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Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This could result in the spread of fire and smoke from one smoke compartment to another, in the event of a fire. This affected the two of three floors in main building at Tulare Regional Medical Center.

Findings:

During a tour of the facility with the Director of Plant Operations on July 24, 2012 through July 27, 2012, the walls and ceilings were observed.

7/25/12 - Tulare Regional Medical Center Building - 2nd Floor
1. At 11 A.M., there was an approximately 1-inch round penetration around red wires, in the ceiling, in Room 2154 on the 2nd floor.

7/25/12 - 1st Floor
2. At 1:35 P.M., there was an approximately 1-inch round penetration in the ceiling, around a television cable, in the Physician Consultant room next to Endoscopy.

3. At 1:45 P.M., there were six approximately 1-inch round penetrations, in the wall, in Room 1202.

4. At 1:50 P.M., there were six approximately 2-inch round penetrations in the wall in Room 123.

5. At 1:50 P.M., there were four approximately 1 ? inch round penetrations, in the wall in Room 120.

6. At 1:51 P.M., there were two approximately 1 ? inch round penetrations, in the wall above the sink, in Room 124.

7. At 1:52 P.M., there were two approximately 1-inch round penetrations, in the wall in Room 119.

Based on observation, the facility failed to maintain their doors to resist the passage of smoke, as evidenced by doors that were obstructed from closing. This affected two of three clinics in the clinic building, and had the potential to allow the spread of smoke in the event of a fire.

Findings:

During a tour of the facility with the Director of Plant Operations on July 26, 2012, the doors were observed in the Clinic Building.

Outpatient Clinic Building - Specialty Clinic
1. At 3:05 P.M., the door to Room 19 was blocked by a metal cart containing casting supplies. The cart was pushed up against the door and obstructed the door from closing. The door had a self-closing device.

2. At 3:23 P.M., one of two 3 hour smoke barrier doors at the Women's Clinic, was held open by a wooden door wedge.

Based on observation, the facility failed to ensure that smoke barrier doors close after activation of any fire alarm device. This was evidenced by a smoke barrier door that failed to release and by a smoke barrier door that failed to latch. This could allow smoke and fire to travel throughout the facility and increased the risk of harm to the patients. This affected one of three floors and the basement at the Tulare Regional Medical Center Building.

Findings:

During alarm testing with the Director of Plant Operations, on July 26, 2012, the smoke barrier doors were observed and tested.

7/26/12 - Tulare Regional Medical Center
1. At 11:48 A.M., the smoke barrier doors, failed to latch on the right side after a smoke detector was tested, on the 1st floor by Room 115.

2. At 12:08 P.M., the smoke barrier doors on the basement level, by the boiler room, failed to release from the magnet on both sides after testing a manual pull station.

Based on record review and observation, the facility failed to maintain their emergency lighting in accordance with NFPA 101. This was evidenced by no record of maintenance and testing for emergency lights in three of three clinics and one physical therapy clinic, in two of four hospital buildings. This had the potential to delay evacuation in the event of a fire or other emergency. This affected the Outpatient Clinic Building and the Outpatient Services Physical Therapy Building.

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.

Findings:

During document review and the facility tour, on July 26, 2012, the maintenance records were requested, and emergency lighting was observed in the facility buildings.

7/26/12 - Outpatient Clinic Building (Women's Clinic, Specialty Clinic and Family Practice):
1. At 4 P.M., the facility failed to provide documentation for maintenance and testing of the emergency lighting system. During an interview, the Director of Plant Operations stated that he did not know if the emergency lighting was tested in the three clinics. He reported that the person that maintains the documentation was not available.

The facility was asked to provide additional testing information by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received Monday, at 4:47 P.M. The e-mail indicated that they did not find the items requested.

Outpatient Services Physical Therapy Building
2. At 9:57 A.M., the facility failed to provide documentation for maintenance and testing of the emergency lighting system. During an interview, the Director of Plant Operations stated that he did not know if the emergency lighting was tested. He reported that the person was on vacation that was responsible for the PT clinic. The facility was asked to provide additional testing information by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received Monday, at 4:47 P.M. The e-mail indicated that they did not find the items requested.

3. At 9:58 A.M., the lighting in the East stairwell failed to illuminate.

Based on document review and interview, the facility failed to ensure all staff were trained on disaster procedures. This was evidenced by 555 of 578 staff who did not participate in 2 of 2 disaster drills, and by no current evacuation map for one of three clinics. This failure could result in a delay in staff response to a disaster. This affected Tulare Regional Medical Center Building and the Outpatient Clinic Building.

NFPA 101?, Life Safety Code?, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator ' s position or at the security center.
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.


Findings:

During document review with the Director of Plant Operations, on July 25, 2012, the facility disaster drills were reviewed.

Tulare Regional Medical Center Building
1. At 2 P.M., facility documentation indicated one disaster drill was conducted on 11/15/11. The drill indicated 23 of 578 employees participated in the drill. No other documentation was provided for a second required disaster drill.

During an interview at 2:02 p.m., Staff 2 stated that a second disaster was planned, but had not been conducted. Staff 2 stated that the next drill was scheduled for October/November 2012.

Outpatient Clinic Building Women's Clinic
2. At 3:30 P.M., the evacuation map on the wall in the Women's Clinic stated "Specialty Clinic." The map failed to illustrate the second exit from the clinic.

During an interview, the Vice President of Patient Clinics stated that they had moved a couple of years ago, and had not updated the map.

Based on document review and interview, the facility failed to conduct fire drills at least quarterly, for each shift of personnel, in all hospital buildings. This was evidenced by missing fire drill records at two of three clinics in the Outpatient Clinic Building and the Outpatient Services Physical Therapy Building. There were no records for four of four quarters in the Physical Therapy building and the Specialty Clinic, and for three of four quarters in the Women's Clinic. This failure could result in a delay in staff response to a fire or disaster.

Findings:

During document review with facility staff, on July 26, 2012, the fire drill records were reviewed for the off site clinics.

7/26/12 - Outpatient Services Physical Therapy Building
1. At 10:45 A.M., there was no documentation for 4 of 4 quarterly fire drills at the physical therapy building.
During an interview, the Director of Plant Operations stated that the staff responsible for the documentation was out that day. The facility was asked to provide additional records when available, by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received Monday, 7/30/12 at 4:47 P.M. The e-mail indicated that they did not find any records.

Outpatient Clinics Building - Specialty Clinic
2. At 3:35 P.M., there was no documentation for 4 of 4 quarterly fire drills in the Specialty Clinic. During an interview, the Director of Plant Operations stated that the staff responsible for the documentation was out that day. The facility was asked to provide additional records when available, by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received Monday, 7/30/12 at 4:47 P.M. The e-mail indicated that they did not find the records requested.

Women's Clinic
3. At 3:35 P.M., there were no fire drill records for 3 of 4 quarters, in the Women's Clinic.

Based on observation, document review and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by no smoke detector for the fire alarm control panel (FACP) area, by no documentation of an annual test of the complete fire alarm system, by incomplete records for testing their battery operated smoke detectors, and by the failure of one smoke detector to alarm. This affected the basement in the Tulare Regional Medical Center Building, two of two floors in the Lab/Administration Building, three of three clinics in the Outpatient Clinics Building and the Physical Therapy Building. This could result in a failure of the fire alarm system and the potential delay in notifying patients, visitors and staff in the event of a fire.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.6 Protection of Fire Alarm Control Unit(s).
In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

During a tour of the facility and document review, with the Director of Plant Operations, from July 24, 2012 through July 27, 2012, the fire alarm system and smoke detectors were observed and testing documentation was requested.

7/26/12 - Tulare Regional Medical Center Building
1. At 2:30 P.M., the room containing the FACP failed to have a smoke detector installed above the panel. The basement room, where the fire alarm control panel was installed, was locked and not continuously occupied.

Outpatient Clinic Building C (Women's Clinic, Specialty Clinic and Family Practice Clinic
2. At 3:23 P.M., the Kidde, 10 year, battery powered, smoke alarms were labeled "WEEKLY TESTING IS REQUIRED" on the smoke alarms. The facility failed to provide documentation that the smoke alarms had been tested weekly.

Tulare Regional Medical Center Lab/Administration Building
3. At 4 P.M., the battery operated smoke detector failed to alarm when tested, in the lab, by the Supervisor's office.

4. At 4:05 P.M., the battery operated smoke detector in the lab failed to contain a battery.

5. At 5 P.M., the quarterly testing records from the vendor were reviewed. The records failed to document testing of the duct detectors and battery operated smoke detectors in the building.

7/26/12 - Outpatient Services Physical Therapy Building
6. At 9:20 A.M., the annual certification for the fire alarm system was requested. No documentation was provided by the facility. During an interview, the Director of Plant Operations stated that the staff responsible for the documentation was out that day. The facility was asked to provide the records by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received on Monday, 7/30/12 at 4:47 P.M. The e-mail indicated that they did not find the items requested.

Based on document review and interview, the facility failed to provide documentation of smoke detector sensitivity testing for 31 of 59 combination door hold open and smoke detector devices and the smoke detectors in the physical therapy building. This affected the Tulare Regional Medical Center Building and the Outpatient Services Physical Therapy Building. This could result in a delay in detecting a fire if a smoke detector failed.

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

Findings:

During document review with the Director of Plant Operations, July 26, 2012, the records for smoke detector sensitivity testing were reviewed.

7/26/12 - Tulare Regional Medical Center Building
1. At 4:25 P.M., the documentation for smoke detector sensitivity testing was reviewed. The vendor testing report indicated that 28 of 59 smoke detectors were tested. During an interview, the Director of Plant Operations stated that the smoke detectors in the doors were tested to see if they worked. He reported that the vendor did not know how to conduct sensitivity testing on that type of detector.

Outpatient Services Physical Therapy Building
2. At 9:50 A.M., no documentation for smoke detector sensitivity testing was provided by the facility. During an interview, the Physical Therapist stated that the person that maintains the building was not there. The facility was asked to provide the testing records by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received Monday, 7/30/12 at 4:47 P.M. The e-mail indicated that they did not find the testing records.

Based on observation, record review and interview, the facility failed to maintain the integrity of their automatic sprinkler system. This was evidenced by no alarm or trouble signal transmitted to the Fire Alarm Control Panel (FACP) and the monitoring company, during sprinkler system testing, at the Lab/Administration Building. This affected one of four hospital buildings and could result in a delay in notifying occupants if the sprinkler system was activated during a fire.

NFPA 101, Life Safety Code, 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.

9.7.2.2 Alarm Signal Transmission. Where supervision of automatic sprinkler systems is provided in accordance with another provision of this Code, water-flow alarms shall be transmitted to an approved, proprietary alarm receiving facility, a remote station, a central station, or the fire department. Such connection shall be in accordance with 9.6.1.4.

Findings:

During alarm testing with the Director of Plant Operations, on July 26, 2012, the automatic sprinkler system was tested in the hospital Lab/Administration Building. The Inspector Test Valve (ITV) is tested to mimic the water flow after activation of a sprinkler head and initiation of a fire alarm signal.

7/26/12 - Tulare Regional Medical Center Lab/Administration Building
1. At 12:22 P.M., the ITV was tested and failed to transmit a signal to the fire alarm panel or the monitoring company.

During an interview, the Vendor stated that the ITV has never transmitted a signal to the monitoring company. The Vendor stated that the only alarm that activates when the ITV is tested is the gong on the outside of the building. No fire alarm was initiated inside of the building.

The Vendor was asked if there was a Tamper for the building. He stated that there was no tamper alarm to indicate a problem with the water supply. The automatic sprinkler system riser, on the side of the building, was observed and did not have a Tamper alarm.

During record review, the Director of Plant Operations stated that he thought both buildings had quarterly duct detector, ITV and Tamper testing. He stated he did not know that the Lab/Administration building did not have a Tamper, and that the ITV did not transmit an alarm signal.

Based on document review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. This was evidenced by no documentation of an Automatic Sprinkler System 5 year certification and no records for quarterly testing during four of four quarters. This affected the Outpatient Services Physical Therapy Building. This could result in a failure of the sprinkler system in the event of a fire.

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

Table 2-1 Summary of Sprinkler System Inspection, Testing, and Maintenance
Gauges Test 5 years
Sprinklers - extra high temp. Test 5 years
Obstruction investigation Test 5 years

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
Pressure Reducing and Relief Valves
Sprinkler systems Test 5 years


Findings:

During document review and a tour of the facility, with the Director of Plant Operations, on July 26, 2012, the 5 year automatic sprinkler certificate and quarterly testing records were requested.

7/26/12 - Outpatient Services Physical Therapy Building
1. At 9:42 A.M., no documentation of a 5 year automatic sprinkler test was provided by the facility. During an interview, the Director of Plant Operations stated that the staff responsible for keeping the documentation was out that day.

2. At 10:30 A.M., the facility failed to provide documentation that the sprinkler test/inspections were conducted for 4 of 4 quarters. The Director of Plant Operations stated that the staff responsible for the documentation was out that day.

The facility was asked to provide the missing records by Monday, 7/30/12. An E-mail from the Director of Plant Operations was received Monday, 7/30/12 at 4:47 P.M. The e-mail indicated that they did not find the items requested.

Based on observation, the facility failed to ensure that their portable fire extinguishers were accessible and installed appropriately in accordance with NFPA 10. This was evidenced by a fire extinguisher that was blocked from access. This affected one of two floors in one of four buildings, the Tulare Regional Medical Center Lab/Administration Building. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

NFPA 10, Standard for Portable Fire Extinguishers, 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.

Findings:

During a tour of the facility with the Director of Plant Operations, on July 25, 2012, the fire extinguishers were observed in the Lab/Administration Building.

On 7/25/12 at 3:10 P.M., in the Break Room, there was a fire extinguisher blocked by two trash cans.

Based on observation, the facility failed to ensure oxygen storage in accordance with NFPA 99. This was evidenced by oxygen stored next to combustible material and electrical panels, and by no signs indicating oxygen was stored inside these areas. This affected two of three floors of the Tulare Regional Medical Center Building, and could potentially cause an increased risk that a fire would spread in the presence of oxygen.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(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 ft (6.1 m), or
2. A minimum distance of 5 ft (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, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

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 tour of the facility with the Director of Plant Operations, from July 24, 2012 through July 27, 2012, the oxygen storage areas were observed.

Tulare Regional Medical Center Building
1. On 7/25/12 at 1:25 P.M., there were five E-Oxygen tanks stored in the clean Utility Supply Room on the 1st floor. There were no signs indicating oxygen was stored inside the room.

2. On 7/26/12 at 11:3 P.M., there were four E-Oxygen tanks stored next to the electrical panels and supplies, in "Room 6 Unsterile Storage," on the 2nd floor. The room failed to have a sign indicating the room was used for oxygen storage.

Based on observation, the facility failed to maintain electrical wiring and connections, as evidenced by the use of surge protectors, by a broken receptacle wall outlet cover, and by a missing receptacle outlet cover. This affected the basement level of Tulare Regional Medical Center Building, the CT Modular building, and one of two floors of the Lab/Administration Building. This could result in an increased risk of an electrical fire and electrical shock, potentially harming patients, visitors, and staff.

NFPA 70, National Electrical Code, 1999 Edition
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 a 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, 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) Receptacles.
2. Minimum Number of Receptacles.
The number of receptacles shall be determined by the intended use of 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 a tour of the facility with the Director of Plant Operations, on July 25, 2012, the electrical equipment was observed in three areas.

Tulare Regional Medical Center Building - Basement
1. At 2:36 P.M., there was a 2-plug outlet with a cracked cover and two broken ground ports, in Room 2116, in the basement.

2. At 2:40 P.M., there was a refrigerator plugged in to a surge protector, instead of directly into a fixed wired receptacle, in the EVS Employee Lounge.

Tulare Regional Medical Center Lab/Administration Building B:
3. At 3:23 P.M., there was a broken electrical outlet, in the IT Room, on the 2nd floor.

CT Modular Building
4. At 4:36 P.M., there was an electrical receptacle wall outlet missing a cover plate, in the main area.