility automatic sprinkler system was observed. Escutcheon rings are used to cover penetrations around sprinkler pipes and sprinkler heads. The sprinkler deflector diverts the water to create a spray pattern when the sprinkler is activated.

5 Story Building - 10/9/12
5th Floor -
1. At 2:16 p.m., the escutcheon ring was corroded, in the Room 503 bathroom.

2. At 2:31 p.m., the escutcheon ring was missing in Patient Shower A, located across from Room 548.

3. At 2:32 p.m., the escutcheon ring was corroded in Patient Shower B, located across from Room 548.

5 Story Building
4th Floor -
4. At 2:47 p.m., 1 of 8 sprinklers in Room 408 was covered with dust and/or dirt.

3rd Floor -
5. At 3:47 p.m., the escutcheon ring was corroded in Patient Shower A, located near Room 308.

6. At 4:02 p.m., the escutcheon ring was corroded in Patient Shower A, located across from Room 348.

7. At 4:03 p.m., the escutcheon ring was corroded in Patient Shower B, located across from Room 348.

5 Story Building - 10/10/12
2nd Floor -
8. At 8:05 a.m., the escutcheon ring was corroded in Patient Shower B, near Room 206.

9. At 8:21 a.m., the escutcheon ring was corroded in Patient Shower A, located across from Room 248.

10. At 8:36 a.m., there was a box of head covers on the top closet shelf in the closet next to Surgery Med Room 2 Central. The box was approximately 4 inches below the sprinkler deflector.

11. At 9:11 a.m., the escutcheon ring was corroded in the patient bath, located across from Room 230.

12. At 9:13 a.m., the escutcheon ring was corroded in the patient shower, located across from Room 230.

Med Surge - 5 Story Building
1st Floor -
13. At 1:12 p.m., 3 of 3 sprinklers in the kitchen pantry area were covered with dust and/or dirt.

14. At 1:30 p.m., the escutcheon ring was not flush to the ceiling in the Manager Support Services office. There was an approximately 2 inch gap. Staff 4 tried to push the escutcheon ring back up.

Surveyor: Rodriguez-Herrera, A
During record review on 10/8/12 and 10/9/12, the records for quarterly sprinkler inspection and testing were reviewed.

Five and Ten Story Buildings - 10/8/12
15. At 1:27 p.m., there were no testing records for the sprinkler system for the 1st quarter of 2012. The facility provided three testing records titled, "Inspection, Testing, Maintenance of Water Based Fire Protection Systems."
At 1:28 p.m., during an interview, Staff 2 reported that there was a change in vendors in May of this year. He reported that the previous vendor failed to perform the quarterly sprinklered testing for the first quarter.

5 Story Building - 10/9/12
16. At 8:45 a.m., the quarterly sprinkler system testing records dated 9/24/12, indicated the system "failed." The document reported "Risers 1 and 2 in 5 Story, risers 1/2 time valves are leaking. Recommend replace time valves with new."
At 8:46 a.m., during an interview, the vendor (technician) reported that the repair is currently taking place together with the 5 year certification.

Trauma Building - 10/9/12
17. At 8:52 a.m., the quarterly sprinkler system testing records dated 9/24/12, indicated the system "failed." The document reported "Loaded and painted fire sprinkler heads in various areas (see 5 year report)."
At 8:53 a.m., during an interview, the vendor (technician) reported that the repairs are currently taking place together with the 5 year certification.

10/10/12
5th Floor
18. At 8:07 a.m., the escutcheon ring was not flush to the ceiling in the Burn Unit OR. There was an approximately 1/2 inch gap between the escutcheon ring and the ceiling exposing an approximately 1/4 inch penetration around the sprinkler pipe.

Surveyor: Naser, Zeina
Record Review for Radiology Center
10/12/12
19. At 1:30 p.m., records indicated that the sprinkler system was tested on 10/11/12. There were no records for testing the sprinkler system during the first, second, and third quarters (January to September) of 2012.

Fresno Dialysis Clinic
10/8/12 -
20. During record review at 1:30 p.m., records indicated that the sprinkler system was tested on 1/5/12, 5/23/12, and 8/2/12. There were no records for testing the sprinkler system during the fourth quarter of 2011.

Based on an interview at 1:45 p.m., Engineering Staff 2 stated that the Fresno Dialysis Clinic sprinkler system was under contract for semi-annual testing with the previous vendor. The new vendor, which began their contract in May, started testing the system quarterly.





29665

Based on observation, the facility failed to maintain their portable ABC fire extinguishers. This was evidenced by one fire extinguisher that was overcharged, one fire extinguisher that was obstructed, and by one fire extinguisher that was missing the nozzle ring. This could result in a delay to extinguish a fire if the extinguisher was non-operable in the event of a fire. This affected 3 of 5 floors in the 5 story building.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition
1-6.2 Portable fire extinguishers shall be maintained in a fully charged and operable condition, and kept in their designated places at all times when they are not being used.

4-3.1 Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of a least the following items:
(a) Location in designated Place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged
nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

During the facility tour with Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the fire extinguishers were observed.

5 Story Building - 10/9/12
5th Floor -
1. At 2:15 p.m., a portable ABC fire extinguisher was obstructed by a work station on wheels, located near Room 505.
Staff 6 confirmed the work station on wheels obstructed access to the fire extinguisher.

10/10/12
1st Floor
2. At 9:39 a.m., the fire extinguisher, in the Electrical Room in the Endoscopy Unit, was missing the nozzle ring. The fire extinguisher was mounted on the bracket backwards to prevent the hose from obstructing the door entrance.

5 Story Building Trauma Unit - Critical Care
2nd Floor -
3. At 2:23 p.m., the fire extinguisher located in Sterile Processing, next to the ETU vestibule, was overcharged. The needle pointed to the red zone marked overcharged.
Staff 6 confirmed the fire extinguisher was overcharged.

Based on record review, the facility failed to maintain their air duct fire protection system, as evidenced by no records for testing two of seventeen fire dampers in the Cancer Center. This affected one of two floors of the Cancer Center and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a facility tour and record review from 10/8/12 to 10/12/12, the fire dampers were observed and maintenance records were reviewed.

Cancer Center
10/11/12
At 11:46 a.m., the Fire Inspection Report indicated that the fire dampers were tested on 1/19/12. The report stated that Fire Link Damper 001, located in the library storage room, and Fire Link Damper 005, located in the hatch by the men's restroom in the lobby, were in-accessible and not tested. There were no documents showing that the dampers were made accessible for testing after the findings were identified.

Based on observation and interview, the facility failed to use portable space heaters in accordance with the manufacturer's recommendation. This was evidenced by space heaters with a maximum temperature above 212 degrees F, and by heaters placed adjacent to furnishings and under desks. This affected 2 of 5 floors in the 5 Story Building, in the Administration office areas and the Resident Call Room Unit. This could result in an increased risk of fire.

Findings:

During the facility tour with Staff 4, Staff 6 and Staff 7, on 10/9/12 and 10/10/12, the office areas were observed in the 5 Story Building.

3rd Floor
1. At 3:38 p.m., there was a gray portable space heater located inside the Perinatal/Newborn Manager's office, next to the desk. The Manager's office is located in a smoke compartment with resident rooms, across from Room 323.

Based on the manufacture's specification information, received from Staff 4, the brand of the heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear."

2. At 3:42 p.m., there was a gray portable space heater located inside the PNU/NBU Clinical Supervisor's office. The Clinical Supervisors office faces the corridor. The heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

3. At 4:27 p.m., there were 2 gray portable space heaters located inside the Resident Call Room Unit. There was one gray portable space heater located under the computer desk and one portable space heater sitting on a table near the couch. The heater was on. The room was empty and the gray portable space heater was left unattended. Both heaters were identified by Staff 4, as Dayton Oil-Filled Flat Panel Heaters. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear."

5 Story Building - 10/10/12
2nd Floor -
4. At 9:17 a.m., there was a gray portable space heater inside the Administration offices located under the desk of Executive Assistant 1.
During an interview, Staff 4 confirmed the heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear".

5. At 9:18 a.m., there were two heaters located in the Associate Administration office. There was a Dayton Oil-Filled Flat Panel Heater under the desk and a Dakota brand portable electric heater with a Oil-Filled Column in the office space.

Based on the manufactures heater specification information received from Staff 4, the Dakota brand portable electric heater is 120 Voltage and the Rated Maximum Power is 1500w.
The Dayton brand Oil-Filled Flat Panel Heater maximum Fahrenheit is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear".

6. At 9:22 a.m., the was a gray portable space heater inside the Administration offices located under the desk of Executive Assistant 2.
Staff 4 confirmed the heater was a Dayton Oil-Filled Flat Panel Heater. The maximum Fahrenheit of the Dayton heater is 239F and the over limit switch is 248F cutoff.

The sticker affixed to the heater reads: "Warning: risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3 feet (0.9m) from the front of the heater and away from sides and rear".

Based on observation, the facility failed to ensure that all means of egress are continuously maintained free of obstructions. This was evidenced by items that were stored in the path of egress in an exit access. This had the potential to affect all staff and patients on one of seven floors in the Trauma Building and could potentially result in injury or a delayed evacuation in the event of an emergency.

Findings:

During the facility tour with staff from 10/8/12 to 10/12/12, the corridors were observed.

Trauma Building - 10/9/12
1st Floor
1. At 2:10 p.m., there were 2 gurneys with patients, lined up against the wall, in the Green Zone corridor, Rooms 16-21, next to Zone E.
At 2:11 p.m., during an interview, the patient next to Zone E reported she had been at this location for approximately 23 hours.

2. At 2:17 p.m., there were 2 gurneys with patients, lined up against the wall, in the Yellow "M" Zone by the Nurses Station.
At 2:18 p.m., during an interview, one patient reported he had been at this location since yesterday at approximately 6:30 p.m.

3. At 2:20 p.m., there were 2 gurneys with patients, lined up against the wall, in the Yellow Hall G and H.
At 2:21 p.m., during an interview, one patient reported he had been at this location since yesterday at approximately 7:30 p.m.

4. At 2:23 p.m., there was 1 gurney with a patient, lined up against the wall, in the Yellow J Hall, across room Yellow 8. There was an empty gurney across room Yellow 7.
At 2:24 p.m., during an interview, the patient reported she had been at this location since this morning, at approximately 9:30 a.m.

5. At 2:42 p.m., there was 1 gurney with a patient, lined up against the wall, in the Green Hall P.
At 2:43 p.m., during an interview, the patient reported he had been at this location for approximately 2 1/2 hours.

10/10/12
6. At 4:12 p.m., there was an empty gurney, lined up against the wall, in Red Hall A, against the wall, near an exit door.

7. At 4:22 p.m., there was a gurney with a patient in the Yellow Hall G. There were also privacy dividers blocking approximately 100% of the connecting corridor.

On 10/11/12, at 8:10 a.m., during an interview, the clinical supervisor reported that the gurney had to be pulled away from the wall as an additional nurse was needed to assist with the IV. She reported that this was not a usual occurrence, as the gurneys were always against the wall and that the privacy partitions were needed for patient privacy. She stated that the privacy partitions do not normally block the entire corridor.

Based on observation and interview, the facility failed to maintain their soiled linen and trash receptacles. This was evidenced by rooms storing more than 32 gallons of soiled linen, that were not protected as hazardous areas, and by soiled linen and trash receptacles with capacities greater than 32-gallons that were not stored in rooms protected as hazardous areas. This affected the basement of the 10-Story Building and one of two floors of the Ambulatory Care Center. This could result in the increased risk of a fire.

Findings:

During the facility tour from 10/8/12 to 10/12/12, soiled linen and trash receptacles were observed throughout the facility.

10-Story Building - 10/10/12
Basement
1. At 1:55 p.m., there was an approximately 100-gallon trash cart filled with cardboard, in the corridor outside the pharmacy.
During an interview at 1:56 p.m., the pharmacy buyer stated that the cart sometimes stays in the corridor for two or three days before housekeeping staff picks it up.

2. At 2:01 p.m., there was a soiled linen cart with more than 96 gallons of soiled linen, in the corridor leading to the ramp into the Trauma Center basement.
During an interview at 2:02 p.m., Engineering Staff 3 stated that the soiled linen stays in the corridor until it is picked up once a day.

Ambulatory Care Center - 10/12/12
2nd Floor
3. At 9:14 a.m., the special services soiled utility room contained three 32-gallon soiled linen bins. The door to the utility room was not equipped with a self-closing device.


28602

Trauma Building - 10/9/12
5th Floor
4. At 4:24 p.m., there was one 40 gallon soiled linen cart outside Rooms 53332A and 53333A, against the wall.
During an interview, nursing staff reported that the soiled linen container (cart) is always stored at the same location.

10/10/12
5. At 8:14 a.m., a 55 gallon and a 32 gallon trash container were lined up against the wall in the Burn Unit hallway. The carts were within a 64 square foot area.

6. At 8:22 a.m., a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin were lined up, side by side, against the wall in the Room T533. The carts were within a 64 square foot area.

7. At 8:24 a.m., there were a tan 23 gallon trash container, and one 18 gallon Biohazard bin lined up, side by side, against the wall in the Patient Room T531. The carts were within a 64 square foot area.

8. At 8:27 a.m., a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin were lined up, side by side, against the wall in the Patient Room T530. The carts were within a 64 square foot area.
At 8:28 a.m., during an interview, nursing staff reported that all the patient rooms in the Burn Unit contain the trash, linen and Biohazard containers.

9. At 8:30 a.m., a tan 23 gallon trash container, and one 18 gallon trash bin were lined up, side by side, against the wall in the ante room. The carts were within a 64 square foot area.

10. At 8:33 a.m., there were 2 tan 23 gallon trash containers lined up, side by side, against the wall in room 118A, Procedure Room of the Burn Unit. The carts were within a 64 square foot area.

11. At 8:47 a.m., there was a tan 23 gallon trash container, and one 18 gallon Biohazard bin lined up, side by side, against the wall in Patient Room 524, 5-ICU North Unit. The carts were within a 64 square foot area.

10/10/12
4th Floor
12. At 9:52 a.m., a tan 23 gallon trash container, and one 18 gallon Biohazard bin were lined up, side by side, against the wall in Room T432, in the Cardio Vascular Unit. The carts were within a 64 square foot area.

13. At 9:56 a.m., a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin were lined up, side by side, against the wall in the Patient Room 4131A. The carts were within a 64 square foot area.

14. At 10:10 a.m., there was a tan 23 gallon trash container, a 32 gallon soiled linen container, and one 18 gallon Biohazard bin lined up, side by side, against the wall in Room T413, in the ICU 4 North Unit. The carts were within a 64 square foot area.
During an interview, nursing staff reported that all rooms in the ICU 4 North (413 to 424) have these containers.

15. At 10:15 a.m., there were two tan 23 gallon trash containers, one 32 gallon soiled linen cart, and one 18 gallon Biohazard bin lined up, side by side, against the wall in Room 4428A. The carts were within a 64 square foot area.

10/10/12
3rd Floor
16. At 2:05 p.m., one tan 23 gallon trash container, and one 23 gallon Biohazard bin were lined up, side by side, against the wall in the X-Ray Room 5, in Radiology. The carts were within a 64 square foot area.

17. At 2:14 p.m., there were a tan 23 gallon trash container, a 32 gallon soiled linen cart and one 18 gallon Biohazard bin lined up, side by side, against the wall in the X-Ray Room 6, in Radiology. The carts were within a 64 square foot area.

1st Floor
18. At 4:05 p.m., there was a 23 gallon trash container, and a 32 gallon soiled linen cart lined up, side by side, against the wall in the trauma area, Room 2. The carts were within a 64 square foot area.

19. At 4:08 p.m., there was a 23 gallon trash container and a 23 gallon Biohazard bin lined up, side by side, against the wall in the trauma area, Room 3. The carts were within a 64 square foot area.

20. At 4:10 p.m., there was a 23 gallon trash container and a 23 gallon Biohazard bin lined up, side by side, against the wall in X-Ray Room 3. The carts were within a 64 square foot area.

21. At 4:13 p.m., there was a 23 gallon trash container and an 18 gallon Biohazard bin lined up, side by side, against the wall in Room 113A, in the Red Zone in the emergency department.

Based on observation, the facility failed to maintain their medical gas storage areas. This was evidenced by an oxygen room with a self-closing door that failed to latch, by electrical fixtures in a medical gas supply room that were mounted less than 5 feet from the floor, and by oxygen cylinders that were not secured. This affected two of ten floors of the 10-Story Building, three of seven floors of the Trauma Building, and could result in damage to the medical gas cylinders.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the Standard of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches, and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.

4-3.5.2.2 Storage of Cylinders and Containers. If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

Findings:

During a facility tour from 10/8/12 to 10/12/12, the medical gas storage areas were observed.

10-Story Building - 10/10/12
2nd Floor
1. At 11:04 a.m., there were six nitrogen H-tanks and two argon H-tanks in the medical gas storage room in the surgery corridor. There was a light switch approximately 4 feet from the floor, near the argon tanks. There was a four-plug receptacle outlet approximately 10 inches from the floor, near the nitrogen tanks.

Trauma Center - 10/10/12
Basement
2. At 2:31 p.m., the medical storage room contained more than 100 oxygen E-tanks. The door into the storage room was equipped with a self-closing device. The door closed but failed to latch.

Trauma Center
1st Floor
3. At 4:09 p.m., there were three oxygen E-tanks on the floor, unsecured, in the emergency department storage room (Room 1166 B).


28602

Trauma Building
3rd Floor
4. At 3:00 p.m., the oxygen storage room in the Hot Lab (Nuclear) had full and empty E sized cylinders stored in the same racks. There were two racks with full and empty cylinders in the racks. There was no sign indicating which cylinders were empty or which were full.
During an interview, lab staff reported that the oxygen cylinders are mixed storage and have always been stored this way.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities. This was evidenced by electrical panels that were not maintained with 36 inch clearance, by missing electrical box outlet/fixture and call light cover plates, by surge protected multi-outlet extension cords (surge protectors), connected to other surge protectors, by appliances that were plugged into a surge protector, and by the use of extension cords and adapters without overcurrent protection. This affected four of five floors in the 5 Story Building, two of ten in the 10 Story Building, and three of seven floors in the Trauma Building and could result in an increased risk of an electrical fire.

NFPA 70 National Electrical Code 1999 Edition
110-32. Work Space About Equipment. Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6 1/2 feet (1.98 m) high (measured vertically from the floor or platform), or less than 3 ft. (914 mm) wide (measured parallel to the equipment). The depth shall be as required in Section 110-34(a). In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels.

(a) Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces Minimum Clear Distance (ft)
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of electrical equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(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.

NFPA 99 Health Care Facilities 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

Findings:

During the facility tour with Staff 1, Staff 5, Staff 4, Staff 6, and Staff 7, between 10/8/12 and 10/12/12, the electrical wiring and equipment were observed.

Trauma Building - 10/9/12
5th Floor
1. At 4:30 p.m., there was a six plug surge protector connected to another six plug surge protector in Room 5322A, Executive Secretary Burn Services Office. The surge protectors were used to connect computer and office equipment to the wall outlet.

10/10/12
5th Floor
2. At 8:05 a.m., there was a six plug surge protector connecting medical equipment, "Bovie," a "Fibrin Glue Sprayer," a bed plug and a SCD (Sequential Compression Device), to the wall outlet in the burn unit OR.

3. At 8:45 a.m., there was a six plug adapter, without overcurrent protection, connecting a mid size refrigerator, and office and computer equipment to the wall outlet in the Critical Care Director's Office 524, 5-ICU North Unit.

4th Floor
4. At 10:06 a.m., there was a six plug surge protector connecting a mid-size refrigerator to the wall outlet in Room 4158A, Manager's Office.

5. At 10:28 a.m., there was a six plug surge protector connected to another six plug surge protector, in Room 4254A, the Clinical Supervisor's Office.

3rd Floor
6. At 1:20 p.m., there was a black extension cord, without overcurrent protection, connecting a water cooler to the wall outlet in Room 3212A, Radiology Break Room.

7. At 2:20 p.m., there was a six plug surge protector connecting a mid size refrigerator, a microwave, an ultra sound machine and a phone charger to the wall outlet, in Room 3003, PICC. The surge protector was on a metal rack.

8. At 2:22 p.m., there was an eight plug surge protector connected to a six plug surge protector, connected to the wall outlet, in Room 3003A.

9. At 2:24 p.m., there was an orange heavy duty extension cord, without overcurrent protection, connected to a six plug surge protector in Room 3003A, underneath the desk.

10. At 2:38 p.m., there was a six plug surge protector connecting a microwave to the wall outlet in Room 3124B, Radiology Staff Lounge.


29665


10-Story Building - 10/9/12
10th Floor
11. At 2:28 p.m., there was an approximately 8 inch by 8 inch electrical box with no cover, in the Step Down 1 medication room.

12. At 2:55 p.m., there was an approximately 6 inch by 6 inch electrical box with no cover, in the Internal Medicine clinical pharmacy office.

10-Story Building - 10/10/12
1st Floor
13. At 11:26 a.m., there was a lamp plugged into an extension cord in the Critical Care/Trauma Fellows office. The extension cord was plugged into a six-plug surge protector.

Trauma Center
1st Floor
14. At 4:23 p.m., there was a refrigerator plugged into a six-plug surge protector, in the office across from the Behavioral Care Unit.


31070

5 Story Building - 10/9/12
4th Floor -
15. At 3:17 p.m., the electrical panel labeled 4E had no cover. The panel was located in the linen closet near Nurses Station 4 (east). The cover to the electrical panel was on the floor leaning against the wall.

16. At 3:33 p.m., the call light cover was missing above the door labeled Employee Only in the alcove next to Room 429.

3rd Floor
17. At 4:25 p.m., there was no cover on the light fixture, in the storage closet, located in the Resident Call Room Unit.

18. At 4:33 p.m., the electrical panel labeled 3D, located near Room 321, was obstructed by a weight scale and perinatal care stand.

5 Story Building - 10/10/12
2nd Floor -
19. At 8 a.m., the telephone outlet was not flush to the wall, in the storage room across from Room 201.

1st Floor
20. At 9:28 a.m., a microwave was plugged into a surge protector located in the Doctor's Lounge.

21. At 9:30 a.m., the computer port outlet, located in the Doctor's Lounge, was missing a cover.

22. At 9:34 p.m., a refrigerator and microwave were plugged into a surge protector, located in the Medical Records office.

23. At 9:38 a.m., a refrigerator, microwave, radio and a fan, were plugged into a surge protector located in the Endoscopy Scheduling room.

24. At 9:43 a.m., a refrigerator, coffee machine, microwave and a fan were plugged into a surge protector located in P.A. 1.

25. At 9:56 a.m., a refrigerator was plugged into a surge protector located in the Endoscopy scope storage room.

26. At 10:44 a.m., a refrigerator was plugged into a surge protector located in the Endoscopy Administration office H1756.

5 Story Building - Med Surge
1st Floor -
27. At 11:23 a.m., the electrical panels labeled XA and XB, located next to Exam 4 room, in the Neurodiagnostic Unit, were obstructed by a wheelchair.

29. At 11:38 a.m., a coffee maker was plugged into a gray extension cord, in the Employee Breakroom, located in the Pulmonary Function Unit.

30. At 11:47 a.m. the call light cover, above the door to the Nursing Administration office, was broken.

31. At 1:03 p.m., a radio was plugged into a surge protector located in the kitchen offices under the staff desk.

32. At 1:20 p.m., a microwave was plugged into a surge protector located in the Medical Staff office.

33. At 4:29 p.m., a refrigerator was plugged into a surge protector located in the ED Administrative Support office 1284A.

The Fire and Life Safety Inspection Manual states "Extension cords should be used only to connect temporary portable equipment, not as part of permanent wiring. Nor should they be used to supply equipment that will load them beyond their rated capacity."