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Based on observation, the facility failed to maintain the building construction. This was evidenced by penetrations in ceilings and walls in two utility rooms. This could result in the spread of fire or smoke, in the event of a fire, affecting one of four smoke compartments.

Findings:

During the facility tour with maintenance staff, the hospital building construction was observed.

6/25/13
At 4:25 p.m., there was an approximately 1 inch diameter penetration, around a 1 1/2 inch diameter pipe, in the ceiling of the compressor/vacuum room.

At 4:41 p.m., there were three penetrations in the back wall of the telephone equipment room. There was an approximately 1 inch penetration and two unsealed 2 inch diameter conduit sleeves.

6/26/13
At 10:02 a.m., there was an approximately 2 inch diameter penetration, around multiple cables, in the electrical room off the main corridor.

At 10:05 a.m., there was an approximately 2 inch diameter penetration, in the wall next to conduit sleeves, in the Med Surgical electrical room. There were two unsealed pipe sleeves around data cable bundles.

At 11:24 a.m., there was an approximately 4 inch diameter penetration, in the wall, next to the ER desk. A plumbing clean-out was set back 2 1/2 inches into the wall.

Based on observation, the facility failed to ensure corridor doors close and latch. This was evidenced by doors that failed to self-close and latch and by one door that was obstructed. This could result in the spread of smoke in the event of a fire and affected three of four smoke compartments.

Findings:

During a facility tour with maintenance staff, on 6/26/13, corridor doors were observed.

Hospital
At 9:30 a.m., the door to Room 108 was obstructed from closing by a rubber wedge.

At 10:15 a.m., the janitors closet door failed to latch in the surgical area. Maintenance Staff 1 indicated the door needed adjustment.

At 10:17 a.m., the equipment room was equipped with a self-closing device in the sterilizer room. The door closer arm was disconnected.

At 11:21 a.m., the door on the electrical equipment room, near registration, was equipped with a self-closing device. The door failed to self close. The arm for the self closer was disconnected.

At 11:50 a.m., the Nurse Lounge door was equipped with a self-closing device. The door closer arm was disconnected.

At 12:20 p.m., the door failed to self close in the cardio/respiratory room. The door closer arm was disconnected.

Based on observation, the facility failed to maintain smoke barrier walls. This was evidenced by 13 penetrations in three of three smoke barrier walls. This could result in the spread of fire or smoke affecting four of four smoke compartments.

Findings:

During a facility tour with maintenance staff on 6/25/13, the smoke barrier walls were observed.

At 2:04 p.m., there were five unsealed penetrations in the smoke barrier wall, in the attic above the corridor, near the administrator's office. There was an approximately 1 1/2 inch penetration around cables inside a 2 inch conduit sleeve, and there were three approximately 1/2 inch penetrations in the smoke barrier near the conduit sleeve.

At 2:13 p.m., there were four unsealed penetrations in the smoke barrier wall, in the attic above the corridor, next to Medical Records. There were three approximately 1/8 circular penetrations, and an approximately 1 1/2 inch penetration, around cables, inside four 2 inch conduit sleeves.

At 2:40 p.m., there were four unsealed penetrations in the smoke barrier wall, in the attic above the smoke barrier doors at acute nursing. There was an approximately 3/4 inch penetration around a cable inside a 1 inch conduit sleeve near Room 110. There were two approximately 1/2 inch penetrations and one 3/4 inch penetration, in the attic, over the smoke barrier doors near Room 115.

Based on observation and interview, the facility failed to maintain all smoke barrier doors. This was evidenced by one smoke barrier door that failed to close completely. This could result in the spread of smoke in the event of a fire affecting two of four smoke compartments.

Findings:

During a tour of the facility with Maintenance Staff 2, on 6/25/13, the smoke barrier doors were observed.

At 3:52 p.m., one of two smoke barrier doors failed to close completely. The doors were located near Patient Room 101. The left side door released but failed to close completely leaving an approximately four inch gap.

During an interview, Maintenance Staff 2 indicated that the push bar hardware failed to release a latch at the top of the door, which obstructed it from closing completely.

Based on observation, the facility failed to provide hazardous area doors with self-closing mechanisms, as evidenced by one door that failed to self -close and latch. This could result in the spread of smoke or fire during a fire emergency affecting one of four smoke compartments.

Findings:

During a tour of the facility with Maintenance Staff 2 on 7/2/13, the hazardous areas were observed. Soiled linen and trash rooms, fuel fire heater rooms and combustible storage rooms are considered hazardous areas.

At 2:10 p.m., the door for the EEG/EKG room failed to self close. The room was greater than 100 square feet in area and contained more than 50 boxes of miscellaneous supplies. There was no self closer installed on the door.

Based on observation and interview, the facility failed to maintain and test the battery operated emergency lighting in the operating rooms and at Physical Therapy. This was evidenced by no records provided for monthly and annual testing. This could result in a failure of the emergency lights and a delay in evacuation, in the event of a fire or other emergency.

NFPA 101 Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1 1/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Finding:

During the facility tour with Maintenance Staff 2 on 6/26/13, the facility emergency lighting was observed and testing records were requested.

Hospital Building
At 10:57 a.m., there were two battery operated emergency lights in the surgery area. There was one installed in each operating room.

Physical Therapy Building
At 2:32 p.m., there were three battery back-up exit lights located within the Physical Therapy area.

At 2:40 p.m., there was a battery operated emergency light mounted over the exit access door in Physical Therapy.

At 2:42 p.m., there was a battery ballast light in the egress corridor, leading to the front exit, from Physical Therapy.

During an interview on 6/26 at 2:43 a.m., Maintenance Staff 2 reported that they did not perform annual 90 minute or monthly 30 second testing on the emergency lights in the Rehabilitation Building or at the main hospital.

Based on record review and interview, the facility failed to hold fire drills at least quarterly. This was evidenced by no records of fire drills during the last 12 months for the Physical Therapy Department. This could increase staff response in the event of fire or smoke. This affected all staff and patients in the Physical Therapy Building.

Findings:

During record review on 6/26/13 at 2:35 p.m., the fire drill reports for the preceding twelve months were requested. No report was provided for quarterly fire drills at the Physical Therapy Building.

During an interview at 2:40 p.m., the physical therapy director explained that they do not practice quarterly fire drills. She stated that they participate in an annual disaster and fire drill exercise with the hospital.

Based on observation, interview and record review, the facility failed to maintain the complete fire alarm system at Outpatient Physical Therapy. This was evidenced by no documentation of annual testing of the complete fire alarm system. This could result in a fire alarm failure and a potential delay in evacuation, in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-3.2* Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual.
Table 7-3.2 shall apply.

Findings:

During record review with Maintenance Staff 1 on 6/25/13, the building maintenance and testing information was requested for Physical Therapy.

At 10:10 a.m., Maintenance Staff 1 provided plan approval drawings labeled "New Rural Medical Treatment Improvements Coalinga Regional Medical Center" dated 11/4/09. The plans indicated the fire alarm system was approved on 1/6/10.
At 2:45 there were no records available for fire alarm system annual testing.

Based on record review and interview, the facility failed to ensure inspection and testing of the smoke detectors was completed. This was evidenced by no documentation of smoke sensitivity testing during the last two years. This could result in a failure of a smoke detector and a delay of notification and evacuation in a fire emergency. This affected four of four smoke compartments.

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.

Any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.

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 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.

Findings:

During record review and interview with Maintenance Staff 1, the smoke sensitivity testing report was requested.

6/25/13 - Hospital
At 11:02 a.m., the annual fire alarm inspection report, dated 4/22/13, did not include smoke sensitivity testing.

6/26/13
At 2 p.m., no other documents were provided for smoke sensitivity testing. Maintenance Staff 1 agreed to fax any documents by the end of the following business day.

6/27/13
At 5 p.m., there was no fax received for smoke sensitivity testing, by the end of the business day.

Based on observation, the facility failed to maintain the complete sprinkler system. This was evidenced by less than 18 inch clearance around the sprinkler heads, by missing escutcheon rings, by recessed sprinkler heads, by debris on sprinkler heads, and by no quarterly sprinkler inspections for one building. This could affect the operation of the sprinkler system, obstruct spray patterns, and delay the response time. In the event of a fire, the activation and effective operation of the automatic sprinkler system may not occur if sprinkler heads are not properly maintained. This affected two of four smoke compartments in two of two buildings.

NFPA 25 1999 Edition Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems
2-1 General. This chapter provides the minimum requirements for the routine inspection, testing, and maintenance of sprinkler systems. 2-1 shall be used to determine the minimum required frequencies for inspection, testing, and maintenance.
Table 2-1
Alarm devices Test Quarterly

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.

NFPA 13, Installation of Sprinkler Systems, 1999 Edition.
5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed.

5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During the facility tour with staff, on 6/25/13 and 6/26/13, the complete sprinkler system was observed and testing records were requested. Sprinkler escutcheon rings are used as part of the sprinkler assembly to cover the penetration around the sprinkler head.

6/25/13
At 5:09 p.m., under the wooden walkway canopy, there were six sprinkler heads that were loaded with spider webs and debris at the main hospital.
6/26/13
Hospital
At 9:40 a.m., there was no escutcheon ring on the sprinkler head in the bathroom in Room 102.
At 10:30 a.m., there was a missing escutcheon ring on the sprinkler head in the housekeeping locker room.
At 10:31 a.m., there was a missing escutcheon ring on the sprinkler head in the second housekeeping locker room.
At 10:37 a.m., there were two fast acting sprinkler heads installed in the kitchen ceiling along with six standard response sprinkler heads.
At 10:34 a.m., there were two sprinkler heads that were recessed into the ceiling an additional inch. This created an obstruction for the thermal elements by the escutcheon ring.
At 11:10 a.m., there were two sprinklers in the ceiling of the waiting area that were recessed an additional inch. This created an obstruction for the thermal elements by the escutcheon ring.
At 11:12 a.m., there were two sprinkler heads in the waiting area that were loaded with dust.
At 11:14 a.m., there was a missing escutcheon ring on the sprinkler head in the medical records area.

Physical Therapy - 6/26/13
During record review at the Physical Therapy building with Maintenance Staff 1, Maintenance Staff 2, and Physical Therapy Staff, records were requested for fire sprinkler system testing.

At 8:15 a.m., there were no quarterly sprinkler system inspection records available. During an interview, Maintenance Staff 2 reported no quarterly testing was completed in the Physical Therapy Building.

Based on observation, the facility failed to maintain their fire/smoke dampers. This was evidenced by fire/smoke dampers that were not inspected within the past four years. This affected four of four smoke compartments and could result in the spread of smoke to other locations, if a fire/smoke damper failed to close.

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

5.4.7 Maintenance. At least every 4 years, the following maintenance shall be performed:
(1) Fusible links (where applicable) shall be removed.
(2) All dampers shall be operated to verify that they close fully.
(3) The latch, if provided, shall be checked.
(4) Moving parts shall be lubricated as necessary.

Findings:

During a facility tour with staff, on 6/26/13, from 9:30 a.m. to 2:15 p.m., fusible link type fire/smoke dampers were observed. The testing and maintenance records for the dampers were requested. There were no records provided that indicated the dampers were tested, cleaned, lubricated, and inspected during the past four years.

Based on observation, the facility failed to ensure that medical gases were stored according to NFPA 99. This was evidenced by medical gas cylinders stored in an area where the electrical switch was located less than 5 feet above the floor. This could result in damage to the electrical switch, and affected one of four smoke compartments on one building.

NFPA 99, Standard for Healthcare Facilities, 1999 Edition
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 standards 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.

Findings:

6/25/13
During the facility tour with Maintenance Staff 1 and Maintenance Staff 2, the medical gas enclosures and equipment were observed.

At 5:10 p.m., there was a bank of H-sized cylinders of Nitrous Oxide in the surgery compressed gas supply closet. The cylinders were within two feet of an electrical light switch mounted less than 4 feet from the floor.

Based on record review and interview, the facility failed to perform monthly load tests that met the minimum load rating for 8 of 12 months. There was no annual load bank test performed. This could result in a failure of the emergency power system in an actual utility outage affecting four of four smoke compartments at the main hospital.

NFPA 110 Standard for Emergency and Standby Power Systems (1999 Edition)

6-3.6* Storage batteries, including electrolyte levels, used in connection with Level 1 and Level 2 systems shall be inspected at intervals of not more than 7 days and shall be maintained in full compliance with manufacturer ' s specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects.

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.

6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods: (a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating (b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer. The date and time of day for required testing shall be
decided by the owner, based on facility operations.

6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a
total of 2 continuous hours.

Findings

During document review and interview, the emergency generator weekly inspection and the monthly testing reports were requested.

6/25/13 - Hospital

At 10:30 a.m., The document labeled "400KW Monthly Generator Full Load Test" provided current calculations and a listing that indicated "Pass" or "Fail" for each load test. The records indicated that eight of the 12 monthly load tests failed to test at 30% of the name plate rating. There was no indication that the generator was tested at a specific exhaust gas temperature.

During an interview, at 10:35 a.m., Maintenance Staff 1 indicated that there had been no load bank test performed during the last year.

Based on observation, the facility failed to maintain electrical wiring and equipment. This was evidenced by the use of surge protectors, by obstructed electrical panels, and by the use of extension cords. This could increase the risk of electrical shock or fire affecting two of four smoke compartments in one building.

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.

Section 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:

6/26/13 - Hospital

During the facility tour with Maintenance Staff 1 and Maintenance Staff 2, electrical devices and wiring connections were observed.

At 9:37 a.m., in the doctors sleeping quarters near Room 119, there was a microwave plugged into a surge protector which was plugged into a wall outlet.

At 10:01 a.m., access to electrical panel EML1 and LG1 were obstructed by telemetry equipment that was placed on a pallet in front of the two panels.

At 11:43 a.m., in the Nurse's Lounge, there was a microwave plugged into a surge protector which was plugged into a 6-way adaptor. The adaptor was plugged into a wall outlet. There was a commercial coffee maker, a portable toaster oven, and a refrigerator plugged into the same 6-way adaptor.

At 11:56 a.m., in the laboratory, there was a blood analyzer plugged into a red 25 foot long extension cord which was run to an adjacent wall that had a critical power outlet.

At 12:45 p.m., in the server utility room, in the Respiratory Therapy area, there was a power cord from an air conditioner condensate pump that passed through the ceiling tile into the attic area.

At 12:53 p.m., in the Clinical Services office, there was a refrigerator plugged into a surge protector which was plugged into a wall outlet.