HospitalInspections.org

Based on observation, the facility failed to maintain the building construction, as evidenced by unsealed penetrations in the walls or ceilings.
This affected one of three smoke compartments on the first floor and the smoke compartment on the second floor. This could result in the spread of smoke from one area to another in the event of a fire.

Findings:

During the facility tour with facility staff on 8/30 and 8/31/10, the walls and ceilings were observed.

8/30/10 - 2nd Floor
1. At 12:28 p.m., there was an approximately 1/8 inch round penetration in the communication room located inside the conference room. The penetration was on the back wall.

2. At 12:30 p.m., there was an approximately 1/8 inch round penetration in the medical storage room located inside the conference room. The penetration was on the South wall.

1st Floor-
3. At 2:11 p.m., there was an approximately 1/8 to 1/4 inch round penetration in the pharmacy storage room. The penetration was in the right wall.




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4. At 12:22 p.m., there was an approximately 1/8 inch penetration around wires in the ceiling of the Lab reception area.

5. At 2:12 p.m., there was an approximately 1/8 inch penetration around a blue wire, in the left wall near the window, in the administration assistant's office.

6. At 2:18 p.m., there was an approximately 1/4 inch penetration around wires in the ceiling and an approximately 1/8 inch round penetration in the ceiling of the pharmacy office.

7. At 2:19 p.m., there were two approximately 1/8 inch penetrations in the left wall of the pharmacy. There were four approximately 1/8 - 1/4 inch penetrations in the back wall near the Micro Sphere Hood. There was an approximately 1/4 - 1/2 inch penetration around blue wires in the ceiling, above the shelves, on the front wall.

8. At 2:20 p.m., there was an approximately 1/8 inch penetration around a wire, in the ceiling near the vent, in the medication night locker.

9. At 2:48 p.m., there was an approximately 1/8 inch penetration around the conduit, above the entrance to Radiology Room 1. There was an approximately 1/4 inch penetration around the conduit, above the entrance to Radiology Room 2. The conduits provided power to the red lights above the doors.

10. At 2:49 p.m., there was an approximately 1/8 inch penetration around a pipe sleeve in the ceiling in the Pacs Station area, Radiology. There was an approximately 1/8 inch penetration around computer wires in the ceiling of the hallway near the processor room.

Based on observation, the facility failed to ensure corridor walls are constructed to resist the passage of smoke. This was evidenced by penetrations located in one corridor wall. This could allow the spread of smoke or fire in the event of a fire, affecting one of three exit corridors.

Findings:

During the facility tour with facility staff on 8/30/10, the corridor walls and ceilings were observed.

At 10:05 a.m., there was an approximately 1/8 - 1/4 inch penetration around the magnetic hold open device for the smoke barrier doors near the OR (operating room) area. The magnetic device was loose, on the right side corridor wall, exposing the penetration on two sides of the device.

Based on observation, the facility failed to ensure that corridor doors resist the passage of smoke, that there are no impediments to closing the doors, and that doors close and latch. This was evidenced by doors that were obstructed and by doors that failed to close and latch. This could result in the spread of smoke or fire, in the event of a fire. This affected three of three smoke compartments in the main hospital.

Findings:

During the facility tour with facility staff on 8/30 and 8/31/10, the corridor doors were observed.

8/30/10 - 1st floor
1. At 2:14 p.m., the corridor door to the Director of Nursing Office failed to fully close and latch. The door was equipped with a self-closing device.

2. At 2:17 p.m., the corridor door to Room 104 closed but failed to latch.

3. At 2:21 p.m., the corridor door to Room 110 closed but failed to latch.

4. At 2:23 p.m., the corridor door to Room 112 closed but failed to latch.

5. At 2:43 p.m., the corridor door to the Respiratory Therapy Cardio-Pulmonary Room failed to fully close and latch. The top of the door was obstructed by the frame. The door was equipped with a self-closing device.

6. At 3:00 p.m., the corridor door to the doctor's lounge closed but failed to latch. The door was tested a couple of times.

7. At 3:06 p.m., the corridor door to the registration area for the emergency department closed but failed to latch.



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8. At 2:46 p.m., the door to the Radiology waiting room was impeded from closing. Chairs were placed against the walls on both sides of the door. A chair placed against the right wall obstructed the door from closing on the right side. A chair placed against the left wall kept the door from closing completely on the latching side. There was an approximately 5-6 inch gap between the door and the door frame on the left side.

9. At 2:58 p.m., the corridor doors to Radiology Rooms 1 and 2 were equipped with kick stand type hardware. The door to Radiology Room 1 was held open by the kick stand. No one was present in the room.

10. At 3:09 p.m., the self closing door to the emergency department waiting room closed but failed to latch.

Based on observation, the facility failed to ensure that smoke barrier walls maintain a 1/2 hour fire resistance rating and are constructed in accordance with 8.3. This was evidenced by smoke barrier walls that had unsealed penetrations around pipes or wires. This could result in the spread of smoke or fire, between smoke compartments, in the event of a fire.
This affected 2 of 3 smoke compartments.

8.3.2 - Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous throughout all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During the facility tour with staff on 8/30/10, the smoke barrier walls were observed in the facility.

1. At 11:27 a.m., the smoke barrier wall, above the smoke barrier doors at the emergency department, was accessed from the roof.
There was an approximately 3/4 - 1 inch penetration around a conduit/pipe sleeve to the right side of the attic access door.
There was an arched shaped cut out in the access door around wires. There was an approximately 1/8 - 1/4 inch penetration around the wires going through the door. The door was not secured.
There was an approximately 1/4 - 1/2 inch penetration around blue wires to the left side of the sprinkler pipe near the air duct.
There was an approximately 1/2 - 3/4 inch penetration around a copper pipe on the right side of the air duct.
There was an approximately 1/8 - 1/4 inch penetration around four separate conduits/pipe sleeves.
There was an approximately 4 inch penetration around a two inch silver pipe.
There was an approximately 1 inch penetration around a silver pipe and cable on the far right side section of the wall.

2. At 11:42 a.m., the smoke barrier wall above the med surge compartment, was accessed from the roof.
There was an approximately 1/8 inch penetration around a conduit on the far right side of the wall.
There was an approximately 1 1/2 x 1 inch penetration at the left side of four conduits, to the right of the hot water pipes. There was an approximately 1/2 inch penetration under the fourth conduit, to the right.
There was an approximately 1/4 inch penetration around a conduit six inches above the floor of the attic, to the left of the four conduits.
There was an approximately 1/8 inch penetration around a conduit to the left of the same area.
There was an approximately 1/8 - 1/2 inch penetration around wires and a plastic conduit, in the attic access door.
There was an approximately 4 inch penetration around a pipe sleeve two feet above the hot water pipes.
There was an approximately 3 inch penetration around a silver pipe above the hot water pipes.

During an interview at 11:50 a.m., Staff 3 reported some of the penetrations were due to the ongoing renovation project.

3. At 12:05 p.m., the corridor smoke barrier wall above the new emergency department was observed. There was an approximately 1/4 inch around a pipe sleeve in the center of the wall near the air duct. The pipe sleeve was unsealed.

Based on observation and interview, the facility failed to maintain the smoke barrier doors, as evidenced by door frame and door labels that were painted over or missing on one of three sets of smoke barrier doors. This could result in the installation of a non fire rated door in the smoke barrier. This affected 2 of 3 smoke compartments.

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

Findings:

During a tour of the facility with staff, on 8/30/10, the smoke barrier doors were observed.

At 11:22 a.m., there was no fire rating label on the smoke barrier doors near the med surge area. The rating label on the door frame had been painted over and could not be read.

During an interview at 11:25 a.m., Staff 1 reported the doors had been certified and a label from the vendor was posted on the doors. There was no information for the fire rating of the doors and door frame on the label.
During the exit conference on 8/31/10, information for the fire rating of the smoke barrier doors was requested. No information was received in the district office as of 9/3/10.

Based on observation, the facility failed to ensure that emergency lighting is maintained in operating condition, as evidenced by the failure of one emergency light. This affected one of three smoke compartments and could result in a delay in evacuation in the event of a fire.

Findings:

During the facility tour with staff on 8/30/10, the emergency lighting was observed in the lab area. At 12:24 p.m., Staff 1 pressed the test button on the emergency light. The light failed to illuminate.

Based on observation, document review and interview, the facility failed to ensure smoke detectors are maintained, inspected, and tested in accordance with NFPA 72. This was evidenced by incomplete records for smoke sensitivity testing for 40 of 47 smoke detectors and by no testing records for single station smoke detectors at the clinic. This affects the entire hospital and one smoke compartment in the Oak View Clinic. This could result in the failure of a smoke detector and a delay in notification, in the event of a fire.

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 the 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 outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or aerosol into the detector.

Findings:

During record review with facility staff on 8/31/10, the smoke sensitivity records were requested.

At 11:47 a.m., the record titled, "Sensitivity Testing Report," dated 9/21/09, reported seven smoke detectors were tested by the vendor. There are 47 smoke detectors in the facility.

During an interview at 11:48 a.m., Staff 2 stated that the vendor conducted smoke sensitivity testing for all of the smoke detectors and he does not understand why only seven smoke detectors were documented.





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During the clinic tour on 8/31/10 at 11:15 a.m., four single station smoke detectors were observed in the corridors at the Oak View Clinic. Directions from the manufacturer for weekly testing of the smoke detectors, were printed on the detectors.

At 11:19 a.m., records were requested for testing the smoke detectors. During an interview at 11:19 a.m., Staff 2 reported there were no current records for testing the smoke detectors. He stated he tested the detectors during fire drills.

During an interview at 11:20 a.m., clinic nursing staff revealed they did not test the smoke detectors. The nurse reported they did not keep any records of battery replacement for the smoke detectors. She reported the batteries are replaced when the detectors beep. No records were provided by the facility for weekly testing of the detectors as recommended by the manufacturer or for battery replacement.

During record review on 8/31/10, the records for fire drills for the Oak View Clinic failed to indicate that smoke detectors were tested during each drill.

Based on observation, interview and record review, the facility failed to ensure that at least a local alarm will sound when the sprinkler system valves are closed. This was evidenced by no supervised alarm for 2 of 2 valves on the OS & Y (outside stem and yolk), by no trouble alarm signal to the monitoring company, and by no tamper alarm for the PIV (post indicator valve) at the Keeler Center. There were no records for testing all of the valves in the sprinkler system. This affected the entire facility and could result in a delay in extinguishing a fire if the water supply was turned off. The OS & Y valves and the PIV control the water flow from the water source into the building.

Findings:

1. During the facility tour with facility staff on 8/31/10, the fire sprinkler system was observed.

At 9:55 a.m., the PIV for the sprinkler system for the Keeler Center was observed. The PIV was unsecured. There was no tamper alarm present on the PIV. During an interview at 9:55 a.m., the DSS reported the facility does not test the sprinkler system at the Keeler Center. The building owner is responsible for testing and maintenance of the sprinkler system.

At 10:44 a.m., the waterflow valve at the Riser was closed.
During an interview at 10:50 a.m., the monitoring company confirmed the alarm signals received during alarm testing. They failed to receive a trouble signal at the time when the waterflow valve was closed. The tamper alarm sounded at the panel but was not received by the monitoring company.

At 11 a.m., the valves at the OS & Y were observed on Cuyama Road. There was no tamper alarm provided for the valves that were located approximately 30 feet from the road. During an interview at 11:05 a.m., Engineering Staff 1 reported there was no tamper alarm for the OS & Y valves. He stated the only tamper alarm was located on the water shut off valve at the riser, in the supply room.

2. During record review and interview with facility staff on 8/31/10 the records for quarterly sprinkler inspection and testing were requested.

At 8:30 a.m., the facility provided records for quarterly testing at the hospital. The report for quarterly testing at the main hospital, failed to indicate testing and maintenance of the OS & Y valves located on Cuyama Road.

Based on observation, interview and record review, the facility failed to
ensure maintenance, inspection, and quarterly testing of the sprinkler system were completed as required by NFPA 13 and NFPA 25. This was evidenced by escutcheon rings (ER), that were missing or not flush with the ceiling, by missing spare sprinklers, by storage within 18 inches of the sprinkler and by incomplete records for testing the sprinkler system. There were no records for quarterly inspection and testing of the sprinkler system for 4 of 4 quarters in the Keeler Center.
This could potentially limit the effectiveness of the automatic sprinkler system to extinguish a fire in the event of a fire, affecting the entire hospital and the Keeler Center.

Escutcheon rings function to cover penetrations around sprinkler pipes.

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 in. (457 mm) or greater.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition

1.8 Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request.
1.8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.
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.

9-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of valves, valve components, and trim. 9-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 9-1
Control Valves
Supervisory Test Semi-annually

Findings:

1. During the facility tour, record review and interview with staff on 8/30 and 8/31/10, the fire sprinkler system was observed and testing records were reviewed.

8/30/10 - Main Hospital
1. At 2:39 p.m., the escutcheon ring was missing in the shower storage room. This exposed an approximately 1/4 inch penetration around the sprinkler pipe in the ceiling. The ER was found lying on the floor of the shower stall.

At 3:01 p.m., two escutcheon rings had gaps, approximately 1/8 and 1/2 inch from the ceiling, in the doctor's lounge and bathroom.

8/31/10
2. At 9 a.m., the spare sprinkler box was observed in the supply storage room, near the riser.
There were no quick response sprinkler heads in the box. The new emergency department and PACU are equipped with quick response sprinklers.
There was only one side wall type sprinkler head and one large pendant type sprinkler head in the box.

During an interview at 9:05 a.m., Staff 1 reported there were no other spare sprinklers in the facility.

8/31/10 - Keeler Center
3. At 9:48 a.m., the kitchenette closet area was observed at the Keeler Center. There were cardboard boxes stacked on a shelf within approximately 3 inches of the sprinkler deflector. The deflector creates the water spray pattern when the sprinkler is activated.

At 9:50 a.m., the reception area closet had boxes and files stacked on a shelf within approximately 5 inches of the sprinkler deflector. The shelf was within approximately 14 inches of the deflector.

4. At 8:30 a.m., the facility provided records for quarterly testing at the hospital. The report provided for quarterly testing at the main hospital failed to indicate testing and maintenance of the OS & Y valves located on Cuyama Road.

At 9:54 a.m., records for quarterly and annual testing of the sprinkler system were requested for the Keeler Center.
During an interview at 9:55 a.m., the DSS reported the facility does not test the sprinkler system at the Keeler Center. The building owner is responsible for testing and maintenance of the sprinkler system. No records were provided for maintenance, inspection or testing of the sprinkler system as of 9/3/10.


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8/30/10 - Main Hospital
At 12:24 p.m., there was an approximately 3/4 to 1 inch penetration on the left side of the escutcheon ring inside the supply room in the Medical Records Office.

At 2:13 p.m., there was an approximately 1/4 - 1/2 inch gap between the escutcheon ring and the ceiling in the bathroom, in the Director of Nursing Office, exposing an approximately 1/8 to 1/4 inch penetration around the sprinkler pipe.

Based on observation and interview, the facility failed to ensure that soiled linen or trash collection receptacles do not exceed a capacity of 32 gallons within any 64 square foot area and that receptacles, when not attended, are located in a room protected as a hazardous area. This was evidenced by multiple receptacles placed in one open area in the facility. This could result in an increased risk of fire in an unprotected area in the facility.

Findings:

During the facility tour with staff on 8/30/10, soiled linen and trash receptacles (carts) were observed in the facility.

1st floor -
At 2:30 p.m., there were two trash carts, side by side, against one wall in the ICU housekeeping utility area. There was a biohazard bin against the back wall of the utility area. The carts and bins were placed approximately 2-3 feet apart. There is no door separating the utility area from the ICU suite.

During an interview Staff 2 reported the trash carts were approximately 25-30 gallons in size and the biohazard bin was approximately 18 to 20 gallons in size. Staff 2 reported the carts and the biohazard bin are kept in this area. Facility staff stated that they were not aware of the requirement to store 32 gallon capacity trash and soiled linen carts in an area protected as a hazardous area.

Based on observation, interview and record review, the facility failed to maintain the medical gas system in accordance with NFPA 99. This was evidenced by oxygen cylinders stored within 5 feet of combustible supplies and furniture, and by the failure to maintain the zone valves per the Medical Gas Inspection Report. This affects 1 of 3 smoke compartments and could result in the increased spread of fire in areas where oxygen is stored or in use.

NFPA 99
8-3.1.11.2(c)(2) Storage for nonflammable gases less than 3000 cubic feet.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d

4 -3.1.1.2(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
7. Combustible materials, such as paper, cardboard, plastics and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Findings:

During the facility tour with staff, on 8/30/10, oxygen cylinders were observed in the facility.

At 2:44 p.m., there were six E cylinders of oxygen stored in the respiratory office.
Two cylinders were within approximately 10 inches of two cardboard boxes of respiratory supplies, within approximately 2 inches of a wooden counter and within approximately 24 inches of two upholstered office chairs.
Four cylinders were within approximately 30 inches of an upholstered office chair and within approximately 40 inches of a wooden counter, shelves, binders and papers, near the office door.

During record review with staff, on 8/31/10, the medical gas discrepancy report was requested.
At 8:40 a.m., the "Ojai Valley Community Hospital Discrepancies" report, dated 1/8/10, indicated there were three discrepancies.
During an interview, Staff 1 stated the discrepancies involving the zone valves in the ICU area were not resolved.

The report indicated that the facility must relocate the zone valve so that a wall intervenes between the valve and the medical gas outlets in accordance with NFPA 99, 2005. The report recommended replacement of the main alarm panel with a newer style panel with sensors located downstream of the ICU zone valve. The report indicated the medical air main alarm located in the ICU "does not have power to it and is not working at this time."

Based on record review, the facility failed to maintain anesthetizing locations in accordance with NFPA 99. This was evidenced by the failure to maintain humidity equal or greater than 35% for multiple days during 9 of the last 12 months. This affected two of two operating rooms and could increase the risk of fire.

NFPA 99, Health Care Facilities 1999 edition
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 per cent or greater.

Findings:

During record review with staff, on 8/31/10, the humidity logs were requested for operating rooms I and II (OR I and II).

At 11:19 a.m., logs indicated the humidity was below 35 % on the following dates:
On 5/11 and 5/12/10, the humidity level was 30 % in OR I and OR II.

On 4/1 and 4/2/10, the humidity level was 30 % in OR I.
On 4/6/10, the humidity level was 30 % in OR II.
On 4/7/10, the humidity level was 32 % in OR I and OR II.
On 4/8, 4/9, and 4/22/10, the humidity level was 32 % in OR II.
From 4/27 - 4/30/10, the humidity level was 30 % in OR I.

From 3/8 - 3/12/10, the humidity level was 30-32 % in OR II.
From 3/15 - 3/19/10, the humidity level was 30-32 % in OR I and was 30-31% in OR II.
From 3/29 - 3/31/10, the humidity level was 30 % in OR I and OR II.

On 2/16 and 2/17/10, the humidity level was 30-32 % in OR I and OR II.
On 2/23/10, the humidity level was 30 % in OR I and OR II.

From 1/4 - 1/8/10, the humidity level was 30-34 % in OR I.
From 1/11 - 1/15/10, the humidity level was 31-34 % in OR I and OR II.

From 12/1 - 12/4/09, the humidity level was 30-32 % in OR I and 32-34% in OR II.
On 12/7 and 12/8/09, the humidity level was 30 % in OR I and OR II.
From 12/28 - 12/30/09, the humidity level was 30-34 % in OR I and OR II.

From 11/17 - 11/19/09, the humidity level was 30-34 % in OR I and OR II.
On 11/23, 11/24, 11/27 and 11/30/09, the humidity level was 30 % in OR I and OR II.

On 10/28 and 10/29/09, the humidity level was 30-32 % in OR I and OR II.

From 9/23 - 9/25/09, the humidity level was 30-33 % in OR I and OR II.

Based on record review and interview, the facility failed to ensure the generator is checked weekly and tested monthly under load for 30 minutes per month in accordance with NFPA 99 and NFPA 110. This was evidenced by incomplete documentation for weekly checks and 30 minute testing for 12 of 12 months.

NFPA 99, Health Care Facilities 1999 edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

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

Findings:

During record review and interview with facility staff on 8/31/10, the generator records provided by the facility were reviewed. The generator logs, "Ojai Valley Community Hospital Standby Emergency Generator Weekly Testing," documented generator transfer switch testing for transfer switches 1, 2, 3, and 4. The records indicated transfer times of 1 Min, 37 Sec, 59 Sec, 3 Sec, and no time for Switch 4 in 2/2010. Other months had similar documentation. There was no record for weekly visual inspection of the generator and no record that indicated the generator was tested under load for 30 minutes each month. No meter readings were documented on the logs.

During an interview at 11:45 a.m., Staff 1 reported he ran the generator for 30 minutes but only recorded information on testing the transfer switches.

Based on observation and interview, the facility failed to ensure electrical wiring and equipment are in accordance with NFPA 70 and failed to prevent the use of flexible cords and cables in the facility. This was evidenced by surge protectors plugged into surge protectors, by the use of extension cords and outlet adaptors, and by items stored in front of electrical panels. This could result in an increased risk of an electrical fire. This affected two of three smoke compartments on the first floor and the second floor of the main hospital.

NFPA 70 National Electrical Code
Article 110 - Requirements for Electrical Installations
B. 60 Volts, Nominal, or Less
110-26. Spaces about Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(a) #2 Width of Working Space. The width of the working space in front of the electric 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.
(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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.

Findings:

During a tour of the facility with staff on 8/30 and 8/31/10, the electrical wiring and equipment were observed.

8/30/10
2nd floor -
At 12:18 p.m., there was an orange heavy duty extension cord plugged into a surge protector. The surge protector was connected to another surge protector connecting computer equipment to the wall outlet in the Computer Training Room.

At 12:23 p.m., there was a surge protector plugged into a surge protector, connecting computer equipment to the wall outlet in the Medical Records office. There was an orange heavy duty extension cord plugged into one of the surge protectors connecting the back up battery for the computer.

At 12:28 p.m., the face plate on the electrical wall outlet was missing in the Communication Room.


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At 12:22 p.m., a surge protector was connected to a six plug adaptor in the lab area. There was no over current protection for the adaptor.

At 2:14 p.m., there was a red extension cord connectin the printer to the wall outlet.

At 2:18 p.m., an electrical box cover was missing in the pharmacy office, above the clock.
At 2:20 p.m., a light fixture was missing, exposing wires in the electrical box, in the pharmacy area.

At 2:23 p.m., an outlet cover was hanging loose from the ceiling in the med/surge nurses' station. There was an approximately 1/4 inch gap between the cover plate and the ceiling.

At 2:56 p.m., there was a printer and a shredder stored in the med/surge corridor in front of electrical panel boxes 4 and 5. The printer was within approximately 6 inches of the electrical panel and the shredder was approximately 12 inches from the panel.

During an interview at 2:57 p.m., DSS stated the equipment was there due to the renovation project.