HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction of the corridors as evidenced by penetrations on the corridor ceiling. This could result in the spread of fire and smoke, potentially causing injury to patients, visitors, and staff evacuating through the corridors. This affected 1 of 5 floors in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the corridors were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Second Floor:
On 9/8/15, at 11:32 a.m., there was a penetration going through the ceiling in the corridor by Room 2826, located on the South-East Wing of the 2nd Floor. The penetration measured approximately 6-inches in diameter.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain doors to operate without interference. This was evidenced by a door that was obstructed from closing. This had the potential to allow the migration of fire or smoke and result in injury to patients. This affected 1 of 5 floors in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's corridor doors were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Second Floor:
On 9/9/15, at 8:59 a.m., the door to the South Lounge, Room 2760 located on the 2nd Floor, was obstructed from closing by a chair. The door opened into the operating room corridor.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation and interview, the facility failed to maintain exit signs in accordance with NFPA 101 (2000 edition), as evidenced by a exit sign that did not have a directional indicator showing the direction of travel to the nearest exit. This failure affected 1 of 4 Outpatient Centers.

NFPA 101, Life Safety Code (2000) Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During the facility tour with Dir. FPM, Safety 4, and Staff 7, on 9/08/15 through 9/11/15, the exit signs were observed.

Outpatient Clinic- Pediatric Specialty Team Center:
On 9/8/15, at 1:55 p.m., the exit sign above treatment room 55 did not indicate which direction to travel to the nearest exit. During an interview, Dir. FPM and Safety 4, confirmed there was no direct exit inside treatment room 55.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain their fire doors to operate without interference and to prevent the passage of smoke or fire. This was evidenced by fire doors that failed to close and positive latch upon activation of the fire alarm system. This could result in the spread of smoke and fire, increasing the risk of injury to residents. This affected 1 of 5 floors in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL and 1 of 4 Outpatient Centers.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
3-1.4 Operation of Doors. The doors shall swing easily and freely on their hinges. The latches shall operate freely.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.1 Inspections.
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's cross-corridor fire doors were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Fifth Floor:
1. On 9/9/15, at 10:48 a.m., 1 of 2 cross corridor fire doors, located between the 5200 unit and the South corridor, failed to close and positive latch when a smoke detector was activated in the area. The door remained open to its full extent for more than 30 seconds.

Outpatient Surgery Center:
2. On 9/9/15, at 3:50 p.m., 1 of 2 cross corridor fire doors, located in the Operating Room corridor by the Decontamination Room, failed to positive latch.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain illumination throughout its means of egress as evidenced by lighting units that failed to illuminate. This could result in a delay in evacuation due to low or no visibility, and result in injury to visitors and staff. This affected 2 of 5 floors in the South-East Stairwell in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's the lighting units throughout the means of egress were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Fourth & Fifth Floors:
1. On 9/8/15, at 2:40 p.m., two lighting fixtures in the South-East Stairwell on the 5th Floor did not illuminate, leaving its means of egress with low visibility.

2. At 2:55 p.m., a lighting fixture in the South-East Stairwell on the 4th Floor did not illuminate, leaving its means of egress with low visibility.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation and interview, the facility failed to ensure that their anesthetizing locations were provided with battery-powered emergency lighting in accordance with NFPA 70, 1999 Edition and maintain them in accordance with NFPA 101, 2000 Edition. This was evidenced by Operating Rooms (ORs) not equipped with battery-powered emergency light and by a battery-powered emergency light that failed to illuminate when tested. This could result in no illumination in the ORs during a power outage and during the generator start-up period, and could result in harm to patients in the event of generator failure. This affected 3 ORs on the 3rd Floor at LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL, 6 ORs at the Outpatient Surgery Center, 16 ORs on the 2nd floor at LOMA LINDA UNIVERSITY HOSPITAL, and the Outpatient Clinic-Pediatric Specialty Team Center.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard forHealth Care Facilities.
NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
NFPA 70, National Electrical Code, 1999 Edition.
700-12. (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 871/2 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 11/2 hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 11/2 hours. Storage batteries, whether of the acid or alkali type,
shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the
normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's Operating Rooms (OR) were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Third Floor:
1. On 9/9/15, at 10:21 a.m., the Labor and Delivery (L&D) ORs 1 and 2 were not equipped with battery-powered emergency lighting units. The L&D OR 3 had an ongoing procedure at the time of the tour and was not observed.

Outpatient Surgery Center:
2. On 9/9/15, at 3:45 p.m., the Outpatient Surgery ORs 2, 3, 4, and 6 were not equipped with battery-powered emergency lighting units. The ORs 1 and 5 had ongoing procedures at the time of the tour and were not observed.

Loma Linda Hospital, Second Floor:
3. On 9/10/15, at 10:07 a.m., OR 10 was not equipped with battery-powered emergency lighting unit/s.

4. At 10:10 a.m., OR 9 was not equipped with battery-powered emergency lighting unit/s.

5. At 10:17 a.m., OR 13 was not equipped with battery-powered emergency lighting unit/s.

6. At 10:19 a.m., the Director of Adult Operating Room (Dir.OR) was interviewed and stated that there are sixteen ORs on the 2nd Floor and that during power outages it takes "a few seconds" for the lights to come back on.

7. At 2:15 p.m., the Manager of Facilities Management (Mgr.FM2) was interviewed and stated that he confirmed that the ORs did not have battery powered emergency lighting units.

8. At 3:03 p.m., ORs 12, 11, 8, 5, 4, and 1 were not equipped with battery-powered emergency lighting units. ORs 2, 3, 6, 7, 14, 15, and 16 had ongoing procedures at the time of the tour and were not observed.




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Outpatient Surgery Center:
9. On 9/08/15, at 11:22 a.m., ORs 2, 3 and 4 were observed to have no emergency battery powered lighting units in the rooms. ORs 1, 5 and 6 had ongoing procedures at the time of the tour. During an interview, staff confirmed there were no emergency battery powered lighting units in any of the six operating rooms.

Outpatient Clinic-Pediatric Specialty Team Center:
10. On 9/10/15, at 4:50 p.m., the emergency lighting unit in the men's restroom failed to illuminate when pushing down on its test button.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72,1999 edition. This was evidenced by sealed lead acid batteries in the main fire alarm control panel that had exceeded their four year replacement period and by failing to maintain the recording device at the supervising station. This could result in the fire alarm control panel not functioning as designed and failing to notify staff of a fire. This affected 1 of 4 outpatient clinics and the Loma Linda Children's Hospital..

NFPA 101, Life Safety Code (2000) Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
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
5-2.6.1.5 All test signals received shall be recorded to indicate date, time, and type.
5-2.6.2.3 The central station shall make arrangements to furnish reports of signals received to the authority having jurisdiction in a manner approved by the authority having jurisdiction.
7-5.3 For supervising station fire alarm systems, records pertaining to signals received at the supervising station that result from maintenance, inspection, and testing, shall be maintained for not less than 12 months. Upon request, a hard copy record shall be provided to the authority having jurisdiction. Paper or electronic media shall be permitted.

Table 7-3.2 Testing Frequencies:
6. Batteries - Fire Alarm Systems (d) Sealed Lead Acid Type
1. Charger Test (Replace battery every 4 years.): Initial/Reacceptance and Annually
2. Discharge Test (30 minutes): Initial/Reacceptance and Annually.
Table 7-2.2 Test Methods:
5. Batteries (d) Discharge Test
With the battery charger disconnected, the batteries shall be load tested following the manufacturer's recommendations. The voltage level shall not fall below the levels specified.

Findings:

During a tour of the facility with Dir. FPM, Safety 3 & 4, Mgr. FM 1 & 2, and Staff 7, on 9/08/15 through 9/11/15, the main fire alarm panel batteries were observed.

Outpatient Surgery Center:
1. On 9/09/15, at 3:30 p.m., the sealed lead-acid type batteries in the main fire alarm control panel were dated 2/15/2011. Batteries are required to be replaced every four years, from the date installed and a load test is required every year, the last load test date on the batteries was 9/2012. This was confirmed by Safety Staff 3 and 4.


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Loma Linda Hospital:
2. On 9/9/15, at 2:21 p.m., the fire alarm system supervising station, located in the Private Branch Exchange (PBX) and Security Unit, had a printer that was out of paper and with low ink. The printer was the supervising station's secondary (backup) display of the fire alarm signals.

3. At 2:34 p.m., the fire alarm system supervising station primary display of fire alarm signals had its time stamps that were not synchronized with actual times. The time stamps had a difference of approximately 1 hour and 7 minutes ahead of current time when compared to the att cellular network time.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, document review and interview, the facility failed to maintain the sprinkler system in accordance with NFPA 25 (1998 edition), as evidenced by an expired 5 year certification tag attached to the main sprinkler riser, a missing sprinkler escutcheon ring, and a leaking valve. This affected 1 of 4 outpatient clinics and 1 of 5 floors at Loma Linda Children's Hospital.

NFPA 101, Life Safety Code (2000) Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.5 Maintenance and Testing. all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
9-3.3.2* The valve inspection shall verify that the valves are in the following condition:
(e) Free from external leaks

Findings:

During the facility tour with Dir. FPM, Safety 3 & 4, and Staff 7, on 9/08/15 through 9/11/15, the sprinkler system was observed and sprinkler maintenance records were reviewed.

Outpatient Clinic-Pediatric Specialty Team Center:
1. On 9/8/15, at 2:10 p.m., the five year certification tag on the main sprinkler riser was expired, the tag was dated 7/26/2010.
Between 9/08/15 and 9/11/15, the facility failed to provide current documentation for the five year certification of the sprinkler system located at the Outpatient Pediatric Specialty Team Center. During interview, Dir. FPM stated the sprinkler vendor is schedule to certify the system on 9/12/15.

Loma Linda Children's Hospital, Fourth Floor:
2. On 9/9/15, at 11:22 a.m., the ceiling sprinkler escutcheon ring was missing in room 4410.


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Loma Linda Children's Hospital, Fourth Floor:
3. On 9/9/15, at 11:09 a.m., the Inspector's Test Valve (ITV), located in the Center Stairwell on the 4th Floor, had water leaking from the bottom portion of the valve's handle.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 Edition. This was evidenced by using non tamper resistant receptacles and extension cords in the pediatric areas. This had the potential for increasing the risk of electrical fire and electrical shock that could result in the injury to residents, visitors, and staff. This affected 1 of 2 smoke compartments on the 1st Floor.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
210-23 Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.
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
517-18. General Care Areas.
(c) Pediatric Locations. Fifteen- and 20-ampere, 125-volt receptacles intended to supply patient care areas of pediatric wards, rooms, or areas shall be listed tamper resistant or shall employ a listed tamper resistant cover.

Findings:

During the facility tour with Dir. FPM, Safety 3 & 4, and Staff 7 on 9/08/15 through 9/11/15, the facility electrical wiring and equipment was observed.

Loma Linda Children's Hospital, Fifth Floor:
1. On 9/8/15, at 1:56 p.m., the electrical receptacles in the 5100 pediatric acute care unit were not listed tamper resistant and they did not have listed tamper resistant covers. They included the following pediatric rooms: 5101, 5102, 5103, 5104, 5105, 5106, 5107, 5108, 5110, 5111, 5112.

2. At 2:15 p.m., the electrical receptacles in the 5200 pediatric intenstive care unit were not listed tamper resistant and they did not have listed tamper resistant covers.

3. At 2:41 p.m., the red colored electrical receptacle in Room 5809 was not a listed tamper resistant outlet and it did not have listed tamper resistant cover.

4. At 2:43 p.m., the red colored electrical receptacle in Room 5805 was not a listed tamper resistant outlet and it did not have listed tamper resistant cover.


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Outpatient Clinic-Pediatric Specialty Team Center:
5. On 9/08/15, at 1:53 p.m., there was a power strip plugged into a power strip located inside charting room 52.

Loma Linda Children's Hospital, Fourth Floor:
6. On 9/10/15, at 10:14 a.m., the microwave in room 4719 was plugged into a power strip and not directly into the wall receptacle.

7. At 10:41 a.m., there were two white extension cords plugged into a power strip and the power strip was plugged into another power strip in room 4318.

8. At 11:07 a.m., a power strip was plugged into another power strip in room 4402.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridors as evidenced by penetrations on the corridor ceiling. This could result in the spread of fire and smoke, potentially causing injury to patients, visitors, and staff evacuating through the corridors. This affected 1 of 5 floors in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the corridors were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Second Floor:
On 9/8/15, at 11:32 a.m., there was a penetration going through the ceiling in the corridor by Room 2826, located on the South-East Wing of the 2nd Floor. The penetration measured approximately 6-inches in diameter.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain doors to operate without interference. This was evidenced by a door that was obstructed from closing. This had the potential to allow the migration of fire or smoke and result in injury to patients. This affected 1 of 5 floors in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL.

NFPA 101, Life Safety Code, 2000 Edition
19.3.6.3.2* Doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.2.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's corridor doors were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Second Floor:
On 9/9/15, at 8:59 a.m., the door to the South Lounge, Room 2760 located on the 2nd Floor, was obstructed from closing by a chair. The door opened into the operating room corridor.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation and interview, the facility failed to maintain exit signs in accordance with NFPA 101 (2000 edition), as evidenced by a exit sign that did not have a directional indicator showing the direction of travel to the nearest exit. This failure affected 1 of 4 Outpatient Centers.

NFPA 101, Life Safety Code (2000) Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.
7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During the facility tour with Dir. FPM, Safety 4, and Staff 7, on 9/08/15 through 9/11/15, the exit signs were observed.

Outpatient Clinic- Pediatric Specialty Team Center:
On 9/8/15, at 1:55 p.m., the exit sign above treatment room 55 did not indicate which direction to travel to the nearest exit. During an interview, Dir. FPM and Safety 4, confirmed there was no direct exit inside treatment room 55.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain their fire doors to operate without interference and to prevent the passage of smoke or fire. This was evidenced by fire doors that failed to close and positive latch upon activation of the fire alarm system. This could result in the spread of smoke and fire, increasing the risk of injury to residents. This affected 1 of 5 floors in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL and 1 of 4 Outpatient Centers.

NFPA 101, Life Safety Code, 2000 Edition
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.
7.2.1.9.2 Doors Required to Be Self-Closing. Where doors are required to be self-closing and (1) are operated by power upon the approach of a person or (2) are provided with power-assisted manual operation, they shall be permitted in the means of egress under the following conditions:
(1) Doors can be opened manually in accordance with 7.2.1.9.1 to allow egress travel in the event of power failure.
(2) New doors remain in the closed position unless actuated or opened manually.
(3) When actuated, new doors remain open for not more than 30 seconds.
(4) Doors held open for any period of time close - and the power-assist mechanism ceases to function - upon operation of approved smoke detectors installed in such a way as to detect smoke on either side of the door opening in accordance with the provisions of NFPA 72, National Fire Alarm Code.
(5) Doors required to be self-latching are either self-latching or become self-latching upon operation of approved smoke detectors per 7.2.1.9.2(4).
(6) New power-assisted swinging doors comply with BHMA/ANSI A156.19, American National Standard for Power Assist and Low Energy Power Operated Doors.
8.2.3.2 Fire Protection-Rated Opening Protectives.
8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) *Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
3-1.4 Operation of Doors. The doors shall swing easily and freely on their hinges. The latches shall operate freely.
3-4.3.2 Components. Fire door hardware shall include hinge brackets, hinges, latches, latch keepers, and operating handle mechanisms; hardware for inactive door or pairs of doors includes top and bottom bolts and keepers.
15-1.4 Repairs. Repairs shall be made and defects that could interfere with operation shall be corrected immediately.
15-2.1 Inspections.
15-2.1.1 Hardware shall be examined frequently and any parts found to be inoperative shall be replaced immediately.
15-2.4.1 Self-closing devices shall be kept in proper working condition at all times.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's cross-corridor fire doors were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Fifth Floor:
1. On 9/9/15, at 10:48 a.m., 1 of 2 cross corridor fire doors, located between the 5200 unit and the South corridor, failed to close and positive latch when a smoke detector was activated in the area. The door remained open to its full extent for more than 30 seconds.

Outpatient Surgery Center:
2. On 9/9/15, at 3:50 p.m., 1 of 2 cross corridor fire doors, located in the Operating Room corridor by the Decontamination Room, failed to positive latch.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain illumination throughout its means of egress as evidenced by lighting units that failed to illuminate. This could result in a delay in evacuation due to low or no visibility, and result in injury to visitors and staff. This affected 2 of 5 floors in the South-East Stairwell in LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's the lighting units throughout the means of egress were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Fourth & Fifth Floors:
1. On 9/8/15, at 2:40 p.m., two lighting fixtures in the South-East Stairwell on the 5th Floor did not illuminate, leaving its means of egress with low visibility.

2. At 2:55 p.m., a lighting fixture in the South-East Stairwell on the 4th Floor did not illuminate, leaving its means of egress with low visibility.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation and interview, the facility failed to ensure that their anesthetizing locations were provided with battery-powered emergency lighting in accordance with NFPA 70, 1999 Edition and maintain them in accordance with NFPA 101, 2000 Edition. This was evidenced by Operating Rooms (ORs) not equipped with battery-powered emergency light and by a battery-powered emergency light that failed to illuminate when tested. This could result in no illumination in the ORs during a power outage and during the generator start-up period, and could result in harm to patients in the event of generator failure. This affected 3 ORs on the 3rd Floor at LOMA LINDA UNIVERSITY CHILDREN'S HOSPITAL, 6 ORs at the Outpatient Surgery Center, 16 ORs on the 2nd floor at LOMA LINDA UNIVERSITY HOSPITAL, and the Outpatient Clinic-Pediatric Specialty Team Center.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing Locations. Anesthetizing locations shall be protected in accordance with NFPA 99, Standard forHealth Care Facilities.
NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-3.2.1.2 All Patient Care Areas. 5. Wiring in Anesthetizing Locations.
e. Battery-Powered Emergency Lighting Units. One or more battery-powered emergency lighting units shall be provided in accordance with NFPA 70, National Electrical Code, Section 700-12(e).
NFPA 70, National Electrical Code, 1999 Edition.
700-12. (e) Unit Equipment. Individual unit equipment for emergency illumination shall consist of the following:
(1) A rechargeable battery
(2) A battery charging means
(3) Provisions for one or more lamps mounted on the equipment, or shall be permitted to have terminals for remote lamps, or both, and
(4) A relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment
The batteries shall be of suitable rating and capacity to supply and maintain at not less than 871/2 percent of the nominal battery voltage for the total lamp load associated with the unit for a period of at least 11/2 hours, or the unit equipment shall supply and maintain not less than 60 percent of the initial emergency illumination for a period of at least 11/2 hours. Storage batteries, whether of the acid or alkali type,
shall be designed and constructed to meet the requirements of emergency service
Unit equipment shall be permanently fixed in place (i.e., not portable) and shall have all wiring to each unit installed in accordance with the requirements of any of the wiring methods in Chapter 3. Flexible cord and plug connection shall be permitted, provided that the cord does not exceed 3 ft (914 mm) in length. The branch circuit feeding the unit equipment shall be the same branch circuit as that serving the
normal lighting in the area and connected ahead of any local switches. The branch circuit that feeds unit equipment shall be clearly identified at the distribution panel. Emergency illumination fixtures that obtain power from a unit equipment and are not part of the unit equipment shall be wired to the unit equipment as required by Section 700-9 and by one of the wiring methods of Chapter 3.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30-day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During the facility tour on 9/8/15 through 9/11/15, the facility's Operating Rooms (OR) were observed with the Safety Representative (Safety3).

Loma Linda Children's Hospital, Third Floor:
1. On 9/9/15, at 10:21 a.m., the Labor and Delivery (L&D) ORs 1 and 2 were not equipped with battery-powered emergency lighting units. The L&D OR 3 had an ongoing procedure at the time of the tour and was not observed.

Outpatient Surgery Center:
2. On 9/9/15, at 3:45 p.m., the Outpatient Surgery ORs 2, 3, 4, and 6 were not equipped with battery-powered emergency lighting units. The ORs 1 and 5 had ongoing procedures at the time of the tour and were not observed.

Loma Linda Hospital, Second Floor:
3. On 9/10/15, at 10:07 a.m., OR 10 was not equipped with battery-powered emergency lighting unit/s.

4. At 10:10 a.m., OR 9 was not equipped with battery-powered emergency lighting unit/s.

5. At 10:17 a.m., OR 13 was not equipped with battery-powered emergency lighting unit/s.

6. At 10:19 a.m., the Director of Adult Operating Room (Dir.OR) was interviewed and stated that there are sixteen ORs on the 2nd Floor and that during power outages it takes "a few seconds" for the lights to come back on.

7. At 2:15 p.m., the Manager of Facilities Management (Mgr.FM2) was interviewed and stated that he confirmed that the ORs did not have battery powered emergency lighting units.

8. At 3:03 p.m., ORs 12, 11, 8, 5, 4, and 1 were not equipped with battery-powered emergency lighting units. ORs 2, 3, 6, 7, 14, 15, and 16 had ongoing procedures at the time of the tour and were not observed.




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Outpatient Surgery Center:
9. On 9/08/15, at 11:22 a.m., ORs 2, 3 and 4 were observed to have no emergency battery powered lighting units in the rooms. ORs 1, 5 and 6 had ongoing procedures at the time of the tour. During an interview, staff confirmed there were no emergency battery powered lighting units in any of the six operating rooms.

Outpatient Clinic-Pediatric Specialty Team Center:
10. On 9/10/15, at 4:50 p.m., the emergency lighting unit in the men's restroom failed to illuminate when pushing down on its test button.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72,1999 edition. This was evidenced by sealed lead acid batteries in the main fire alarm control panel that had exceeded their four year replacement period and by failing to maintain the recording device at the supervising station. This could result in the fire alarm control panel not functioning as designed and failing to notify staff of a fire. This affected 1 of 4 outpatient clinics and the Loma Linda Children's Hospital..

NFPA 101, Life Safety Code (2000) Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
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
5-2.6.1.5 All test signals received shall be recorded to indicate date, time, and type.
5-2.6.2.3 The central station shall make arrangements to furnish reports of signals received to the authority having jurisdiction in a manner approved by the authority having jurisdiction.
7-5.3 For supervising station fire alarm systems, records pertaining to signals received at the supervising station that result from maintenance, inspection, and testing, shall be maintained for not less than 12 months. Upon request, a hard copy record shall be provided to the authority having jurisdiction. Paper or electronic media shall be permitted.

Table 7-3.2 Testing Frequencies:
6. Batteries - Fire Alarm Systems (d) Sealed Lead Acid Type
1. Charger Test (Replace battery every 4 years.): Initial/Reacceptance and Annually
2. Discharge Test (30 minutes): Initial/Reacceptance and Annually.
Table 7-2.2 Test Methods:
5. Batteries (d) Discharge Test
With the battery charger disconnected, the batteries shall be load tested following the manufacturer's recommendations. The voltage level shall not fall below the levels specified.

Findings:

During a tour of the facility with Dir. FPM, Safety 3 & 4, Mgr. FM 1 & 2, and Staff 7, on 9/08/15 through 9/11/15, the main fire alarm panel batteries were observed.

Outpatient Surgery Center:
1. On 9/09/15, at 3:30 p.m., the sealed lead-acid type batteries in the main fire alarm control panel were dated 2/15/2011. Batteries are required to be replaced every four years, from the date installed and a load test is required every year, the last load test date on the batteries was 9/2012. This was confirmed by Safety Staff 3 and 4.


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Loma Linda Hospital:
2. On 9/9/15, at 2:21 p.m., the fire alarm system supervising station, located in the Private Branch Exchange (PBX) and Security Unit, had a printer that was out of paper and with low ink. The printer was the supervising station's secondary (backup) display of the fire alarm signals.

3. At 2:34 p.m., the fire alarm system supervising station primary display of fire alarm signals had its time stamps that were not synchronized with actual times. The time stamps had a difference of approximately 1 hour and 7 minutes ahead of current time when compared to the att cellular network time.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, document review and interview, the facility failed to maintain the sprinkler system in accordance with NFPA 25 (1998 edition), as evidenced by an expired 5 year certification tag attached to the main sprinkler riser, a missing sprinkler escutcheon ring, and a leaking valve. This affected 1 of 4 outpatient clinics and 1 of 5 floors at Loma Linda Children's Hospital.

NFPA 101, Life Safety Code (2000) Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
9.7.5 Maintenance and Testing. all automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
9-3.3.2* The valve inspection shall verify that the valves are in the following condition:
(e) Free from external leaks

Findings:

During the facility tour with Dir. FPM, Safety 3 & 4, and Staff 7, on 9/08/15 through 9/11/15, the sprinkler system was observed and sprinkler maintenance records were reviewed.

Outpatient Clinic-Pediatric Specialty Team Center:
1. On 9/8/15, at 2:10 p.m., the five year certification tag on the main sprinkler riser was expired, the tag was dated 7/26/2010.
Between 9/08/15 and 9/11/15, the facility failed to provide current documentation for the five year certification of the sprinkler system located at the Outpatient Pediatric Specialty Team Center. During interview, Dir. FPM stated the sprinkler vendor is schedule to certify the system on 9/12/15.

Loma Linda Children's Hospital, Fourth Floor:
2. On 9/9/15, at 11:22 a.m., the ceiling sprinkler escutcheon ring was missing in room 4410.


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Loma Linda Children's Hospital, Fourth Floor:
3. On 9/9/15, at 11:09 a.m., the Inspector's Test Valve (ITV), located in the Center Stairwell on the 4th Floor, had water leaking from the bottom portion of the valve's handle.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 70, 1999 Edition. This was evidenced by using non tamper resistant receptacles and extension cords in the pediatric areas. This had the potential for increasing the risk of electrical fire and electrical shock that could result in the injury to residents, visitors, and staff. This affected 1 of 2 smoke compartments on the 1st Floor.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition
210-23 Permissible Loads. In no case shall the load exceed the branch-circuit ampere rating. An individual branch circuit shall be permitted to supply any load for which it is rated. A branch circuit supplying two or more outlets or receptacles shall supply only the loads specified in (a) through (d) and as summarized in Section 210-24 and Table 210-24.
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
517-18. General Care Areas.
(c) Pediatric Locations. Fifteen- and 20-ampere, 125-volt receptacles intended to supply patient care areas of pediatric wards, rooms, or areas shall be listed tamper resistant or shall employ a listed tamper resistant cover.

Findings:

During the facility tour with Dir. FPM, Safety 3 & 4, and Staff 7 on 9/08/15 through 9/11/15, the facility electrical wiring and equipment was observed.

Loma Linda Children's Hospital, Fifth Floor:
1. On 9/8/15, at 1:56 p.m., the electrical receptacles in the 5100 pediatric acute care unit were not listed tamper resistant and they did not have listed tamper resistant covers. They included the following pediatric rooms: 5101, 5102, 5103, 5104, 5105, 5106, 5107, 5108, 5110, 5111, 5112.

2. At 2:15 p.m., the electrical receptacles in the 5200 pediatric intenstive care unit were not listed tamper resistant and they did not have listed tamper resistant covers.

3. At 2:41 p.m., the red colored electrical receptacle in Room 5809 was not a listed tamper resistant outlet and it did not have listed tamper resistant cover.

4. At 2:43 p.m., the red colored electrical receptacle in Room 5805 was not a listed tamper resistant outlet and it did not have listed tamper resistant cover.


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Outpatient Clinic-Pediatric Specialty Team Center:
5. On 9/08/15, at 1:53 p.m., there was a power strip plugged into a power strip located inside charting room 52.

Loma Linda Children's Hospital, Fourth Floor:
6. On 9/10/15, at 10:14 a.m., the microwave in room 4719 was plugged into a power strip and not directly into the wall receptacle.

7. At 10:41 a.m., there were two white extension cords plugged into a power strip and the power strip was plugged into another power strip in room 4318.

8. At 11:07 a.m., a power strip was plugged into another power strip in room 4402.

The above findings were acknowledged during the exit conference on 9/17/15 by the Hospital Administration and Staff.