HospitalInspections.org

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings, and by the use of paper and foam to seal conduits and penetrations. This affected four of four floors in the main hospital, one of five floors in the Academic Family Medicine Center, and the VCMC physical therapy clinic. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the walls and ceilings were observed.

The main hospital was surveyed on 7/19/11.
Fourth Floor -
At 10:43 a.m., there was an approximately 1 foot by 1 foot ceiling tile removed in the phone storage closet in the North Wing.

At 10:55 a.m., the gastrointestinal laboratory nurses station storage room was observed. There was an approximately four inch penetration around a shower valve, an approximately 2 inch penetration around a water valve, and an approximately 1 inch penetration in the back wall of the storage room.

At 11:00 a.m., there was an approximately 1 inch penetration in the back wall of the respiratory care manager's storage room.

Third Floor -
At 1:20 p.m., there were eight approximately 1/2 inch penetrations on the left wall, and two approximately 1/2 inch penetrations in the right wall, of the infection control storage room.

Second Floor -
At 2:37 p.m., there was an approximately 3 inch by 1 inch penetration in the back wall of the OR laundry chute room.

The Academic Family Medical Center was surveyed on 7/19/11.

Fourth Floor -
At 4:26 p.m., there were two approximately 4 inches conduits, around communication lines, in the floor of Room 474. A foam-like caulking material was used to seal the conduits.

During an interview at 4:27 p.m., the Engineering Manager stated that the foam-like material is not smoke-resistant and is not commonly used to seal penetrations and conduits in the facility.

The VCMC Physical Therapy Clinic was surveyed on 7/21/11.

At 9 :06 a.m., there was an approximately 1 1/2 inch by 1 1/2 inch penetration in the ceiling tile, in the center of the children's play room.




29566

The main hospital was surveyed on 7/19/11.

Main Hospital First Floor -
At 11:32 a.m., the deck above the ceiling tiles, near the emergency room smoke barrier, was observed. There was brown paper stuffed into an approximately 1/2 inch by 2 inch penetration in the ceiling deck between the first and second floor.

Based on observation, the facility failed to maintain corridor walls free from penetrations. This was evidenced by penetrations in one area. This affected one of four floors of the main hospital, and could result in the spread of smoke and fire within the facility, and the increased risk of injury to patients.

Findings:

During the tour of facility with staff from 7/18/11 to 7/21/11, the corridor walls were observed.

The main hospital was surveyed on July 19, 2011.
First Floor -

At 11:40 a.m., there was a dime size penetration in the corridor wall, above the ceiling tile, by the restroom near the emergency room smoke barrier wall.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected two of four floors in the main hospital and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the corridor doors were observed.

The main hospital was surveyed on 7/19/11.
Third floor -

At 1:24 p.m., the door to the cardiology waiting room was held open by a wooden wedge.

At 1:31 p.m., the cardiology front office door was held open by a wedge.



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First Floor -

At 10:45 a.m., the door of the cast room, in the emergency unit, was held open by tall plastic trash can.

Based on observation and interview, the facility failed to maintain one stairway, as evidenced by storage under the stairs. This affected the basement of the main hospital, one of five levels. This could cause a delay in evacuation of staff and patients in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.3 Stairs. Stairs complying with 7.2.2 shall be permitted.

7.2.2.5.3 Usable Space. There shall be no enclosed usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Exception: Enclosed usable space shall be permitted under stairs provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.


Findings:

During tour of facility with staff from 7/18/11 to 7/21/11, vertical openings in the facility were observed.

The main hospital was surveyed on 7/19/11.

At 10:15 a.m., there was a large, wheeled, machine, stored beneath the staircase, leading to the exit discharge in the basement. The top of the machine reached approximately 1/2 inch from the sprinkler head.
During an interview at 10:15 a.m., Maintenance Staff 1 confirmed that the machine was stored under the stairs. He stated that he did not know the name of the machine or what it was used for.

Based on observation, the facility failed to maintain all doors held open by devices designed to release upon activation of the fire alarm system. This was evidenced by one smoke barrier door that failed to release and close during fire alarm testing. This affected one of four floors and two smoke compartments. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 7/20/11, doors held open with magnetic and electronic hold-open devices were observed.

Third Floor -
At 8:56 a.m., the smoke barrier door, next to the conference room, was held open by an electronic hold-open device. The door did not release and close during activation of the fire alarm.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by no exit sign marking approved exits. This affected one of six smoke compartments in the Santa Paula Hospital, and could result in a delay in evacuation, in the event of a fire.

Findings:

During a facility tour with staff on 7/20/11, the exit signs were observed at the Santa Paula Hospital.

At 2:40 p.m., the exit door by the changing room, in the x-ray unit, opened to the exit access corridor. There was no exit sign near the exit door.

During an interview at 2:41 p.m., the maintenance supervisor stated that the door is used as an exit from the x-ray unit to the exit access corridor.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by smoke barrier doors that failed to close during fire alarm testing. This affected one of four floors in the main hospital and could result in the spread of smoke and fire from one smoke compartment to another, in the event of a fire.

Findings:

During the facility tour with staff from 7/19/11 to 7/20/11, the smoke barrier doors were observed.

The main hospital was surveyed on 7/19/11.

Second Floor -
At 9:24 a.m., the smoke barrier double doors by the auxiliary gift shop did not close completely during fire alarm testing. There was an approximately 1 inch gap between the doors.

At 9:38 a.m., the smoke barrier double doors, between Building 401 and Building 306, did not close completely during fire alarm testing. There was an approximately 1 inch gap between the doors.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self-closing doors. This was evidenced by one hazardous area with no self-closure on the door. This affected one of six smoke compartments in the Santa Paula Hospital and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour with staff on 7/20/11, the hazardous areas were observed in the Santa Paula hospital. Soiled linen and trash storage areas, and combustible storage rooms greater than 50 square feet in size, are considered hazardous areas.

At 2:25 p.m., the med surge clean storage room was 7 feet by 8 feet in size. It contained approximately nine shelves of clean linens, one shelf of diapers, and two shelves of medical equipment in combustible plastic wrapping. The door to the storage room was not equipped with a self-closing device.

Based on observation, the facility failed to ensure that exits are readily accessible, as evidenced by exit doors that were obstructed from opening, and by exit doors that opened against egress. This affected four of five floors in the Academy Family Medical Center and could result in a delay of egress, in the event of a fire.

Findings:

During a facility tour with staff from 7/18/11 to 7/20/11, the exits were observed.

The Academic Family Medical Center was surveyed on 7/19/11 and 7/21/11.
Second Floor on 7/19/11-
At 4:50 p.m., the brown exit door, by Room 256, was obstructed from opening by a white exit door to the immediate right of the brown exit door.

Third Floor on 7/21/11 -
At 2:05 p.m., Exit Door 356, in the Pediatric Diagnostic Center, opened against egress.

Fourth Floor on 7/21/11 -
At 2:11 p.m., the brown exit door, from the patient room hallway in the Women's Health Center, was blocked from opening by a white exit door to the immediate right of the brown exit door.

Fifth Floor on 7/21/11 -
At 2:14 p.m., the brown exit door, in the Hematology Oncology Clinic, opened against egress.

Based on observation and interview, the facility failed to maintain patient care areas in accordance with NFPA 70 and NFPA 99. This was evidenced by anesthetizing locations with no battery-powered emergency lighting. This affected one of four floors in the main hospital, and one of six smoke compartments in the Santa Paula Hospital. This could result in no lights during procedures where anesthetics are used, in the event of a power outage.

NFPA 70
Article 700 - Emergency Systems
A. General
700-12 (e). Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.


NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. (See Chapter 2 for definition of Patient Care Area.)
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the emergency lighting was observed.

The main hospital was surveyed on 7/19/11.

Fourth Floor -
At 11:15 a.m., there was no battery-powered emergency back-up light in Delivery Room 3.

During an interview at 11:16 a.m., Maintenance Staff 2 confirmed that there was no battery-powered emergency lighting in the delivery room.

During an interview at 11:18 a.m., Staff 1 stated that the facility uses anesthesia during their procedures in the delivery room.



The Santa Paula Hospital was surveyed on 7/20/11

At 2:15 p.m., there was no battery back-up emergency lighting in Operating Room 1.

At 2:16 p.m., there was no battery back-up emergency lighting in Operating Room 2.

Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by obstructed pull stations in two locations. This affected one of four floors in the main hospital, and one of six smoke compartments in the Santa Paula hospital. This could result in a delay in notification, in the event of a fire.

NFPA 101
SECTION 9.6 Fire Detection, Alarm, and Communications Systems
9.6.2.3 A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code.

9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72 National Fire Alarm Code 1999 Edition
2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the fire alarm system was observed.

The OR in the main hospital was surveyed on 7/20/11.

Second Floor -

At 9:25 a.m., the pull station by Operating Room 3 was obstructed by a gurney.


The Santa Paula Hospital was surveyed on 7/20/11.

At 2:41 p.m., the pull station near the emergency room exit was obstructed by a wheelchair.

Based on observation, record review, and interview, the facility failed to maintain their single station smoke detectors in accordance with the manufacturer's specifications. This was evidenced by no record for testing two of two single station smoke detectors in one outpatient clinic. This could result in a delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the smoke detectors were observed.

The Plastic Reconstructive and Hand Surgery Clinic was surveyed on 7/20/11.

At 11:52 a.m., there was no record for testing two of two single station smoke detectors. The manufacturer recommends weekly push button tests and annually battery replacement.

During an interview at 11:54 a.m., Maintenance Staff 3 stated that the smoke detectors have not been tested weekly.

Based on observation and interview, the facility failed to ensure one sprinkler system valve was supervised with a local alarm. This was evidenced by a post indicator valve (PIV) that was not monitored, tested or locked. This affected four of four floors and the basement of the main hospital. This could result in a delay in notification if the sprinkler system water supply was turned off, and a delay in extinguishing 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.


NFPA 72, National Fire Alarm Code, 1999 Edition
5.4.7 Distinctive Signals Audible alarm notification appliances for a fire alarm system shall produce signals that are distinctive from other similar appliances used for other purposes in the same area. The distinction among signals shall be as follows:
(a) Fire alarm signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose. The requirements of 3-8.4.1.2.1 shall apply.
(b) Supervisory signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose.
Exception: A supervisory signal sound shall be permitted to be used to indicate a trouble condition. If the same sound is used for both supervisory signals and trouble signals, the distinction between signals shall be by other appropriate means such as visible annunciation.
(c) Fire alarm, supervisory, and trouble signals shall take precedence, in that respective order of priority, over all other signals.
Exception: Signals from hold-up alarms or other life-threatening signals shall be permitted to take precedence over supervisory and trouble signals if acceptable to the authority having jurisdiction.

Findings:

During fire alarm testing with staff on 7/20/11, the sprinkler supervisory signals were tested at the main hospital. An outside vendor was on hospital grounds assisting with the fire alarm testing. The vendor regularly performs the fire alarm testing at the hospital.

At 10:11 a.m., the PIV was not locked.

During an interview at 10:12 a.m., the outside vendor stated that during his quarterly and annual maintenance tests of the sprinkler system, he does not test the post indicator valve because it is not monitored through the fire alarm system. Closing the PIV valve shuts off the water to the sprinkler system. According to interviews the PIV is not maintained and tested.

At 10:18 a.m., the backflow valve was locked with a padlock. The vendor reported that the backflow valve has a supervisory signal. He stated that the supervisory signal for the backflow is monitored by the alarm system.

Based on observation and interview, the facility failed to maintain their sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by missing escutcheon rings, by sprinkler heads covered with rust or ice, by the use of standard-response sprinkler heads in areas protected with quick-response sprinkler heads and by the failure to maintain 18 inch clearance below one sprinkler deflector. This affected two of four floors in the main hospital and two of six smoke compartments in the Santa Paula Hospital. This could result in a delay in extinguishing a fire.

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

2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
NFPA 13, Standard for the 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 a facility tour with staff from 7/18/11 to 7/21/11, the sprinkler system was observed. Escutcheon rings cover the penetrations around sprinklers.

The Santa Paula Hospital was surveyed on 7/20/11.

At 2:20 p.m., there was a standard-response sprinkler head in the medical surgery medication room.
During an interview at 2:21 p.m., staff stated that the entire hospital had been switched to quick-response sprinkler heads.

At 2:30 p.m., three of three sprinkler heads in the x-ray room were standard-response. There was no escutcheon ring around one of the sprinkler heads.



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The main hospital was surveyed on 7/19/11.

First Floor -
At 10:15 a.m., there was a large, wheeled machine, stored beneath the stairway, leading to the exit discharge in the basement. The top of the machine reached approximately 1/2 inch from the sprinkler head. There was no 18 inch clearance below the sprinkler.

At 12:05 p.m., three of four sprinkler heads in Meat Freezer 7, in the kitchen, were missing escutcheon rings.

At 12:06 p.m., a layer of ice covered the deflector of one of three sprinkler heads that were missing escutcheon rings, in Meat Freezer 7.

Second Floor -
At 2:20 p.m., the sprinkler head and escutcheon ring in the laboratory walk-in refrigerator were rusty.

Based on observation, the facility failed to ensure that fire extinguishers are maintained in accordance with NFPA 10. This was evidenced by one fire extinguisher that was obstructed, and by one fire extinguisher that was unsecured on the floor. This affected one of four floors in the main hospital and the VCMC Physical Therapy clinic and could result in a delay in extinguishing a fire.

NFPA 10, Standard for Portable Fire Extinguishers 1998 edition
1.6 General Requirements
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.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).


Findings:

During a facility tour from 7/18/11 to 7/21/11, the fire extinguishers were observed.

The main hospital was surveyed on 7/19/11.

Second Floor -
At 2:22 p.m., there was a ABC fire extinguisher placed upright on the floor of the pharmacy manager's office.

The O.R. on the second floor was surveyed on 7/20/11.
At 9:22 a.m., the fire extinguisher by Operating Room 3 was blocked by a gurney.






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The VCMC Physical Therapy clinic was surveyed on 7/21/11.

At 8:58 a.m., a skeleton frame and a portable tray blocked access to the fire extinguisher, mounted on the wall of the main therapy room.

Based on record review and interview, the facility failed to maintain their fire dampers in accordance with NFPA 90A. This was evidenced by seven fire dampers that were inaccessible and were not maintained for more than four years. This affected two of four floors in the main hospital and could result in the failure of the fire damper to close, in the event of a fire.

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

Findings:

During record review on 7/18/11, the fire damper maintenance records were requested. A document titled "Fire Damper Drop Test Report" was provided. The document showed results from an inspection done by an outside vendor from 11/10/08 to 3/31/09.

At 3:10 p.m., the document showed that on 1/23/09, three fire dampers, #8338, # 8339, and # 8340 in Four East, were identified as inaccessible and were not maintained. The document showed that on 1/28/09, two fire dampers, # 8370 and # 8371 in Three West, were inaccessible and not maintained. The document showed that on 2/25/09 two fire dampers, # 7295 and # 7297 in the ultrasound department, were inaccessible and not maintained.

During an interview at 3:11 p.m., the Engineering Manager confirmed that the dampers had not been tested. He stated that the facility is in the middle of a six year construction project, that started in 2009, to alter the ceiling and make those dampers accessible for maintenance.

Based on observation, the facility failed to ensure that means of egress are free from obstructions. This was evidenced by equipment stored in exit access corridors. This affected one of four floors in the main hospital, one of six smoke compartments in the Santa Paula Hospital, and two of five floors of the Academic Family Medical Center. This could result in a delay in the evacuation of patients and staff, in the event of a fire.

Findings:

During the facility tour with staff from 7/18/11 to 7/19/11, the exit corridors were observed.

The main hospital was surveyed on 7/19/11.

At 12:01 p.m., there were four wheelchairs stored in the Ortho Unit, approximately 5 feet away from the exit door.

The Academic Family Medical Center was surveyed on 7/19/11.

First Floor -

At 4:05 p.m., there was a five-gallon water cooler and stand placed in the back corridor of Urgent Care.

Second Floor -

At 4:35 p.m., there was a five-gallon water cooler and stand placed in the back corridor of Family Care Center.

Based on observation, the facility failed to maintain their medical gas storage areas, as evidenced by full and empty oxygen cylinders stored together, and by storage of medical gas less than 10 feet from a facility door. This affected four of four floors of the main hospital, and could cause increased risk to patients who need oxygen in an emergency.

NFPA 99 , Standard for Health Care Facilities, 1999 Edition.
4-3.1.1.2 (10) (b)Storage facilities that are outside, but adjacent to a building wall, shall be accordance with NFPA 50, Standard For Bulk Oxygen System at Consumer Sites.
4-3.5.2.2 (b) (2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 50 , Standard For Bulk Oxygen System at Consumer Sites, 1996 Edition.
2-2.1 Not less than 1 foot (0.3 m)(or other distance to permit system maintenance ) form buildings of other than wood frame construction.
2-2.3 At least 10 feet (3 m) from any opening in walls or adjacent structures. This provision shall apply to all elements of a bulk oxygen system where the oxygen storage is high pressure gas. Where the storage is as a liquid, this provision shall apply to only pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping.

Findings:

During tour of facility with staff on 7/19/11, the medical gas storage area was observed.
Main Hospital
At 3:14 p.m., the outdoor medical gas storage area was enclosed with a chain link fence and a galvanized metal roof. The storage area contained 16,694 cubic feet of compressed oxygen, 5,512 cubic feet of compressed nitrogen oxide, 95 gallons of liquid nitrogen, and other cylinders of non-flammable compressed gases. The chain link metal gate of the medical storage area was approximately 4 feet 8 inches from the exit door of the housekeeping unit on the first floor. There were H-tanks of compressed gases, on the right side of the storage area, stored up against the wall of the housekeeping unit in the hospital.
At 3:15 p.m., there were both empty and full oxygen cylinders stored in the outdoor medical storage area. There was no indication which cylinders were full and which were empty.

Based on observation, the facility failed to maintain their anesthetizing locations in accordance with NFPA 99. This was evidenced by an obstructed emergency shutoff valve outside one operating room. This affected one of four floors, and could result in a delay in shutting off the medical gas lines in the event of a fire, or other emergency.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a facility tour with staff on 7/20/11, the anesthetizing locations were observed.

Second Floor -
At 9:20 a.m., there was a gurney blocking the shut-off valve for the medical gas outside of Operating Room 3.

Based on observation, the facility failed to maintain their electrical wiring, as evidenced by the use of multi-plug adaptors (surge protectors) for appliances. This affected three of four floors and the basement, in the main hospital, and one outpatient clinic. This could result in an increased risk of an electrical fire.

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 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 the facility tour with staff from 7/18/11 to 7/21/11, the electrical wiring in the was observed.

The main hospital was surveyed on 7/19/11.

Fourth Floor -
At 10:59 a.m., there was a refrigerator plugged into a six-plug surge protector in the respiratory care manager's office.

Third Floor -
At 1:29 p.m., there was a microwave plugged into a six-plug surge protector in the ECHO department office.

Second Floor -
At 2:29 p.m., there was a refrigerator plugged into a multi-plug power strip in the trauma services office.

The Plastic Reconstructive and Hand Surgery Clinic was surveyed on 7/20/11.

At 11:45 a.m., there was a microwave, a refrigerator, and a clock radio plugged into a three-plug wall adaptor, with no surge protection, in the nursing office.

The Santa Paula Hospital was surveyed on 7/20/11.

At 2:48 p.m., there was a refrigerator plugged into a six-plug surge protector in the laboratory break room.



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Main Hospital Basement -
At 10:30 a.m. , there was a multi-plug surge protector, microwave, coffee maker, and a toaster, plugged into another multi-plug surge protector in the medical records room.

Based on observation, the facility failed to maintain their Alcohol Based Hand Rub (ABHR) dispensers, as evidenced by two ABHR dispensers that were installed over ignition sources, and by the use of ABHR dispensers in a non-sprinklered, carpeted facility. This affected the VCMC Physical Therapy Clinic and could result in an increased risk of a fire.

Findings:

During a facility tour from 7/18/11 to 7/21/11, the ABHR dispensers were observed.

The VCMC Physical Therapy Clinic was surveyed on 7/21/11. The clinic has carpeted floors and is non-sprinklered.

At 9:07 a.m., an ABHR dispenser was mounted approximately 4 inches above a light switch in the children's play area.




29566


At 9:10 a.m., in Room 5, the ABHR dispenser was mounted above a light switch. The room is carpeted and is not sprinklered.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings, and by the use of paper and foam to seal conduits and penetrations. This affected four of four floors in the main hospital, one of five floors in the Academic Family Medicine Center, and the VCMC physical therapy clinic. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the walls and ceilings were observed.

The main hospital was surveyed on 7/19/11.
Fourth Floor -
At 10:43 a.m., there was an approximately 1 foot by 1 foot ceiling tile removed in the phone storage closet in the North Wing.

At 10:55 a.m., the gastrointestinal laboratory nurses station storage room was observed. There was an approximately four inch penetration around a shower valve, an approximately 2 inch penetration around a water valve, and an approximately 1 inch penetration in the back wall of the storage room.

At 11:00 a.m., there was an approximately 1 inch penetration in the back wall of the respiratory care manager's storage room.

Third Floor -
At 1:20 p.m., there were eight approximately 1/2 inch penetrations on the left wall, and two approximately 1/2 inch penetrations in the right wall, of the infection control storage room.

Second Floor -
At 2:37 p.m., there was an approximately 3 inch by 1 inch penetration in the back wall of the OR laundry chute room.

The Academic Family Medical Center was surveyed on 7/19/11.

Fourth Floor -
At 4:26 p.m., there were two approximately 4 inches conduits, around communication lines, in the floor of Room 474. A foam-like caulking material was used to seal the conduits.

During an interview at 4:27 p.m., the Engineering Manager stated that the foam-like material is not smoke-resistant and is not commonly used to seal penetrations and conduits in the facility.

The VCMC Physical Therapy Clinic was surveyed on 7/21/11.

At 9 :06 a.m., there was an approximately 1 1/2 inch by 1 1/2 inch penetration in the ceiling tile, in the center of the children's play room.




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The main hospital was surveyed on 7/19/11.

Main Hospital First Floor -
At 11:32 a.m., the deck above the ceiling tiles, near the emergency room smoke barrier, was observed. There was brown paper stuffed into an approximately 1/2 inch by 2 inch penetration in the ceiling deck between the first and second floor.

Based on observation, the facility failed to maintain corridor walls free from penetrations. This was evidenced by penetrations in one area. This affected one of four floors of the main hospital, and could result in the spread of smoke and fire within the facility, and the increased risk of injury to patients.

Findings:

During the tour of facility with staff from 7/18/11 to 7/21/11, the corridor walls were observed.

The main hospital was surveyed on July 19, 2011.
First Floor -

At 11:40 a.m., there was a dime size penetration in the corridor wall, above the ceiling tile, by the restroom near the emergency room smoke barrier wall.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected two of four floors in the main hospital and could result in the spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the corridor doors were observed.

The main hospital was surveyed on 7/19/11.
Third floor -

At 1:24 p.m., the door to the cardiology waiting room was held open by a wooden wedge.

At 1:31 p.m., the cardiology front office door was held open by a wedge.



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First Floor -

At 10:45 a.m., the door of the cast room, in the emergency unit, was held open by tall plastic trash can.

Based on observation and interview, the facility failed to maintain one stairway, as evidenced by storage under the stairs. This affected the basement of the main hospital, one of five levels. This could cause a delay in evacuation of staff and patients in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.3 Stairs. Stairs complying with 7.2.2 shall be permitted.

7.2.2.5.3 Usable Space. There shall be no enclosed usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

Exception: Enclosed usable space shall be permitted under stairs provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure.


Findings:

During tour of facility with staff from 7/18/11 to 7/21/11, vertical openings in the facility were observed.

The main hospital was surveyed on 7/19/11.

At 10:15 a.m., there was a large, wheeled, machine, stored beneath the staircase, leading to the exit discharge in the basement. The top of the machine reached approximately 1/2 inch from the sprinkler head.
During an interview at 10:15 a.m., Maintenance Staff 1 confirmed that the machine was stored under the stairs. He stated that he did not know the name of the machine or what it was used for.

Based on observation, the facility failed to maintain all doors held open by devices designed to release upon activation of the fire alarm system. This was evidenced by one smoke barrier door that failed to release and close during fire alarm testing. This affected one of four floors and two smoke compartments. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During fire alarm testing with staff on 7/20/11, doors held open with magnetic and electronic hold-open devices were observed.

Third Floor -
At 8:56 a.m., the smoke barrier door, next to the conference room, was held open by an electronic hold-open device. The door did not release and close during activation of the fire alarm.

Based on observation, the facility failed to maintain their exit signs. This was evidenced by no exit sign marking approved exits. This affected one of six smoke compartments in the Santa Paula Hospital, and could result in a delay in evacuation, in the event of a fire.

Findings:

During a facility tour with staff on 7/20/11, the exit signs were observed at the Santa Paula Hospital.

At 2:40 p.m., the exit door by the changing room, in the x-ray unit, opened to the exit access corridor. There was no exit sign near the exit door.

During an interview at 2:41 p.m., the maintenance supervisor stated that the door is used as an exit from the x-ray unit to the exit access corridor.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by smoke barrier doors that failed to close during fire alarm testing. This affected one of four floors in the main hospital and could result in the spread of smoke and fire from one smoke compartment to another, in the event of a fire.

Findings:

During the facility tour with staff from 7/19/11 to 7/20/11, the smoke barrier doors were observed.

The main hospital was surveyed on 7/19/11.

Second Floor -
At 9:24 a.m., the smoke barrier double doors by the auxiliary gift shop did not close completely during fire alarm testing. There was an approximately 1 inch gap between the doors.

At 9:38 a.m., the smoke barrier double doors, between Building 401 and Building 306, did not close completely during fire alarm testing. There was an approximately 1 inch gap between the doors.

Based on observation, the facility failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self-closing doors. This was evidenced by one hazardous area with no self-closure on the door. This affected one of six smoke compartments in the Santa Paula Hospital and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour with staff on 7/20/11, the hazardous areas were observed in the Santa Paula hospital. Soiled linen and trash storage areas, and combustible storage rooms greater than 50 square feet in size, are considered hazardous areas.

At 2:25 p.m., the med surge clean storage room was 7 feet by 8 feet in size. It contained approximately nine shelves of clean linens, one shelf of diapers, and two shelves of medical equipment in combustible plastic wrapping. The door to the storage room was not equipped with a self-closing device.

Based on observation, the facility failed to ensure that exits are readily accessible, as evidenced by exit doors that were obstructed from opening, and by exit doors that opened against egress. This affected four of five floors in the Academy Family Medical Center and could result in a delay of egress, in the event of a fire.

Findings:

During a facility tour with staff from 7/18/11 to 7/20/11, the exits were observed.

The Academic Family Medical Center was surveyed on 7/19/11 and 7/21/11.
Second Floor on 7/19/11-
At 4:50 p.m., the brown exit door, by Room 256, was obstructed from opening by a white exit door to the immediate right of the brown exit door.

Third Floor on 7/21/11 -
At 2:05 p.m., Exit Door 356, in the Pediatric Diagnostic Center, opened against egress.

Fourth Floor on 7/21/11 -
At 2:11 p.m., the brown exit door, from the patient room hallway in the Women's Health Center, was blocked from opening by a white exit door to the immediate right of the brown exit door.

Fifth Floor on 7/21/11 -
At 2:14 p.m., the brown exit door, in the Hematology Oncology Clinic, opened against egress.

Based on observation and interview, the facility failed to maintain patient care areas in accordance with NFPA 70 and NFPA 99. This was evidenced by anesthetizing locations with no battery-powered emergency lighting. This affected one of four floors in the main hospital, and one of six smoke compartments in the Santa Paula Hospital. This could result in no lights during procedures where anesthetics are used, in the event of a power outage.

NFPA 70
Article 700 - Emergency Systems
A. General
700-12 (e). Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment.


NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. (See Chapter 2 for definition of Patient Care Area.)
5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the emergency lighting was observed.

The main hospital was surveyed on 7/19/11.

Fourth Floor -
At 11:15 a.m., there was no battery-powered emergency back-up light in Delivery Room 3.

During an interview at 11:16 a.m., Maintenance Staff 2 confirmed that there was no battery-powered emergency lighting in the delivery room.

During an interview at 11:18 a.m., Staff 1 stated that the facility uses anesthesia during their procedures in the delivery room.



The Santa Paula Hospital was surveyed on 7/20/11

At 2:15 p.m., there was no battery back-up emergency lighting in Operating Room 1.

At 2:16 p.m., there was no battery back-up emergency lighting in Operating Room 2.

Based on observation, the facility failed to maintain their fire alarm system in accordance with NFPA 72. This was evidenced by obstructed pull stations in two locations. This affected one of four floors in the main hospital, and one of six smoke compartments in the Santa Paula hospital. This could result in a delay in notification, in the event of a fire.

NFPA 101
SECTION 9.6 Fire Detection, Alarm, and Communications Systems
9.6.2.3 A manual fire alarm box shall be provided in the natural exit access path near each required exit from an area, unless modified by another section of this Code.

9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72 National Fire Alarm Code 1999 Edition
2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the fire alarm system was observed.

The OR in the main hospital was surveyed on 7/20/11.

Second Floor -

At 9:25 a.m., the pull station by Operating Room 3 was obstructed by a gurney.


The Santa Paula Hospital was surveyed on 7/20/11.

At 2:41 p.m., the pull station near the emergency room exit was obstructed by a wheelchair.

Based on observation, record review, and interview, the facility failed to maintain their single station smoke detectors in accordance with the manufacturer's specifications. This was evidenced by no record for testing two of two single station smoke detectors in one outpatient clinic. This could result in a delay in notification in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During a facility tour with staff from 7/18/11 to 7/21/11, the smoke detectors were observed.

The Plastic Reconstructive and Hand Surgery Clinic was surveyed on 7/20/11.

At 11:52 a.m., there was no record for testing two of two single station smoke detectors. The manufacturer recommends weekly push button tests and annually battery replacement.

During an interview at 11:54 a.m., Maintenance Staff 3 stated that the smoke detectors have not been tested weekly.

Based on observation and interview, the facility failed to ensure one sprinkler system valve was supervised with a local alarm. This was evidenced by a post indicator valve (PIV) that was not monitored, tested or locked. This affected four of four floors and the basement of the main hospital. This could result in a delay in notification if the sprinkler system water supply was turned off, and a delay in extinguishing 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.


NFPA 72, National Fire Alarm Code, 1999 Edition
5.4.7 Distinctive Signals Audible alarm notification appliances for a fire alarm system shall produce signals that are distinctive from other similar appliances used for other purposes in the same area. The distinction among signals shall be as follows:
(a) Fire alarm signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose. The requirements of 3-8.4.1.2.1 shall apply.
(b) Supervisory signals shall be distinctive in sound from other signals. Their sound shall not be used for any other purpose.
Exception: A supervisory signal sound shall be permitted to be used to indicate a trouble condition. If the same sound is used for both supervisory signals and trouble signals, the distinction between signals shall be by other appropriate means such as visible annunciation.
(c) Fire alarm, supervisory, and trouble signals shall take precedence, in that respective order of priority, over all other signals.
Exception: Signals from hold-up alarms or other life-threatening signals shall be permitted to take precedence over supervisory and trouble signals if acceptable to the authority having jurisdiction.

Findings:

During fire alarm testing with staff on 7/20/11, the sprinkler supervisory signals were tested at the main hospital. An outside vendor was on hospital grounds assisting with the fire alarm testing. The vendor regularly performs the fire alarm testing at the hospital.

At 10:11 a.m., the PIV was not locked.

During an interview at 10:12 a.m., the outside vendor stated that during his quarterly and annual maintenance tests of the sprinkler system, he does not test the post indicator valve because it is not monitored through the fire alarm system. Closing the PIV valve shuts off the water to the sprinkler system. According to interviews the PIV is not maintained and tested.

At 10:18 a.m., the backflow valve was locked with a padlock. The vendor reported that the backflow valve has a supervisory signal. He stated that the supervisory signal for the backflow is monitored by the alarm system.

Based on observation and interview, the facility failed to maintain their sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by missing escutcheon rings, by sprinkler heads covered with rust or ice, by the use of standard-response sprinkler heads in areas protected with quick-response sprinkler heads and by the failure to maintain 18 inch clearance below one sprinkler deflector. This affected two of four floors in the main hospital and two of six smoke compartments in the Santa Paula Hospital. This could result in a delay in extinguishing a fire.

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

2-2 Inspection.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
NFPA 13, Standard for the 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 a facility tour with staff from 7/18/11 to 7/21/11, the sprinkler system was observed. Escutcheon rings cover the penetrations around sprinklers.

The Santa Paula Hospital was surveyed on 7/20/11.

At 2:20 p.m., there was a standard-response sprinkler head in the medical surgery medication room.
During an interview at 2:21 p.m., staff stated that the entire hospital had been switched to quick-response sprinkler heads.

At 2:30 p.m., three of three sprinkler heads in the x-ray room were standard-response. There was no escutcheon ring around one of the sprinkler heads.



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The main hospital was surveyed on 7/19/11.

First Floor -
At 10:15 a.m., there was a large, wheeled machine, stored beneath the stairway, leading to the exit discharge in the basement. The top of the machine reached approximately 1/2 inch from the sprinkler head. There was no 18 inch clearance below the sprinkler.

At 12:05 p.m., three of four sprinkler heads in Meat Freezer 7, in the kitchen, were missing escutcheon rings.

At 12:06 p.m., a layer of ice covered the deflector of one of three sprinkler heads that were missing escutcheon rings, in Meat Freezer 7.

Second Floor -
At 2:20 p.m., the sprinkler head and escutcheon ring in the laboratory walk-in refrigerator were rusty.

Based on observation, the facility failed to ensure that fire extinguishers are maintained in accordance with NFPA 10. This was evidenced by one fire extinguisher that was obstructed, and by one fire extinguisher that was unsecured on the floor. This affected one of four floors in the main hospital and the VCMC Physical Therapy clinic and could result in a delay in extinguishing a fire.

NFPA 10, Standard for Portable Fire Extinguishers 1998 edition
1.6 General Requirements
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.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer's instructions. Wheeled-type fire extinguishers shall be located in a designated location.
1.6.10 Fire extinguishers having a gross weight not exceeding 40 lbs (18.4 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight of more than 40 lb (18.4 kg) (except wheel type) shall be so installed that the top of the fire extinguisher is not more than 3.5 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in (10.2 cm).


Findings:

During a facility tour from 7/18/11 to 7/21/11, the fire extinguishers were observed.

The main hospital was surveyed on 7/19/11.

Second Floor -
At 2:22 p.m., there was a ABC fire extinguisher placed upright on the floor of the pharmacy manager's office.

The O.R. on the second floor was surveyed on 7/20/11.
At 9:22 a.m., the fire extinguisher by Operating Room 3 was blocked by a gurney.






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The VCMC Physical Therapy clinic was surveyed on 7/21/11.

At 8:58 a.m., a skeleton frame and a portable tray blocked access to the fire extinguisher, mounted on the wall of the main therapy room.

Based on record review and interview, the facility failed to maintain their fire dampers in accordance with NFPA 90A. This was evidenced by seven fire dampers that were inaccessible and were not maintained for more than four years. This affected two of four floors in the main hospital and could result in the failure of the fire damper to close, in the event of a fire.

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

Findings:

During record review on 7/18/11, the fire damper maintenance records were requested. A document titled "Fire Damper Drop Test Report" was provided. The document showed results from an inspection done by an outside vendor from 11/10/08 to 3/31/09.

At 3:10 p.m., the document showed that on 1/23/09, three fire dampers, #8338, # 8339, and # 8340 in Four East, were identified as inaccessible and were not maintained. The document showed that on 1/28/09, two fire dampers, # 8370 and # 8371 in Three West, were inaccessible and not maintained. The document showed that on 2/25/09 two fire dampers, # 7295 and # 7297 in the ultrasound department, were inaccessible and not maintained.

During an interview at 3:11 p.m., the Engineering Manager confirmed that the dampers had not been tested. He stated that the facility is in the middle of a six year construction project, that started in 2009, to alter the ceiling and make those dampers accessible for maintenance.

Based on observation, the facility failed to ensure that means of egress are free from obstructions. This was evidenced by equipment stored in exit access corridors. This affected one of four floors in the main hospital, one of six smoke compartments in the Santa Paula Hospital, and two of five floors of the Academic Family Medical Center. This could result in a delay in the evacuation of patients and staff, in the event of a fire.

Findings:

During the facility tour with staff from 7/18/11 to 7/19/11, the exit corridors were observed.

The main hospital was surveyed on 7/19/11.

At 12:01 p.m., there were four wheelchairs stored in the Ortho Unit, approximately 5 feet away from the exit door.

The Academic Family Medical Center was surveyed on 7/19/11.

First Floor -

At 4:05 p.m., there was a five-gallon water cooler and stand placed in the back corridor of Urgent Care.

Second Floor -

At 4:35 p.m., there was a five-gallon water cooler and stand placed in the back corridor of Family Care Center.

Based on observation, the facility failed to maintain their medical gas storage areas, as evidenced by full and empty oxygen cylinders stored together, and by storage of medical gas less than 10 feet from a facility door. This affected four of four floors of the main hospital, and could cause increased risk to patients who need oxygen in an emergency.

NFPA 99 , Standard for Health Care Facilities, 1999 Edition.
4-3.1.1.2 (10) (b)Storage facilities that are outside, but adjacent to a building wall, shall be accordance with NFPA 50, Standard For Bulk Oxygen System at Consumer Sites.
4-3.5.2.2 (b) (2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

NFPA 50 , Standard For Bulk Oxygen System at Consumer Sites, 1996 Edition.
2-2.1 Not less than 1 foot (0.3 m)(or other distance to permit system maintenance ) form buildings of other than wood frame construction.
2-2.3 At least 10 feet (3 m) from any opening in walls or adjacent structures. This provision shall apply to all elements of a bulk oxygen system where the oxygen storage is high pressure gas. Where the storage is as a liquid, this provision shall apply to only pressure regulators, safety devices, vaporizers, manifolds, and interconnecting piping.

Findings:

During tour of facility with staff on 7/19/11, the medical gas storage area was observed.
Main Hospital
At 3:14 p.m., the outdoor medical gas storage area was enclosed with a chain link fence and a galvanized metal roof. The storage area contained 16,694 cubic feet of compressed oxygen, 5,512 cubic feet of compressed nitrogen oxide, 95 gallons of liquid nitrogen, and other cylinders of non-flammable compressed gases. The chain link metal gate of the medical storage area was approximately 4 feet 8 inches from the exit door of the housekeeping unit on the first floor. There were H-tanks of compressed gases, on the right side of the storage area, stored up against the wall of the housekeeping unit in the hospital.
At 3:15 p.m., there were both empty and full oxygen cylinders stored in the outdoor medical storage area. There was no indication which cylinders were full and which were empty.

Based on observation, the facility failed to maintain their anesthetizing locations in accordance with NFPA 99. This was evidenced by an obstructed emergency shutoff valve outside one operating room. This affected one of four floors, and could result in a delay in shutting off the medical gas lines in the event of a fire, or other emergency.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a facility tour with staff on 7/20/11, the anesthetizing locations were observed.

Second Floor -
At 9:20 a.m., there was a gurney blocking the shut-off valve for the medical gas outside of Operating Room 3.

Based on observation, the facility failed to maintain their electrical wiring, as evidenced by the use of multi-plug adaptors (surge protectors) for appliances. This affected three of four floors and the basement, in the main hospital, and one outpatient clinic. This could result in an increased risk of an electrical fire.

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 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 the facility tour with staff from 7/18/11 to 7/21/11, the electrical wiring in the was observed.

The main hospital was surveyed on 7/19/11.

Fourth Floor -
At 10:59 a.m., there was a refrigerator plugged into a six-plug surge protector in the respiratory care manager's office.

Third Floor -
At 1:29 p.m., there was a microwave plugged into a six-plug surge protector in the ECHO department office.

Second Floor -
At 2:29 p.m., there was a refrigerator plugged into a multi-plug power strip in the trauma services office.

The Plastic Reconstructive and Hand Surgery Clinic was surveyed on 7/20/11.

At 11:45 a.m., there was a microwave, a refrigerator, and a clock radio plugged into a three-plug wall adaptor, with no surge protection, in the nursing office.

The Santa Paula Hospital was surveyed on 7/20/11.

At 2:48 p.m., there was a refrigerator plugged into a six-plug surge protector in the laboratory break room.



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Main Hospital Basement -
At 10:30 a.m. , there was a multi-plug surge protector, microwave, coffee maker, and a toaster, plugged into another multi-plug surge protector in the medical records room.