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Based on observation, the facility failed to maintain the integrity of the wall construction. This was evidenced by unsealed penetrations in walls throughout the facility. This affected three of six buildings, and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the walls in the facility were observed.

Feather River Anti-Coagulation Clinic:

1. On 8/31/10 at 2:30 p.m., there was an approximately two inch diameter unsealed penetration in the wall of the office across from exam Room 6.

Feather River Outpatient Center:

1. On 8/31/10 at 2:55 p.m., there was an approximately one and one half inch wide unsealed penetration in the wall of the medical records room in Suite 4.

Main Hospital:

1. On 9/1/10 at 1:04 p.m., there were five approximately one quarter inch wide unsealed penetrations in the closet wall of Room 235.

2. On 9/1/10 at 1:41 p.m., there was an approximately two inch by three inch unsealed penetration in the wall of the pre-admit office. The penetration was located on the wall behind the desk, and had red and gray cables running through it.

3. On 9/1/10 at 2:02 p.m., there was an approximately two foot by two foot area of dry wall damage behind Bed 7 in the emergency room.

4. On 9/1/10 at 2:05 p.m., there was an approximately two inch wide unsealed penetration in the wall of the janitor's closet near the ambulance entrance to the emergency room.

5. On 9/1/10 at 2:46 p.m., there were two approximately one inch diameter unsealed penetrations, and one approximately two inch diameter penetration, in the wall of the environmental services department. The penetrations were located on the wall above the refrigerator in that room.

Based on observation, the facility failed to maintain the corridor doors. This was evidenced by two doors that were obstructed from latching. This affected two of six buildings, and could result in a delay to contain smoke or fire to a room.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the doors in the facility were observed.

Feather River Sleep Medicine Clinic:

1. On 8/31/10 at 2:01 p.m., the door to the utility room failed to latch when in the closed position. The door was obstructed from latching due to the latching barrel hardware that was not aligned with the strike plate.

Main Hospital:

1. On 9/1/10 at 2:16 p.m., the door to the janitor's closet by the catheterization lab entrance was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain their exits. This was evidenced by two exits that did not have EXIT directional signs leading to them. This affected two of six buildings, and could result in a delay in evacuation in the event of an emergency.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the facility's exits were observed.

Feather River Outpatient Center:

1. On 8/31/10 at 3:30 p.m., the door to the lymphedema therapy office in suite 1 led to an emergency exit. There was no EXIT directional sign indicating there was an emergency exit door in the lymphedema therapy office.

Paradise Midwifery and Nursing Services:

1. On 9/1/10 at 4:31 p.m., the emergency exit located in the back office was observed. There were no EXIT directional signs in the hall leading to the office that indicated there was an emergency exit in that office.

Based on observation, the facility failed to maintain the smoke barrier walls. This was evidenced by one unsealed penetration in one smoke barrier wall. This affected one of six buildings, and and could result in the spread of smoke or fire to other smoke compartments.

NFPA 101, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a facility tour with staff on 9/1/10, the facility's smoke barrier walls were observed.

Main Hospital:

1. At 9:57 a.m., there was an approximately one inch diameter unsealed penetration in the smoke barrier wall near the intensive care unit. There were blue and grey cables running through the penetration.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by one smoke barrier door that was obstructed from latching. This affected one of six buildings, and could result in a delay to contain smoke or fire to a smoke compartment.

Findings:

During a facility tour with staff on 9/1/10, the facility's smoke barrier doors were observed.

Main Hospital:

At 1:52 p.m., the smoke barrier doors by medical imaging were equipped with self-closing devices and magnetic hold-open devices. The doors were released from their magnetic hold-open devices and allowed to close. One of the two door leafs of the smoke barrier doors failed to latch. The door was obstructed from latching by the door frame.

Based on observation, the facility failed to maintain the hazardous areas. This was evidenced by one hazardous area that was not equipped with a self-closing door, and by two corridor doors to hazardous areas that were obstructed from latching. This affected two of six buildings, and could result in a delay to contain smoke or fire to a hazardous area.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the facility's hazardous areas were observed.

Feather River Outpatient Center:

On 8/31/10 at 3:11 p.m., the linen room in Suite 4 was approximately sixty square feet in size, and contained clean linens. The door to the room was not equipped with a self-closing device.

Main Hospital:

1. On 9/1/10 at 10:59 a.m., the corridor door to the pathologist office located in the laboratory was observed. The door was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from latching due to air pressure difference.

2. On 9/1/10 at 11:20 a.m., the corridor door to the soiled linen room by Room 290 was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close. The door failed to latch. The door was obstructed from closing by the door frame.

Based on document review and interview, the facility failed to maintain their fire drill records. This was evidenced by the facility's failure to maintain fire drill records for conducting two of the past four quarterly fire drills for the Feather River Anti-Coagulation Clinic. This affected one of six buildings, and could result in a delay in response to a fire emergency due to facility staff members that are unfamiliar with the proper fire emergency procedures.

Findings:

During document review from 8/30/10 to 8/31/10, the facility's fire drill records were reviewed.

Feather River Anti-Coagulation Clinic:

On 8/31/10 at 10:04 a.m., the facility failed to provide documentation that confirmed fire drills were completed during the third and fourth Quarters of 2009. Staff 1 was interviewed at that time. Staff 1 indicated that the Anti-Coagulation Clinic had moved to its current location approximately eight months ago. Staff 1 indicated that fire drills were completed at the previous location, but that the records could not be located. The last fire drill completed at the Anti-Coagulation Clinic was on 6/7/10.

Based on document review and interview, the facility failed to maintain the smoke detectors in accordance with NFPA 72. This was evidenced by the facility's failure to provide documentation of conducting smoke detector sensitivity testing at Feather River Outpatient Center, and at Feather River Sleep Medicine Clinic. This affected two of six buildings, and could result in a delay in notification of a fire due to smoke detectors outside the manufacturer's sensitivity range.

NFPA 72, 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 be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During document review from 8/30/10 to 8/31/10, the facility's smoke detector sensitivity records were reviewed.

Feather River Sleep Medicine Clinic:

1. On 8/31/10 at 10:04 a.m., the facility did not have records of a smoke detector sensitivity test for the Feather River Sleep Medicine Clinic. Staff 1 was interviewed at that time. Staff 1 indicated they believed the facility's fire alarm system vendor had completed a sensitivity test at that location. Staff 1 contacted the facility's fire alarm system vendor at that time. Staff 1 confirmed with the facility's fire alarm system vendor that a smoke detector sensitivity test had not been completed at the Feather River Sleep Medicine Clinic.

Feather River Outpatient Center:

1. On 8/31/10 at 10:04 a.m., the facility did not have records of a smoke detector sensitivity test for the Feather River Outpatient Center, Suites 1, 4, and 6. Staff 1 was interviewed at that time. Staff 1 indicated they believed the facility's fire alarm system vendor had completed a sensitivity test at that location. Staff 1 contacted the facility's fire alarm system vendor at that time. Staff 1 confirmed with the facility's fire alarm system vendor that a smoke detector sensitivity test had not been completed at the Feather River Outpatient Center, Suites 1, 4 , and 6.

Based on observation, interview, and document review, the facility failed to maintain their sprinkler system shut-off valves. This was evidenced by one post indicator valve and one outside screw and yoke assembly that were not equipped with tamper switches. This affected one of six buildings, and could result in a delay in notification of a suspension in water supply to the sprinkler system.

NFPA 101, 2000 edition
9.7.2.1 Supervisory Signals.
Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the facility's sprinkler system control valves were observed.

Main Hospital:

On 8/31/10 at 12:00 p.m., the post indicator valve and outside screw and yoke assembly near the emergency department construction area was observed. Both devices were not equipped with tamper switches that would alarm the facility if the valves were moved to the closed position. Staff 1 was interviewed at that time. Staff 1 did not know why the valves were not equipped with tamper switches. Staff 1 indicated that the facility would maintain a fire watch at that location until the tamper switches were installed. A facsimile received on 9/3/10 was reviewed. The facsimile indicated that supervisory switches were installed on the post indicator valve and outside screw and yoke assembly on 9/3/10, and tested for function at approximately 11:00 a.m.

Based on observation, the facility failed to maintain access to the portable fire extinguishers in accordance with NFPA 10. This was evidenced by one fire extinguisher that was not readily accessible. This affected one of six buildings, and could result in a delay to extinguish a fire due to obstructed access of a fire extinguisher.

NFPA 10, 1998 edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the fire extinguishers in the facility were observed.

Main Hospital:

On 9/1/10 at 11:29 a.m., the fire extinguisher near Room 286 was located in a wall mounted enclosure. The door to the enclosure could not be opened. Staff 1 had to disassemble the enclosure to access the fire extinguisher.

Based on observation and document review, the facility failed to maintain their kitchen hood exhaust. This was evidenced by an accumulation of grease deposits on the interior kitchen hood exhaust. This affected one of six buildings, and could result in a grease fire to ignite in the kitchen.

NFPA 96, 1998 edition
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the kitchen hood exhaust was observed.

Main Hospital:

On 9/1/10 at 10:36 a.m., the facility's kitchen hood exhaust was observed. There was a thick accumulation of grease deposits on the interior kitchen hood exhaust. There was grease deposits on extinguishing system pipes in the interior of the kitchen hood above the vents. An invoice from the facility's kitchen hood steam cleaning vendor indicated that the hood exhaust was last cleaned on 11/19/09. A cleaning policy for the kitchen hood exhaust was requested on 9/2/10. No policy was provided as of 9/7/10.

Based on observation, the facility failed to maintain their means of egress. This was evidenced by two means of egress that were obstructed. This affected two of six buildings, and could result in a delay in evacuation in the event of an emergency.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the facility's means of egress were observed.

Main Hospital:

On 9/1/10 at 2:25 p.m., the back exit leading from the catheterization lab to the outside was observed. There were condenser units stored directly outside the exit door. The clear width at the narrowest point was measured to be approximately twelve inches. The exit door had an EXIT sign above the door, indicating it was an emergency exit.

Paradise Midwifery and Nursing Services:

On 9/1/10 at 4:27 p.m., the exit door in the back office was obstructed from opening by a brown sofa. The door was opened to the fullest extent, and the clear width was measured to be approximately eighteen inches. The exit door had an EXIT sign above the door, indicating it was an emergency exit.

Based on observation, the facility failed to maintain the mobile soiled linen and trash collection receptacles. This was evidenced by one large trash collection receptacle and two large soiled linen collection receptacles that were not stored in a room protected as a hazardous area. This affected one of six buildings, and could result in a soiled linen or trash ignited fire emergency.

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the facility's soiled linen and trash collection receptacles were observed.

Main Hospital:

1. On 9/1/10 at 2:13 p.m., a ninety-eight gallon capacity trash collection receptacle was stored in an alcove in the intensive care unit. The alcove had sprinkler protection, but did not have a self-closing door.

2. On 9/1/10 at 3:13 p.m., a two foot by three foot by five foot soiled linen collection receptacle was stored in corridor alcoves by Room 113 and Room 145. The alcoves had sprinkler protection, but did not have a self closing door.

Based on observation, the facility failed to maintain their storage of compressed gas in accordance with NFPA 99. This was evidenced by two compressed gas cylinders that were stored unsecured, and by one medical gas storage location that did not have signs identifying it as a storage location. This affected one of six buildings, and could result in a compressed gas cylinder initiated emergency.

NFPA 99, 1999 edition
4-3.1.1.2(a)3 Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

Caution
Oxidizing Gas(es) Stored Within
No Smoking

Findings:

During a facility tour from 8/31/10 to 9/1/10, the facility's compressed gas cylinders and medical gas storage locations were observed.

Main Hospital:

1. On 9/1/10 at 9:47 a.m., one oxygen E cylinder located in the front lobby near the gift shop was stored free standing and unsecured.

2. On 9/1/10 at 10:32 a.m., one compressed gas cylinder in the dietary storage area near the kitchen was observed. The compressed gas cylinder had one chain loosely wrapped around the valve. There was no other protection device that would prevent the cylinder from falling over.

3. On 9/1/10 at 1:34 p.m., sixteen medical gas E cylinders were observed in a storage room near operating Room 4. There was no sign on the door to that storage room indicating oxygen or any kind of medical gas was being stored in that room.

Based on document review and interview, the facility failed to maintain the relative humidity levels in their anesthetizing locations for six of twelve months. This was evidenced by the facility's failure to maintain their relative humidity levels at their anesthetizing locations equal to or greater than thirty-five percent. This affected four of four operating rooms, and could result in a fire emergency due to electrostatic charges in an oxygen-rich environment.

Findings:

During document review from 8/30/10 to 8/31/10, the facility's humidity logs and policy were reviewed.

Main Hospital:

On 8/31/10 at 1:30 p.m., the facility's relative humidity logs for their anesthetizing locations during the past six calendar months were observed. The relative humidity levels for four of four operating rooms had dropped below thirty-five percent on multiple instances during the past six months. The facility's humidity level policy was reviewed. The policy indicated that the relative humidity would be maintained at fifty to sixty percent. Staff 2 was interviewed at that time. Staff 2 indicated that the current alarm setting for the humidity monitoring system was set at a range of twenty to sixty percent. Staff 2 confirmed that the system would not alarm if the relative humidity was in the range of twenty to fifty percent. The facility did not have any other means to monitor their relative humidity levels for their anesthetizing locations in order to maintain the levels at thirty-five percent or above.

Based on observation and interview, the facility failed to maintain their electrical equipment and utilities in accordance with NFPA 70. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords, the use of non-surge protected extension cords, a surge protected multi-outlet extension cord that was plugged into uninterrupted power supply source that was plugged into a surge protected multi-outlet extension cord, and electrical wiring contacts that were exposed. This affected five of six buildings, and could result in an electrical fire to occur.

NFPA 70, 1999 edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the facility's electrical equipment and wiring were observed.

Feather River Sleep Medicine Clinic:

1. On 8/31/10 at 2:04 p.m., two microwave ovens and one top loading toaster oven located in the utility room were plugged into one surge protected multi-outlet extension cord.

Feather River Outpatient Center:

1. On 8/31/10 at 3:27 p.m., a vending machine in the waiting area for Suite 1 was plugged into a surge protected multi-outlet adapter.

Feather River Hospital Cancer Center:

1. On 9/1/10 at 9:14 a.m., a weight scale on the second floor by reception was plugged into a brown non-surge protected multi-outlet extension cord. The cord was plugged into an electrical outlet in a closet, and ran underneath the door to the scale, which was positioned in the hall.

2. On 9/1/10 at 9:37 a.m., a microwave oven in the first floor staff lounge was plugged into a surge protected multi-outlet extension cord.

Main Hospital:

1. On 9/1/10 at 11:12 a.m., computer equipment in the vice president for patient care office was plugged into a surge protected multi-outlet extension cord, that was plugged into an uninterrupted power supply source, that was plugged into a surge protected multi-outlet extension cord.

2. On 9/1/10 at 11:44 a.m., a television in the Same Day Services waiting room was plugged into a white non-surge protected multi-outlet extension cord.

3. On 9/1/10 at 1:07 p.m., television equipment in Room 236 was plugged into a white non-surge protected multi-outlet extension cord.

4. On 9/1/10 at 1:57 p.m., telephone equipment at the nurse station in the emergency room was plugged into a non-surge protected multi-outlet adapter.

5. On 9/1/10 at 2:20 p.m., two miniature refrigerators and one microwave oven in the catheterization lab conference room were plugged into one surge protected multi-outlet extension cord.

6. On 9/1/10 at 2:44 p.m., a refrigerator in the environmental services department was plugged into a surge protected multi-outlet extension cord.

7. On 9/1/10 at 3:00 p.m., a refrigerator near the waiting area in the rehabilitation services department was plugged into a surge protected multi-outlet extension cord.

8. On 9/1/10 at 3:05 p.m., a portable space heater in the wound care office was plugged into a surge protected multi-outlet extension cord.

9. On 9/1/10 at 3:39 p.m., a miniature refrigerator in the social worker's office was plugged into a surge protected multi-outlet extension cord.

Paradise Midwifery and Nursing Services:

On 9/1/10 at 4:36 p.m., electrical wiring running along side the back exterior side of the building was observed. Electrical wiring contacts were exposed, and observed lying on the ground near some scattered dead brush. In an interview, Staff 1 indicated that the contacts were not live.

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

Findings:

During a facility tour with staff from 8/31/10 to 9/1/10, the alcohol based hand rub dispensers were observed.

Feather River Sleep Medicine Clinic:

1. On 8/31/10 at 1:56 p.m., an alcohol based hand rub dispenser in the front office was mounted approximately nine inches above a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

Feather River Outpatient Center:

1. On 8/31/10 at 3:21 p.m., an alcohol based hand rub dispenser by treatment Room 1 located in Suite 6 was mounted approximately five inches to the upper left of a light switch. The hand rub was 62.5 percent ethyl alcohol by volume.

Feather River Hospital Cancer Center:

1. On 9/1/10 at 9:17 a.m., an alcohol based hand rub dispenser in the second floor physician's office was mounted approximately six inches to the upper left of a light switch. The hand rub was 62 percent ethyl alcohol by volume.

2. On 9/1/10 at 9:19 a.m., an alcohol based hand rub dispenser in the second floor medication room was mounted approximately six inches to the upper left of a light switch. The hand rub was 62 percent ethyl alcohol by volume.