HospitalInspections.org

Based on observation, document review, and interview, the facility failed to meet the Condition of Participation in Physical Environment by failing to:

1. Maintain the physical plant in a manner that assured the safety and well-being of patients (Refer to A 701 and A 710).

2. Ensure the safety of patients and staff when the hospital failed to ensure the Inspector of Record was present during hot works construction(Refer to A 701).

3. Ensure the safety of patients and staff when the hospital failed to have an approved and effective Hot Work policy and procedure(Refer to A 701).

4. Ensure the safety of patients and staff when the hospital failed to ensure relays at the fire alarm air handler shutoff control panel remained installed in place (Refer to A 701).

5. Ensure the safety of patients and staff when the hospital failed to ensure the air system operated continuously and provided balanced air-supply to patient rooms (Refer to A 701).

6. Ensure the safety of patients and staff when the hospital removed self-closing area separation fire doors from the fourth and fifth floors (Refer to A 701).

7. Ensure the safety of patients and staff when the hospital failed to ensure an air handler automatically shut down with the presence of smoke (Refer to A 710 and K 067).

8. Ensure the safety of patients and staff when the hospital failed to ensure that all automatic shutdown devices were tested annually (Refer to A 710 and K 067).

9. Ensure the safety of patients and staff when the hospital used egress corridors as plenums (Refer to A 710 and K 067).

10. Ensure the safety of patients and staff when the hospital failed to ensure electrical power cords were maintained intact (Refer to A 710 and K 147).

11. Ensure 2 of 4 elevators Phase II fire fighter operation were fully functional at all times (Refer to K 051).

The cumulative effect of these systemic issues resulted in the facility's inability to ensure and provide a safe patient care environment.

Based on interview and document review, the hospital failed to assure a safe environment for the patients by not ensuring the IOR (Inspector of Record) was present during hot works construction done on the roof, failing to ensure two relays at the fire alarm air handler shutoff control panel remained installed in place, failing to have an approved and effective Hot Work policy and procedure, failure to provide an air system to operate continuously and provide balanced air-supply to patient rooms for the 2nd, front of 3rd (SDU), 4th, 5th, and 6th floors, removing self-closing area separation fire doors, and failing to ensure privacy curtains were in place.

These deficient practices had the potential to have hot work construction being conducted in an unsafe manner, permitted the accelerated spread of smoke and gases during a fire, discontinued the provision of balanced air-supply to patient rooms on the 2nd, front of 3rd, 4th, 5th, and 6th floors, and affected the patients well-being, dignity and comfort while in the hospital.

Findings:

1. On 2/3/15, a review of an OSHPD (Office of Statewide Health Planning & Development) Fire and Life Safety Field Visit Report dated 2/2/15, indicated that on 1/29/15 a fire occurred as a direct result of the scope of work for the "parapet" reconstruction project. That work being performed when the fire occurred was being performed without the knowledge or the presence of the Inspector of Record (IOR), as well as without an appropriate "Fire Watch."

Review of the Inspector's Daily Report dated 3/4/14 from the IOR for the parapet roof repair project indicated that there was a kick off meeting with the roofing company, Corporate Project Manager, and the Special Inspector for preconstruction meeting. The report indicated that a minimum 48 hours notice was required for inspections.

Review of the hot works permit dated 1/26/15, indicated there would be parapet roof replacement at the roof of the pavilion.

Review of the roofing company's fire watch log sheet dated 1/29/15, at 12 p.m., indicated the torch was started at "top of wing."

Review of the Notice of Non-Conformance dated 1/29/15 (revised 1/30/15), from the IOR for the parapet roof repair project indicated that the contractor failed to notify the IOR that their intent was to perform hot work in order for the IOR to verify that a hot work permit had been obtained and posted in the direct area of work, confirm times allowed for hot work, verify that the interim life safety measures were in place, which included, fire extinguishers and required personnel available for fire watch for the entire duration of the work being performed. That without such notification, IOR was not scheduled to be onsite or aware of the work that needed to be observed. And that the contractor was in violation of CAC (California Administrative Code) Section 7-145.

On 2/5/15 at 1:15 p.m., during an interview, the Director of Plant Operations stated the plant operations did not know the workers on the pavilion roof were going to use a torch. He further stated that when he knows there will be hot works he calls and ensures the IOR is present. Also, he would know if hot works are to be conducted because the vendors/contractors are suppose to notify him or the Lead Man before doing hot work, that usually the vendors/contractors notify the IOR first, and usually the IOR comes and stays the whole time the hot work is conducted. In addition,it was always the procedure for the vendors/contractors to notify plant operations before conducting hot work and that the vendors/contractors know they are suppose to report to plant operations first.


2. On 2/3/15, a review of an OSHPD Fire and Life Safety Field Visit Report dated 2/2/15, indicated that on 1/29/15 a fire appeared to have damaged the HVAC supply air-intake filter banks that apparently supply air to the 2nd, 4th , 5th, and 6th floor patient rooms. That the HVAC system did not automatically shut-down during the fire on 1/29/15 and the smoke from the fire was dispersed from the roof supply intake to other areas and floors of the building.

On 2/4/15 at 11:05 a.m., during an interview, the Lead Man stated that the automatic shut down of the air handlers could be bi-passed by pulling (removing) the relays in the fire alarm air handler shutoff control panel.

On 2/5/15 at 10:10 a.m., during an interview, the Lead Man stated that on the day of the fire (1/29/15), he heard a code red announced from the 3rd floor, that he went to the 3rd floor and saw smoke coming from vents at the 3rd floor, that he went up to the penthouse and saw smoke coming from air handler 2, and saw fire at the door of the air handler, and that he saw the air handler was still on, so he (manually) shut off the air handler.

The Lead Man also stated that the engineers can pull the relays in the fire alarm air handlers control panel if a vendor is scheduled to conduct a fire alarm test and then reconnect them after the test, that it was the practice when he came to the hospital, and its what they (engineering) have continued to do, that the relays have to be pulled, otherwise air conditioning and heating is lost for the whole building and that there was no other reason to pull the relays.

On 2/5/15 at 2:42 p.m., during an interview, the 2nd shift Stationary Engineer stated that on 1/29/15 he had arrived to the hospital at 1:30 p.m., after the fire, and discovered there had been a fire on the roof of the Pavilion. That around 5 p.m. the Lead Man asked asked him to go up to the penthouse to the fire alarm air handlers control panel to check if the relays for air handlers 1 and 2 were installed in place. That upon opening the relay box, he found both relays unplugged and laying at the bottom of the panel at which time he installed them in their place.

The 2nd shift Stationary Engineer, also stated he did not know who pulled the relays, and did not tell anyone that on Thursday (1/29/15) he had found the relays laying in the panel until the Lead Man asked him about it on Wednesday (2/4/15).

On 2/5/15 at 2:45 p.m., during an interview, the Lead Man stated he did not know the relays were unplugged until Wednesday (2/4/15), when he asked the Stationary Engineer. That the last communication he had with the Stationary Engineer was on the day of the fire (1/29/15) and did not try to call the Stationary Engineer between that Thursday (1/29/15) and Wednesday (2/4/15).


3. On 2/3/15, a review of an OSHPD Fire and Life Safety Field Visit Report, dated 2/2/15, indicated that on 1/29/15 a fire occurred as a direct result of the scope of work for the parapet reconstruction project. That work being performed when the fire occurred was being performed without the knowledge or the presence of the IOR (Inspector of Record), as well as without an appropriate "Fire Watch".

Review of the hot works construction permit dated 1/26/15 indicated there would be parapet roof replacement at the roof of the pavilion.

Review of the roofing company's fire watch log sheet dated 1/29/15, at 12 p.m. indicated the torch was started at "top of wing."

Review of the Notice of Non-Conformance dated 1/29/15 (revised 1/30/15) from the IOR for the parapet roof repair project indicated that the contractor failed to notify the Inspector of Record (IOR) that their intent was to perform hot work, in order for the IOR to verify that a hot work permit had been obtained and posted in the direct area of work, confirm times allowed for hot work, verify that the interim life safety measures were in place, which included, fire extinguishers and required personnel available for fire watch for the entire duration of the work being performed.

On 2/5/15 at 1:15 p.m., during an interview, the Corporate Vice President of Plant Operations stated that plant operations did not know the workers on the pavilion roof were using a torch to put down roofing material. Also, the vendor/contractor did not contact plant operations or the IOR.

On 2/5/15 at 1:15 p.m., during an interview, the Director of Plant Operations stated that plant operations did not know the workers on the pavilion roof were going to use a torch. That he would know if hot works are to be conducted because the vendor/contractor are suppose to notify him or the Lead Man before doing hotworks. That it was always the procedure for the vendors to notify plant operations before conducting hot works and that the vendors/contractors know they are suppose to report to plant operations first.

Review of a document provided by the facility as a policy titled Hot Works, indicated there was no date of submittal to the governing body of the document and there was no effective date of the document. The document indicated that the purpose of the document was to maintain current policies and guidelines for Hot Work. The document did not indicate the procedure notifying the IOR when hot work would be performed, and did not indicate the procedure to ensure the facility was aware of hot work being performed.


4. On 2/3/15, a review of an OSHPD Fire and Life Safety Field Visit Report dated 2/2/15, indicated that on 1/29/15 a fire appeared to have damaged the HVAC supply air-intake filter banks that apparently supply air to the 2nd, 4th,5th, and 6th floor patient rooms. That the HVAC system serving these rooms had been shut down pending repairs to the damaged system.

On 2/3/15 at 12:05 p.m., during an interview, the Project Manager stated that one of two air handlers (air handler 2) in the penthouse was affected by the fire, and that air handler 2 affected patient rooms of the 2nd, front 3rd SDU, 4th, 5th, and 6th floors that it served.

On 2/3/15 at 12:35 p.m., the Corporate Vice President of Facilities Operations stated that patient room temperatures were not being monitored and there was no plan if there was a change in temperature due to inclement weather.

At 1:10 p.m., the Corporate Vice President of Facilities Operations stated that plant operations would begin monitoring patient room temperatures immediately.

At 2:10 p.m., the Project Manager stated that scrubbers were placed in the corridors of the affected floors to clean and circulate the air.

Between 4:15 p.m. and 5:20 p.m., HEPA (High Efficiency Particulate Air) filtration systems (air scrubbers) were observed at the 2nd, 3rd, 4th, 5th, and 6th floors.

A letter from the hospital dated 2/3/15 indicated that due to to the fire on 1/29/15, air handler #2 that provides supply air to patient rooms on P2, P3 SDU, P4, P5 and P6 was off line. That air scrubbers were installed on each of the floors to clean and circulate the air. That all patient rooms on the affected floors would be monitored for temperature every four hours, twenty four hours a day to insure ambient temperatures were between the range of 73 and 77 degrees Fahrenheit, and that because there was no temperature control, windows would be open for fresh air ensuring screens were in place and additional blankets were deployed to each affected floor should temperatures cool.

5. On 2/5/15 at 8:52 a.m., in response to a request of the incident report from the local fire department, the Corporate Vice President of Facilities Operations stated that the local fire department would not have the report until two weeks after the date of the incident.

Review of the local fire department report undated Fire Investigation Report regarding the fire incident at the hospital on 1/29/15, indicated in its summary that it was noted at the time of the fire, that self-closing area separation fire doors had been removed from the fourth and fifth floors, and that an OTC (Order to Comply) for replacement of the doors had been issued.

6. On 2/3/15 at 5:07 p.m., 9 patient rooms (210, 211, 212, 214, 216 A, 217 B, 219 B, 220 A, and 221 A) in 2nd floor Telemetry, were observed to be without privacy curtains. There were patients in the beds of the 9 rooms at the time of the observation.

Between 5:07 p.m. and 5:10 p.m., the Director of Environmental Services (EVS) stated that the curtains had been taken down to be sent away to be washed. That the curtains had arrived at 4 p.m., that EVS staff had been downstairs checking that the replacement curtains were not stained, and that the curtains were being hung now.

On 2/5/15 at 10:35 a.m., the Director of EVS stated that on Tuesday (2/3/15), the privacy curtains were taken down because the patients were complaining that the curtains were stained. That she had the Lead EVS take the curtains down and had EVS staff gather the replacement curtains.

Based on observation, interview, and document review, the facility failed to meet the applicable provisions of the Life Safety Code of the National Fire Protection Association (NFPA) including NFPA 70 National Electrical Code 1999 edition, NFPA 90A, Standard for the Installation of Air Conditioning and Ventilating Systems, and NFPA 101 Code for Safety to Life from Fire in Buildings and Structures 2000 Edition, as indicated in tags K 067 and K 147 of the Statement of Deficiencies.

These codes and standards were not met as evidenced by:

Based on observation, interview and document review, the hospital failed to ensure an air handler automatically shut down with the presence of smoke. The hospital failed to ensure that all automatic shutdown devices were tested annually. The hospital used corridors as plenums. The hospital failed to ensure electrical power cords were maintained in tact.

The deficiencies permitted, and had the potential to permit accelerated spread of smoke and gases during a fire, and bypassed the safe use and maintenance of electrical power cords and their safeguards against fire and electric shock.