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Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of eight floors in the main hospital and one of two clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 2/15/11 - 2/17/11, the walls and ceilings in the main hospital and two outpatient clinics were observed.

Floors 2 through 8 of the hospital were surveyed on 2/15/11.
7th Floor -
At 10:33 a.m., a ceiling tile was missing in Room 7W-27, clean side utility room. This exposed an approximately 10 x 10 inch penetration in the ceiling.

5th Floor -
At 11:01 a.m., there was an approximately 1/2 x 1 inch penetration around a conduit in the ICU ceiling above the charting station.

4th Floor -
At 1:09 p.m., there were two approximately 1/2 x 1 inch penetrations in the right wall, behind the bed in Room 4E-15.
At 1:10 p.m., there was an approximately 3 1/2 x 3 inch penetration behind Bed A in Room 4E-17.
At 1:12 p.m., there were two approximately 1/2 - 3/4 inch penetrations in the ceiling in Room R.R. 401.

3rd Floor -
At 1:33 p.m., there was an approximately 1 x 2 inch damaged area on the wall behind Bed A in Room 3E-7.
At 2:01 p.m., there was an approximately 1/2 inch penetration around a water pipe in Bathroom 3E-11.

2nd Floor -
At 2:35 p.m., there was an approximately 1/2 inch penetration around blue computer wire in the right side of the morgue ceiling.
There was an approximately 1/2 x 3/4 inch penetration around one side of a copper pipe on the right wall of the morgue.
There were three unsealed copper pipes on the right wall. There was an approximately 1/8 inch penetration around each pipe.
At 3:54 p.m., there were two approximately 1/8 - 1/4 inch penetrations in the right wall of Room 2W-6. The penetrations were below the blood pressure machine.

On 2/16/11, the 1st floor and Basement areas were observed.
1st floor -
At 9:21 a.m., there were two approximately 1/8 - 1/4 inch penetrations in the front wall above the light switch plate, in the dietary retail office. The office is located in the cafeteria kitchen area.

Basement -
At 10:50 a.m., there were three to four broken and damaged ceiling tiles in the area above the sterilizer, in the basement sterile area.
At 1:22 p.m., there was an approximately 1/8 inch penetration around the magnetic hold, behind the door B154.
At 1:30 p.m., there was an approximately 3 inch penetration around a phone line, inside the pipe sleeve, in the ceiling of Room B116.

2/17/11 - Clinic Building N24
At 3:03 p.m., there were two approximately 1/4 inch penetrations in the wall above the door, at Room 22, Module B.
At 3:05 p.m., there was an approximately 3 x 1 1/2 inch penetration above Room 30 in the loft area. There was an approximately 1/2 inch penetration around a wire bundle in the ceiling outside of Room 32.


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1st Floor -
At 9:30 a.m., there were two approximately 1/4 inch penetrations near the sink on the east wall of 1C1.

2/17/11 - 2nd Floor - OR area
At 8:30 a.m., there was an approximately 6 x 1/2 inch penetration along the base board in the center of the right wall in OR 2.
At 8:47 a.m., there was an approximately 3 x 3/4 inch penetration in the ceiling above the emergency light in OR 2.
At 8:50 a.m., there were four approximately 1/2 inch penetrations in the center of the ceiling, around cords, in OR 2. The penetrations were confirmed by OR Staff I, OR Staff II and OR Staff III.
At 9:12 a.m., in OR 2, there was an approximately 1 x 1/2 inch penetration by the emergency switch on the left wall.

N-24 Clinic
At 3:01 p.m., there were two 1/2 inch unsealed penetrations above the entrance to the Men's Restroom RR9.







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2/15/11 - 3rd Floor
At 1:50 p.m., there were four approximately 1/2 inch penetrations, in the left wall of Room 3W - 29.

2/16/11 - Basement
At 12:57 p.m., there were eight approximately 3/4 inch penetrations in the left wall of Room B-206.
At 1:00 p.m., there was an uncovered junction box, creating an approximately 3 x 3 inch penetration in the right wall of Room B-205.

Based on observation, the facility failed to maintain the integrity of the corridor walls to resist the passage of smoke. This was evidenced by a penetration in one corridor wall. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected one of eight floors and one of three smoke compartments.

Findings:

During the facility tour with Facilities Management (FM) Staff 2, on February 15, 2011, the corridor walls were observed.

At 2:10 p.m., there was an approximately three inch circular penetration, in the center of the corridor wall by Room 6E-3. FM Staff 2 confirmed the penetration in the corridor wall.

2/15/11 - 5th Floor
At 10:46 a.m., there was a latch cover plate missing from the 5 East convenience doors. A round penetration was exposed in one door.
At 10:58 a.m., storage behind the door obstructed the door from opening in Room 5#GCRC-20. The door opened at an approximately 50 degree angle.
At 11 a.m., the door to Room 5E-21 was held open with a trash can. When the trash can was removed the door hardware obstructed the door from closing and latching.
At 11:07 a.m., the East corridor door was held open by a rubber glove stuffed at the bottom of the door.
At 11:08 a.m., the door to Room 5E-12 failed to latch. The latch plate was broken.
At 11:12 a.m., the door to Room 5E-10 closed but failed to latch.

4th Floor -
At 1:21 p.m., storage behind the door obstructed the door from opening in Room 4E-33. The door opened approximately 24 inches.

2nd Floor -
At 2:27 p.m., storage behind the door obstructed the door from opening in Room 2-S-1. The door opened approximately 28 inches.
At 2:42 p.m., the self-closing device was disabled on the door to locker room 2S-32.
At 4:01 p.m., the door to the cast room, 2A-8, closed but failed to latch.
At 4:07 p.m., the door to Room 2B-6 was obstructed from closing by a urology cart.

2/16/11 - 1st Floor -
At 9:47 a.m., a personal protective equipment (PPE) cart was obstructing the door, 1J-6. During an interview at 9:47 a.m., direct care staff reported that the PPE cart stays in this location, in front of the door.


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2/15/11 - 8th Floor
At 11:10 a.m., the self-closing double door to LC 801 failed to fully close and positive latch.
At 11:15 a.m., eight patient rooms had roller latches on bathroom doors, in the Psychiatric Unit, 8W. The FM Staff 2 confirmed that there were roller latches on 8 of 8 bathroom doors.
At 11:30 a.m., in Room 8W10, there was an approximately 1/2 inch penetration through the door, above the door knob.

6th Floor -
At 1:00 p.m., the self-closing door to Conference Room, 6L2, failed to positive latch.
At 1:15 p.m., the door to Patient Room, 6W14, was tied open with a cord.
At 1:20 p.m., the door to Patient Room 6W16 was obstructed from closing by a chair and a monitor. The power cord extended from the corridor to inside of the room.
At 1:25 p.m., the door latch to Office 6W29 was taped over preventing the door from positive latching.
At 1:30 p.m., the door to Patient Room, 6W20, failed to positive latch.
At 1:40 p.m., the door to the 6W2 Nurses Lounge was obstructed from closing by a trash can.
At 2:05 p.m., the door to the 6E42C was obstructed from closing by a chair.
At 2:35 p.m., the door to Office 6E29 was obstructed from closing by a rubber wedge.

2/16/11 - 1st Floor
At 9:15 a.m., the self-closing door to CLC201 was held open with a kick stand.
At 9:22 a.m., in Office 1F12, there was an approximately 1/4 inch penetration through the door above the door knob.
At 9:50 a.m., the self-closing door to 1G4B Multi-Exam Room failed to fully close and positive latch.

Basement -
At 10:15 a.m., the self-closing door to B109 was held open with a wedge.
At 11:00 a.m., the self-closing door to B017 Exam Room A5 was held open with a chair.

2/17/11 - 2nd Floor
At 8:30 a.m., the self-closing door to 2E12, the OR dirty linen room, failed to fully close and positive latch.

2/17/11 - N24 Clinic -
At 3:00 p.m., the door to the Men's Restroom RR9 was held open with a kick stand.
At 3:20 p.m., the self-closing door from Registration A to Registration B failed to fully close and positive latch when released from the magnetic lock during fire alarm testing.
At 3:25 p.m., the self-closing door to Room B17, the doctors conference room, was held open with a kick stand.






29665

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected eight of eight floors, the basement, and the N-24 clinic, and could result in the spread of smoke and fire, in the event of a fire.

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

Findings:

During the facility tour with facilities management staff, from 2/15/11 - 2/17/11, the facility doors were observed.

On 2/15/11, Floors 2 though 8 of the hospital were surveyed.

7th Floor -
At 10:07 a.m., the door to Room 7E-14 failed to positive latch.
At 10:17 a.m., the door to Room 7W-39 was equipped with a self-closer. The door closed but failed to latch.

5th Floor -
At 10:48 a.m., the door to Room 5W-5 closed but failed to positive latch.

4th Floor -
At 1:10 p.m., the door to Room 4W-26 was equipped with a self-closer. The door closed but failed to latch.

3rd Floor -
At 1:37 p.m., the door to Room 3L-4 was equipped with a self-closer. The door was held open with a trash bin that obstructed the door from closing.

2nd Floor -
At 3:51 p.m., the door to Room 206 was equipped with a self-closer. The door was held open with a rubber wedge.

At 3:55 p.m., the door to Room 202-6 was equipped with a self-closer. The door was held open with a rubber wedge.

At 4:06 p.m., the door to Room 2-D-2 was equipped with a self-closer. The door was held open with a protective equipment cart.

2/16/11 - 1st Floor
At 10:06 a.m., the door to the storage closet, in the PCDC registration office, closed but failed to latch. The door was equipped with a self-closing device.
At 10:09 a.m., the door from the waiting area to the PCDC registration office, was held open by a "take-a-ticket" number dispenser stand. The door was equipped with a self-closing device.

Basement -
At 1:19 p.m., the door to Room B-258 was equipped with a self-closer. The door closed but failed to latch.

2/17/11 - N-24
At 3:16 p.m., the door to Room 30 was held open by a rubber wedge.

On 2/17/11, the N-24 clinic and the Family Medical Clinic were surveyed.

At 1:25 p.m., there were two approximately 1/4 - 1/2 inch penetrations in the front wall, above the door, exiting from the South stairway in the Family Medical Clinic.
At 2:15 p.m., there was an approximately 1/8 - 1/4 inch penetration in the 2 North stairway.



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Based on observation, the facility failed to maintain their vertical openings. This was evidenced by penetrations in three stairway enclosures. This affected one of three stairwells on the 4th floor of the main hospital, and two of two stairways in the UCLA-Harbor Family Medical Clinic. This could result in the spread of smoke and fire that could affect evacuation, in the event of a fire.

Findings:

During the facility tour with FM Staff, from 2/15/11 to 2/17/11, the stairways were observed.

4th Floor -
On 2/15/11, at 1:15 p.m., there was an approximately 1 inch penetration in the West wall of the West stairway.

Based on observation, the facility failed to maintain the exit signs in 1 of 1 smoke compartment at the Family Medical Clinic. This was evidenced by a directional sign pointing away from the exit path. This could delay evacuation and increased the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During the facility tour with FM Staff 3, on 2/17/11, the exit directional signs were observed at the Family Medical Clinic.

At 2:10 p.m., the exit sign by the Men's Restroom, Module A, was pointing towards the clinic instead of to the exit stairway. FM Staff 3 confirmed that the direction arrow was pointing away from the exit.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations in the walls. This could result in the spread of smoke and fire from one smoke compartment to another. This affected two of eight floors and the basement in the main hospital, and one of two outpatient clinics.

Findings:

During the facility tour with Facilities Management Staff, from 2/15/11 - 2/17/11, the smoke barrier walls were observed.

2/15/11 - 2nd Floor
At 3:04 p.m., there was an approximately 1/2 - 3/4 inch penetration around a pipe sleeve, in the smoke barrier at the Chem Lab, CC2-9. The penetration was to the right side of the wall.

2/16/11 - 1st Floor
At 9:42 a.m., there was an approximately 1/2 - 3/4 inch penetration around a pipe sleeve, in the smoke barrier at 1-P-1, on the right wall.
At 10:21 a.m., there was an approximately 5 x 6 inch penetration around pipe sleeves, in the smoke barrier above the south side of the emergency department.

Basement -
At 1:15 p.m., there was an approximately 2 1/2 - 3 inch penetration around a conduit in the right wall, of the smoke barrier across from B-409.
There was an approximately 3 inch penetration around a conduit on the left side of the main kitchen doors. The smoke barrier wall was accessed above the ceiling tiles, in the kitchen corridor.
At 1:37 p.m., there was an approximately 1/2 - 3/4 inch penetration between two pipes, in the right side of the smoke barrier wall at the Ultra Sound Unit.


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At 10:05 a.m., there was an approximately 1/2 x 1 inch penetration, by a conduit, above the dropped ceiling on the right center of the smoke barrier wall by Room B06-16.
11:05 a.m., there was an approximately 1 x 1/2 inch penetration, near the lower conduits, on the left center of the smoke barrier wall by Room B157.
2/17/11 - Family Health Clinic
At 1:26 p.m., there was an approximately 3 x 1/2 inch penetration in the smoke barrier wall, in the corridor in front of the Module A sign, above the dropped ceiling.

At 1:30 p.m., there was an approximately 4 x 6 inch cut-out penetration in the smoke barrier wall at the end of the Module A corridor, by the Men's Restroom.

At 1:45 p.m., there was an approximately 8 foot by 3 foot cut-out penetration in the smoke barrier wall, by the Women's Restroom.

At 1:50 p.m., there was an approximately 3 inch circular penetration in the smoke barrier wall in front of the entrance to the Module B waiting room.

At 1:55 p.m., there was an approximately 6 x 6 inch penetration in the smoke barrier wall by the exit sign in the Module C corridor.

Based on observation and interview, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke, that doors are self-closing, and that doors are provided with a means suitable for keeping the door closed. This was evidenced by doors that failed to latch after closing and by one door that failed to open. This affected two of eight floors and the basement, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff from 2/15/11 - 2/17/11 the smoke barrier doors were observed.

2/15/11 - 2nd Floor
At 3:26 p.m., the smoke barrier doors at CC-2-7 were closed. The right side door failed to open when the panic hardware was depressed. The door hardware was activated three times but the door remained closed.

During an interview at 3:28 p.m., FM Staff 1 explained that the astragal on the left door held the right door closed. When the left door was opened first the right door could be opened.

2/17/11 - 7th Floor
At 7:29 a.m., the smoke barrier doors CC-74, were observed during fire alarm testing. The doors closed but failed to latch in four of four attempts.

3rd Floor -
At 8:09 a.m., the smoke barrier doors CC3-3, closed but failed to latch in
three of three attempts.

Basement -
At 10:02 a.m., the doors CCB-4 closed but failed to latch. The doors were retested and failed to latch the 2nd time.


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At 9:40 a.m., the right side door was held open with a trash can, of the smoke barrier double doors to the linen room B303D.

At 9:50 a.m., the left side door failed to fully close and positive latch when released from the magnetic hold, of the smoke barrier doors at B151.

2/15/11 - 5th Floor
At 11:16 a.m., there were six 32 gallon soiled linen bins in Shower room 5E-19. There was no self-closing device on the door.

2nd Floor
At 2:47 p.m., the hazardous materials storage room was greater than 50 square feet in size. The room contained more than 50 cardboard boxes of supplies and containers of hazardous waste. There was no self-closing device on the door.
At 3:34 p.m., the storage room at 2WR-5 was greater than 50 square feet in size. There was no self-closing device on the door.
At 4 p.m., the storage room 2A7S was greater than 50 square feet in size. The door self closed but failed to latch.

2/16/11 - Basement (Kitchen Area)
At 11:11 a.m., there was an approximately 1/2 inch penetration in right wall near the vegetable prep area.
At 11:12 a.m., there was an approximately 2 1/2 x 3/4 inch penetration around one pipe sleeve, above the ansul system, in the ceiling above the right wall. There was an approximately 1 x 3/4 inch penetration around a second pipe sleeve. There was an approximately 1/4 inch around electrical conduits and an approximately 1 x 2 inch penetration along one side of the control head box.

During an interview at 11:13 a.m., FM Staff 1 reported the ansul system was installed approximately two years ago.

At 11:30 a.m., there was an approximately 1/2 inch penetration around four pipe sleeves, above the ansul system in the bake shop area. There was a penetration around each pipe sleeve.

Basement Mechanical Area
At 12:55 p.m., there was an approximately 1/2 - 3/4 inch penetration around a white pipe on the right wall of Mechanical Room 1 South. The penetration was near the entrance.
At 1:17 p.m., there were four approximately 3/4 inch penetration in the front wall of the sterilizer access room, ME 223. The penetrations were in the area accessing the back of the sterilizers.

2/17/11 - Family Medical Clinic
At 1:30 p.m., the interior door to the pharmacy storage room was observed. The room is greater than 50 square feet in size and contained shelves with cardboard boxes and paper and plastic packages of medications and supplies. The door was not equipped with a self-closer.







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Based on observation and interview, the facility failed to maintain hazardous areas with 1 hour rated construction and failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by hazardous areas with penetrations and with doors that failed to self close and latch. This affected six of eight floors and the basement, and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour from 2/15/11 - 2/16/11, the hazardous areas were observed in the main hospital. Soiled linen and trash storage areas, and combustible storage rooms greater than 50 square feet in size, are considered hazardous areas.

2/15/11 - 8th Floor
At 11:12 a.m., the 8W21 Laundry Room measured over 50 square feet in size. The door failed to have a self closing device.

6th Floor -
At 2:15 p.m., Office 6E40 measured over 50 square feet in size. There were quantities of combustible materials such as loose papers, books binders, files, and paper materials stacked around the office. There was no self-closure on the door.
At 2:20 p.m., in the 6W38 Storage Room, there was an approximately 1? inch penetration around a pipe on the North West wall.
At 2:30 p.m., the self-closing door to LC601, Clean Linen Only, failed to fully close and positive latch. The room was greater than 50 square feet in size.

2/16/11 - 1st Floor
At 9:18 a.m., the Child Life Center storage room, measured over 50 square feet in size. There was no self-closing device on the door. The storage room contained an combustible materials such as papers, books, toys, cardboard boxes and plastic materials.

3rd Floor -
At 12:55 p.m., in B340A, Office A, there were combustible materials, including loose papers, books binders, files, cardboard boxes of paper materials, and shelves in the office area. The office failed to have a self-closure on the door.

At 1:00 p.m., in B340A, Office D, there were combustible materials including loose papers, books, binders, files, paper materials, and shelves in the office area. There was no self-closure on the door.

At 1:10 p.m., in B340A, Doctor Office G, there were combustible materials such as loose papers, books, files, binders, and paper materials stacked around the office. There was no self-closure on the door.

At 1:15 p.m., in B340A, Doctor Office H, there were combustible materials such as loose papers, books, binders, files and stacks of paper materials stacked around the office. There was no self-closure on the door.

At 1:35 p.m., in Anesthesiology Storage A, there were combustible materials such as boxes, supplies, plastics, and paper materials stacked around the office. There was no self-closure on the door.

At 1:40 p.m., in Anesthesiology Storage B, there were combustible materials such as boxes, supplies, plastics, and paper materials stored in the office. There was no self-closure on the door.

These rooms were larger than 50 square feet in size and contained combustible storage. They are considered hazardous areas.

Based on observation, the facility failed to maintain exit access as evidenced by obstructed exits. This affected two of eight floors and the basement. This could delay evacuation in the event of an emergency and increase the risk of injury to patients, visitors and staff.

Findings:

During observations with Facilities Management Staff 4, from 2/15/11 through 2/17/11, the exit access was observed in the main hospital.

2/15/11 - 6th Floor
At 2:25 p.m., the emergency exit door in 6E-ICE, was blocked by a 64 gallon gray trash cart.

2/16/11- Basement
At 2:25 p.m., in the Anesthesiology Office Area, the exit door across from Office I was blocked by boxes.

2/17/11 - 2nd Floor
At 9:20 a.m., on the inside of the OR entrance, the right door was blocked by a gurney.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by one bull-frog light that failed to illuminate when tested. This affected the elevator penthouse of the hospital, and could result in a lack of illumination during a power outage.

Findings:

During a facility tour from 2/15/11 to 2/17/11, the emergency lighting was observed in the main hospital.

On 2/15/11, the elevator penthouse of the hospital, was surveyed.

Elevator penthouse -
At 9:46 a.m., the bull-frog light on the right wall failed to illuminate when staff pushed the test button. The light was re-tested and failed to illuminate.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift. This was evidenced by records for fire drills during the first, second, and third quarters of 2010. This affected the N-24 clinic and the Family Medical Clinic, and could result in a delay staff response in the event of a fire.

Findings:

During record review on 2/16/11, the fire drill records were requested.

At 2:38 p.m., the fire drill records for the N-24 clinic and the Family Medical Clinic were provided. One fire drill was conducted at each location during 2010.

During an interview at 2:40 p.m., FM Staff 2 stated that drills are conducted annually, not quarterly, for the N-24 clinic and the Family Medical Clinic.

2/17/11 - 2nd Floor
At 9:20 a.m., the audible/visual alarm device at 2-A-9 failed to illuminate during fire alarm testing.







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2/16/11 - 1st Floor
At 9:20 a.m., the pull station, inside the entrance to the Child Life Care Center, was blocked by a trash can.

2/17/11 - N-24 Trauma Clinic
At 3:05 p.m., the pull station located in Registration B was blocked by chairs occupied by patients.


29665

Based on observation, record review, and interview, the facility failed to maintain their complete fire alarm system. This was evidenced by an obstructed fire alarm sub-panel and pull station, by alarm devices that failed, by one area with no alarm annunciator, and by no fire alarm system testing records for the Family Medical Clinic. This affected two of eight floors and the basement, in the main hospital, and two of two Medical Clinics. This could result in a failure of the alarm system or a delay in notification, in the event of a fire.

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.

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

Table 7-3.2 requires annual testing of building systems connected to the fire supervising station.

Findings:

During the facility tour on from 2/15/11 - 2/17/11, the fire alarm system was observed. The system was tested on 2/17/11.

2/16/11 - 1st Floor
At 10:37 a.m., the fire alarm sub-panel was obstructed by two plastic storage bins, in the storage area of the volunteers' office.

2/17/11 - Basement
At 10:20 a.m., the strobe light of the alarm device, on the left side of the kitchen storage area, did not activate during fire alarm testing.

At 10:29 a.m., there was no fire alarm annunciator in the mechanical equipment room, near the tunnel. No alarm signal could be seen or heard during fire alarm testing.

During an interview at 10:30 a.m., FM Staff confirmed that there was no audible alarm in the mechanical equipment room.

During record review on 2/17/11, the fire alarm maintenance records for the Family Medical Clinic were requested.

At 2:31 p.m., there were no documents available for annual testing of the fire alarm system.

During an interview at 2:35 p.m., Clinic Staff stated that the building owner is responsible for testing the fire alarm system and has all the records. Staff stated that maintenance and testing records would be faxed to the Ventura District Office by Monday morning. No records were received.

Based on observation, record review and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documents for quarterly testing of the sprinkler system at one clinic location. This affected one of two clinics. This could result in a delay in extinguishing a fire or the potential failure of the sprinkler system.


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

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During record review on 2/17/11, the automatic sprinkler system maintenance records for the Family Medical Clinic were requested.
At 2:31 p.m., there were no documents for the quarterly testing of the sprinkler system available at the clinic.

During an interview at 2:35 p.m., Clinic Staff stated that the building owner is responsible for sprinkler maintenance and has all the records. Staff stated that testing records would be faxed to the Ventura District Office by Monday morning. No records were received by 2/22/11.

At 2:15 p.m., the fire extinguisher in the morgue, autopsy room, was tagged indicating the last date of certification. The date on the tag was punched out for 1/2010. The extinguisher was not recertified in 1/2011 as required.

At 3:49 p.m., a fire extinguisher was located in the x-ray corridor near 2V-29. The next fire extinguisher in the corridor was located approximately 215 feet away in the adjacent corridor.

During an interview at 3:51 p.m., FM Staff 1 explained that due to construction, the nearest fire extinguisher was not accessible. The extinguisher was sealed behind a construction barricade.


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Based on observation and interview, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were obstructed, by one fire extinguisher installed over 60 inches above the floor and by a fire extinguisher that was located further than 75 feet from another extinguisher. This affected three of eight floors at the main hospital. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1.6 General Requirements
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight 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 clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

3-1.4 On each floor level, the area protected and the travel distances shall be based on fire extinguishers installed in accordance with Table 3-2.1 and Table 3-3.1.

Table 3-2.1 Fire Extinguisher Size and Placement for Class A Hazards

Maximum travel distance to extinguisher Light Hazard Occupancy Ordinary Hazard Occupancy or Extra Hazard Occupancy - 75 ft

4.3.1 *Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected, manually or by electronic monitoring, at more frequent intervals when circumstances require.

6-3.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Findings:

During the facility tour with the facilities management staff, from 2/15/11 - 2/17/11, the fire extinguishers were observed.

2/15/11- 8th Floor
At 11:05 a.m., in the Psychiatric Unit Nurses Station, the fire extinguisher was blocked by a pencil sharpener. FM Staff 4 confirmed that the fire extinguisher was blocked from access by a pencil sharpener located directly above the extinguisher.

6th Floor -
At 1:45 p.m., in 6W8, the fire extinguisher was blocked by bear huggers.

5th Floor -
At 1:55 p.m., in the 5E Nurses Station, the fire extinguisher was blocked from access by a fan and a trash can.

2/16/11 - 1st Floor
At 9:19 a.m., on the inside of the entrance to the Child Life Center, the fire extinguisher was blocked by a trash can.
At 9:35 a.m., in Exam Room 1C9, the fire extinguisher was blocked by a soiled linen cart. The fire extinguisher was located behind the door and was not visible.
At 9:40 a.m., in the Dental Clinic 1AC, the fire extinguisher 0543 was blocked by a cabinet, a sharps container and a biohazard linen cart.
At 9:45 a.m., in the Peds ER 1G4B, the fire extinguisher was blocked by a soiled linen cart.

Basement
At 2:00 p.m., in the Medical Air Compressor Room, the fire extinguisher was blocked by equipment and installed at approximately 70 inches from the top of the extinguisher to the floor. FM Staff 4 confirmed that the fire extinguisher was installed over 70 inches above the floor and was obstructed.

2/17/11 - 2nd Floor
At 8:15 a.m., in the OR Clean Work Room, the fire extinguisher was obstructed by a table.

At 8:20 a.m., in the OR corridor, the fire extinguisher 1157 was blocked by a table.


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2/15/11 - 2nd Floor
At 3:15 p.m., there were two cardboard boxes obstructing the fire extinguisher outside Room 2S - 28.

Based on observation and interview, the facility failed to ensure the means of egress was free of all obstructions, as evidenced by gurneys and mobile carts in the egress path, and obstructing the use of the handrails. This affected five of eight floors of the main hospital and the N-24 clinic, and could result in a delayed evacuation, in the event of a fire.

Findings:

During a facility tour from 2/15/11 to 2/17/11, exit corridors were observed in the main hospital and in two clinics.

2/15/11 - 7th Floor
At 10:01 a.m., a computer on wheels (COW) was placed in the corridor at Room 7E-8.
There was a Personal Protective Equipment (PPE) cart in the corridor at Room 7E-8.
There was an ultra-sound cart in the corridor at Room 7E-12.

During an interview at 10:11 a.m., Nursing Staff stated that the COWs are kept in the corridor. She stated that the PPE carts are always in the corridors for easy access.

5th Floor -
At 10:51 a.m., there was a COW and a chair at Room 5EGCRC12. No staff were present in the area.
During an interview at 10:52 a.m., the charge nurse stated that COWs are kept in the corridor for charting.
At 11:08 a.m., there was a PPE cart in the corridor at Room 5E-12.
There was a PPE cart in the corridor at Room 5E-10.
During an interview, a CNA reported that the carts are kept in the corridor for easy access.
At 11:16 a.m., there was a PPE cart in the corridor at Room 5E-5.

4th Floor -
At 1:20 p.m., there was a PPE cart in the corridor at Room 4E-8.
During an interview, nursing staff stated that the corridor is always in the corridor.

3rd Floor -
At 1:54 p.m., there was a PPE cart in the corridor at 3E-8.
At 1:59 p.m., there was a PPE cart in the corridor at 3E-20 and 3E-19.

2/16/11 - 1st Floor
At 9:42 a.m., there were four chairs and a table set up in the corridor between Rooms 1K-10 and 1K-11.
During an interview at 9:44 a.m., nursing staff stated that the chairs are used as a waiting room for patients. She reported the table was used to process forms and that it is always in the corridor.

Basement -
At 1:17 p.m., there were 16 chairs on the left side of the corridor at B-153 and B-154.
During an interview, housekeeping staff reported the chairs are kept in the corridor and used as a waiting room. She stated they are always in the corridor.
At 1:40 p.m., there were four soiled linen carts in the corridor outside of the exam rooms in Nuclear Medicine.
During an interview, the supervisor reported the carts are used for radioactive linens. He stated they stay in the corridor all day, until they are picked up around 4-4:30 p.m.


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At 11:20 a.m., there was a gurney stationed in the corridor by Room B01, blocking the path of egress.
At 11:50 a.m., there was a gurney stationed in the corridor by Room B124, blocking the path of egress.


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2/17/11 - N-24
At 3:08 p.m., there was one crash cart, and three supply carts, obstructing the exit corridor, near Room 22.

During an interview at 3:09 p.m., Nursing Staff 3 stated that the carts are stored in the corridor during the day, and stored in a room at the end of the shift.

2/16/11 - 1st Floor
At 9:58 a.m., there was a soiled linen and trash cart, side by side, in the corridor outside of X-ray room 2, in the psychiatric emergency department. The bags on the carts are approximately 30 gallons in size.


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Based on observation and interview, the facility failed to maintain their soiled linen and trash receptacles at 32 gallon capacity in a 64 square foot area. This was evidenced by 100 gallon soiled linen carts and trash receptacles unattended in the corridors and by soiled linen and trash carts side by side in the corridors. This could result in an increased risk of fire and potential injury to patients.

Findings:

During the facility tour with the Facilities Management Staff from 2/15/11 through 2/17/11, soiled linen carts and trash receptacles were observed in the corridors.

2/15/11 - 6th Floor
At 3:05 p.m., in the 6E-E corridor, there was a 100 gallon gray trash receptacle left unattended in the hallway.

2nd Floor -
At 3:15 p.m., in the corridor by 2S36, there was a 100 gallon biohazard receptacle left unattended in the hallway.

2/17/11 - 2nd Floor
At 8:35 a.m., in the OR corridor, there were two 100 gallon receptacles - 1 biohazard cart and 1 gray trash receptacle left unattended in the corridor. OR Staff 1 stated that the containers were left there until they were full, sometimes several hours.

Based on observation, the facility failed to maintain the medical gas storage areas in accordance with NFPA 99. This was evidenced by oxygen cylinders stored with combustibles and by unsecured cylinders. This could result in the increased spread of a fire, and the potential injury of patients, in the event of a fire.

NFPA 99 Health Care Facilities 1999 Edition
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft 3 (85 m 3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
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 of fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During the facility tour with facilities management staff, from 2/15/11 through 2/17/11, the oxygen storage areas were observed at the main hospital.

2/15/11 - 7th Floor
At 10:13 a.m., there were five unsecured E cylinders of oxygen in the storage room in the 7L-4 lobby area. There were papers, and a cardboard box stacked on a wheel chair within approximately 6 inches of the cylinders. There were four cardboard boxes on a cart placed approximately 10 inches from the cylinders. A bag of clothes, a crate of papers and other combustibles were on the same cart.
A wheel chair with an oxygen cylinder attached was stored between two other wheel chairs and within approximately 4 feet of the five oxygen cylinders.
At 10:15 a.m., a seven shelf storage unit contained papers, binders and other supplies. The shelving unit was approximately 2 feet from the oxygen cylinders.
At 10:16 a.m., there were three pink, plastic coated chairs, (birthing chairs)on the other side of the storage room. An oxygen cylinder was attached to the back of each chair. Bags of clothes, cardboard boxes and other items were stored on the seat of the chairs. The room was not sprinklered.

5th Floor -
At 11:06 a.m., there were seven E cylinders of oxygen stored within approximately 10 inches of a soiled linen cart and within approximately three feet of a second soiled linen cart, in the ICU area.

2/16/11 - Basement
At 1 p.m., there were 15 E cylinders and an H cylinder of oxygen stored in the tunnel outside of the mechanical room. The tunnel contains equipment, supplies and other storage items.

Outside Oxygen and Bulk Gas Storage Area
At 2:02 p.m., H Cylinders of oxygen and other medical gases were stored in rows of five. There were three rows in each section. A top and bottom chain was placed across the exterior row. No other cylinders in the section were secured.
At 2:05 p.m., H Cylinders were missing in some sections. When a cylinder was tipped in these sections the cylinder could be knocked over.
During an interview at 2:06 p.m., FM Staff 1 confirmed that some cylinders could be knocked over, in sections where there were less than five cylinders in the row.


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At 2:07 p.m., there were groups of compressed gas stored together. The first two racks of cylinders, on the right side of the entrance, contained an assortment of sizes, approximately 30 cylinders per rack. The smaller cylinders were unsecured. The E cylinders were loosely secured. The H cylinders stored across the back of the first section, were not individually secured.

Based on record review and interview, the facility failed to ensure that piped in medical gas systems are in accordance with NFPA 99. This was evidenced by one control valve that was not located on the same floor as the area it controlled. This affected the piped in medical gas system on one of eight floors in the main hospital and could result in a delay in shutting down the system in an emergency.

Findings:

During record review on 2/16/11, records for the piped in medical gas system were requested and reviewed.

At 3:15 p.m., the report "Medical Gas Systems Preventative Maintenance Inspection 2010" was reviewed. The report indicated the repair status of the discrepancies identified in the 11/2010 medical gas certification report.

There was no date for repair for the issue of the control outlet location on another floor for 2W-10, the peds ER 1G3-1G10. Other leaks and alarm issues were listed on the report that were not yet repaired.

During an interview at 3:20 p.m., FM Staff 4 indicated that repairs were still in process. He indicated that moving the control valve would take OSHPD approval and more time to complete.

Based on observation, document review and interview, the facility failed to maintain the humidity levels at 35% or greater in accordance with NFPA 99. This was evidenced by documentation of humidity levels less than 35% in ten hospital operating rooms (OR) and at the four Labor and Delivery Rooms. This failure could increase the risk of a fire in an oxygen enriched environment in an operating room, resulting in potential harm to patients and staff.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During observation, record review and interview with facilities management staff and OR Staff, on 2/17/11, the operating rooms were observed and humidity documents were reviewed. Portable humidifiers were installed in each operating room.

2/17/11
At 8:15 a.m., OR Staff 1 was interviewed and humidity logs were requested for the ten operating rooms. OR Staff 1 stated the range for humidity levels was 20% - 60% per hospital guidelines and stated that plant operations was responsible for the humidity levels.

The current humidity levels were OR 1 at 35%, OR 2 at 29%, OR 3 at 34%, OR 4 at 37%, OR 5 at 22%, OR 6 at 36%, OR 7 at 41%, OR 8 at 32%, OR 9 at 41% and OR 10 at 37%.

During an interview, FM Staff 4 stated there was no policy and procedure in place for humidity levels and the facility was in the process of creating them. The monitoring process was to go over the humidity readings weekly. The portable humidifiers were serviced monthly.

During record review, the facility provided humidity level documentation for OR 1 thru OR 10 and Labor and Delivery 1 through 4. A sample of the humidity levels were noted to be below the 35 percent during 2-3 days in November and December 2010 and January and February 2011 for every OR except OR 3.

There was no procedure in effect to ensure humidity levels were monitored daily and adjusted when needed.

7th Floor -
At 9:55 a.m., there was a surge protector connected to a surge protector in the OB-GYN Resident Library. The surge protectors were used to connect computer equipment to the wall outlet.
At 9:56 a.m., an orange heavy duty extension cord was used to connect a microwave oven to a surge protector in the same area.
At 10:22 a.m., an extension cord was connected to a surge protector, connected to the wall outlet in Office A, 7W-12.
An electric timer was connected to the wall outlet in 7W-13. The outlets on the timer were used to provide power to a fountain and a lamp. There was no over current protection for the timer.

5th Floor -
At 10:45 a.m., a surge protector was connected to a surge protector in 5L2A. Computer equipment was connected to the surge protectors.
There was a missing cover plate on the outlet outside of Room 5L2A.

2nd Floor -
At 3:36 p.m., the cover plate was missing on the phone outlet box in Office 2W-34A.

At 3:56 p.m., Electrical Panel 2W4P was obstructed by two stacks of chairs and a cart with boxes, placed within approximately 1-4 inches of the panel. There were three working breakers in the panel.
At 4:08 p.m., Electrical Panel 2MFED was obstructed by a cart with forms, placed within approximately 3 inches of the panel. The panel is located between Rooms 2B1 and 2B2.

2/16/11 - 1st Floor
At 9:18 a.m., there was a white extension cord connecting a TV to a surge protector, in the Retail Office, cafeteria kitchen area. The cover plate was hanging from the wall, around phone and computer wiring.
At 9:52 a.m., a chair was placed against the front of Electrical Panel 1PD (1075).

Basement
At 12:55 p.m., the electrical panels were obstructed by work carts in the Mechanical Room 1 South. The carts were within approximately 2-3 inches of the panels.

During an interview at 12:56 p.m., FM Staff 1 stated that the carts are only there temporarily when staff are not using them.

At 1:28 p.m., the cover plate was missing from the phone outlet in Room B116.

2/17/11 - N-24 Clinic
At 3:10 p.m., a brown, multi outlet extension cord was used to connect the fax machine to the wall outlet in the back office area.
At 3:12 p.m., there was an open electrical box above Room 37.


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2/15/11 - 8th Floor
At 10:30 a.m., in the EEG Room, 8E12, there was a refrigerator plugged into a surge protector and not directly into the wall.
At 10:40 a.m., in 8E24, there was a microwave plugged into a surge protector and not directly into the wall.
At 11:00 a.m., in the Medical Records Kitchen, there was a microwave plugged into a surge protector and not directly into the wall.

At 1:35 p.m., there was a refrigerator, microwave, toaster oven and a TV plugged into a surge protector attached to a metal cart with twist ties. Facilities Management Staff 4 confirmed that the electrical equipment was plugged into a multi-outlet adapter attached to a metal cart and not directly into the wall.




29665

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by the use of surge protectors and extension cords, and by electrical panels that were obstructed. This affected five of eight floors in the main hospital and one of two clinics. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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.

During the facility tour with facilities management staff, from 2/15/11 to 2/17/11, the electrical wiring and connections were observed.

2/15/11 - 7 th Floor
At 9:53 a.m., there was a six plug surge protector plugged into a six-plug surge protector, in Room 7E - 3.

At 9:54 a.m., there was a heavy duty extension cord plugged into a six-plug surge protector, in Room 7E - 4. There was a microwave plugged into the extension cord, and a refrigerator plugged into the surge protector.

5th Floor
At 11:14 a.m., there was a microwave and refrigerator plugged into a six-plug surge protector in Room 5W - 35A.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls and ceilings. This affected two of eight floors in the main hospital and one of two clinics. This could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff, from 2/15/11 - 2/17/11, the walls and ceilings in the main hospital and two outpatient clinics were observed.

Floors 2 through 8 of the hospital were surveyed on 2/15/11.
7th Floor -
At 10:33 a.m., a ceiling tile was missing in Room 7W-27, clean side utility room. This exposed an approximately 10 x 10 inch penetration in the ceiling.

5th Floor -
At 11:01 a.m., there was an approximately 1/2 x 1 inch penetration around a conduit in the ICU ceiling above the charting station.

4th Floor -
At 1:09 p.m., there were two approximately 1/2 x 1 inch penetrations in the right wall, behind the bed in Room 4E-15.
At 1:10 p.m., there was an approximately 3 1/2 x 3 inch penetration behind Bed A in Room 4E-17.
At 1:12 p.m., there were two approximately 1/2 - 3/4 inch penetrations in the ceiling in Room R.R. 401.

3rd Floor -
At 1:33 p.m., there was an approximately 1 x 2 inch damaged area on the wall behind Bed A in Room 3E-7.
At 2:01 p.m., there was an approximately 1/2 inch penetration around a water pipe in Bathroom 3E-11.

2nd Floor -
At 2:35 p.m., there was an approximately 1/2 inch penetration around blue computer wire in the right side of the morgue ceiling.
There was an approximately 1/2 x 3/4 inch penetration around one side of a copper pipe on the right wall of the morgue.
There were three unsealed copper pipes on the right wall. There was an approximately 1/8 inch penetration around each pipe.
At 3:54 p.m., there were two approximately 1/8 - 1/4 inch penetrations in the right wall of Room 2W-6. The penetrations were below the blood pressure machine.

On 2/16/11, the 1st floor and Basement areas were observed.
1st floor -
At 9:21 a.m., there were two approximately 1/8 - 1/4 inch penetrations in the front wall above the light switch plate, in the dietary retail office. The office is located in the cafeteria kitchen area.

Basement -
At 10:50 a.m., there were three to four broken and damaged ceiling tiles in the area above the sterilizer, in the basement sterile area.
At 1:22 p.m., there was an approximately 1/8 inch penetration around the magnetic hold, behind the door B154.
At 1:30 p.m., there was an approximately 3 inch penetration around a phone line, inside the pipe sleeve, in the ceiling of Room B116.

2/17/11 - Clinic Building N24
At 3:03 p.m., there were two approximately 1/4 inch penetrations in the wall above the door, at Room 22, Module B.
At 3:05 p.m., there was an approximately 3 x 1 1/2 inch penetration above Room 30 in the loft area. There was an approximately 1/2 inch penetration around a wire bundle in the ceiling outside of Room 32.


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1st Floor -
At 9:30 a.m., there were two approximately 1/4 inch penetrations near the sink on the east wall of 1C1.

2/17/11 - 2nd Floor - OR area
At 8:30 a.m., there was an approximately 6 x 1/2 inch penetration along the base board in the center of the right wall in OR 2.
At 8:47 a.m., there was an approximately 3 x 3/4 inch penetration in the ceiling above the emergency light in OR 2.
At 8:50 a.m., there were four approximately 1/2 inch penetrations in the center of the ceiling, around cords, in OR 2. The penetrations were confirmed by OR Staff I, OR Staff II and OR Staff III.
At 9:12 a.m., in OR 2, there was an approximately 1 x 1/2 inch penetration by the emergency switch on the left wall.

N-24 Clinic
At 3:01 p.m., there were two 1/2 inch unsealed penetrations above the entrance to the Men's Restroom RR9.







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2/15/11 - 3rd Floor
At 1:50 p.m., there were four approximately 1/2 inch penetrations, in the left wall of Room 3W - 29.

2/16/11 - Basement
At 12:57 p.m., there were eight approximately 3/4 inch penetrations in the left wall of Room B-206.
At 1:00 p.m., there was an uncovered junction box, creating an approximately 3 x 3 inch penetration in the right wall of Room B-205.

Based on observation, the facility failed to maintain the integrity of the corridor walls to resist the passage of smoke. This was evidenced by a penetration in one corridor wall. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected one of eight floors and one of three smoke compartments.

Findings:

During the facility tour with Facilities Management (FM) Staff 2, on February 15, 2011, the corridor walls were observed.

At 2:10 p.m., there was an approximately three inch circular penetration, in the center of the corridor wall by Room 6E-3. FM Staff 2 confirmed the penetration in the corridor wall.

2/15/11 - 5th Floor
At 10:46 a.m., there was a latch cover plate missing from the 5 East convenience doors. A round penetration was exposed in one door.
At 10:58 a.m., storage behind the door obstructed the door from opening in Room 5#GCRC-20. The door opened at an approximately 50 degree angle.
At 11 a.m., the door to Room 5E-21 was held open with a trash can. When the trash can was removed the door hardware obstructed the door from closing and latching.
At 11:07 a.m., the East corridor door was held open by a rubber glove stuffed at the bottom of the door.
At 11:08 a.m., the door to Room 5E-12 failed to latch. The latch plate was broken.
At 11:12 a.m., the door to Room 5E-10 closed but failed to latch.

4th Floor -
At 1:21 p.m., storage behind the door obstructed the door from opening in Room 4E-33. The door opened approximately 24 inches.

2nd Floor -
At 2:27 p.m., storage behind the door obstructed the door from opening in Room 2-S-1. The door opened approximately 28 inches.
At 2:42 p.m., the self-closing device was disabled on the door to locker room 2S-32.
At 4:01 p.m., the door to the cast room, 2A-8, closed but failed to latch.
At 4:07 p.m., the door to Room 2B-6 was obstructed from closing by a urology cart.

2/16/11 - 1st Floor -
At 9:47 a.m., a personal protective equipment (PPE) cart was obstructing the door, 1J-6. During an interview at 9:47 a.m., direct care staff reported that the PPE cart stays in this location, in front of the door.


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2/15/11 - 8th Floor
At 11:10 a.m., the self-closing double door to LC 801 failed to fully close and positive latch.
At 11:15 a.m., eight patient rooms had roller latches on bathroom doors, in the Psychiatric Unit, 8W. The FM Staff 2 confirmed that there were roller latches on 8 of 8 bathroom doors.
At 11:30 a.m., in Room 8W10, there was an approximately 1/2 inch penetration through the door, above the door knob.

6th Floor -
At 1:00 p.m., the self-closing door to Conference Room, 6L2, failed to positive latch.
At 1:15 p.m., the door to Patient Room, 6W14, was tied open with a cord.
At 1:20 p.m., the door to Patient Room 6W16 was obstructed from closing by a chair and a monitor. The power cord extended from the corridor to inside of the room.
At 1:25 p.m., the door latch to Office 6W29 was taped over preventing the door from positive latching.
At 1:30 p.m., the door to Patient Room, 6W20, failed to positive latch.
At 1:40 p.m., the door to the 6W2 Nurses Lounge was obstructed from closing by a trash can.
At 2:05 p.m., the door to the 6E42C was obstructed from closing by a chair.
At 2:35 p.m., the door to Office 6E29 was obstructed from closing by a rubber wedge.

2/16/11 - 1st Floor
At 9:15 a.m., the self-closing door to CLC201 was held open with a kick stand.
At 9:22 a.m., in Office 1F12, there was an approximately 1/4 inch penetration through the door above the door knob.
At 9:50 a.m., the self-closing door to 1G4B Multi-Exam Room failed to fully close and positive latch.

Basement -
At 10:15 a.m., the self-closing door to B109 was held open with a wedge.
At 11:00 a.m., the self-closing door to B017 Exam Room A5 was held open with a chair.

2/17/11 - 2nd Floor
At 8:30 a.m., the self-closing door to 2E12, the OR dirty linen room, failed to fully close and positive latch.

2/17/11 - N24 Clinic -
At 3:00 p.m., the door to the Men's Restroom RR9 was held open with a kick stand.
At 3:20 p.m., the self-closing door from Registration A to Registration B failed to fully close and positive latch when released from the magnetic lock during fire alarm testing.
At 3:25 p.m., the self-closing door to Room B17, the doctors conference room, was held open with a kick stand.






29665

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to latch, and by doors that were obstructed from closing. This affected eight of eight floors, the basement, and the N-24 clinic, and could result in the spread of smoke and fire, in the event of a fire.

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

Findings:

During the facility tour with facilities management staff, from 2/15/11 - 2/17/11, the facility doors were observed.

On 2/15/11, Floors 2 though 8 of the hospital were surveyed.

7th Floor -
At 10:07 a.m., the door to Room 7E-14 failed to positive latch.
At 10:17 a.m., the door to Room 7W-39 was equipped with a self-closer. The door closed but failed to latch.

5th Floor -
At 10:48 a.m., the door to Room 5W-5 closed but failed to positive latch.

4th Floor -
At 1:10 p.m., the door to Room 4W-26 was equipped with a self-closer. The door closed but failed to latch.

3rd Floor -
At 1:37 p.m., the door to Room 3L-4 was equipped with a self-closer. The door was held open with a trash bin that obstructed the door from closing.

2nd Floor -
At 3:51 p.m., the door to Room 206 was equipped with a self-closer. The door was held open with a rubber wedge.

At 3:55 p.m., the door to Room 202-6 was equipped with a self-closer. The door was held open with a rubber wedge.

At 4:06 p.m., the door to Room 2-D-2 was equipped with a self-closer. The door was held open with a protective equipment cart.

2/16/11 - 1st Floor
At 10:06 a.m., the door to the storage closet, in the PCDC registration office, closed but failed to latch. The door was equipped with a self-closing device.
At 10:09 a.m., the door from the waiting area to the PCDC registration office, was held open by a "take-a-ticket" number dispenser stand. The door was equipped with a self-closing device.

Basement -
At 1:19 p.m., the door to Room B-258 was equipped with a self-closer. The door closed but failed to latch.

2/17/11 - N-24
At 3:16 p.m., the door to Room 30 was held open by a rubber wedge.

On 2/17/11, the N-24 clinic and the Family Medical Clinic were surveyed.

At 1:25 p.m., there were two approximately 1/4 - 1/2 inch penetrations in the front wall, above the door, exiting from the South stairway in the Family Medical Clinic.
At 2:15 p.m., there was an approximately 1/8 - 1/4 inch penetration in the 2 North stairway.



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Based on observation, the facility failed to maintain their vertical openings. This was evidenced by penetrations in three stairway enclosures. This affected one of three stairwells on the 4th floor of the main hospital, and two of two stairways in the UCLA-Harbor Family Medical Clinic. This could result in the spread of smoke and fire that could affect evacuation, in the event of a fire.

Findings:

During the facility tour with FM Staff, from 2/15/11 to 2/17/11, the stairways were observed.

4th Floor -
On 2/15/11, at 1:15 p.m., there was an approximately 1 inch penetration in the West wall of the West stairway.

Based on observation, the facility failed to maintain the exit signs in 1 of 1 smoke compartment at the Family Medical Clinic. This was evidenced by a directional sign pointing away from the exit path. This could delay evacuation and increased the risk of injury to patients, visitors and staff in the event of a fire.

Findings:

During the facility tour with FM Staff 3, on 2/17/11, the exit directional signs were observed at the Family Medical Clinic.

At 2:10 p.m., the exit sign by the Men's Restroom, Module A, was pointing towards the clinic instead of to the exit stairway. FM Staff 3 confirmed that the direction arrow was pointing away from the exit.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls, as evidenced by penetrations in the walls. This could result in the spread of smoke and fire from one smoke compartment to another. This affected two of eight floors and the basement in the main hospital, and one of two outpatient clinics.

Findings:

During the facility tour with Facilities Management Staff, from 2/15/11 - 2/17/11, the smoke barrier walls were observed.

2/15/11 - 2nd Floor
At 3:04 p.m., there was an approximately 1/2 - 3/4 inch penetration around a pipe sleeve, in the smoke barrier at the Chem Lab, CC2-9. The penetration was to the right side of the wall.

2/16/11 - 1st Floor
At 9:42 a.m., there was an approximately 1/2 - 3/4 inch penetration around a pipe sleeve, in the smoke barrier at 1-P-1, on the right wall.
At 10:21 a.m., there was an approximately 5 x 6 inch penetration around pipe sleeves, in the smoke barrier above the south side of the emergency department.

Basement -
At 1:15 p.m., there was an approximately 2 1/2 - 3 inch penetration around a conduit in the right wall, of the smoke barrier across from B-409.
There was an approximately 3 inch penetration around a conduit on the left side of the main kitchen doors. The smoke barrier wall was accessed above the ceiling tiles, in the kitchen corridor.
At 1:37 p.m., there was an approximately 1/2 - 3/4 inch penetration between two pipes, in the right side of the smoke barrier wall at the Ultra Sound Unit.


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At 10:05 a.m., there was an approximately 1/2 x 1 inch penetration, by a conduit, above the dropped ceiling on the right center of the smoke barrier wall by Room B06-16.
11:05 a.m., there was an approximately 1 x 1/2 inch penetration, near the lower conduits, on the left center of the smoke barrier wall by Room B157.
2/17/11 - Family Health Clinic
At 1:26 p.m., there was an approximately 3 x 1/2 inch penetration in the smoke barrier wall, in the corridor in front of the Module A sign, above the dropped ceiling.

At 1:30 p.m., there was an approximately 4 x 6 inch cut-out penetration in the smoke barrier wall at the end of the Module A corridor, by the Men's Restroom.

At 1:45 p.m., there was an approximately 8 foot by 3 foot cut-out penetration in the smoke barrier wall, by the Women's Restroom.

At 1:50 p.m., there was an approximately 3 inch circular penetration in the smoke barrier wall in front of the entrance to the Module B waiting room.

At 1:55 p.m., there was an approximately 6 x 6 inch penetration in the smoke barrier wall by the exit sign in the Module C corridor.

Based on observation and interview, the facility failed to ensure that smoke barrier doors are capable to resist the passage of smoke, that doors are self-closing, and that doors are provided with a means suitable for keeping the door closed. This was evidenced by doors that failed to latch after closing and by one door that failed to open. This affected two of eight floors and the basement, and could result in the spread of smoke and fire, in the event of a fire.

Findings:

During the facility tour with staff from 2/15/11 - 2/17/11 the smoke barrier doors were observed.

2/15/11 - 2nd Floor
At 3:26 p.m., the smoke barrier doors at CC-2-7 were closed. The right side door failed to open when the panic hardware was depressed. The door hardware was activated three times but the door remained closed.

During an interview at 3:28 p.m., FM Staff 1 explained that the astragal on the left door held the right door closed. When the left door was opened first the right door could be opened.

2/17/11 - 7th Floor
At 7:29 a.m., the smoke barrier doors CC-74, were observed during fire alarm testing. The doors closed but failed to latch in four of four attempts.

3rd Floor -
At 8:09 a.m., the smoke barrier doors CC3-3, closed but failed to latch in
three of three attempts.

Basement -
At 10:02 a.m., the doors CCB-4 closed but failed to latch. The doors were retested and failed to latch the 2nd time.


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At 9:40 a.m., the right side door was held open with a trash can, of the smoke barrier double doors to the linen room B303D.

At 9:50 a.m., the left side door failed to fully close and positive latch when released from the magnetic hold, of the smoke barrier doors at B151.

2/15/11 - 5th Floor
At 11:16 a.m., there were six 32 gallon soiled linen bins in Shower room 5E-19. There was no self-closing device on the door.

2nd Floor
At 2:47 p.m., the hazardous materials storage room was greater than 50 square feet in size. The room contained more than 50 cardboard boxes of supplies and containers of hazardous waste. There was no self-closing device on the door.
At 3:34 p.m., the storage room at 2WR-5 was greater than 50 square feet in size. There was no self-closing device on the door.
At 4 p.m., the storage room 2A7S was greater than 50 square feet in size. The door self closed but failed to latch.

2/16/11 - Basement (Kitchen Area)
At 11:11 a.m., there was an approximately 1/2 inch penetration in right wall near the vegetable prep area.
At 11:12 a.m., there was an approximately 2 1/2 x 3/4 inch penetration around one pipe sleeve, above the ansul system, in the ceiling above the right wall. There was an approximately 1 x 3/4 inch penetration around a second pipe sleeve. There was an approximately 1/4 inch around electrical conduits and an approximately 1 x 2 inch penetration along one side of the control head box.

During an interview at 11:13 a.m., FM Staff 1 reported the ansul system was installed approximately two years ago.

At 11:30 a.m., there was an approximately 1/2 inch penetration around four pipe sleeves, above the ansul system in the bake shop area. There was a penetration around each pipe sleeve.

Basement Mechanical Area
At 12:55 p.m., there was an approximately 1/2 - 3/4 inch penetration around a white pipe on the right wall of Mechanical Room 1 South. The penetration was near the entrance.
At 1:17 p.m., there were four approximately 3/4 inch penetration in the front wall of the sterilizer access room, ME 223. The penetrations were in the area accessing the back of the sterilizers.

2/17/11 - Family Medical Clinic
At 1:30 p.m., the interior door to the pharmacy storage room was observed. The room is greater than 50 square feet in size and contained shelves with cardboard boxes and paper and plastic packages of medications and supplies. The door was not equipped with a self-closer.







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Based on observation and interview, the facility failed to maintain hazardous areas with 1 hour rated construction and failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by hazardous areas with penetrations and with doors that failed to self close and latch. This affected six of eight floors and the basement, and could result in the spread of fire from a hazardous area to other areas of the facility.

Findings:

During the facility tour from 2/15/11 - 2/16/11, the hazardous areas were observed in the main hospital. Soiled linen and trash storage areas, and combustible storage rooms greater than 50 square feet in size, are considered hazardous areas.

2/15/11 - 8th Floor
At 11:12 a.m., the 8W21 Laundry Room measured over 50 square feet in size. The door failed to have a self closing device.

6th Floor -
At 2:15 p.m., Office 6E40 measured over 50 square feet in size. There were quantities of combustible materials such as loose papers, books binders, files, and paper materials stacked around the office. There was no self-closure on the door.
At 2:20 p.m., in the 6W38 Storage Room, there was an approximately 1? inch penetration around a pipe on the North West wall.
At 2:30 p.m., the self-closing door to LC601, Clean Linen Only, failed to fully close and positive latch. The room was greater than 50 square feet in size.

2/16/11 - 1st Floor
At 9:18 a.m., the Child Life Center storage room, measured over 50 square feet in size. There was no self-closing device on the door. The storage room contained an combustible materials such as papers, books, toys, cardboard boxes and plastic materials.

3rd Floor -
At 12:55 p.m., in B340A, Office A, there were combustible materials, including loose papers, books binders, files, cardboard boxes of paper materials, and shelves in the office area. The office failed to have a self-closure on the door.

At 1:00 p.m., in B340A, Office D, there were combustible materials including loose papers, books, binders, files, paper materials, and shelves in the office area. There was no self-closure on the door.

At 1:10 p.m., in B340A, Doctor Office G, there were combustible materials such as loose papers, books, files, binders, and paper materials stacked around the office. There was no self-closure on the door.

At 1:15 p.m., in B340A, Doctor Office H, there were combustible materials such as loose papers, books, binders, files and stacks of paper materials stacked around the office. There was no self-closure on the door.

At 1:35 p.m., in Anesthesiology Storage A, there were combustible materials such as boxes, supplies, plastics, and paper materials stacked around the office. There was no self-closure on the door.

At 1:40 p.m., in Anesthesiology Storage B, there were combustible materials such as boxes, supplies, plastics, and paper materials stored in the office. There was no self-closure on the door.

These rooms were larger than 50 square feet in size and contained combustible storage. They are considered hazardous areas.

Based on observation, the facility failed to maintain exit access as evidenced by obstructed exits. This affected two of eight floors and the basement. This could delay evacuation in the event of an emergency and increase the risk of injury to patients, visitors and staff.

Findings:

During observations with Facilities Management Staff 4, from 2/15/11 through 2/17/11, the exit access was observed in the main hospital.

2/15/11 - 6th Floor
At 2:25 p.m., the emergency exit door in 6E-ICE, was blocked by a 64 gallon gray trash cart.

2/16/11- Basement
At 2:25 p.m., in the Anesthesiology Office Area, the exit door across from Office I was blocked by boxes.

2/17/11 - 2nd Floor
At 9:20 a.m., on the inside of the OR entrance, the right door was blocked by a gurney.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by one bull-frog light that failed to illuminate when tested. This affected the elevator penthouse of the hospital, and could result in a lack of illumination during a power outage.

Findings:

During a facility tour from 2/15/11 to 2/17/11, the emergency lighting was observed in the main hospital.

On 2/15/11, the elevator penthouse of the hospital, was surveyed.

Elevator penthouse -
At 9:46 a.m., the bull-frog light on the right wall failed to illuminate when staff pushed the test button. The light was re-tested and failed to illuminate.

Based on record review and interview, the facility failed to conduct fire drills quarterly on each shift. This was evidenced by records for fire drills during the first, second, and third quarters of 2010. This affected the N-24 clinic and the Family Medical Clinic, and could result in a delay staff response in the event of a fire.

Findings:

During record review on 2/16/11, the fire drill records were requested.

At 2:38 p.m., the fire drill records for the N-24 clinic and the Family Medical Clinic were provided. One fire drill was conducted at each location during 2010.

During an interview at 2:40 p.m., FM Staff 2 stated that drills are conducted annually, not quarterly, for the N-24 clinic and the Family Medical Clinic.

2/17/11 - 2nd Floor
At 9:20 a.m., the audible/visual alarm device at 2-A-9 failed to illuminate during fire alarm testing.







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2/16/11 - 1st Floor
At 9:20 a.m., the pull station, inside the entrance to the Child Life Care Center, was blocked by a trash can.

2/17/11 - N-24 Trauma Clinic
At 3:05 p.m., the pull station located in Registration B was blocked by chairs occupied by patients.


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Based on observation, record review, and interview, the facility failed to maintain their complete fire alarm system. This was evidenced by an obstructed fire alarm sub-panel and pull station, by alarm devices that failed, by one area with no alarm annunciator, and by no fire alarm system testing records for the Family Medical Clinic. This affected two of eight floors and the basement, in the main hospital, and two of two Medical Clinics. This could result in a failure of the alarm system or a delay in notification, in the event of a fire.

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.

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

Table 7-3.2 requires annual testing of building systems connected to the fire supervising station.

Findings:

During the facility tour on from 2/15/11 - 2/17/11, the fire alarm system was observed. The system was tested on 2/17/11.

2/16/11 - 1st Floor
At 10:37 a.m., the fire alarm sub-panel was obstructed by two plastic storage bins, in the storage area of the volunteers' office.

2/17/11 - Basement
At 10:20 a.m., the strobe light of the alarm device, on the left side of the kitchen storage area, did not activate during fire alarm testing.

At 10:29 a.m., there was no fire alarm annunciator in the mechanical equipment room, near the tunnel. No alarm signal could be seen or heard during fire alarm testing.

During an interview at 10:30 a.m., FM Staff confirmed that there was no audible alarm in the mechanical equipment room.

During record review on 2/17/11, the fire alarm maintenance records for the Family Medical Clinic were requested.

At 2:31 p.m., there were no documents available for annual testing of the fire alarm system.

During an interview at 2:35 p.m., Clinic Staff stated that the building owner is responsible for testing the fire alarm system and has all the records. Staff stated that maintenance and testing records would be faxed to the Ventura District Office by Monday morning. No records were received.

Based on observation, record review and interview, the facility failed to maintain their sprinkler system. This was evidenced by no documents for quarterly testing of the sprinkler system at one clinic location. This affected one of two clinics. This could result in a delay in extinguishing a fire or the potential failure of the sprinkler system.


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

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.
2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Findings:

During record review on 2/17/11, the automatic sprinkler system maintenance records for the Family Medical Clinic were requested.
At 2:31 p.m., there were no documents for the quarterly testing of the sprinkler system available at the clinic.

During an interview at 2:35 p.m., Clinic Staff stated that the building owner is responsible for sprinkler maintenance and has all the records. Staff stated that testing records would be faxed to the Ventura District Office by Monday morning. No records were received by 2/22/11.

At 2:15 p.m., the fire extinguisher in the morgue, autopsy room, was tagged indicating the last date of certification. The date on the tag was punched out for 1/2010. The extinguisher was not recertified in 1/2011 as required.

At 3:49 p.m., a fire extinguisher was located in the x-ray corridor near 2V-29. The next fire extinguisher in the corridor was located approximately 215 feet away in the adjacent corridor.

During an interview at 3:51 p.m., FM Staff 1 explained that due to construction, the nearest fire extinguisher was not accessible. The extinguisher was sealed behind a construction barricade.


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Based on observation and interview, the facility failed to maintain their portable fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguishers that were obstructed, by one fire extinguisher installed over 60 inches above the floor and by a fire extinguisher that was located further than 75 feet from another extinguisher. This affected three of eight floors at the main hospital. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
1.6 General Requirements
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight 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 clearance between the bottom of the fire extinguisher and the floor be less than 4 in.

3-1.4 On each floor level, the area protected and the travel distances shall be based on fire extinguishers installed in accordance with Table 3-2.1 and Table 3-3.1.

Table 3-2.1 Fire Extinguisher Size and Placement for Class A Hazards

Maximum travel distance to extinguisher Light Hazard Occupancy Ordinary Hazard Occupancy or Extra Hazard Occupancy - 75 ft

4.3.1 *Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected, manually or by electronic monitoring, at more frequent intervals when circumstances require.

6-3.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Findings:

During the facility tour with the facilities management staff, from 2/15/11 - 2/17/11, the fire extinguishers were observed.

2/15/11- 8th Floor
At 11:05 a.m., in the Psychiatric Unit Nurses Station, the fire extinguisher was blocked by a pencil sharpener. FM Staff 4 confirmed that the fire extinguisher was blocked from access by a pencil sharpener located directly above the extinguisher.

6th Floor -
At 1:45 p.m., in 6W8, the fire extinguisher was blocked by bear huggers.

5th Floor -
At 1:55 p.m., in the 5E Nurses Station, the fire extinguisher was blocked from access by a fan and a trash can.

2/16/11 - 1st Floor
At 9:19 a.m., on the inside of the entrance to the Child Life Center, the fire extinguisher was blocked by a trash can.
At 9:35 a.m., in Exam Room 1C9, the fire extinguisher was blocked by a soiled linen cart. The fire extinguisher was located behind the door and was not visible.
At 9:40 a.m., in the Dental Clinic 1AC, the fire extinguisher 0543 was blocked by a cabinet, a sharps container and a biohazard linen cart.
At 9:45 a.m., in the Peds ER 1G4B, the fire extinguisher was blocked by a soiled linen cart.

Basement
At 2:00 p.m., in the Medical Air Compressor Room, the fire extinguisher was blocked by equipment and installed at approximately 70 inches from the top of the extinguisher to the floor. FM Staff 4 confirmed that the fire extinguisher was installed over 70 inches above the floor and was obstructed.

2/17/11 - 2nd Floor
At 8:15 a.m., in the OR Clean Work Room, the fire extinguisher was obstructed by a table.

At 8:20 a.m., in the OR corridor, the fire extinguisher 1157 was blocked by a table.


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2/15/11 - 2nd Floor
At 3:15 p.m., there were two cardboard boxes obstructing the fire extinguisher outside Room 2S - 28.

Based on observation and interview, the facility failed to ensure the means of egress was free of all obstructions, as evidenced by gurneys and mobile carts in the egress path, and obstructing the use of the handrails. This affected five of eight floors of the main hospital and the N-24 clinic, and could result in a delayed evacuation, in the event of a fire.

Findings:

During a facility tour from 2/15/11 to 2/17/11, exit corridors were observed in the main hospital and in two clinics.

2/15/11 - 7th Floor
At 10:01 a.m., a computer on wheels (COW) was placed in the corridor at Room 7E-8.
There was a Personal Protective Equipment (PPE) cart in the corridor at Room 7E-8.
There was an ultra-sound cart in the corridor at Room 7E-12.

During an interview at 10:11 a.m., Nursing Staff stated that the COWs are kept in the corridor. She stated that the PPE carts are always in the corridors for easy access.

5th Floor -
At 10:51 a.m., there was a COW and a chair at Room 5EGCRC12. No staff were present in the area.
During an interview at 10:52 a.m., the charge nurse stated that COWs are kept in the corridor for charting.
At 11:08 a.m., there was a PPE cart in the corridor at Room 5E-12.
There was a PPE cart in the corridor at Room 5E-10.
During an interview, a CNA reported that the carts are kept in the corridor for easy access.
At 11:16 a.m., there was a PPE cart in the corridor at Room 5E-5.

4th Floor -
At 1:20 p.m., there was a PPE cart in the corridor at Room 4E-8.
During an interview, nursing staff stated that the corridor is always in the corridor.

3rd Floor -
At 1:54 p.m., there was a PPE cart in the corridor at 3E-8.
At 1:59 p.m., there was a PPE cart in the corridor at 3E-20 and 3E-19.

2/16/11 - 1st Floor
At 9:42 a.m., there were four chairs and a table set up in the corridor between Rooms 1K-10 and 1K-11.
During an interview at 9:44 a.m., nursing staff stated that the chairs are used as a waiting room for patients. She reported the table was used to process forms and that it is always in the corridor.

Basement -
At 1:17 p.m., there were 16 chairs on the left side of the corridor at B-153 and B-154.
During an interview, housekeeping staff reported the chairs are kept in the corridor and used as a waiting room. She stated they are always in the corridor.
At 1:40 p.m., there were four soiled linen carts in the corridor outside of the exam rooms in Nuclear Medicine.
During an interview, the supervisor reported the carts are used for radioactive linens. He stated they stay in the corridor all day, until they are picked up around 4-4:30 p.m.


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At 11:20 a.m., there was a gurney stationed in the corridor by Room B01, blocking the path of egress.
At 11:50 a.m., there was a gurney stationed in the corridor by Room B124, blocking the path of egress.


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2/17/11 - N-24
At 3:08 p.m., there was one crash cart, and three supply carts, obstructing the exit corridor, near Room 22.

During an interview at 3:09 p.m., Nursing Staff 3 stated that the carts are stored in the corridor during the day, and stored in a room at the end of the shift.

2/16/11 - 1st Floor
At 9:58 a.m., there was a soiled linen and trash cart, side by side, in the corridor outside of X-ray room 2, in the psychiatric emergency department. The bags on the carts are approximately 30 gallons in size.


27272

Based on observation and interview, the facility failed to maintain their soiled linen and trash receptacles at 32 gallon capacity in a 64 square foot area. This was evidenced by 100 gallon soiled linen carts and trash receptacles unattended in the corridors and by soiled linen and trash carts side by side in the corridors. This could result in an increased risk of fire and potential injury to patients.

Findings:

During the facility tour with the Facilities Management Staff from 2/15/11 through 2/17/11, soiled linen carts and trash receptacles were observed in the corridors.

2/15/11 - 6th Floor
At 3:05 p.m., in the 6E-E corridor, there was a 100 gallon gray trash receptacle left unattended in the hallway.

2nd Floor -
At 3:15 p.m., in the corridor by 2S36, there was a 100 gallon biohazard receptacle left unattended in the hallway.

2/17/11 - 2nd Floor
At 8:35 a.m., in the OR corridor, there were two 100 gallon receptacles - 1 biohazard cart and 1 gray trash receptacle left unattended in the corridor. OR Staff 1 stated that the containers were left there until they were full, sometimes several hours.

Based on observation, the facility failed to maintain the medical gas storage areas in accordance with NFPA 99. This was evidenced by oxygen cylinders stored with combustibles and by unsecured cylinders. This could result in the increased spread of a fire, and the potential injury of patients, in the event of a fire.

NFPA 99 Health Care Facilities 1999 Edition
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft 3 (85 m 3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 feet (6.1 meters), or
2. A minimum distance of 5 feet (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.
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 of fastenings to protect cylinders from accidental damage or dislocation.

Findings:

During the facility tour with facilities management staff, from 2/15/11 through 2/17/11, the oxygen storage areas were observed at the main hospital.

2/15/11 - 7th Floor
At 10:13 a.m., there were five unsecured E cylinders of oxygen in the storage room in the 7L-4 lobby area. There were papers, and a cardboard box stacked on a wheel chair within approximately 6 inches of the cylinders. There were four cardboard boxes on a cart placed approximately 10 inches from the cylinders. A bag of clothes, a crate of papers and other combustibles were on the same cart.
A wheel chair with an oxygen cylinder attached was stored between two other wheel chairs and within approximately 4 feet of the five oxygen cylinders.
At 10:15 a.m., a seven shelf storage unit contained papers, binders and other supplies. The shelving unit was approximately 2 feet from the oxygen cylinders.
At 10:16 a.m., there were three pink, plastic coated chairs, (birthing chairs)on the other side of the storage room. An oxygen cylinder was attached to the back of each chair. Bags of clothes, cardboard boxes and other items were stored on the seat of the chairs. The room was not sprinklered.

5th Floor -
At 11:06 a.m., there were seven E cylinders of oxygen stored within approximately 10 inches of a soiled linen cart and within approximately three feet of a second soiled linen cart, in the ICU area.

2/16/11 - Basement
At 1 p.m., there were 15 E cylinders and an H cylinder of oxygen stored in the tunnel outside of the mechanical room. The tunnel contains equipment, supplies and other storage items.

Outside Oxygen and Bulk Gas Storage Area
At 2:02 p.m., H Cylinders of oxygen and other medical gases were stored in rows of five. There were three rows in each section. A top and bottom chain was placed across the exterior row. No other cylinders in the section were secured.
At 2:05 p.m., H Cylinders were missing in some sections. When a cylinder was tipped in these sections the cylinder could be knocked over.
During an interview at 2:06 p.m., FM Staff 1 confirmed that some cylinders could be knocked over, in sections where there were less than five cylinders in the row.


27272

At 2:07 p.m., there were groups of compressed gas stored together. The first two racks of cylinders, on the right side of the entrance, contained an assortment of sizes, approximately 30 cylinders per rack. The smaller cylinders were unsecured. The E cylinders were loosely secured. The H cylinders stored across the back of the first section, were not individually secured.

Based on record review and interview, the facility failed to ensure that piped in medical gas systems are in accordance with NFPA 99. This was evidenced by one control valve that was not located on the same floor as the area it controlled. This affected the piped in medical gas system on one of eight floors in the main hospital and could result in a delay in shutting down the system in an emergency.

Findings:

During record review on 2/16/11, records for the piped in medical gas system were requested and reviewed.

At 3:15 p.m., the report "Medical Gas Systems Preventative Maintenance Inspection 2010" was reviewed. The report indicated the repair status of the discrepancies identified in the 11/2010 medical gas certification report.

There was no date for repair for the issue of the control outlet location on another floor for 2W-10, the peds ER 1G3-1G10. Other leaks and alarm issues were listed on the report that were not yet repaired.

During an interview at 3:20 p.m., FM Staff 4 indicated that repairs were still in process. He indicated that moving the control valve would take OSHPD approval and more time to complete.

Based on observation, document review and interview, the facility failed to maintain the humidity levels at 35% or greater in accordance with NFPA 99. This was evidenced by documentation of humidity levels less than 35% in ten hospital operating rooms (OR) and at the four Labor and Delivery Rooms. This failure could increase the risk of a fire in an oxygen enriched environment in an operating room, resulting in potential harm to patients and staff.

NFPA 99, Health Care Facilities, 1999 Edition
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During observation, record review and interview with facilities management staff and OR Staff, on 2/17/11, the operating rooms were observed and humidity documents were reviewed. Portable humidifiers were installed in each operating room.

2/17/11
At 8:15 a.m., OR Staff 1 was interviewed and humidity logs were requested for the ten operating rooms. OR Staff 1 stated the range for humidity levels was 20% - 60% per hospital guidelines and stated that plant operations was responsible for the humidity levels.

The current humidity levels were OR 1 at 35%, OR 2 at 29%, OR 3 at 34%, OR 4 at 37%, OR 5 at 22%, OR 6 at 36%, OR 7 at 41%, OR 8 at 32%, OR 9 at 41% and OR 10 at 37%.

During an interview, FM Staff 4 stated there was no policy and procedure in place for humidity levels and the facility was in the process of creating them. The monitoring process was to go over the humidity readings weekly. The portable humidifiers were serviced monthly.

During record review, the facility provided humidity level documentation for OR 1 thru OR 10 and Labor and Delivery 1 through 4. A sample of the humidity levels were noted to be below the 35 percent during 2-3 days in November and December 2010 and January and February 2011 for every OR except OR 3.

There was no procedure in effect to ensure humidity levels were monitored daily and adjusted when needed.

7th Floor -
At 9:55 a.m., there was a surge protector connected to a surge protector in the OB-GYN Resident Library. The surge protectors were used to connect computer equipment to the wall outlet.
At 9:56 a.m., an orange heavy duty extension cord was used to connect a microwave oven to a surge protector in the same area.
At 10:22 a.m., an extension cord was connected to a surge protector, connected to the wall outlet in Office A, 7W-12.
An electric timer was connected to the wall outlet in 7W-13. The outlets on the timer were used to provide power to a fountain and a lamp. There was no over current protection for the timer.

5th Floor -
At 10:45 a.m., a surge protector was connected to a surge protector in 5L2A. Computer equipment was connected to the surge protectors.
There was a missing cover plate on the outlet outside of Room 5L2A.

2nd Floor -
At 3:36 p.m., the cover plate was missing on the phone outlet box in Office 2W-34A.

At 3:56 p.m., Electrical Panel 2W4P was obstructed by two stacks of chairs and a cart with boxes, placed within approximately 1-4 inches of the panel. There were three working breakers in the panel.
At 4:08 p.m., Electrical Panel 2MFED was obstructed by a cart with forms, placed within approximately 3 inches of the panel. The panel is located between Rooms 2B1 and 2B2.

2/16/11 - 1st Floor
At 9:18 a.m., there was a white extension cord connecting a TV to a surge protector, in the Retail Office, cafeteria kitchen area. The cover plate was hanging from the wall, around phone and computer wiring.
At 9:52 a.m., a chair was placed against the front of Electrical Panel 1PD (1075).

Basement
At 12:55 p.m., the electrical panels were obstructed by work carts in the Mechanical Room 1 South. The carts were within approximately 2-3 inches of the panels.

During an interview at 12:56 p.m., FM Staff 1 stated that the carts are only there temporarily when staff are not using them.

At 1:28 p.m., the cover plate was missing from the phone outlet in Room B116.

2/17/11 - N-24 Clinic
At 3:10 p.m., a brown, multi outlet extension cord was used to connect the fax machine to the wall outlet in the back office area.
At 3:12 p.m., there was an open electrical box above Room 37.


27272

2/15/11 - 8th Floor
At 10:30 a.m., in the EEG Room, 8E12, there was a refrigerator plugged into a surge protector and not directly into the wall.
At 10:40 a.m., in 8E24, there was a microwave plugged into a surge protector and not directly into the wall.
At 11:00 a.m., in the Medical Records Kitchen, there was a microwave plugged into a surge protector and not directly into the wall.

At 1:35 p.m., there was a refrigerator, microwave, toaster oven and a TV plugged into a surge protector attached to a metal cart with twist ties. Facilities Management Staff 4 confirmed that the electrical equipment was plugged into a multi-outlet adapter attached to a metal cart and not directly into the wall.




29665

Based on observation and interview, the facility failed to maintain their electrical wiring in accordance with NFPA 70. This was evidenced by the use of surge protectors and extension cords, and by electrical panels that were obstructed. This affected five of eight floors in the main hospital and one of two clinics. This could result in an increased risk of an electrical fire.

NFPA 70, National Electrical Code, 1999 Edition.
110-26
(a)Working Space
(1) Depth of Working Space. The depth of the working space in the direction of access to live parts shall not be less than indicated in Table 110-26(a). Distances shall be measured from the live parts if such are exposed or from the enclosure front or opening if such are enclosed.

Table 110-26(a). Working Spaces
Nominal Voltage to Ground Condition 1, 2 and 3
1- 150 3 feet
151-600 3, 3 1/2, & 4 feet

(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 inches (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

(b) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.

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.

During the facility tour with facilities management staff, from 2/15/11 to 2/17/11, the electrical wiring and connections were observed.

2/15/11 - 7 th Floor
At 9:53 a.m., there was a six plug surge protector plugged into a six-plug surge protector, in Room 7E - 3.

At 9:54 a.m., there was a heavy duty extension cord plugged into a six-plug surge protector, in Room 7E - 4. There was a microwave plugged into the extension cord, and a refrigerator plugged into the surge protector.

5th Floor
At 11:14 a.m., there was a microwave and refrigerator plugged into a six-plug surge protector in Room 5W - 35A.