HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and floors. This affected 2 of 7 buildings which could result in the spread of smoke or fire to other locations in the facility.
NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the building construction was observed.

Medical Center Tower N/S, 1972 Building,

7/7/15
1. At 9:41 a.m. there was an approximately 14 inch by 5 inch unsealed penetration under the drinking fountain near the OB ED nursing station on the 3rd floor.

Medical Center Tower E/W, 1990 Building,

7/7/15
2. At 10:01 a.m., there was an approximately 2 inch unsealed penetration in the wall above the electrical panel 2 EPC in the Air Handler Room on the 2nd floor near CCU.

Emergency Room, Ancillary Building

7/7/15
3. At 10:57 a.m., there was an approximately 3 1/2 inch by 2 1/2 inch unsealed penetration in the wall of the 2nd floor Lab.

4. At 3:53 p.m., there were ten 1/2 inch unsealed penetrations in the wall of the back storeroom in the Kitchen.

Based on observation, the facility failed to maintain their flame spread rating of ceilings. This was evidenced by a missing fire rated ceiling panel. This failure affected 1 of 7 buildings and had the potential to allow the spread of flames in the event of a fire.

Findings:

During a tour of the facility with Facility Staff 1 on 7/6/15, the interior finish of rooms was observed.

Outpatient Fontana Urgent Care
At 3:30 p.m., there was a twelve inch by twelve inch ceiling panel missing in an exam room that was identified as Lab on the door.

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to latch and corridor doors that were impeded from closing. This affected 3 of 7 buildings, and could result in a delay to contain smoke or fire to a room.

NFPA 101 Life Safety Code, 2000 Edition
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.4. All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

A.19.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie backs, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, Facility Manager, and Quality Assurance Representative on 7/6/15 through 7/9/15, the doors in the facility were observed.

Medicval Center Tower N/S, 1972 Building

7/6/15
1. At 10:24 a.m., the corridor door to Room 638 was impeded from closing with a trash can in front of the door.

Medical Center Tower E/W, 1990 Building

7/6/15
2. At 10:50 a.m., the self-closing corridor door to the Mechanical Room on the 6th floor was not latching when tested.

Medical Center Tower N/S, 1972 Building

7/6/15
3. At 3:16 p.m., the self-closing corridor door to the south Soiled Utility Room near Room 507 was not latching when tested.

Medical Center Tower E/W, 1990 Building

7/7/15
4. At 8:57 a.m., the self-closing corridor door to the fetal demise room was not latching when tested.

Medical Center Tower N/S 1972 Building

7/7/15
5. At 9:07 a.m., the west self-corridor door to the Mother Baby Managers office on the 3rd floor was not latching when tested.

6. At 10:03 a.m., the self-closing corridor door to the Soiled Utility Room near side 3 Nursing Station in CCU was not latching when tested.



29751

Outpatient Heart Clinic 7/9/15
7. At 9:06 a.m., the self-closing corridor door to Exam Room 4 was impeded from closing with a chair.

8. At 9:08 a.m., the self-closing corridor door to Exam Room 3 was impeded from closing with a wooden door stop.

Based on observation, the facility failed to maintain their stairwell fire doors. This was evidenced by a fire door that was impeded from closing. This affected 1 of 7 buildings and had the potential to allow the spread of smoke or flames in the event of a fire.
NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the stairwell doors were observed.

Medical Center Tower E/W, 1990 Building
7/6/15
At 11:18 a.m., the stairwell door on the second floor was impeded from closing with a large plastic box in front of the door.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in smoke barrier walls in 2 of 7 buildings. This could result in the spread of smoke in the event of fire.
NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

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

Findings:

During a tour of the facility with the Facility Manager on 7/8/15, the smoke barrier walls were observed.

Medical Center Tower E/W 1990 Building
1. At 1:30 p.m., there was a two inch unsealed penetration in the smoke barrier wall near the entrance to the ICU.

Emergency Rooom, Ancillary Building
2. At 1:59 p.m., there was an approximately two inch unsealed penetration around a blue communication wire pulled through the smoke barrier wall near Operating Room 1.

3. At 2:30 p.m., there was a five inch by two inch unsealed penetration in the smoke barrier wall at the back of Cath Lab 5.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to latch. This had the potential to fail to contain smoke during a fire that could lead to harm of the patients. This affected 1 of 7 buildings.
NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the facility smoke barrier doors were observed.

Medical Center Tower E/W, 1990 Building

7/8/15
1. At 9:23 a.m., the smoke barrier door 003 near Room 676 failed to latch.

2. At 9:41 a.m., the smoke barrier door near Room 546 failed to latch.

Based on observation and interview, the facility failed to protect its hazardous room enclosure. This was evidenced by a room which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and was not equipped with a self-closing mechanism on the door. This deficient practice affected 1 of 7 buildings, and could result in the spread of smoke and/or fire.
NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not morethan 48 in. (122 cm) above the bottom of the door.

NFPA 101, Life Safety Code, 2000 Edition
8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the hazardous area enclosures were observed and a staff person was interviewed.

Medical Center Tower N/S, 1972 Building

7/7/15
1. At 9:32 a.m., there was a room that contained two large containers full of linen with a door without a self-closing mechanism on it. The room was 334 and was greater that 50 square feet.

At 9:33 a.m., Nursing Staff 1 said during an interview that the room was used to store linen supplies in.

Based on observation and interview, the facility failed to ensure that their designated path of exit to a safe location outside the building were provided with continuous lighting in accordance with NFPA 101, 2000 Edition. This was evidenced by an emergency light that failed to illuminate when tested and no emergency continuous illumination in their designated path to a safe location outside the building during the main power outage and generator shutdown. This affected 3 of 7 buildings (Medical Center Tower N/S, Medical Center Tower E/W, and the Emergency Room, Ancillary building. This could result in limited visibility and unsafe evacuation from the building causing potential injury to patients, staff and visitors.

NFPA 101, 2000 Edition

7.8.1.2. Illumination of means of egress shall be continuous
during the time that the conditions of occupancy
require that the means of egress be available for use.
Artificial lighting shall be employed at such places and for
such periods of time as required to maintain the illumination
to the minimum values herein specified.

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15, the stairways were observed and the emergency lights were tested and a staff person was interviewed.

Emergency Room, Ancillary Building and the Medical Center Tower, N/S and E/W.

7/6/15
At 11:12 a.m., there was no emergency lighting in 12 of 12 stairwells during a main power outage and when the generators shut down leaving the stairwells in complete darkness from approximately 11:01 a.m., to 11:26 a.m. At 11:13 a.m., Administrative Staff 1 said during an interview that someone could get hurt in the dark stairwell during the power failure. The designated emergency lights in the stairwells connected to the generators were not lit for the period of the generator shutdown.
At 11:18 a.m., stairwells were manned by staff with flashlights to illuminate the stairways until the lighting was recovered.

Based on observation and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 101, 2000 Edition and NFPA 72, 1999 Edition. This was evidenced by annunciation devices and strobes that failed to activate during fire alarm testing and by the fire alarm system failing to sound an alarm in all occupied spaces. This could fail to notify the occupants during a fire and increase the risk of injury to 174 patients, staff and visitors. This affected 1 of 7 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.7.2 Alarm annunciation at the fire command center shall be audible and visible indicators.
3-2.2 Signal Annunciation. Protected premises fire alarm system shall arranged to annunciate alarm, supervisory , and trouble signal in accordance with 1-5.7.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the fire alarm system was tested and a staff person was interviewed.

Emergency Room, Ancillary Building

7/8/15
1. At 3:36 p.m., the strobe and annunciation devices near the computer stations in the Pharmacy was not sounding and alarm and flashing when tested.

2. At 3:40 p.m., the two strobes and annunciation devices in the Central Supply Room were not sounding an alarm and flashing when tested.

At 3:41 p.m., during interview with the Central Supply Manager, he stated that he could not hear the fire alarm system and see the strobes in central supply room.

At 3:50 p.m., the Facilities Manager said during an interview that he would start a fire watch until the devices are fixed.

Based on document review and interview, the facility failed to maintain their smoke detectors in accordance with manufactureer recommendation. This was evidenced by no records of manufacturers required testing of smoke detectors. This failure affected the 10 of 10 smoke detectors in 1 of 7 buildings. The smoke detectors could fail to notify staff and visitors during a fire emergency.
NFPA 101 Life Safety Code, 2000 Edition
9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.
NFPA 72 National Fire Alarm Code (1999 Edition) 8-1.1* Limitations.
8-1.1.1 Life safety from fire in residential occupancies shall be based primarily on early notification to occupants of the need to escape, followed by the appropriate egress actions by those occupants. Fire warning systems for dwelling units are capable of protecting about half of the occupants in potentially fatal fires. Victims are often intimate with the fire, too old or too young, or physically or mentally impaired such that they cannot escape even when warned early enough that escape should be possible. For these people, other strategies such as protection-in-place or assisted escape or rescue shall be necessary.
8-1.1.2* The performance of fire warning equipment for dwelling units discussed in Chapter 8 shall depend on such equipment being properly selected, installed, operated, tested, and maintained in accordance with the provisions of this code and with the manufacturer ' s instructions provided with the equipment.

Findings:

During a tour of the facility with the Facility Manager on 7/9/15, the smoke detectors were observed and a staff person was interviewed.

Heart Clinic
At 9:08 a.m., there was no documented evidence that the ten battery operated First Alert smoke detectors were inspected weekly according to the manufacturers requirement listed on the inside of the smoke detectors.

At 9:10 a.m., the Facility Manager said during an interview that the facility is not inspecting the smoke detectors weekly.

Based on observation, the facility failed to maintain their fire rated smoke barrier walls in accordance with NFPA 101, 2000 Edition. This was evidenced by unsealed penetrations around conduits in the smoke barrier walls. This affected 5 of 7 buildings. This failure could result in the spread of smoke and fire in the event of a fire.
NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Facility Manager on 7/6/15 through 7/8/15, the smoke barrier walls were observed.

Outpatient Highland Urgent Care, 7/6/15
1. At 2:46 p.m., there was a two inch black sprinkler pipe passing from the riser room to the clinic that had unsealed penetrations around the pipe.

2. At 2:48 p.m., there were three conduits passing from the Fire Alarm Control Panel room to the clinic with unsealed penetrations around the pipes.

Medical Center Tower E/W 1990 Building

7/8/15
3. At 10:40 a.m., there was a conduit sleeve passing through a smoke barrier wall near Fire Door 010 (3rd floor) with no fire caulking around communication wires in the pipe.

4. At 10:45 a.m., there were two conduit sleeves passing through smoke barrier wall near Fire Door 070 with no fire caulking around communication wires in the pipe.

Medical Center Tower N/S, 1972 Building

7/8/15
5. At 11:10 a.m., there was a one inch penetration around an electric conduit pipe in the smoke barrier separation wall near Labor and Delivery.

Medical center Tower E/W 1990 Building

7/8/15
6. At 1:40 p.m., there was a 3 inch conduit sleeve with blue communication wires with no fire caulking in the pipe near the CCU 3 entrance.

Outpatient Services

7/8/15
7. At 1:50 p.m., there was a conduit sleeve in the smoke barrier wall above the Outpatient Check-in with communication wires pulled through with no fire caulking in the pipe.

Emergency Room, Ancillary Building

7/8/15
8. At 2:20 p.m., there were two electric conduits with two unsealed penetrations inside the conduits outside of Operating Room 3.

Based on observation, document review, and interview, the facility failed to provide a reliable back up power in accordance with NFPA 101, 2000 Edition, NFPA 99, 1999 Edition and NFPA 110, 1999 Edition. Two emergency generators failed to provide back-up power during an actual main power outage for approximately 25 minutes. This resulted in darkened hallways and stairways. This could potentially result in failure to evacuate the building safely. 15 patients were using ventilators which rely on electrical power and could be injured if power is not returned within required time. This affected 3 of 7 buildings (Emergency Room, Ancillary building, 1990 and the Medical Center Tower, 1972) with patient census of 174, staff and visitors.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby system.

NFPA 110, Standard for Emergency Power and Standby Power Systems, 1999 Edition
3-4.1.1.8 + Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

4-3 Load Switching (Load Shedding).
4-3.1 General. When two or more engine generator sets are paralleled for emergency power, the paralleled system shall be arranged to inhibit connection of excessive loads.
4-3.2 Transfer Switch Rating. Each transfer switch shall have a continuous current rating and interrupting rating adequate for all classes of loads to be served. The transfer switch shall be capable of withstanding the available fault current at the point of installation.
4-3.3 Operation. First priority loads shall be switched to the emergency bus upon sensing the availability of emergency power on the bus. Each time an additional engine generator set is connected to the bus, a remaining load shall be connected in order of priority until all emergency loads are connected to the bus. The system shall be designed so that, upon failure of one or more engine generator sets, the load is automatically reduced, starting with the load of least priority and proceeding in ascending priority, so that the last load affected is the highest priority load.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15, the generator was observed, a staff person was interviewed, and documents were reviewed.

At approximately 9:00 a.m., the facility lost main electrical power due to an incident caused by Southern California Edition (SCE, the electrical company in the area) doing construction work outside the hospital building. Two emergency generators started and provided emergency power to the hospital at this time.

7/6/15
1. At 10:55 a.m., generator number 2 stopped running. At this time, generator number 1 was still running and still no effect on the life safety systems and equipment.

2. At 10:58 a.m., the written report dated 7/6/15 from a licensed vendor provided the following information: Generator 1 (800 KW) overheated because it was heavily loaded. Generator 1 continued to provide back up power in spite of overheating.

3. At 11:01 a.m., generator number 1 stopped running. At this time all power was lost in the whole Medical Center Tower. The only visible lights were the exit signs. The hallways and the stairways were in total darkness.
At 11:03 a.m., an electrical emergency was declared and a command post was initiated.

At 11:16 a.m., there were 15 patients using ventilators with a two hour battery back up on each one. Eleven patients in Intensive Care Unit (ICU) and four patients in Neonatal Intensive Care Unit (NICU).

At 11:26 a.m., after approximately 25 minutes, Generator number 1 restarted after overheating during the power emergency. The Facility Director stated that they reduced the number of equipment plugged to the outlets to reduce electrical load preventing future overheating of the generator.

At 11:43 a.m., main power was restored by Southern California Edison to the whole hospital.

At 11:48 a.m., an email was read from SCE indicating there would be a power disruption during utility work outside of the building.

At 11:51 a.m., the Facility Director said during an interview that he was informed by two employees from SCE a week ago that the utility work outside of the hospital will not affect the hospital.

At 1:10 p.m., the Facility Manager said during an interview that Generator number 2 failed at 10:55 a.m. because of a low voltage fuse blew out while the generator was running. There was no load reduction during the power failure.

At 1:14 p.m., the licensed vendor provided a report of a possible cause for the blown fuse in generator 2. The report said that the generator 2 circuit breaker would not close.

At 1:22 p.m., the generator vendor said during an interview that the fuse that blew out was very unusual and he said that he has never heard of a low voltage fuse blow out like this one. He said that generator 1 overheated due to the amount of power being used during the main power outage.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 edition. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords, surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord, a missing cover plate, utilizing extension cords, and an outlet pulled out of the wall. This affected 3 of 7 buildings, and could increase the risk of an electrical fire.
NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.1 UTILITIES
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 99, Health Care Facilities, 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There 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
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the facility's electrical equipment and wiring were observed.

Medical Center Tower N/S 1972 Building
7/6/15
1. At 10:44 a.m., there was a white extension cord in use in the 5th floor electrical room.

2. At 2:34 p.m., there was an electrical outlet that was hanging approximately 1 inch out of the wall in Room 539.

3. At 3:22 p.m., there was a microwave and a toaster that were plugged into a surge protected multi-outlet extension cord.

Medical Center Tower E/W, 1990 Building

7/7/15
4. 8:40 a.m., there was an orange extension cord in use (near the fire alarm control panel) in the Mechanical Room near Room 337.

Ememrgency Room, Ancillary Building

7/7/15
5. At 3:19 p.m., there was an orange extension cord in use in the Pharmacy IV compounding Room.

7/8/15
6. At 3:19 p.m., there was a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord in X-ray Room 3 on the 1st floor.

Based on observation, the facility failed to install their alcohol based hand rub dispensers in safe locations. This was evidenced by the mounting of alcohol based hand rub dispensers over ignition sources. This affected 1 of 7 buildings, and could result in an alcohol based hand rub ignited fire.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the alcohol based hand rub dispensers in the facility were observed.

1990 Building, 7/7/15
1. At 8:31 a.m., there was an alcohol based hand rub dispenser in Room 335 that was mounted above a light switch (ignition source).

Ancillary Building, 7/7/15
2. At 2:55 p.m., the alcohol based hand rub dispenser in Central Supply that was mounted above a light switch (ignition source).

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and floors. This affected 2 of 7 buildings which could result in the spread of smoke or fire to other locations in the facility.
NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.
8.3.1* General. Where required by Chapters 12 through 42, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.3.2* Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling,
including interstitial spaces.
Exception: A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the building construction was observed.

Medical Center Tower N/S, 1972 Building,

7/7/15
1. At 9:41 a.m. there was an approximately 14 inch by 5 inch unsealed penetration under the drinking fountain near the OB ED nursing station on the 3rd floor.

Medical Center Tower E/W, 1990 Building,

7/7/15
2. At 10:01 a.m., there was an approximately 2 inch unsealed penetration in the wall above the electrical panel 2 EPC in the Air Handler Room on the 2nd floor near CCU.

Emergency Room, Ancillary Building

7/7/15
3. At 10:57 a.m., there was an approximately 3 1/2 inch by 2 1/2 inch unsealed penetration in the wall of the 2nd floor Lab.

4. At 3:53 p.m., there were ten 1/2 inch unsealed penetrations in the wall of the back storeroom in the Kitchen.

Based on observation, the facility failed to maintain their flame spread rating of ceilings. This was evidenced by a missing fire rated ceiling panel. This failure affected 1 of 7 buildings and had the potential to allow the spread of flames in the event of a fire.

Findings:

During a tour of the facility with Facility Staff 1 on 7/6/15, the interior finish of rooms was observed.

Outpatient Fontana Urgent Care
At 3:30 p.m., there was a twelve inch by twelve inch ceiling panel missing in an exam room that was identified as Lab on the door.

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to latch and corridor doors that were impeded from closing. This affected 3 of 7 buildings, and could result in a delay to contain smoke or fire to a room.

NFPA 101 Life Safety Code, 2000 Edition
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4-in. (4.4-cm) thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. Compliance with NFPA 80, Standard for Fire Doors and Fire Windows, shall not be required. Clearance between the bottom of the door and the floor covering not exceeding 1 in. (2.5 cm) shall be permitted for corridor doors.
Exception No. 1: Doors to toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces that do not contain flammable or combustible materials.
Exception No. 2: In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, the door construction requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
2-4.1.4. All closing mechanisms shall be adjusted to overcome the resistance of the latch mechanism so that positive latching is achieved on each door operation.

19.3.6.3.3* Hold-open devices that release when the door is pushed or pulled shall be permitted.

A.19.3.6.3.3 Doors should not be blocked open by furniture, door stops, chocks, tie backs, drop down or plunger type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, Facility Manager, and Quality Assurance Representative on 7/6/15 through 7/9/15, the doors in the facility were observed.

Medicval Center Tower N/S, 1972 Building

7/6/15
1. At 10:24 a.m., the corridor door to Room 638 was impeded from closing with a trash can in front of the door.

Medical Center Tower E/W, 1990 Building

7/6/15
2. At 10:50 a.m., the self-closing corridor door to the Mechanical Room on the 6th floor was not latching when tested.

Medical Center Tower N/S, 1972 Building

7/6/15
3. At 3:16 p.m., the self-closing corridor door to the south Soiled Utility Room near Room 507 was not latching when tested.

Medical Center Tower E/W, 1990 Building

7/7/15
4. At 8:57 a.m., the self-closing corridor door to the fetal demise room was not latching when tested.

Medical Center Tower N/S 1972 Building

7/7/15
5. At 9:07 a.m., the west self-corridor door to the Mother Baby Managers office on the 3rd floor was not latching when tested.

6. At 10:03 a.m., the self-closing corridor door to the Soiled Utility Room near side 3 Nursing Station in CCU was not latching when tested.



29751

Outpatient Heart Clinic 7/9/15
7. At 9:06 a.m., the self-closing corridor door to Exam Room 4 was impeded from closing with a chair.

8. At 9:08 a.m., the self-closing corridor door to Exam Room 3 was impeded from closing with a wooden door stop.

Based on observation, the facility failed to maintain their stairwell fire doors. This was evidenced by a fire door that was impeded from closing. This affected 1 of 7 buildings and had the potential to allow the spread of smoke or flames in the event of a fire.
NFPA 101, Life Safety Code, 2000 Edition
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the stairwell doors were observed.

Medical Center Tower E/W, 1990 Building
7/6/15
At 11:18 a.m., the stairwell door on the second floor was impeded from closing with a large plastic box in front of the door.

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in smoke barrier walls in 2 of 7 buildings. This could result in the spread of smoke in the event of fire.
NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.
Exception No. 1: Where an atrium is used, smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with
Exception No. 2 to 8.2.5.6(1). Not less than two separate smoke compartments shall be provided on each floor.
Exception No. 2:* Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.3 has been provided for smoke compartments adjacent to the smoke barrier.

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

Findings:

During a tour of the facility with the Facility Manager on 7/8/15, the smoke barrier walls were observed.

Medical Center Tower E/W 1990 Building
1. At 1:30 p.m., there was a two inch unsealed penetration in the smoke barrier wall near the entrance to the ICU.

Emergency Rooom, Ancillary Building
2. At 1:59 p.m., there was an approximately two inch unsealed penetration around a blue communication wire pulled through the smoke barrier wall near Operating Room 1.

3. At 2:30 p.m., there was a five inch by two inch unsealed penetration in the smoke barrier wall at the back of Cath Lab 5.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors that failed to latch. This had the potential to fail to contain smoke during a fire that could lead to harm of the patients. This affected 1 of 7 buildings.
NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the holdopen mechanism is released and the door becomes selfclosing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the facility smoke barrier doors were observed.

Medical Center Tower E/W, 1990 Building

7/8/15
1. At 9:23 a.m., the smoke barrier door 003 near Room 676 failed to latch.

2. At 9:41 a.m., the smoke barrier door near Room 546 failed to latch.

Based on observation and interview, the facility failed to protect its hazardous room enclosure. This was evidenced by a room which contained combustible storage that posed a degree of hazard greater than that normal to the general occupancy of the building, and was not equipped with a self-closing mechanism on the door. This deficient practice affected 1 of 7 buildings, and could result in the spread of smoke and/or fire.
NFPA 101, Life Safety Code, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not morethan 48 in. (122 cm) above the bottom of the door.

NFPA 101, Life Safety Code, 2000 Edition
8.4.1.1* Protection from any area having a degree of hazard greater than that normal to the general occupancy of the building or structure shall be provided by one of the following means:
(1) Enclose the area with a fire barrier without windows that has a 1-hour fire resistance rating in accordance with Section 8.2.
(2) Protect the area with automatic extinguishing systems in accordance with Section 9.7.
(3) Apply both 8.4.1.1(1) and (2) where the hazard is severe or where otherwise specified by Chapters 12 through 42.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the hazardous area enclosures were observed and a staff person was interviewed.

Medical Center Tower N/S, 1972 Building

7/7/15
1. At 9:32 a.m., there was a room that contained two large containers full of linen with a door without a self-closing mechanism on it. The room was 334 and was greater that 50 square feet.

At 9:33 a.m., Nursing Staff 1 said during an interview that the room was used to store linen supplies in.

Based on observation and interview, the facility failed to ensure that their designated path of exit to a safe location outside the building were provided with continuous lighting in accordance with NFPA 101, 2000 Edition. This was evidenced by an emergency light that failed to illuminate when tested and no emergency continuous illumination in their designated path to a safe location outside the building during the main power outage and generator shutdown. This affected 3 of 7 buildings (Medical Center Tower N/S, Medical Center Tower E/W, and the Emergency Room, Ancillary building. This could result in limited visibility and unsafe evacuation from the building causing potential injury to patients, staff and visitors.

NFPA 101, 2000 Edition

7.8.1.2. Illumination of means of egress shall be continuous
during the time that the conditions of occupancy
require that the means of egress be available for use.
Artificial lighting shall be employed at such places and for
such periods of time as required to maintain the illumination
to the minimum values herein specified.

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15, the stairways were observed and the emergency lights were tested and a staff person was interviewed.

Emergency Room, Ancillary Building and the Medical Center Tower, N/S and E/W.

7/6/15
At 11:12 a.m., there was no emergency lighting in 12 of 12 stairwells during a main power outage and when the generators shut down leaving the stairwells in complete darkness from approximately 11:01 a.m., to 11:26 a.m. At 11:13 a.m., Administrative Staff 1 said during an interview that someone could get hurt in the dark stairwell during the power failure. The designated emergency lights in the stairwells connected to the generators were not lit for the period of the generator shutdown.
At 11:18 a.m., stairwells were manned by staff with flashlights to illuminate the stairways until the lighting was recovered.

Based on observation and interview, the facility failed to maintain their fire alarm system in accordance with NFPA 101, 2000 Edition and NFPA 72, 1999 Edition. This was evidenced by annunciation devices and strobes that failed to activate during fire alarm testing and by the fire alarm system failing to sound an alarm in all occupied spaces. This could fail to notify the occupants during a fire and increase the risk of injury to 174 patients, staff and visitors. This affected 1 of 7 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.7.2 Alarm annunciation at the fire command center shall be audible and visible indicators.
3-2.2 Signal Annunciation. Protected premises fire alarm system shall arranged to annunciate alarm, supervisory , and trouble signal in accordance with 1-5.7.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the fire alarm system was tested and a staff person was interviewed.

Emergency Room, Ancillary Building

7/8/15
1. At 3:36 p.m., the strobe and annunciation devices near the computer stations in the Pharmacy was not sounding and alarm and flashing when tested.

2. At 3:40 p.m., the two strobes and annunciation devices in the Central Supply Room were not sounding an alarm and flashing when tested.

At 3:41 p.m., during interview with the Central Supply Manager, he stated that he could not hear the fire alarm system and see the strobes in central supply room.

At 3:50 p.m., the Facilities Manager said during an interview that he would start a fire watch until the devices are fixed.

Based on document review and interview, the facility failed to maintain their smoke detectors in accordance with manufactureer recommendation. This was evidenced by no records of manufacturers required testing of smoke detectors. This failure affected the 10 of 10 smoke detectors in 1 of 7 buildings. The smoke detectors could fail to notify staff and visitors during a fire emergency.
NFPA 101 Life Safety Code, 2000 Edition
9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.
NFPA 72 National Fire Alarm Code (1999 Edition) 8-1.1* Limitations.
8-1.1.1 Life safety from fire in residential occupancies shall be based primarily on early notification to occupants of the need to escape, followed by the appropriate egress actions by those occupants. Fire warning systems for dwelling units are capable of protecting about half of the occupants in potentially fatal fires. Victims are often intimate with the fire, too old or too young, or physically or mentally impaired such that they cannot escape even when warned early enough that escape should be possible. For these people, other strategies such as protection-in-place or assisted escape or rescue shall be necessary.
8-1.1.2* The performance of fire warning equipment for dwelling units discussed in Chapter 8 shall depend on such equipment being properly selected, installed, operated, tested, and maintained in accordance with the provisions of this code and with the manufacturer ' s instructions provided with the equipment.

Findings:

During a tour of the facility with the Facility Manager on 7/9/15, the smoke detectors were observed and a staff person was interviewed.

Heart Clinic
At 9:08 a.m., there was no documented evidence that the ten battery operated First Alert smoke detectors were inspected weekly according to the manufacturers requirement listed on the inside of the smoke detectors.

At 9:10 a.m., the Facility Manager said during an interview that the facility is not inspecting the smoke detectors weekly.

Based on observation, the facility failed to maintain their fire rated smoke barrier walls in accordance with NFPA 101, 2000 Edition. This was evidenced by unsealed penetrations around conduits in the smoke barrier walls. This affected 5 of 7 buildings. This failure could result in the spread of smoke and fire in the event of a fire.
NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Facility Manager on 7/6/15 through 7/8/15, the smoke barrier walls were observed.

Outpatient Highland Urgent Care, 7/6/15
1. At 2:46 p.m., there was a two inch black sprinkler pipe passing from the riser room to the clinic that had unsealed penetrations around the pipe.

2. At 2:48 p.m., there were three conduits passing from the Fire Alarm Control Panel room to the clinic with unsealed penetrations around the pipes.

Medical Center Tower E/W 1990 Building

7/8/15
3. At 10:40 a.m., there was a conduit sleeve passing through a smoke barrier wall near Fire Door 010 (3rd floor) with no fire caulking around communication wires in the pipe.

4. At 10:45 a.m., there were two conduit sleeves passing through smoke barrier wall near Fire Door 070 with no fire caulking around communication wires in the pipe.

Medical Center Tower N/S, 1972 Building

7/8/15
5. At 11:10 a.m., there was a one inch penetration around an electric conduit pipe in the smoke barrier separation wall near Labor and Delivery.

Medical center Tower E/W 1990 Building

7/8/15
6. At 1:40 p.m., there was a 3 inch conduit sleeve with blue communication wires with no fire caulking in the pipe near the CCU 3 entrance.

Outpatient Services

7/8/15
7. At 1:50 p.m., there was a conduit sleeve in the smoke barrier wall above the Outpatient Check-in with communication wires pulled through with no fire caulking in the pipe.

Emergency Room, Ancillary Building

7/8/15
8. At 2:20 p.m., there were two electric conduits with two unsealed penetrations inside the conduits outside of Operating Room 3.

Based on observation, document review, and interview, the facility failed to provide a reliable back up power in accordance with NFPA 101, 2000 Edition, NFPA 99, 1999 Edition and NFPA 110, 1999 Edition. Two emergency generators failed to provide back-up power during an actual main power outage for approximately 25 minutes. This resulted in darkened hallways and stairways. This could potentially result in failure to evacuate the building safely. 15 patients were using ventilators which rely on electrical power and could be injured if power is not returned within required time. This affected 3 of 7 buildings (Emergency Room, Ancillary building, 1990 and the Medical Center Tower, 1972) with patient census of 174, staff and visitors.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby system.

NFPA 110, Standard for Emergency Power and Standby Power Systems, 1999 Edition
3-4.1.1.8 + Load Pickup. The generator set(s) shall have sufficient capacity to pick up the load and meet the minimum frequency and voltage stability requirements of the emergency system within 10 seconds after loss of normal power. [110: 34.1]

4-3 Load Switching (Load Shedding).
4-3.1 General. When two or more engine generator sets are paralleled for emergency power, the paralleled system shall be arranged to inhibit connection of excessive loads.
4-3.2 Transfer Switch Rating. Each transfer switch shall have a continuous current rating and interrupting rating adequate for all classes of loads to be served. The transfer switch shall be capable of withstanding the available fault current at the point of installation.
4-3.3 Operation. First priority loads shall be switched to the emergency bus upon sensing the availability of emergency power on the bus. Each time an additional engine generator set is connected to the bus, a remaining load shall be connected in order of priority until all emergency loads are connected to the bus. The system shall be designed so that, upon failure of one or more engine generator sets, the load is automatically reduced, starting with the load of least priority and proceeding in ascending priority, so that the last load affected is the highest priority load.

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15, the generator was observed, a staff person was interviewed, and documents were reviewed.

At approximately 9:00 a.m., the facility lost main electrical power due to an incident caused by Southern California Edition (SCE, the electrical company in the area) doing construction work outside the hospital building. Two emergency generators started and provided emergency power to the hospital at this time.

7/6/15
1. At 10:55 a.m., generator number 2 stopped running. At this time, generator number 1 was still running and still no effect on the life safety systems and equipment.

2. At 10:58 a.m., the written report dated 7/6/15 from a licensed vendor provided the following information: Generator 1 (800 KW) overheated because it was heavily loaded. Generator 1 continued to provide back up power in spite of overheating.

3. At 11:01 a.m., generator number 1 stopped running. At this time all power was lost in the whole Medical Center Tower. The only visible lights were the exit signs. The hallways and the stairways were in total darkness.
At 11:03 a.m., an electrical emergency was declared and a command post was initiated.

At 11:16 a.m., there were 15 patients using ventilators with a two hour battery back up on each one. Eleven patients in Intensive Care Unit (ICU) and four patients in Neonatal Intensive Care Unit (NICU).

At 11:26 a.m., after approximately 25 minutes, Generator number 1 restarted after overheating during the power emergency. The Facility Director stated that they reduced the number of equipment plugged to the outlets to reduce electrical load preventing future overheating of the generator.

At 11:43 a.m., main power was restored by Southern California Edison to the whole hospital.

At 11:48 a.m., an email was read from SCE indicating there would be a power disruption during utility work outside of the building.

At 11:51 a.m., the Facility Director said during an interview that he was informed by two employees from SCE a week ago that the utility work outside of the hospital will not affect the hospital.

At 1:10 p.m., the Facility Manager said during an interview that Generator number 2 failed at 10:55 a.m. because of a low voltage fuse blew out while the generator was running. There was no load reduction during the power failure.

At 1:14 p.m., the licensed vendor provided a report of a possible cause for the blown fuse in generator 2. The report said that the generator 2 circuit breaker would not close.

At 1:22 p.m., the generator vendor said during an interview that the fuse that blew out was very unusual and he said that he has never heard of a low voltage fuse blow out like this one. He said that generator 1 overheated due to the amount of power being used during the main power outage.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 edition. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords, surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord, a missing cover plate, utilizing extension cords, and an outlet pulled out of the wall. This affected 3 of 7 buildings, and could increase the risk of an electrical fire.
NFPA 101, Life Safety Code, 2000 Edition
SECTION 9.1 UTILITIES
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.
NFPA 99, Health Care Facilities, 1999 Edition
3-3.2.1.2, All patient care areas.
d(2) Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use in the patients care area. There 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
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code

Findings:

During a tour of the facility with the Facility Director, Administrative Staff, and Quality Assurance Representative on 7/6/15 through 7/9/15, the facility's electrical equipment and wiring were observed.

Medical Center Tower N/S 1972 Building
7/6/15
1. At 10:44 a.m., there was a white extension cord in use in the 5th floor electrical room.

2. At 2:34 p.m., there was an electrical outlet that was hanging approximately 1 inch out of the wall in Room 539.

3. At 3:22 p.m., there was a microwave and a toaster that were plugged into a surge protected multi-outlet extension cord.

Medical Center Tower E/W, 1990 Building

7/7/15
4. 8:40 a.m., there was an orange extension cord in use (near the fire alarm control panel) in the Mechanical Room near Room 337.

Ememrgency Room, Ancillary Building

7/7/15
5. At 3:19 p.m., there was an orange extension cord in use in the Pharmacy IV compounding Room.

7/8/15
6. At 3:19 p.m., there was a surge protected multi-outlet extension cord that was plugged into another surge protected multi-outlet extension cord in X-ray Room 3 on the 1st floor.