HospitalInspections.org

Based on observation, interview, and document review, the hospital failed to provide a permanent 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, provide a Construction Final (CF) for the new temporary air handler and fire alarm control panel, and provide self-closing area separation fire doors.

The deficiencies had the potential to permit the spread of smoke and gases during a fire, and not provide a permanent provision of balanced air-supply to patient rooms on the 2nd, front of 3rd, 4th, 5th, and 6th floors.

Findings:

1. On 6/4/15 the evaluator conducted a follow up visit for a complaint validation survey dated 2/5/15, for a fire that occurred on the roof, and at air handler 2 of the pavilion building on 1/29/15, during roofing work. Relays at the air handler control panel had been disconnected, permitting air handlers 1 and 2 to not shut down with the presence of smoke, dispersing smoke from the roof and air handler 2 to other areas and floors of the pavilion.

On 6/4/15 at 10 a.m., during an interview, the VP of Corporate Facilities Operations stated that with the new design of the fire alarm control panel (FACP), if the relays are disconnected, air handler 1, and the replacement for air handler 2, when installed, will shut down and activate an alarm at the FACP.

At 10:38 a.m., there was a new temporary air handler, and new ducting on the roof of the pavilion building. There was a work crew on the roof, a hot works permit #5218589 dated 6/2/15 with an expiration date of 6/5/15 at 4 p.m., for roofing patch back was posted on the air duct frame, and a fire watch was being conducted at the work site.

During an interview at the same time as the observation, the VP of Corporate Facilities Operations stated that the air handler was temporary and could not be used as the permanent because it did not meet the seismic requirements of a permanent air handler, but that the new air ducting the temporary air handler was connected to was the new permanent ducting.

At 10:50 a.m., during an interview, the Fire Alarm System Vendor/Technician present on site, stated that both relays at the air handler control panel are now wired fail safe so that if the relays are disconnected, air handler 1, and the replacement for air handler 2, when installed, will shut down and activate a visual and audible alarm at the FACP and annunciator panels located at the basement and lobby of the pavilion building, and PBX of the tower building. The Fire Alarm System Vendor/Technician also stated that the temporary air handler does not shut down when the relays are disconnected because that air handler is not controlled by the relays, but that the temporary air handler will shut down with the activation of any smoke detector in the building, and that once installed the permanent air handler replacing air handler 2 will be controlled by the relays, and will also shut down when the relays are disconnected.

During an observation at the same time as the interview, engineering staff demonstrated the shutting down of air handler 1 by disconnecting a relay from the air handler control panel.

At 1:25 p.m., during document review, there was an Office of Statewide Health Planning and Development (OSHPD) permit, and Certificate of Occupancy (CO) from the OSHPD Fire Life Safety Officer (FLSO) dated 5/28/15, but there was no Construction Final (CF) for the new temporary air handler. There was no documented evidence of submitted architect drawings, OSHPD permit, contracts, and completion timeline for the installation of the permanent air handler replacing air handler 2. There was an OSHPD Verified Compliance Report (VR) dated 6/3/15 for the replacement of the FACP, but there was no acceptance test and CF for the new FACP.

During an interview at the same time as the document review, the VP of Corporate Facilities Operations stated that there was not a CF for the new FACP because the hospital is waiting for the OSHPD FLSO for the CF.

On 6/9/15, a copy of an OSHPD FLSO Field Visit (FV) dated 6/8/15, was provided by the VP of Corporate Facilities Operations, that indicated the FACP project was 80% complete, that with the exception of minor "punch-list" items the scope of work had been inspected and accepted by the Inspector of Record (IOR) and is ready for the required acceptance testing with the Authority Having Jurisdiction (AHJ) or OSHPD. That the OSHPD Fire Marshall has agreed to accept any testing that has been witnessed and accepted by personnel from the Culver City Fire Department in lieu of testing with the OSHPD Fire Marshall.

2. On 6/4/15 the evaluator conducted a follow up visit for a complaint validation survey dated 2/5/15. As a result of the complaint validation survey dated 2/5/15 it was revealed through review of the local fire departments undated Fire Investigation Report regarding a fire incident at the hospital on 1/29/15, 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.

On 6/4/15 at 11:29 a.m., on the 5th floor, the VP of Corporate Facilities Operations identified a cross corridor door frame near room 533 as one of the areas where the doors were missing. There were no cross corridor doors within the door frame.

During an interview at the same time as the observation, the VP of Corporate Facilities Operations stated that construction on the fire doors should start in 3 weeks (6/25/15) and be completed by 7/6/15.

At 11:42 a.m., on the 5th floor, the VP of Corporate Facilities Operations identified a cross corridor door frame near room 523 as one of the areas where the doors were missing. There were no cross corridor doors within the door frame.

Between 11:42 a.m. and 12:07 p.m., on the 4th floor, the VP of Corporate Facilities Operations identified a cross corridor door frame near room 423 as one of the areas where the doors were missing. There were no cross corridor doors within the door frame.

During document review, there was an application to OSHPD for the installation of cross-corridor doors at the second, third, fourth and fifth floors. Review of a Gantt chart for the installation of the doors indicated the installation of the doors would start on 6/18/15 on the 2nd floor, 6/29/15 on the 4th floor, and 7/2/15 on the 5th floor, and would finish on 6/18/15 on the 2nd floor, 7/1/15 on the 4th floor, and 7/6/15 on the 5th floor, with OSHPD final approvals between 7/7/15 and 7/13/15.

On 6/5/15, a copy of purchase order for 6 doors and 3 frames, dated 6/5/15, was provided by the VP of Corporate Facilities Operations.

Based on observation, and interview, the hospital staff failed to ensure the hospital was maintained to ensure an acceptable level of safety for patients, staff and visitors, by having a water leak at the ceiling of a nurses' station.

The deficiency had the potential for the water with contaminants within it, from running through the area between the roof and the 6th floor ceiling, to act as a conductor of electricity, and the electrical wires and/or box touched by the water from the leak had the potential for electrical short, arcs and other failures.

Findings:

On 6/4/15 at 11:19 a.m., at the 6th floor nurses' station there was water leaking from above the drop down suspended ceiling into a receptacle below. Closer observation revealed the water was dripping from an electrical box containing wires that was connected to an electrical conduit.

During an interview at the same time as the observation, the VP of Corporate Facilities Operations stated that the leak originated at the roof from a steam line for a boiler, and that it would be repaired in the afternoon.

During another interview also at the same time as the observation, the Director of Facilities stated that the leak was discovered that morning.