HospitalInspections.org

Based on observation and document review the facility failed to maintain the integrity of two-hour fire resistance rated walls.

Findings:

LOS ANGELES FACILITY

On February 16 , 2010 at 3:38 p.m., during a survey of the facility, the evaluator observed penetrations through four two-hour fire resistance rated walls.

There was a 6-inch by 3-inch penetration through a fire wall in the attic space above the cross corridor door next to room 212.

There was a 1-foot by 6-inch penetration through a fire wall in the attic space above the cross corridor door next to room 215.

There was a 1/2-inch diameter penetration through a fire wall in the attic space above the cross corridor door next to room 115.

There was a 4-inch diameter penetration through a fire wall in the attic space behind the wall of the fire alarm panel room.

Review of the facility floor plan identified the penetrated walls as two-hour fire resistance rated walls.

Based on observation and interview, the facility failed to ensure that the interior finish for the kitchen ceiling and between the kitchen and dining room had a flame spread rating of Class A, Class B, or Class C at all times.

Finding:

Norwalk Campus - On February 9, 2010, at 9:42 a.m., the evaluator conducted an inspection of the kitchen and observed that the door that separated the kitchen from the dining room door had a large hole. The latching device was cut out of the door that measured three inches by three inches.

The evaluator also observed an unsealed hole in the ceiling around one of the fire sprinklers located in the kitchen around the preparation island.

An interview was held with the Building Supervisor and he stated that he would have the area serviced as soon as possible.

NORWALK FACILITY

On February 9, 2010, between 8:00 a.m. and 10:00 a.m., the evaluator observed that impediments in the following rooms blocked the corridor from closing: Rooms 153, 154, 103, 105, 107, and the ICU Dump Sink room



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Based on observation, the facility failed to ensure there was no impediment to the closing of corridor doors and that a means was provided for keeping the corridor doors closed.

Findings:

LOS ANGELES FACILITY

On February 9, 2010, at 8:05 a.m., the evaluator observed the kitchen corridor door was impeded from closing by a scarf draped over the door latch and a rag at the floor between the edge of the door and the door frame.

NORWALK FACILITY

On February 10, 2010, between 1:03 p.m. and 1:58 p.m., during a survey of the facility, the evaluator observed that the following two doors were not able to close and four doors were unable to be kept closed.

The corridor door of room 103 failed to close. Closer observation revealed there were two loose screws at the door hinge.
The corridor door of room 105 failed to latch
The corridor door of room 106 failed to latch.
The corridor door of room 107 failed to latch.
The corridor door of room 109 failed to latch.
The corridor door of room 111 failed to close.

Based on observation, the facility failed to maintain the integrity of a smoke barrier wall in a condition to provide at least a one half hour fire resistance rating.

Findings:

NORWALK FACILITY

On February 10, 2010 between 12:48 p.m. and 12:55 p.m., during a survey of the facility, the evaluator observed 3-inch diameter penetration through a smoke barrier wall in the attic space above the cross corridor by dietary.


14041

Los Angeles Campus

On 2/18/10, at 3:15 p.m, the evaluator conducted an inspection and observed an 1/4 inch unsealed penetration over the smoke barrier doors located near Patient room 107.

Based on observation, the facility failed to separate a hazardous area from other spaces.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 10:15 a.m., during a survey of the facility, the evaluator observed two penetrations through the wall that separated the boiler and electrical room from the water softener room. One penetration was 2 1/2 feet by 1 1/2 feet and the other penetration was 1 1/2 feet by 1 foot.

NFPA 101 Life Safety Code 2000 Edition

7.2.2.5.3 Usable Space. There shall be no enclosed, usable spaces 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.

Based on observation, the facility failed to maintain space under two interior stairways free of storage.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 9:42 a.m., during a survey of the Los Angeles campus facility, the evaluator observed storage under an interior stairway that included; 17 bedside table tops, six cardboard boxes containing plumbing supplies, four audio speakers, two framed pictures, two light fixtures, a patient lift, a lamp, a fan and ceiling tiles. The stairway was located near the purchasing office and exited to Rowan street.

At 10:46 a.m., there were two chairs stored under an interior stairway near the human resources office.

Based on observation and interview, the facility failed to ensure that the exit access corridor remained clear and unobstructed.

Finding:

Norwalk Campus

On February 9, 2010, at 9:42 a.m., the evaluator observed that the exit access corridor located near Patient room 150 was used for storage of a bed, a Hoyer lift, a wheelchair, a soiled linen cart, a portable privacy curtain, and four dialysis machines.

An interview was held with the Nurse in Charge and she stated that the equipment would be removed as soon as possible.

NFPA 72 National Fire Alarm Code 1999 Edition

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

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/central unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101 Life Safety Code 2000 Edition

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

The standard was not met as evidenced by:

Based on observation and record review, the facility failed to maintain the fire alarm system in accordance with NFPA 72.

Findings Include:

LOS ANGELES FACILITY

On February 16, 2010 between 12:28 p.m. and 2:31 p.m., there was medical equipment stored in front of the door to a second floor exit stairwell located next to the purchasing room. Closer observation revealed a manual fire alarm next to the stairwell exit was obstructed from view and accessibility by the medical equipment.

NORWALK FACILITY

On February 10, 2010 at 10:44 a.m., during a survey of the facility, the evaluator observed a letter tray located in front of a wall at the east wing nurses station. Closer observation revealed a manual fire alarm was obstructed from view and accessibility by the letter tray.

On February 12, 2010 at 9:00 a.m., during a review of the fire alarm system records, the evaluator noted there was no documented evidence to indicate the smoke detectors had undergone a sensitivity test within the past five years.

During an interview, the Director of Plant Operations stated the facility never had the smoke detectors' sensitivity tested.

By the end of the survey the facility failed to provide any documented evidence the smoke detectors had undergone a sensitivity test within the past five years.

NFPA 13, Standard for the Installation of Sprinkler Systems 1999 edition

3-2.8 Guards and Shields

Sprinklers subject to mechanical injury shall be protected with listed guards.

5-5.6 Clearance to Storage

The clearance between the deflector and the stop of storage shall be 18 in. (457 mm) or greater.

Based on observation, the facility failed to maintains sprinklers in accordance with NFPA 13.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 between 8:34 a.m. and 9:45 a.m., during a survey of the facility, the evaluator observed paper goods stored at a height above the sprinkler heads in the pantry.

At 12:19 p.m., the sprinkler guard was missing from the sprinkler head in the kitchen walk in refrigerator.


NORWALK FACILITY

On February 10, 2010 at 12:55 p.m., during a survey of the facility, the evaluator observed storage at a height above the sprinkler heads in the dry goods storage room and in the file room behind the dry goods storage room .

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation, the facility failed to provide three fire extinguishers in accordance with NFPA 10.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 between 10: 15 a.m. and 10:32 a.m., during a survey of the facility, the evaluator observed a portable fire extinguisher stored on the floor in the dialysis supply room.

On February 16, 2010 between 12:28 p.m. and 2:31 p.m., there was medical equipment stored in front of the door to a second floor exit stairwell located next to the purchasing room. Closer observation revealed a fire extinguisher next to the stairwell exit was obstructed from view and accessibility by the medical equipment.



14041

Norwalk Campus

On February 9, 2010, at 9:40 a.m., the evaluator inspected the facility and observed a portable fire extinguisher was blocked by an isolation cart located near Room 153 and 154.

An interview was held with the Nurse in Charge and she stated that the isolation cart would be relocated as soon as possible.

The evaluator conducted an inspection and observed a portable fire extinguisher mounted on the wall located in the corridor near the Cardio Pulmonary Department. The portable fire extinguisher device was not secured with a seal or tamper indicator.

An interview was held with the Maintenance Engineer and he stated that he would have the portable fire extinguisher changed as soon as possible.

Based on observation, interview and record review, the facility failed to prevent the use of portable space heating devices within the facility.

Findings:

NORWALK FACILITY

On February 10, 2010 between 10:15 a.m. and 2:46 p.m., during a survey of the facility, the evaluator observed four space heaters in the facility. The heaters were located at the reception desk, nursing supervisor's office, nursing office and the emergency room.

The space heater at the reception desk was located behind the reception desk.

The space heater in the nursing supervisor's office was located under a desk.

The radiant space heater in the nursing office was connected to an electrical receptacle and was located next to a trash can containing paper and was also 8 1/2 inches from a wood desk. The warning label on the heater indicated, "Risk of Fire - Keep combustible materials such as furniture, papers, clothes and curtains at least 3 feet from the front of and away from sides and rear."

The ceramic space heater in the emergency room was connected to an electrical receptacle at the back of the room.

At the time of the survey, the facility was unable to provide any documented evidence the heating elements of the space heaters did not exceed 212 degrees F. (100 degrees C).

The facility's policy and procedure entitled Portable Heating Devices, dated June 15, 2009, indicated the hospital would not allow the use of any portable space heating devices for the purpose of supplying individual warmth and comfort.

The facility's policy and procedure entitled Fire safety Hazards dated June 15, 2009 indicated that electric heaters, particularly the portable type, were not permitted in the hospital.

Based on observation and document review, the facility failed to maintain means of egress free of obstructions and impediments to full instant use.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 between 9:42 a.m. and 10:15 a.m., during a survey of the facility, the evaluator observed beds stored throughout the exterior exit access pathway from a hospital building exit to the exit discharge gate at Olympic Boulevard.

On February 16, 2010 between 12:28 p.m. and 2:31 p.m., there were five pieces of medical equipment stored in front of the door to a second floor exit stairwell located next to the purchasing room. The medical equipment included two dialysis machines and a medication cart.

Review of the evacuation floor plan identified both the exit pathway and second floor stairwell door as evacuation routes.

(1) NFPA 99, Standard for Health Care Facilities, 1999 Edition, 3-4.1.2.4 Receptacles.
(a) Types of Receptacles. Each power receptacle shall provide at least one separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug despite electrical and mechanical abuse. Special receptacles such as four-pole units providing an extra pole for redundant grounding or ground continuity monitoring; or locking-type receptacles; or, where required for reduction of electrical noise on the grounding circuit, receptacles in which the grounding terminals are purposely insulated for the receptacle yoke) shall be permitted.
(b) Minimum number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. Thee shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 70 National Electrical Code 1999 Edition, Chapter 5 Special Occupancies, 517-19 Critical Care Areas. (a) Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal receptacles shall be identified and shall also indicate the panelboard and circuit number supplying the.
(b) Patient Bed Location Receptacles. (1) Each patient bed location shall be provided with a minimum of six receptacles, at least one of which shall be connected to: (b) An emergency system branch circuit supplied by a different transfer switch than the other receptacles at the same location

NFPA 99 Standard for Health Care Facilities 1999 Edition, Chapter 2 Definitions, 2-2 Definitions of Terms used in the Standard Patient Care Area Any portion of a health care facility wherein patients are intended to be examined or treated (b) Critical Care Areas Critical care areas are those special care units in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances. Examples of critical care areas include intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, postanesthetics recovery rooms, and emergency rooms.

Patient -Care Related Electrical Appliance. An electrical appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in patient care vicinity.

This standard is not met as evidence by:

Based on observation, record review, and interview, the facility failed to ensure and provide adequate numbers of electrical outlets for patients in the Critical Care Areas so as to preclude the use of extension cords and multiple outlet adapters, under normal power and during an interruption of normal power. This is a repeat deficiency from the Life Safety Report dated 8/18/2009.

Finding:

Los Angeles Campus

On February 11, 2009, the evaluators conducted an inspection of the facility and observed the following: Los Angeles campus - electric surge protectors used for Ominicell in Nurse across from Room 126, and in Rooms 120, 153, 201, 202, 203, 205, and 207. In rooms 202 and 203, the ventilators were connected directly to the surge protectors.

Norwalk Campus

The evaluator conducted an inspection and observed surge protectors in use in Rooms 151 and 154. In bed 15,1 the Intravenous Pump (IV)and bed control; Room 153/bed C the blood pressure machine; room 207 - the ventilator, IV pump and G.Tube; room 205 - IV, tube feeding, and suction machine; room 203 - Cardiac monitor, ventilator, and IV.

A record review of the Policy and Procedure, "Management of Utility System Failure," stipulated "Emergency Extension cords are located in the maintenance shop and can be used to receive power from another area, if there is a critical need as determined by the department director."

An interview was held with a licensed staff and she stated that the Building Engineer provided the surge protectors for the staff to use in the patients' rooms on a daily basis. An interview was held with a Biomedical Supervisor, and he stated that all the ventilators should be connected directly into an outlet in the wall at all times.

(2) NFPA 99, Standards for Health Care Facilities, 1999 Edition, Section 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a)* Nonflammable Gases (Any Quantity; In-Storage, Connected or Both) 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

This requirement is not met as evidenced by:

Based on observation and interview, the facility failed to ensure that a Medical Crash Cart oxygen tank was properly secured at all times. The pressure inside the tank may be high enough to propel the cylinder, possibly resulting in the cylinder impacting and injuring a person or other object.

Findings include:

Norwalk Campus

On February 9, 2010, 9:50 a.m., during a tour of the facility, the evaluator observed a Medical Crash Cart with a small oxygen cylinder. The oxygen cylinder was not secured at the time of the observation.

During the exit conference, the deficiency was discussed and brought to the attention to the Administrator.

(3) NFPA 99 Standard for Heath Care Facilities 1999 Edition, Chapter 4 Gas and Vacuum Systems, 4-5 Level 3 Piped Systems,
4-5.5.2.2 Storage of Cylinders and Containers Level 3 (B Nonflammable Gases 1. Storage shall be planned so that cylinders can be used in the order in which they are received from the suppliers. 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.

Based on observation and interview, the facility failed to ensure that the oxygen canisters were readily available and easily identified in case of an emergency.

Finding:

Norwalk Campus

On February 9, 2010, at 8:47 a.m., the evaluator conducted an inspection of the Norwalk campus Cardio Pulmonary Room and observed an oxygen rack that held both empty and full oxygen canisters and no information or segregation was immediately available. (eight E-Tanks)

An interview was held with the Respiratory Care Therapist and she stated, "If a staff needs a full oxygen canister they would read the tag around the neck of the canister".















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NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition

15-1.1 Removal of Window. Where a door or window opening is no longer in use, the opening shall be filled with construction equivalent to that of the wall.

15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

15-2.4.4 Fusible links or other heat-actuated devices and release devices shall not be painted.

15-2.4.5 Care shall be taken to prevent paint accumulation on any movable part such as but not limited to, stay rolls, gears, and closing mechanisms.

Findings:

LOS ANGELES FACILITY

On February 9 , 2010 at 9:45 a.m., during a survey of the facility, the evaluator observed a rolling steel door separating the kitchen dishwashing area from the cafeteria. Closer observation revealed a fusible link, chain, and other movable parts were painted. During the observation, the kitchen staff stated the rolling steel door was no longer in use.


NFPA 99 Health Care Facilities, 1999 Edition

8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet (85 cubic meters).

(h.) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

4-3.5.2.1(b)27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.


Based on observation and interview, the facility failed to maintain a rolling steel door in accordance with NFPA 80 and store oxygen cylinders in accordance with NFPA 99.

Findings:

NORWALK FACILITY

On February 10, 2010 between 10:00 a.m. and 11:00 a.m., during a survey of the facility, the evaluator observed oxygen e-cylinders stored on their sides on the floor at the exterior oxygen storage area.

At 2:18 p.m., two oxygen e-cylinders were observed being stored in the operating room storage area. Closer observation revealed the cylinders were not restrained by chains, stands, carts or any other device or method.

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

400-9. Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by section 400-7(a). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400-4) No. 14 and larger shall permitted if conductors are spliced in accordance with Section 110-14-(b) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

Based on observation, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 10:18 a.m., during a survey of the facility, the evaluator observed a computer connected to an extension cord that was in turn connected to a second extension cord that was connected to an electrical receptacle in the purchasing room. One of the extension cords was run from the electrical receptacle through wood shelving and between the back of a resin cabinet and a wall. The second extension cord was coiled on the floor.

At 2:33 p.m., there was a computer connected to a three tap electrical adapter that in turn was connected to a multi tap power strip that was hanging from a wall in the OB managers office.

At 3:10 p.m., there was a multi tap power strip, computer, printer and monitor connected to an extension cord which in turn was connected to a multi tap power strip that was connected to an electrical receptacle in the surgery office.


NORWALK FACILITY

On February 10, 2010 between 2:18 p.m. and 2:46 p.m., during a survey of the facility, the evaluator observed a time clock connected to a ungrounded household cube tap extension cord that was connected to an electrical receptacle in the employee lounge.









14041

LOS ANGELES FACILITY

On February 9, 2010 the evaluator conducted an inspection of Resident room 120 and observed an electric outlet was partially detached from the wall. The evaluator also observed that 1 of 2 sewer pumps was connected to electrical source with the wires taped up and hanging out of the electric box.

An interview was held with the Building Supervisor and he stated that these areas identified would be serviced as soon as possible.

NORWALK FACILITY

On February 9, 2010, between 8:00 a.m., and 10:00 a.m., the evaluator conducted an inspection of the East Wing Boiler Room and observed a missing cover for a electric junction box and an emergency outlet was cracked near the Nurse Station.

Based on observation and document review the facility failed to maintain the integrity of two-hour fire resistance rated walls.

Findings:

LOS ANGELES FACILITY

On February 16 , 2010 at 3:38 p.m., during a survey of the facility, the evaluator observed penetrations through four two-hour fire resistance rated walls.

There was a 6-inch by 3-inch penetration through a fire wall in the attic space above the cross corridor door next to room 212.

There was a 1-foot by 6-inch penetration through a fire wall in the attic space above the cross corridor door next to room 215.

There was a 1/2-inch diameter penetration through a fire wall in the attic space above the cross corridor door next to room 115.

There was a 4-inch diameter penetration through a fire wall in the attic space behind the wall of the fire alarm panel room.

Review of the facility floor plan identified the penetrated walls as two-hour fire resistance rated walls.

Based on observation and interview, the facility failed to ensure that the interior finish for the kitchen ceiling and between the kitchen and dining room had a flame spread rating of Class A, Class B, or Class C at all times.

Finding:

Norwalk Campus - On February 9, 2010, at 9:42 a.m., the evaluator conducted an inspection of the kitchen and observed that the door that separated the kitchen from the dining room door had a large hole. The latching device was cut out of the door that measured three inches by three inches.

The evaluator also observed an unsealed hole in the ceiling around one of the fire sprinklers located in the kitchen around the preparation island.

An interview was held with the Building Supervisor and he stated that he would have the area serviced as soon as possible.

NORWALK FACILITY

On February 9, 2010, between 8:00 a.m. and 10:00 a.m., the evaluator observed that impediments in the following rooms blocked the corridor from closing: Rooms 153, 154, 103, 105, 107, and the ICU Dump Sink room



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Based on observation, the facility failed to ensure there was no impediment to the closing of corridor doors and that a means was provided for keeping the corridor doors closed.

Findings:

LOS ANGELES FACILITY

On February 9, 2010, at 8:05 a.m., the evaluator observed the kitchen corridor door was impeded from closing by a scarf draped over the door latch and a rag at the floor between the edge of the door and the door frame.

NORWALK FACILITY

On February 10, 2010, between 1:03 p.m. and 1:58 p.m., during a survey of the facility, the evaluator observed that the following two doors were not able to close and four doors were unable to be kept closed.

The corridor door of room 103 failed to close. Closer observation revealed there were two loose screws at the door hinge.
The corridor door of room 105 failed to latch
The corridor door of room 106 failed to latch.
The corridor door of room 107 failed to latch.
The corridor door of room 109 failed to latch.
The corridor door of room 111 failed to close.

Based on observation, the facility failed to maintain the integrity of a smoke barrier wall in a condition to provide at least a one half hour fire resistance rating.

Findings:

NORWALK FACILITY

On February 10, 2010 between 12:48 p.m. and 12:55 p.m., during a survey of the facility, the evaluator observed 3-inch diameter penetration through a smoke barrier wall in the attic space above the cross corridor by dietary.


14041

Los Angeles Campus

On 2/18/10, at 3:15 p.m, the evaluator conducted an inspection and observed an 1/4 inch unsealed penetration over the smoke barrier doors located near Patient room 107.

Based on observation, the facility failed to separate a hazardous area from other spaces.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 10:15 a.m., during a survey of the facility, the evaluator observed two penetrations through the wall that separated the boiler and electrical room from the water softener room. One penetration was 2 1/2 feet by 1 1/2 feet and the other penetration was 1 1/2 feet by 1 foot.

NFPA 101 Life Safety Code 2000 Edition

7.2.2.5.3 Usable Space. There shall be no enclosed, usable spaces 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.

Based on observation, the facility failed to maintain space under two interior stairways free of storage.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 9:42 a.m., during a survey of the Los Angeles campus facility, the evaluator observed storage under an interior stairway that included; 17 bedside table tops, six cardboard boxes containing plumbing supplies, four audio speakers, two framed pictures, two light fixtures, a patient lift, a lamp, a fan and ceiling tiles. The stairway was located near the purchasing office and exited to Rowan street.

At 10:46 a.m., there were two chairs stored under an interior stairway near the human resources office.

Based on observation and interview, the facility failed to ensure that the exit access corridor remained clear and unobstructed.

Finding:

Norwalk Campus

On February 9, 2010, at 9:42 a.m., the evaluator observed that the exit access corridor located near Patient room 150 was used for storage of a bed, a Hoyer lift, a wheelchair, a soiled linen cart, a portable privacy curtain, and four dialysis machines.

An interview was held with the Nurse in Charge and she stated that the equipment would be removed as soon as possible.

NFPA 72 National Fire Alarm Code 1999 Edition

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

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/central unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction.

Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.

Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.

The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

NFPA 101 Life Safety Code 2000 Edition

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

The standard was not met as evidenced by:

Based on observation and record review, the facility failed to maintain the fire alarm system in accordance with NFPA 72.

Findings Include:

LOS ANGELES FACILITY

On February 16, 2010 between 12:28 p.m. and 2:31 p.m., there was medical equipment stored in front of the door to a second floor exit stairwell located next to the purchasing room. Closer observation revealed a manual fire alarm next to the stairwell exit was obstructed from view and accessibility by the medical equipment.

NORWALK FACILITY

On February 10, 2010 at 10:44 a.m., during a survey of the facility, the evaluator observed a letter tray located in front of a wall at the east wing nurses station. Closer observation revealed a manual fire alarm was obstructed from view and accessibility by the letter tray.

On February 12, 2010 at 9:00 a.m., during a review of the fire alarm system records, the evaluator noted there was no documented evidence to indicate the smoke detectors had undergone a sensitivity test within the past five years.

During an interview, the Director of Plant Operations stated the facility never had the smoke detectors' sensitivity tested.

By the end of the survey the facility failed to provide any documented evidence the smoke detectors had undergone a sensitivity test within the past five years.

NFPA 13, Standard for the Installation of Sprinkler Systems 1999 edition

3-2.8 Guards and Shields

Sprinklers subject to mechanical injury shall be protected with listed guards.

5-5.6 Clearance to Storage

The clearance between the deflector and the stop of storage shall be 18 in. (457 mm) or greater.

Based on observation, the facility failed to maintains sprinklers in accordance with NFPA 13.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 between 8:34 a.m. and 9:45 a.m., during a survey of the facility, the evaluator observed paper goods stored at a height above the sprinkler heads in the pantry.

At 12:19 p.m., the sprinkler guard was missing from the sprinkler head in the kitchen walk in refrigerator.


NORWALK FACILITY

On February 10, 2010 at 12:55 p.m., during a survey of the facility, the evaluator observed storage at a height above the sprinkler heads in the dry goods storage room and in the file room behind the dry goods storage room .

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Based on observation, the facility failed to provide three fire extinguishers in accordance with NFPA 10.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 between 10: 15 a.m. and 10:32 a.m., during a survey of the facility, the evaluator observed a portable fire extinguisher stored on the floor in the dialysis supply room.

On February 16, 2010 between 12:28 p.m. and 2:31 p.m., there was medical equipment stored in front of the door to a second floor exit stairwell located next to the purchasing room. Closer observation revealed a fire extinguisher next to the stairwell exit was obstructed from view and accessibility by the medical equipment.



14041

Norwalk Campus

On February 9, 2010, at 9:40 a.m., the evaluator inspected the facility and observed a portable fire extinguisher was blocked by an isolation cart located near Room 153 and 154.

An interview was held with the Nurse in Charge and she stated that the isolation cart would be relocated as soon as possible.

The evaluator conducted an inspection and observed a portable fire extinguisher mounted on the wall located in the corridor near the Cardio Pulmonary Department. The portable fire extinguisher device was not secured with a seal or tamper indicator.

An interview was held with the Maintenance Engineer and he stated that he would have the portable fire extinguisher changed as soon as possible.

Based on observation, interview and record review, the facility failed to prevent the use of portable space heating devices within the facility.

Findings:

NORWALK FACILITY

On February 10, 2010 between 10:15 a.m. and 2:46 p.m., during a survey of the facility, the evaluator observed four space heaters in the facility. The heaters were located at the reception desk, nursing supervisor's office, nursing office and the emergency room.

The space heater at the reception desk was located behind the reception desk.

The space heater in the nursing supervisor's office was located under a desk.

The radiant space heater in the nursing office was connected to an electrical receptacle and was located next to a trash can containing paper and was also 8 1/2 inches from a wood desk. The warning label on the heater indicated, "Risk of Fire - Keep combustible materials such as furniture, papers, clothes and curtains at least 3 feet from the front of and away from sides and rear."

The ceramic space heater in the emergency room was connected to an electrical receptacle at the back of the room.

At the time of the survey, the facility was unable to provide any documented evidence the heating elements of the space heaters did not exceed 212 degrees F. (100 degrees C).

The facility's policy and procedure entitled Portable Heating Devices, dated June 15, 2009, indicated the hospital would not allow the use of any portable space heating devices for the purpose of supplying individual warmth and comfort.

The facility's policy and procedure entitled Fire safety Hazards dated June 15, 2009 indicated that electric heaters, particularly the portable type, were not permitted in the hospital.

Based on observation and document review, the facility failed to maintain means of egress free of obstructions and impediments to full instant use.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 between 9:42 a.m. and 10:15 a.m., during a survey of the facility, the evaluator observed beds stored throughout the exterior exit access pathway from a hospital building exit to the exit discharge gate at Olympic Boulevard.

On February 16, 2010 between 12:28 p.m. and 2:31 p.m., there were five pieces of medical equipment stored in front of the door to a second floor exit stairwell located next to the purchasing room. The medical equipment included two dialysis machines and a medication cart.

Review of the evacuation floor plan identified both the exit pathway and second floor stairwell door as evacuation routes.

(1) NFPA 99, Standard for Health Care Facilities, 1999 Edition, 3-4.1.2.4 Receptacles.
(a) Types of Receptacles. Each power receptacle shall provide at least one separate, highly dependable grounding pole capable of maintaining low-contact resistance with its mating plug despite electrical and mechanical abuse. Special receptacles such as four-pole units providing an extra pole for redundant grounding or ground continuity monitoring; or locking-type receptacles; or, where required for reduction of electrical noise on the grounding circuit, receptacles in which the grounding terminals are purposely insulated for the receptacle yoke) shall be permitted.
(b) Minimum number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. Thee shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.

NFPA 70 National Electrical Code 1999 Edition, Chapter 5 Special Occupancies, 517-19 Critical Care Areas. (a) Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal receptacles shall be identified and shall also indicate the panelboard and circuit number supplying the.
(b) Patient Bed Location Receptacles. (1) Each patient bed location shall be provided with a minimum of six receptacles, at least one of which shall be connected to: (b) An emergency system branch circuit supplied by a different transfer switch than the other receptacles at the same location

NFPA 99 Standard for Health Care Facilities 1999 Edition, Chapter 2 Definitions, 2-2 Definitions of Terms used in the Standard Patient Care Area Any portion of a health care facility wherein patients are intended to be examined or treated (b) Critical Care Areas Critical care areas are those special care units in which patients are intended to be subjected to invasive procedures and connected to line-operated, patient-care-related electrical appliances. Examples of critical care areas include intensive care units, coronary care units, angiography laboratories, cardiac catheterization laboratories, delivery rooms, operating rooms, postanesthetics recovery rooms, and emergency rooms.

Patient -Care Related Electrical Appliance. An electrical appliance that is intended to be used for diagnostic, therapeutic, or monitoring purposes in patient care vicinity.

This standard is not met as evidence by:

Based on observation, record review, and interview, the facility failed to ensure and provide adequate numbers of electrical outlets for patients in the Critical Care Areas so as to preclude the use of extension cords and multiple outlet adapters, under normal power and during an interruption of normal power. This is a repeat deficiency from the Life Safety Report dated 8/18/2009.

Finding:

Los Angeles Campus

On February 11, 2009, the evaluators conducted an inspection of the facility and observed the following: Los Angeles campus - electric surge protectors used for Ominicell in Nurse across from Room 126, and in Rooms 120, 153, 201, 202, 203, 205, and 207. In rooms 202 and 203, the ventilators were connected directly to the surge protectors.

Norwalk Campus

The evaluator conducted an inspection and observed surge protectors in use in Rooms 151 and 154. In bed 15,1 the Intravenous Pump (IV)and bed control; Room 153/bed C the blood pressure machine; room 207 - the ventilator, IV pump and G.Tube; room 205 - IV, tube feeding, and suction machine; room 203 - Cardiac monitor, ventilator, and IV.

A record review of the Policy and Procedure, "Management of Utility System Failure," stipulated "Emergency Extension cords are located in the maintenance shop and can be used to receive power from another area, if there is a critical need as determined by the department director."

An interview was held with a licensed staff and she stated that the Building Engineer provided the surge protectors for the staff to use in the patients' rooms on a daily basis. An interview was held with a Biomedical Supervisor, and he stated that all the ventilators should be connected directly into an outlet in the wall at all times.

(2) NFPA 99, Standards for Health Care Facilities, 1999 Edition, Section 4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement). (a)* Nonflammable Gases (Any Quantity; In-Storage, Connected or Both) 3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

This requirement is not met as evidenced by:

Based on observation and interview, the facility failed to ensure that a Medical Crash Cart oxygen tank was properly secured at all times. The pressure inside the tank may be high enough to propel the cylinder, possibly resulting in the cylinder impacting and injuring a person or other object.

Findings include:

Norwalk Campus

On February 9, 2010, 9:50 a.m., during a tour of the facility, the evaluator observed a Medical Crash Cart with a small oxygen cylinder. The oxygen cylinder was not secured at the time of the observation.

During the exit conference, the deficiency was discussed and brought to the attention to the Administrator.

(3) NFPA 99 Standard for Heath Care Facilities 1999 Edition, Chapter 4 Gas and Vacuum Systems, 4-5 Level 3 Piped Systems,
4-5.5.2.2 Storage of Cylinders and Containers Level 3 (B Nonflammable Gases 1. Storage shall be planned so that cylinders can be used in the order in which they are received from the suppliers. 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.

Based on observation and interview, the facility failed to ensure that the oxygen canisters were readily available and easily identified in case of an emergency.

Finding:

Norwalk Campus

On February 9, 2010, at 8:47 a.m., the evaluator conducted an inspection of the Norwalk campus Cardio Pulmonary Room and observed an oxygen rack that held both empty and full oxygen canisters and no information or segregation was immediately available. (eight E-Tanks)

An interview was held with the Respiratory Care Therapist and she stated, "If a staff needs a full oxygen canister they would read the tag around the neck of the canister".















16281

NFPA 80, Standard for Fire Doors and Fire Windows 1999 Edition

15-1.1 Removal of Window. Where a door or window opening is no longer in use, the opening shall be filled with construction equivalent to that of the wall.

15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.

15-2.4.4 Fusible links or other heat-actuated devices and release devices shall not be painted.

15-2.4.5 Care shall be taken to prevent paint accumulation on any movable part such as but not limited to, stay rolls, gears, and closing mechanisms.

Findings:

LOS ANGELES FACILITY

On February 9 , 2010 at 9:45 a.m., during a survey of the facility, the evaluator observed a rolling steel door separating the kitchen dishwashing area from the cafeteria. Closer observation revealed a fusible link, chain, and other movable parts were painted. During the observation, the kitchen staff stated the rolling steel door was no longer in use.


NFPA 99 Health Care Facilities, 1999 Edition

8-3.1.11.2 Storage for nonflammable gases less than 3000 cubic feet (85 cubic meters).

(h.) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

4-3.5.2.1(b)27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.


Based on observation and interview, the facility failed to maintain a rolling steel door in accordance with NFPA 80 and store oxygen cylinders in accordance with NFPA 99.

Findings:

NORWALK FACILITY

On February 10, 2010 between 10:00 a.m. and 11:00 a.m., during a survey of the facility, the evaluator observed oxygen e-cylinders stored on their sides on the floor at the exterior oxygen storage area.

At 2:18 p.m., two oxygen e-cylinders were observed being stored in the operating room storage area. Closer observation revealed the cylinders were not restrained by chains, stands, carts or any other device or method.

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

400-9. Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by section 400-7(a). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400-4) No. 14 and larger shall permitted if conductors are spliced in accordance with Section 110-14-(b) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

Based on observation, the facility failed to provide electrical wiring in accordance with NFPA 70, National Electrical Code.

Findings:

LOS ANGELES FACILITY

On February 9, 2010 at 10:18 a.m., during a survey of the facility, the evaluator observed a computer connected to an extension cord that was in turn connected to a second extension cord that was connected to an electrical receptacle in the purchasing room. One of the extension cords was run from the electrical receptacle through wood shelving and between the back of a resin cabinet and a wall. The second extension cord was coiled on the floor.

At 2:33 p.m., there was a computer connected to a three tap electrical adapter that in turn was connected to a multi tap power strip that was hanging from a wall in the OB managers office.

At 3:10 p.m., there was a multi tap power strip, computer, printer and monitor connected to an extension cord which in turn was connected to a multi tap power strip that was connected to an electrical receptacle in the surgery office.


NORWALK FACILITY

On February 10, 2010 between 2:18 p.m. and 2:46 p.m., during a survey of the facility, the evaluator observed a time clock connected to a ungrounded household cube tap extension cord that was connected to an electrical receptacle in the employee lounge.









14041

LOS ANGELES FACILITY

On February 9, 2010 the evaluator conducted an inspection of Resident room 120 and observed an electric outlet was partially detached from the wall. The evaluator also observed that 1 of 2 sewer pumps was connected to electrical source with the wires taped up and hanging out of the electric box.

An interview was held with the Building Supervisor and he stated that these areas identified would be serviced as soon as possible.

NORWALK FACILITY

On February 9, 2010, between 8:00 a.m., and 10:00 a.m., the evaluator conducted an inspection of the East Wing Boiler Room and observed a missing cover for a electric junction box and an emergency outlet was cracked near the Nurse Station.