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Based on observation, the facility failed to maintain the building construction for 1 of 18 smoke compartments as evidenced by penetrations within the facility walls. These penetrations could result in the spread of smoke and fire throughout the facility and the increased risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During the tour of the facility on September 7, 2010 through 9, 2010, the following were observed:

September 7, 2010, Bldg 9900

1. At 2:05 p.m. there was one penetration measuring 4-inches in diameter through the wall above the power buster in the sprinkler room.

2. At 2:10 p.m. there was one penetration measuring 1-inch in diameter around the base of the sprinkler head through the ceiling in the sprinkler riser room.




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September 9, 2010, Medical Center, Bldg 1

3. At 2:45 p.m., in the OR Neptune Storage Room, 1st Floor, there was an approximately 4 inch by 1/2 inch unsealed penetration along the lower portion of the back wall.

Based on observation, the facility failed to maintain the corridor doors for 6 of 18 smoke compartments as evidenced by corridor doors that failed to positive latch upon closure. These findings could result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During an the facility tour with facility staff on September 7, 2010 through September 9, 2010, the corridor doors were observed.

On September 7, 2010 at Medical Center Bldg. I, 9920 Talbert Avenue:

1. At 1:45 p.m., the 3rd Floor Conference Room door across from Room 392, which was equipped with a self-closure failed to positive latch.

2. At 1:55 p.m., Patient Room 375 door, 3rd Floor, which was equipped with a self-closure failed to fully close and positive latch.

3. At 2:00 p.m., Patient Room 374 door, 3rd Floor, which was equipped with a self-closure failed to fully close and positive latch.

4. At 2:10 p.m., Patient Room 360 door, 3rd Floor, which was equipped with a self-closure failed to fully close and positive latch.

5. At 2:20 p.m., the Supply Room door nest to Room 333, 3rd Floor, which was equipped with a self-closure failed to positive latch.

6. At 2:37 p.m., Patient Room 327 door, 3rd Floor, which was equipped with a self-closure failed to positive latch.

7. At 3:47 p.m., Patient Room 237 door, 2nd Floor, which was equipped with a self-closure failed to positive latch.

On September 8, 2010 at 9920 Talbert Avenue:

8. At 10:05 a.m., the ER Isolation Room door, 1st Floor, which was equipped with a self-closure failed to fully close and positive latch.

9. At 10:30 a.m., the Maternity Postpartum Storage Room door, 1st Floor, which was equipped with a self-closure failed to positive latch.

Based on observation, the facility failed to ensure the integrity and maintenance of 1 of 1 smoke barrier wall located in the attic space over cross-corridor fire doors in order to provide at least a one-half hour fire resistance rating in accordance with Section 8.3, NFPA 101(smoke barriers). In the event of fire and/or smoke, the smoke barrier integrity compromised by a penetration, would not be able to provide at least a one-half hour fire resistance and would allow smoke and/or fire to pass from one smoke compartment to another smoke compartment, thereby affecting all residents in the facility.

Findings:

The smoke barrier walls were observed on 9/7/2010, with the facility staff.

Bldg. 3, 18111 Brookhurst

1. At 1:40 p.m. there was one penetration measuring 1/2-inch in diameter around the electric wire through the smoke barrier walls located in the attic space over the cross-corridor fire doors in front of the elevator in unit 1400.

2. At 1:45 p.m. there was one penetration measuring 2-inches in diameter around the electric wire through the smoke barrier wall located in the attic space over the cross-corridor fire doors next to the dirty utility room of respiratory room in unit 2400.

3. At 1:50 p.m. there were two penetrations measuring 3-inches each in diameter around the air duct through the smoke barrier walls located in the attic space over the cross-corridor fire doors next front door of unit 2450.

4. At 1:55 p.m. there was one penetration measuring 3-inches in diameter around the metal support though the smoke barrier wall located in the attic space over the cross -corridor fire doors next to the front door of unit 2200.

5. At 2:10 p.m. there was one penetration measuring 1-inch in diameter around the exhaust pipe through the smoke barrier wall located in the attic space over the cross-corridor fire doors next the front door of unit 4300.

Bldg. 2, 9900 Talbert Ave.

6. At 2:30 p.m., there was one penetration measuring 1-inch in diameter around the electric pipe through the smoke barrier wall located in the attic space over cross-corridor fire doors at front door of the room # 102.

Based on observation, the facility failed to provide a 20-minute fire protection rating at 2 of 2 set of cross-corridor smoke barrier doors evidenced by having a gap between a set of smoke barrier doors.

In the event of fire and/or smoke, the smoke barrier door with a gap could allow the smoke and/or fire to spread from one smoke compartment to another smoke compartment.

Findings:

The smoke barrier doors were observed with the facility staff on September 8, 2010.

Bldg 3, 18111 Brookhurst

1. At 9:15 a.m., there was a 1/2-inch gap between the set of smoke barier doors located in the second floor.

2. At 9:25 a.m., there was a 3/4-inch gap between the set of smoke barrier doors located in the fourth floor.

The deficiency affected 2 of 2 smoke compartments.

Based on record review, the facility failed to provide documented evidence to indicate that all staff participated in their fire drills. This was evidenced by no records of staff signature in their fire drill document. This could cause confusion and delay in response to fire.

Findings:

Bldg 2, 9900

During a review of the fire drill records on September 7, 2010 at 3:05 p.m., there was no attendance sheet to indicate the staff members participated in the fire drill for the first quarter of 2010.

Based on observation, the facility failed to ensure that their fire alarm activation devices were accessible in 2 of 18 smoke compartments. This was evidenced by the failing to keep impediments from obstructing manual fire alarm pull station devices from view and access. These findings could delay activation of the fire alarm system and increase the risk of injury to patients, visitors and staff in the event of a fire emergency.

Findings:

During the facility tour with facility staff on September 7, 2010 through September 9, 2010, the manual alarm activation devices were observed.

September 7, 2010, Bldg 2, 9920 Talbert Avenue:

1. At 1:50 p.m., in the 3rd Floor 3 C South Elevator Lobby, the manual fire alarm pull station device was impeded by a hand sanitizer station.

2. At 2:40 p.m., in the 3rd Floor 3 North Elevator Lobby, the manual fire alarm pull station device was impeded by a hand sanitizer station.

NFPA 72 section 2-8.2.1
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained in 2 of 18 smoke compartments, as evidenced by missing escutcheon rings and sprinkler heads with debris. These findings could result in a malfunction during a fire and increase the risk of injury to patients, visitors and staff in the event of fire.

Findings:

During the facility tour with facility staff on September 7, 2010 through September 9, 2010, the fire sprinkler system was observed.

September 7, 2010, Bldg #1, 9920 Talbert Avenue:

1. At 8:40 a.m., in the Doctors Lounge, there was 1 of 11 sprinkler heads missing an escutcheon ring.

2. At 3:49 p.m., in the Dialysis Room across from Oncology, 2nd Floor, there was 1 of 1 sprinkler heads missing an escutcheon ring.

September 8, 2010, Bldg #1, 9920 Talbert Avenue:

3. At 9:55 a.m., at the ER Ambulance Entrance, there was 1 of 2 sprinkler heads with a build-up of debris.

4. At 10:00 a.m., in the ER corridor, there were 2 of 5 sprinkler heads with a build-up of debris.

5. At 10:20 a.m., in the ER Clean Linen Room, there was 1 of 1 sprinkler heads covered with yellow tape.

6. At 2:45 p.m., in the ER Neptune Storage Room, there was 1 of 1 sprinkler heads covered with a plastic bag.

7. At 2:45 p.m., in the Cafeteria, there were 7 of 18 sprinkler heads with a build-up of debris.

Based on observation, the facility failed to ensure that their portable fire extinguishers in 2 of 18 smoke compartments were readily accessible as evidenced by a fire extinguisher impeded from access and a K-Class fire extinguisher mounted greater than 42 inches high. These finding could delay response to a fire and increase the risk of injury to patients, visitors and staff in the event of a fire emergency.

Findings:

During the facility tour with facility staff on September 7, 2010 through September 9, 2010, the fire extinguishers were observed.

September 8, 2010, Bldg. 1, 9920 Talbert Avenue:

1. At 10:10 a.m., in the Pre-Op Area, 1st Floor, the fire extinguisher was impeded from access by a recycle bin.

2. At 3:20 p.m., in the Kitchen, the K-Class fire extinguisher was mounted over 60 inches from the floor to the top of the extinguisher and impeded from access by a counter.

NFPA 10 Standard for Portable Fire Extinguishers, 2002 Edition
1.5.3 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 path of travel, including exits from area.

NFPA 10 Standard for Portable Fire Extinguishers, 1998 Edition
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.

Based on observation, the facility failed to maintain the path of egress free of all obstructions and impediments to full instant use in case of fire or other emergency in 2 of 18 smoke compartments, as evidenced by equipment and carts left in the corridors. These findings could create confusion and delay in evacuation in the event of an emergency and increase the risk of injury to patients, visitors and staff.

Findings:

During the facility tour with facility staff on September 7, 2010 through September 9, 2010, the egress paths were observed.

September 8, 2010, Bldg #1, 9920 Talbert Avenue

1. At 10:15 a.m., in the OR exit corridor, there were 10 surgical carts lined up on the right hand side impeding the exit corridor.

2. At 10:25 a.m., in the Radiology corridor, in front of the exit door, there were 2 ultra-sound machines blocking one side of the double doors.

Based on observation, the facility failed to ensure that their stored medical gas cylinders in 1 of 1 storage area were secured from tipping over. This was evidenced by medical gas cylinders that were not secured individually. This finding could result in tipping over of the oxygen cylinder and result in explosion and fire.

Findings:

During the facility tour with facility staff on September 7, 2010 through September 9, 2010, the oxygen storage area was observed.

September 8, 2010, Bldg #1, 9920 Talbert Avenue:

At 3:10 p.m., the Medical Gas Cylinder Storage Area located on the outside of the building had 12 full oxygen H tank secured with one chain, 8 full nitrous with one chain, and 15 empty oxygen H tanks secured with one chain. The chains were not sufficient to prevent the cylinders from tipping over.

NFPA 99, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder
storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches,
and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]. 1999 Edition

Based on observation, the facility failed to maintain electrical safety in 5 of 18 smoke compartments, as evidenced by failing to prevent electrical appliances from being plugged into multi-plug power strips and not directly into electrical outlets and to prevent multi-outlet adapters to be used as part of permanent wiring. These findings could result in an electrical fire and increase the risk of injury to patients, visitors and staff in the event of a fire.

NFPA 70, Section 240-4, 1999 Ed. Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
(b) Branch Circuit Overcurrent Device. Flexible cord shall be protected where supplied by a branch circuit in accordance with one of the methods described below.
(1) Supply Cord of Listed Appliance or Portable Lamps. Where flexible cord or tinsel cord is approved for and used with a specific listed appliance or portable lamp, it shall be permitted to be supplied by a branch circuit of Article 210 in accordance with the following:
20-ampere circuits -- tinsel cord or No. 18 cord and larger
30-ampere circuits -- No. 16 cord and larger
40-ampere circuits -- cord of 20-ampere capacity and over
50-ampere circuits -- cord of 20-ampere capacity and over
(2) Fixture Wire. Fixture wire shall be permitted to be tapped to the branch circuit conductor of a branch circuit of Article 210 in accordance with the following:
20-ampere circuits -- No. 18, up to 50 ft (15.2 m) of run length
20-ampere circuits -- No. 16, up to 100 ft (30.5 m) of run length
20-ampere circuits -- No. 14 and larger
30-ampere circuits -- No. 14 and larger
40-ampere circuits -- No. 12 and larger
50-ampere circuits -- No. 12 and larger
NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with facility staff September 7, through September 9, 2010, the electrical appliances and equipment were observed.

September 7, 2010, Bldg #1, 9920 Talbert Avenue:

1. At 11:10 a.m., in Conference Room D, Basement Floor, there was an orange extension cord in use.

2. At 1:40 p.m., 3rd Floor Office, on the other side of the cubicle wall where the wheel chairs were stored, there was a multi-outlet adapter attached to the wall.

3. At 2:35 p.m., 3rd Floor Manager Office, there was a refrigerator and a microwave plugged into an extension cord.

4. At 2:45 p.m., in Patient Room 317, 3rd Floor, there was a multi-outlet adapter attached to the wall.

5. At 2:50 p.m., in 3rd Floor Surgical Nurses Lounge, there was a multi-outlet adapter attached to the wall.

6. At 3:35 p.m., in Oncology Patient Room 240, 2nd Floor, there were two multi-outlet adapters attached to the wall by the beds.

7. At 3:45 p.m., in Patient Room 237, 2nd Floor, there was a multi-outlet adapter attached to the wall by the bed.

8. At 3:52 p.m., in Patient Room 228, 2nd Floor, there was a multi-outlet adapter attached to the wall by the bed.

September 8, 2010, Bldg #1, 9920 Talbert Avenue:

9. At 9:50 a.m., in the Er Break Room, there was a microwave plugged into an extension cord.