HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the facility's walls that could result in the spread of fire and smoke. This had the potential for injury to patients and staff with burns and/or smoke inhalation in the event of a fire. This affected 1 of 4 floors at Thornton Hospital.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the facility's walls and ceilings were observed.

Second Floor - Thornton Hospital - 3/6/13

At 8:36 a.m., there were 2 penetrations on the wall to Patient Room 208 (#2-445). Each penetration measured approximately 1/2-inch diameter.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor walls as evidenced by penetrations on corridor walls. 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 4 floors at Thornton Hospital.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the corridor walls were observed.

Second Floor - Thornton Hospital - 3/6/13

At 9:53 a.m., there was a penetration on the corridor wall in Corridor 2-C03. The penetration was observed above the drop down ceiling above the door entrance into Corridor 2-116. The penetration surrounded a conduit and it measured approximately 1/2-inch diameter. The building's floor plans identified the wall rating to be 1 hour.

Based on observation, the facility failed to maintain their doors, as evidenced by doors that failed to close and latch, and doors held open by a wedge. This could result in the rapid spread of smoke and fire. This affected 2 of 12 floors of the Main Hospital at Hillcrest and 1 of 2 floors of the West Wing at Hillcrest.

Findings:

During a facility tour with the hospital staff from 3/5/13 to 3/12/13, the doors were observed.

Basement - Main Hospital at Hillcrest - 3/8/13

1. At 8:34 a.m., the door to the Occupational Physical and Speech Therapy Room, Door 1-411, released from its magnetic hold-open device upon activation of the fire alarm system. The door failed to close and latch leaving an approximately 1 inch gap between the door and door frame.

Second Floor - Main Hospital at Hillcrest - 3/8/13

2. At 9:19 a.m., the door to the SICU Storage Room, Door 1-411, released from its magnetic hold-open device upon activation of the fire alarm system. The door closed but failed to latch.



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First Floor - Behavioral Unit, West Wing at Hillcrest - 3/5/13

3. At 2:15 p.m., the corridor door was held open with a plastic wedge positioned under door leaf. Interview with the Head Nurse, she stated the door needs to stay open, so staff can monitor the patients effectively. The door was rated 20 minutes per label.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by unsealed conduits going through the floors. This could result in the spread of smoke and fire from one floor to the other, in the event of a fire. This affected 2 of 3 floors of the Hyperbaric Medicine & Wound Healing Center in Encinitas.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the vertical openings were observed.

Second Floor - Hyperbaric Medicine & Wound Healing Center in Encinitas - 3/8/13

At 1:26 p.m., there were five conduits penetrating the ceiling in the room containing the Fire Control Panel. The conduits did not have fire stop to seal the opening within the tube that measured approximately 2-inches each.

Based on observation and interview, the facility failed to maintain their vertical openings. This was evidenced by unsealed conduits penetrating floors. This could result in the spread of smoke and fire from one floor to the other, in the event of a fire. This affected 4 of 12 floors of the Main Hospital at Hillcrest.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the vertical openings were observed.

Tenth Floor - Main Hospital at Hillcrest - 3/6/13

1. At 10:21 a.m., there was an approximately 4 inch conduit, with an approximately 1 inch bundle of wires going through, in the ceiling of IT Closet 10-257. The conduit was not sealed around the bundle of wires.

During an interview at 10:22 a.m., Engineering Staff 96 stated that the conduit penetrates the eleventh floor.


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First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 2:25 p.m., there were four conduits penetrating the ceiling in Room 1-335B. The conduits did not have fire stop to seal the opening within the tube. The tube had a bundle of cables running through it and the unsealed opening measured approximately 3-inches.

3. At 2:30 p.m., there were two conduits penetrating the ceiling in Room 1-335A. The conduits did not have fire stop to seal the opening within the tube. The unsealed opening measured approximately 3-inches.

4. At 2:37 p.m., there was a penetration on the ceiling in the Telecom Room 1-529. The opening had a bundle of cables running through it and it measured approximately 3-inches.

Based on observation and interview, the facility failed to maintain their smoke barrier doors. This was evidenced by smoke barrier doors that failed to release from hold-open devices and automatically close upon activation of the fire alarm system. This could result in the spread of smoke and fire, in the event of a fire. This affected 1 of 12 floors of the Main Hospital at Hillcrest.

Findings:

During a facility tour with the Engineering Staff on 3/8/13, the smoke barrier doors were observed.

Second Floor - Main Hospital at Hillcrest - 3/8/13

At 9:31 a.m., the two smoke barrier doors into the OR and one smoke barrier door into PACU were held open by electronic hold-open devices. The doors failed to close upon activation of the fire alarm system and remained open to their fullest extent.

During an interview at 9:32 a.m., Engineering Staff 96 stated that the hold-open devices are designed to close the identified doors upon activation of the fire alarm system.

Based on observation, the facility failed to maintain exit signs. This was evidenced by an exit sign that did not clearly identify the exit that was not readily apparent. This could potentially delay evacuation during a fire and result in injury to patients, visitors, and staff. This affected 1 of 3 floors of the Hyperbaric Medicine & Wound Healing Center in Encinitas.

NFPA 101, Life Safety Code, 2000 Edition
7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the exits and exit signs were observed.

Second Floor - Hyperbaric Medicine & Wound Healing Center - 3/8/13

At 1:15 p.m., the signage installed in the 2nd floor corridor by the door to Stairwell-2 read "stair 2 emergency down" and the door did not lead to the exit discharge. The pathway to the exit discharge was through a door adjacently located from the door to Stairwell-2.

Based on observation, the facility failed to maintain smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, potentially harming patients, visitors, and staff. This affected 1 of 4 floors at Thornton Hospital and 1 of 2 floors of the West Wing at Hillcrest.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the smoke barrier walls were observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 9:20 a.m., the smoke barrier wall in Corridor 2-C50, had a penetration on the wall. The penetration was observed above the drop down ceiling above the door entrance into the Pre-Op Area Suite 2-034. The penetration measured approximately 2-inches by 3-inches. The building's floor plans identified the wall rating to be 1 hour.

2. At 9:27 a.m., the smoke barrier wall in Corridor 2-C50, had a penetration on the wall. The penetration was observed above the drop down ceiling by Room 2-030. There was a pipe sleeve that penetrated the wall with no fire stop material within the pipe that measured approximately 1/2-inch. The building's floor plans identified the wall rating to be 1 hour.


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First Floor - Behavioral Unit, West Wing at Hillcrest - 3/5/13

3. At 2:10 p.m., the two hour fire wall had multiple penetrations ranging in sizes approximately 1/2-inch to 1-inch circular penetrations and a 4-inch square penetrations.

4. At 2:12 p.m., the smoke barrier wall to the Behavioral Unit had approximately 8 by 16 inches sheet-rack opening and another 1/2-inch penetration in the smoke barrier wall.

Based on observation, the facility failed to maintain smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, potentially harming patients, visitors, and staff. This affected 1 of 4 floors of the Sulpizio Cardiovascular Center.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the smoke barrier walls were observed.

Second Floor - Sulpizio Cardiovascular Center - 3/5/13

At 2:04 p.m., the smoke barrier wall located by the entrance into the Procedure and Treatment Unit had penetrations on the wall. The penetrations were observed from the corridor in the inter space above the ceiling by Patient Room 1. The penetrations were found inside conduits with no fire stop.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by smoke barrier doors that failed to latch. This finding could result in the spread of smoke from one smoke compartment to another and increase the risk of injury to patients and staff, in the event of a fire. This affected 1 of 3 floors at the Moores Cancer Center.

Findings:

During the facility tour with engineering staff from 3/5/13 to 3/11/13, the smoke barrier doors were observed.

First Floor - Moores Cancer Center - 3/8/13

1. At 2:58 p.m., the smoke barrier double doors by pharmacy and Infusion failed to latch upon activation of the fire alarm system.

2. At 3:01 p.m., the smoke barrier double doors by Imagining failed to close and latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke. This was evidenced by rolling doors that were obstructed from closing and cross corridor doors that failed to positive latch upon activation of the fire alarm system. 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 1 of 4 floors at Thornton Hospital, 3 of 12 floors of the Main Hospital at Hillcrest, 1 of 4 floors of the South Wing at Hillcrest, 1 of 5 floors of the Medical Office North at Hillcrest, and 1 of 3 floors at the Shiley Eye Center.

NFPA 101, Life Safety Code, 2000 Edition
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.

Findings:

During a facility tour with the Engineering Staff on 3/5/13 to 3/12/13, the fire doors were observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 9:10 a.m., the rolling door that opened into the corridor from Room 2-028 had items obstructing the pathway of the door. The items included a box of gloves, cariwipes, and a spray bottle.

First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 1:55 p.m., the rolling door #021675 that opened into the waiting area of the Emergency Department had items obstructing the pathway of the door. The items included two basin trays.

Second Floor - Main Hospital at Hillcrest - 3/8/13

3. At 9:33 a.m., 1 of 2 cross-corridor fire doors, located by Room 2-115, failed to close and positive latch upon activation of the fire alarm system. The door was held open by an electronic hold-open device.


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Basement - Main Hospital at Hillcrest - 3/8/13

4. At 8:41 a.m., the smoke barrier doors by Radiology classroom failed to latch upon activation of the fire alarm system.

First Floor- Main Hospital at Hillcrest - 3/8/13

5. At 8:59 a.m., smoke barrier doors to the cafeteria/ kitchen held open with the electronic automatic closing devices failed to latch upon activation of the fire alarm system.

First Floor - South Wing at Hillcrest - 3/8/13

6. At 9:08 a.m., the gift shop smoke barrier doors were held open with the electronic automatic closing device. One leaf failed to release and close upon activation of the fire alarm system.

7. At 9:11 a.m., double doors, by admission desk in lobby area, held open with the electronic automatic closing device failed to close and latch upon activation of the fire alarm system.

Second Floor - Medical Office North (MON) at Hillcrest - 3/8/13

8. At 9:23 a.m., the smoke barrier doors by Cardiac Cath Laboratory failed to latch.

Third Floor - Shiley Eye Center - 3/11/13

9. At 11:59 a.m., the smoke barrier doors by Room 337 and soiled utility room failed to latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain its hazardous areas as evidenced by penetrations on walls to rooms identified as hazardous areas. This had the potential to allow the spread of smoke and fire, resulting in injury to patients, visitors and staff. This affected 1 of 3 floors at the Shiley Eye Center.

Findings:

During a facility tour with hospital staff on 3/5/13 to 3/12/13, hazardous areas were observed.

Third Floor - Shiley Eye Center- 3/11/13

At 11:56 a.m., the walls and ceiling in the room containing the hot water heater had multiple penetrations that measured approximately 1/2-inch each. Three penetrations were observed around conduits going through the ceilings and three penetrations on the wall.

Based on observation, the facility failed to maintain stairways used as exits. This was evidenced by multiple items being stored underneath the stairwell and a stairway with a missing signage. This had the potential for interfering with egress during a fire emergency and delay evacuating patients, staff, and visitors. This affected 3 of 3 floors at the Shiley Eye Center and 1 of 12 floors of the Main Hospital at Hillcrest .

NFPA 101, Life Safety Code, 2000 Edition
7.2.2.5.3 Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

7.2.2.5.4 Stair Identification Signs. Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the stairwells were observed.

First Floor - Shiley Eye Center - 3/11/13

1. At 11:41 a.m., Stairwell-2 had several items stored underneath the stairs on the 1st Floor. These items included wheeled stands, chairs, and boxes.


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Eleventh Floor - Main Hospital at Hillcrest - 3/6/13

2. At 9:11 a.m., there was no sign in the Link Stairwell identifying the Eleventh Floor and indicating that the exit discharge was on the First Floor.

Based on observation, the facility failed to ensure that exits were readily accessible. This was evidenced obstructions found in the pathway leading to the public way from an exit door. This had the potential to delay egress in the event of a fire, resulting in injury to visitors and staff. This affected 1 of 4 floors at Thornton Hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the exits, exit access, and exit discharges were observed.

Basement - Thornton Hospital- 3/6/13

At 1:13 p.m., the exit door from the mechanical room L-311 had multiple linen carts obstructing the pathway leading to the public way. The linen carts were found throughout the the soiled dock L-C15 and the way to reach the exit was not evident. A staff member working in the dock stated that they typically only clear the area from carts during surveys.

Based on record review, observation, and interview, the facility failed to maintain their battery-powered emergency lights and exit signs. This was evidenced by incomplete documentation for testing the emergency lights and no documentation for testing the exit signs. This could result in the failure of the emergency lights in anesthetizing locations and other areas of the hospital, in the event of a power outage. This affected 12 of 12 floors of the Main Hospital at Hillcrest, 4 of 4 floors at Thornton Hospital, and the MRI Outpatient Services at Hillcrest .

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.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

NFPA 99, 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).

Findings:

During record review from 3/5/13 to 3/12/13, records for testing the battery-powered emergency lights and the battery-powered exit signs were requested and were reviewed.

Main Hospital at Hillcrest - 3/5/13

1. At 3:49 p.m., records for annual 90-minute testing of emergency lights in OR 1 to OR 9, on 10/19/12, were provided. There were no records for monthly testing of the lights and no records for testing the emergency lights in two of two Labor and Delivery rooms.
During an interview at 3:50 p.m., Engineering Staff 101 stated that there were no other records for testing emergency lights.

Main Hospital at Hillcrest - 3/6/13

2. During an interview at 11:00 a.m., Engineering Staff 96 and Engineering Staff 101 stated that the battery-powered exit signs throughout the facility were also backed up by the generator. They stated that there were no records for testing the battery-powered exit signs that were observed on every floor.

Second Floor - Main Hospital at Hillcrest - 3/7/13

3. At 1:52 p.m., battery back-up emergency lights were observed in the SICU and in the laboratories. There were no records provided for testing these lights.

First Floor - Main Hospital at Hillcrest - 3/7/13

4. At 3:37 p.m., battery back-up emergency lights were observed in the kitchen dry storage room. There were no records provided for testing these lights.

Seventh Floor - Main Hospital at Hillcrest - 3/8/13

5. At 10:01 a.m., all the light fixtures at the Senior Behavioral Health Department were equipped with red test buttons. During an interview at 10:02 a.m., Engineering Staff 96 stated that the buttons indicated that the lights were equipped with battery back-up. There were no records for testing these lights.




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First and Second Floor - Thornton Hospital - 3/6/13

6. At 10:16 a.m., the battery powered emergency lighting unit installed in Stairwell 3, between the 1st and 2nd floor, failed to illuminate when tested with the test button.

First Floor - Main Hospital at Hillcrest - 3/7/13

7. At 2:40 p.m., the two battery powered emergency lights installed in the Cath Lab, Room 1-531, failed to illuminate when tested with the test buttons. During an interview with Safety Staff 93, he confirmed that they failed to maintain the batteries to the emergency lights.

Thornton Hospital - 3/7/13

8. At 11:57 a.m., the records for the annual 90-minute testing of emergency lights were provided for battery powered emergency lights installed throughout the facility. Engineering Staff 95 stated that they only check the battery powered emergency lights semi-annually because it is too labor-intensive to be checking them every 30 days.


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MRI Outpatient Services at Hillcrest - 3/6/13

9. At 9:04 a.m., the record showed facility failed to perform the 90 minutes annual test for the battery powered emergency lights (bug lights). Interview with Safety Staff 93 stated facility failed to do 90 minutes annual test for the bugs lights in the MRI buildings and other departments of the Hospitals such as Basement of the Main Building Hillcrest.

Based on observation, the facility failed to maintain exit signs to continuously illuminate. This was evidenced by exit signs installed that did not illuminate. This could potentially delay evacuation in the event of a power outage and an emergency evacuation. This affected 1 of 4 floors at Thornton Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the exit signs were observed.

Third Floor - Thornton Hospital - 3/5/13

At 3:47 p.m., the exit sign installed by the exit door next to Patient Room 307 (#3-247), failed to illuminate.

Based on observation and interview, the facility failed to instruct their staff on their role to protect their patients, in the event of an emergency. This was evidenced by the staff's lack of familiarity with the dedicated patient audio/strobe fire alarm device located at the nurse's station. This could result in delay of notification of the location of the fire and possible harm to patients and staff, in the event of a fire. This affected 1 of 4 floors of the Sulpizio Cardiovascular Center.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During the facility tour with the Engineering Staff on 3/5/13 through 3/11/13, the facility fire alarm system was tested and staff were interviewed to determine their knowledge of the patient room audio alarm devices at the nurse's station.

Third Floor - Sulpizio Cardiovascular Center - 3/11/13

At 9:13 a.m., a smoke detector in a patient room 302 was activated. The audio/strobe device at the nurse's station alarmed with a distinct sound. At 9:15 a.m., 7 of 7 staff interviewed could not recall ever hearing or seeing the patient room audio/strobe alarm that was activated. Staff stated that they did not receive any training and were not given information on their unit being equipped with a dedicated patient room audio/strobe system.

Based on staff interviews and record review, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire and the facility failed to ensure that the fire alarm system is activated during fire drills conducted between 6 a.m. to 9 p.m. This had the potential for staff members to not properly respond to a fire that could result in harm to patients, staff, and visitors. This affected 12 of 12 floors of the Main Hospital at Hillcrest and 1 of 4 floors at Thornton Hospital.


NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility with the Engineering Staff from 3/5/13 to 3/12/13, facility staffs were interviewed to determine their knowledge of their fire emergency procedures and the usage of life safety equipments, and the fire drill records were reviewed.

Second Floor - Thornton Hospital - 3/11/13

At 10:36 a.m., the custodial staff was asked how she would respond to a fire in her working area. The staff member could not describe how to transmit a fire alarm signal by activating the closest manual fire alarm box.


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Main Hospital at Hillcrest - 3/5/13

At 1:24 p.m., the records for two fire drills conducted on 5/17/12, at 12:45 p.m. during the AM shift and at 4 p.m. during the PM shift, indicated that the fire alarm system was not activated during the drills.

Based on observation and record review, the facility failed to ensure that the fire alarm system was properly maintained. This was evidenced by a manual pull station installed with no tool to remove its protective glass cover, an initiating device that did not immediately alarm throughout the building after activation, fire alarms not heard throughout the entire building, audible/visual devices that failed to function, and no smoke or heat detection device installed in rooms containing fire alarm panels . This had the potential for occupants to not be alerted of a fire, resulting in harm to patients, visitors and staff. This affected 1 of 12 floors of the Main Hospital, 2 of 4 floors at Thornton Hospital, 1 of 2 floors of the West Wing, 1 of 5 floors of the Medical Office North, and 1 of 4 floors of the South Wing.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.2.2 Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device.
Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit (s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Findings:

During a tour of the facility with the Engineering Staff from 3/5/13 to 3/12/13, the fire alarm system was tested and documents for the system were reviewed.

Third Floor - Thornton Hospital - 3/5/13

1. At 4:12 p.m., the manual fire alarm pull station installed in the Elevator Lobby 3-C08 had a glass cover with no tool readily available to break the glass.

Basement - Medical Office North (MON) at Hillcrest - 3/8/13

2. At 8:42 a.m., the fire alarm pull station M3-29 that was installed by the stairwell in the MON (also known as OPC) did not actuate throughout the building for more than 20 seconds.

Basement - Thornton Hospital - 3/11/13

3. At 10:17 a.m., a smoke detector was activated in the basement's corridor. The fire alarm could not be heard in the clean linen storage room L-120 while the radio was on. No audible and no visual fire alarm devices where observed in the room.


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First Floor - Main Hospital at Hillcrest - 3/8/13

4. At 8:54 a.m., there were combination audible/visual fire alarm notification devices in the Emergency Department. The strobe on the device in the corridor outside ED Room 1-417, and the chime on the device in the corridor outside ED Bathroom 1-448, failed to activate during fire alarm testing.

First Floor - West Wing at Hillcrest - 3/8/13

5. At 8:54 a.m., there were combination audible/visual fire alarm notification devices in the Psychiatric Unit. The strobe and chime on the device in the corridor outside Room 1 failed to activate during fire alarm testing.


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Basement - Medical Office North (MON) at Hillcrest - 3/5/13

6. At 3:24 p.m., the fire alarm panel (sub panel) was mounted in the telecom room OPC0-01. The room was not equipped with a smoke detector.

Second Floor - South Wing at Hillcrest - 3/7/13

7. At 9:50 a.m., the fire alarm panel (sub panel) was mounted in the tele-com room 2-205. The room was not equipped with a smoke detector.

Based on observation, the facility failed to ensure that their manual fire alarm pull stations were easily accessible to allow for quick activation of fire alarm. This was evidenced by manual fire alarm pull stations and Argon System abort switches that were obstructed from view, batteries in fire control panel exceeding their replacement period, and unlabeled dedicated devices. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff. This affected 4 of 4 floors of the Sulpizio Cardiovascular Center, 3 of 3 floors of the Hyperbaric Medicine & Wound Healing Center in Encinitas, and 1 of 3 floors at the Moores Cancer Center.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72, National Fire Alarm Code, 1999 Edition
Table 7-3.2 Testing Frequencies
6. Batteries - Fire Alarm Systems d. Sealed Lead-Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the the fire alarm system was observed.

Fourth Floor - Sulpizio Cardiovascular Center - 3/5/13

1. At 11:58 a.m., the abort switches for the Argon System located in the Data Center was obstructed by multiple boxes placed in front of them.

Second Floor - Sulpizio Cardiovascular Center - 3/5/13

2. At 2:20 p.m., the two sealed lead-acid batteries for Fire Control Panels 2A and 2B were not dated.

First Floor - Sulpizio Cardiovascular Center - 3/5/13

3. At 2:55 p.m., there were two manual fire alarm pull stations by the door entrance into the main lobby that were obstructed by potted plants. The fire alarm pull stations were not visible.

Second Floor - Hyperbaric Medicine & Wound Healing Center - 3/8/13

4. At 1:24 p.m., the two sealed lead-acid batteries for the Fire Control Panel were dated 5/2007, exceeding their 4 year replacement period.

Third Floor - Sulpizio Cardiovascular Center - 3/11/13

5. At 9:13 a.m., the dedicated strobe light with chime device installed by the nurses station was not labeled to identify the areas affected when the alarm activates. Nursing staff did not know that the alarm was due to a smoke detector activated in a room located by the nurses station.


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First Floor- Moores Cancer Center - 3/8/13

6. At 2:25 p.m., a pull station was blocked by the newly construction security cubicle in the lobby area.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by a smoke detector that was covered with plastic, a smoke detector hanging from the ceiling, and smoke detectors with no record of sensitivity testing. This could result in a delay in notification during a fire. This affected 2 of 12 floors of the Main Hospital, 4 of 4 floors of the Medical Office South, and the MRI Outpatient Services at Hillcrest.

Findings:

During a facility tour from 3/5/13 to 3/8/13, the smoke detectors were observed.

Seventh Floor - Main Hospital at Hillcrest - 3/6/13

1. At 2:04 p.m., the smoke detector in Room 707B, in the Senior Behavioral Health Department, was entirely obstructed by an orange plastic cover. During an interview at 2:05 p.m., Engineering Staff 101 stated there were repairs done in the area approximately one week before.

Second Floor - Main Hospital at Hillcrest - 3/7/13

2. At 10:30 a.m., the smoke detector in Operating Room 9 was hanging by its electrical wires approximately 2 inches from the ceiling.


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Medical Office South (MOS) at Hillcrest - 3/5/13

3. At 3:50 p.m., the were no recorded documents of smoke detectors sensitivity test for 147 of 147 smoke detectors.

MRI Outpatient Services at Hillcrest - 3/5/13

4. At 3:54 p.m., the were no recorded documents of smoke detectors sensitivity test for 26 of 26 smoke detectors.

During an interview with the Engineering staff 95 on 3/12/13, at 9:35 a.m., he stated that his understanding of the regulations was that smoke detectors that are old and cannot be tested for sensitivity do not need to be tested for sensitivity. The smoke detectors were more than 10 years old and the facility failed to show documentation of sensitivity or nuisance alarms.

Based on document review and observation, the facility failed to maintain their sprinkler tamper alarm. This was evidenced by a Post Indicator Valve (PIV) tamper switch and an Outside Stem & Yoke (OS&Y) tamper switch that did not report to the central monitoring station. This had the potential to have a delayed response to the tampering of the sprinkler system, increasing the risk of injury to patients, visitors and staff. This affected 12 of 12 floors of the Main Hospital and the MRI Outpatient Services at Hillcrest.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .
3-8.3.3.1.3 Signals shall distinctively indicate the particular function (e.g., valve position, temperature, or pressure) of the system that is off-normal and also indicate its restoration to normal.
3-8.3.4.2 The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the fire sprinkler system was tested and documents were reviewed.

Main Hospital at Hillcrest - 3/8/13

1. At 10:54 a.m., the PIV, labeled "200 West Arbor," tamper alarm was tested by turning the valve handle for more than three revolutions. No signal was received at the fire control panel and no signal was received at the central monitoring station.


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MRI Outpatient Services at Hillcrest - 3/6/13

2. At 9:53 a.m., the OS&Y valve failed to send a supervisor signal to the Private Branch Exchange (PBX), the facility's central monitoring.

Based on document review and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by an Inspectors Test Valve (ITV) that failed to report to the central monitoring station. This could result in the failure of notifying the fire department in the event that the sprinkler system activates during a fire. This deficient practice affected all staff and patients in the Hyperbaric Medicine & Wound Healing Center.

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.
5-2.6.1.5.1 Test signals initiated by the subscriber, including those for the benefit of an authority having jurisdiction, shall be acknowledged by central station personnel whenever the subscriber or authority inquires.
5-2.6.1.5.2 Any test signal not received by the central station shall be investigated immediately and action shall be taken to reestablish system integrity.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the sprinkler system devices were observed and the records for the system were reviewed.

Hyperbaric Medicine & Wound Healing Center in Encinitas - 3/8/13

At 1:52 p.m., the ITV was tested and an alarm activated within 28 seconds. The event history report was not immdediately available to review. When the event history report from the central monitoring company was reviewed, it did not show that an alarm was received during the time the ITV device was tested. All other devices tested were listed in the central monitoring company's event history report.

Based on observation and record review, the facility failed to maintain their automatic sprinkler system. This was evidenced by incomplete testing of the waterflow alarms, by missing escutcheon rings, paint or debris on sprinkler heads, 18-inches clearance not maintained from deflectors of sprinklers, and failure to provide sprinkler head. This could result in a delay in extinguishing a fire. This affected 12 of 12 floors of the Main Hospital at Hillcrest, 3 of 4 floors at Thornton Hospital, 2 of 2 floors of the West Wing, 2 of 5 floors of the Medical Office North (MON), and 1 of 4 floors of the South Wing.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.6. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During a facility tour with Engineering Staff from 3/5/13 to 3/12/13, the automatic sprinkler system was observed and inspection documents were requested.

Main Hospital at Hillcrest - 3/5/13

1. At 1:55 p.m., documentation provided for testing of the sprinkler system on 10/19/12 by an outside vendor listed all the tamper switches were tested. The document did not indicate that any of the waterflow alarms were tested during that quarter.

First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 3:36 p.m., two of four sprinkler heads in Walk-in Freezer 1 were missing escutcheon rings.


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Second Floor - Thornton Hospital - 3/6/13

3. At 8:42 a.m., a sprinkler head in the pantry by Patient Room 219 was missing its escutcheon ring.

4. At 8:54 a.m., the sprinkler head in Patient Room 255 had heavy accumulation of dust and debris.

First Floor - Thornton Hospital - 3/6/13

5. At 11:03 a.m., the sprinkler head in the electric room, located by the entrance into the Radiology Department from the waiting area, had paint on its deflector.

Basement - Thornton Hospital - 3/6/13

6. At 1:35 p.m., a sprinkler head in the Pharmacy Room L-206 was missing its escutcheon ring.

7. At 1:36 p.m., a sprinkler head in the Central Supply L-011 was missing its escutcheon ring.

8. At 1:50 p.m., the sprinkler heads in the Storage Room L-101 had multiple boxes stored less than 18-inches from the spray pattern of the sprinkler heads.

First Floor - Main Hospital at Hillcrest - 3/7/13

9. At 2:10 p.m., there was no sprinkler head in the closet, Room 1-405. Engineering Staff 96 stated that the closet space was part of the ED project remodel.

10. At 2:12 p.m., a sprinkler head in the corridor by Room 1-405 was missing its escutcheon ring.

11. At 2:50 p.m., a sprinkler head in the Radiology Reading Room 1-610 was missing its escutcheon ring.


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First Floor - West Wing at Hillcrest - 3/5/13

12. At 1:30 p.m., room 446 (storage room) had paint or plaster on the sprinkler head.

Basement - West Wing at Hillcrest - 3/5/13

13. At 2: 35 p.m., in room 446 A, the sprinkler escutcheon ring was removed from around the sprinkler and the opening extended. The extended opening had data cords running through it.

Second Floor - Cardiac Catheterization Suite in MON at Hillcrest - 3/7/13

14. At 8:30 a.m.,boxes of supplies on the top shelf blocked three sprinklers head. The boxes were position approximately 14-inches from the sprinklers

Third Floor - Ortho Suite in MON at Hillcrest - 3/7/13

15. At 9:30 a.m., one of two storage closet was not equipped with a sprinkler head. The room measured 12 square feet. The rest of the suite was sprinklered except for that storage room in the egress path of the suite. Interview with Safety Staff 93, he had no knowledge if the closet was a new addition.

Third Floor - South Wing at Hillcrest - 3/7/13

16. At 9:41 a.m., the insulation surround the supply air duct was on the sprinkler pipe in the Mechanical Room 3-307 A.

Basement - Main Hospital at Hillcrest - 3/7/13

17. At 2:50 p.m., the clean linen room, B-436 A, the sprinkler had the wrong type of escutcheon plate.

Based on observation, the facility failed to maintain portable fire extinguishers readily accessible. This was evidenced by a fire extinguishers that were obscured from view and were obstructed and not accessible to allow for the quick response to a fire. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors, and staff. This affected 2 of 4 floors at Thornton Hospital and 1 of 3 floors at the Shiley Eye Center.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
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.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a facility tour from 3/5/13 to 3/8/13, the fire extinguishers were observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 8:58 a.m., the fire extinguisher in Room 2-C31 was obstructed from being readily accessible.

2. At 9:06 a.m., the fire extinguisher in the PACU Room 2-050 was obstructed from being readily accessible.

First Floor - Thornton Hospital - 3/6/13

3. At 10:47 a.m., the k-type fire extinguisher in the kitchen Room 1-309 was obscured from view by a sink. A kitchen staff was asked to locate the closest k-type fire extinguisher and walked past it when trying to locate one. There was no signage pointing to the mounted fire extinguisher.

Third Floor - Shiley Eye Center- 3/11/13

4. At 12:09 a.m., the fire extinguisher in the OR by Room 315 was obstructed by a wheeled cart and was not readily accessible.

Based on record review and interview, the facility failed to maintain their dampers. This was evidenced by no records for testing two dampers. This could result in the spread of smoke and fire, in the event of a fire. This affected 2 of 12 floors in the Main Hospital at Hillcrest.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Center for Medicare and Medicaid Services S&C-10-04-LSC, dated October 30 2009, states: "After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of 6 years rather than 4 years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital ' s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The 6-year testing interval shall commence on the date of the last documented damper test."

Findings:

During record review on 3/5/13, records for damper testing were requested.

Main Hospital at Hillcrest - 3/5/13

1. At 2:36 p.m., records indicated that dampers throughout the hospital were tested in May 2010. Corresponding work orders for any repairs required by the vendor were provided. For Damper 6-11, on the sixth floor, the vendor indicated "damper could not be tested, conduit in the way, damper rusted open." The paperwork indicated that the corresponding work order number was FH-49343. Records for that work order were not provided.

2. At 2:38 p.m., For Damper 9-5, on the ninth floor, the vendor indicated "damper could not be tested. Statement of Commission. Need to enlarge access door in ductwork." The paperwork indicated that the corresponding work order number was FH-49349. The work order indicated that the damper was not tested because there was a "pipe in the way."

During an interview at 2:40 p.m., Engineering Staff 102 stated that records of Work Order FH-49343 could not be found and therefore the status of repair and testing of Damper 6-11 could not be established. He also confirmed that Damper 9-5 was not tested.

Based on observation, record review, and interview, the facility failed to maintain their cooking facilities. This was evidenced by incomplete maintenance of the hood exhaust systems in the kitchen and grease laden deposits on the kitchen hoods. This could cause injury to patients, staff, and visitors in the event of a fire. This affected 1 of 12 floors in the Main Hospital at Hillcrest.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
7-10.1 Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Such extinguishers shall use agents that saponify upon contact with hot grease such as sodium bicarbonate and potassium bicarbonate dry chemical and potassium carbonate solutions. Class B gas-type portables such as CO2 and halon shall not be permitted in kitchen cooking areas. Manufacturer's recommendations shall be followed.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1
Table 8-3.1 - Type or Volume of Cooking: Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking.
Frequency: Quarterly

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the kitchen was observed.

Main Hospital at Hillcrest - 3/5/13

1. At 3:30 p.m., records indicated that the exhaust hoods at the Hillcrest kitchen were inspected and cleaned semi-annually, on 9/20/12 and 3/22/12. Inspite of the cleaning schedule, the kitchen hood was still observed to have accumulation of grease due to the frequency of use.


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First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 1:45 p.m., the cooking appliances (stove, deep fryer, and grill for charbroiling) under the suppression hood the suppression pipes and filters had a built up of grease, running streaks that form a puddle at the edge of the hood and filters. During an interview with the head kitchen staff at 1:47 p.m., he stated that the kitchen staff does a lot of deep frying of foods and charbroiling on the grill. Kitchen staff cooked approximately 1200 to 1400 meals daily, Mondays through Fridays, for breakfasts and lunches. Kitchen staff stated the kitchen exhaust system gets cleaned every six months by a vendor.

Based on observation, the facility failed to ensure that portable space heaters were not used in patient care smoke compartments. This was evidenced by one portable space heater that was plugged into a surge-protector and was not used in accordance with manufacturer specifications. This affected 1 of 12 floors in the Main Hospital at Hillcrest and could result in an increased risk of a fire.

Findings:

During a facility tour with the engineering satff from 3/5/13 to 3/8/13, portable space heaters were observed.

Second Floor - Main Hospital at Hillcrest - 3/7/13

At 2:01 p.m., there was a portable space heater plugged into a six-plug surge protector in the Labor and Deliver/Burn Unit/ Trauma Admissions Office. A warning sticker on the side of the heater stated: "risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3-feet (0.9m) from the front of the heater and away from the sides and rears." The heater was found under a desk, less than 3-feet away from combustibles, in the admissions office.

Based on observation, the facility failed to maintain means of egress continuously free from obstructions. This was evidenced by items obstructing the exit pathways. This had the potential to delay egress in the event of an emergency evacuation, resulting in injury to patients, visitors and staff. This affected 2 of 12 floors of the Main Hospital, 1 of 2 floors of the West Wing, 1 of 4 floors of the Medical Office South (MOS), and 1 of 4 floors of the South Wing.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/8/13, the exits, exit access, and exit discharges were observed.

First Floor - West Wing at Hillcrest - 3/5/13

1. At 1:26 p.m., a cart was stored by the exit door of the egress path by the Care Coordinator's office.

First Floor - Bio-Med, Main Hospital at Hillcrest - 3/5/13

2. At 1:39 p.m., four gurneys and two patient beds stored in the egress path by the exit door. During an interview with Bio-Med staff at 1:40 p.m., he stated the beds and the gurneys were in a assembly line and waiting to be repaired and stored in the egress path until closing time (approximately 4:30 p.m.) for Bio-Med staffs.

Third Floor - OWN Clinic, MOS - 3/6/13

3. At 11:25 a.m., a patient wheelchair scale blocked the exit door (3-305) of the suit to the reception area and egress path exit.

Third Floor - South Wing at Hillcrest - 3/7/13

4. At 8:55 a.m., the exit door of conference room 3-10 was block with furniture (desk and chairs).

Basement - Main Hospital at Hillcrest - 3/7/13

5. At 2:57 p.m., there were three industrial size approximately 60 gallons trash bins, four trash cans, and 32 gallons trash bins blocked and stored in the egress corridor from the entrance of the morgue to smoke barrier doors.

6. At 3:01 p.m., three 32-gallon bins and two portable trays blocked the egress corridor by Room L- 437.

Based on observation, the facility failed to ensure that soiled linen and trash receptacles with capacities greater than 32 gallons were attended when not stored in a room protected as a hazardous area. This was evidenced by one trash receptacle with a capacity of more than 32 gallons that was unattended in the corridor. This affected 1 of 12 floors in the Main Hospital at Hillcrest and could result in an increased risk of a fire.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/8/13, soiled linen and trash receptacles were observed.

First Floor - Main Hospital at Hillcrest

1. At 8:10 a.m., on 3/6/13, there was an approximately 125-gallon green trash receptacle outside the pharmacy. The receptacle was unattended.

2. At 8:59 a.m., on 3/8/13, there was an approximately 125-gallon green trash receptacle outside the pharmacy. The receptacle was approximately 50% filled with combustible trash and was unattended. During an interview at 9:00 a.m., Engineering Staff 96 stated that the receptacle was the same one observed on 3/6/12 and staff were told to remove it from the corridor.

Based on observation, the facility failed to properly store their medical gas cylinders. This was evidenced by exceeding 300 cubic feet of medical gas stored outside an area meeting storage requirements and oxygen cylinders that were not individually secured. This could cause harm to patients, visitors, and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 1 of 12 floors of the Main Hospital, 1 of 4 floors of the Medical Office South (MOS), 1 of 5 floors of the Medical Office North (MON), and 1 of 3 floors at the Shiley Eye Center.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
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)
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Center for Medicare and Medicaid Services S&C-07-10-LSC, dated January 12, 2007, states: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured. An individual container of medical gas placed in a patient room for 'as needed' (but regular) individual use is not required to be stored in an enclosure, when properly secured."

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the medical gas cylinders and their storage areas were observed.

First Floor- Main Hospital at Hillcrest - 3/7/13

1. At 1:50 p.m., the room identified as SA/SB/SC in the Emergency Department had 17 oxygen cylinders that measured approximately 24 cubic feet each. This amount exceeded the 300 cubic feet of nonflammable medical gas that may be maintained outside of storage.

2. At 2:16 p.m., the MRI corridor had an oxygen cylinder that was laying on the ground and not individually secured. The cylinder measured approximately 24 cubic feet.



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Hyperbaric Chamber, MON at Hillcrest - 3/5/13

2. At 2:40 p.m., piped-in oxygen storage room had six H-sized (measuring approximately 250 cubic feet each) cylinders secured with one chain and an E-sized (measuring approximately 24 cubic feet) cylinder hung from the same chain. The cylinders were not individually secured

Third Floor - OWN Clinic, MOS at Hillcrest - 3/6/13

3. At 11:20 a.m., there were 10 E-sized (measuring approximately 24 cubic feet each) oxygen cylinder and one 10 liters of cryogenic container of liquid nitrogen stored in the central supply room. The room measured 15-feet by 7-feet and had combustible supplies of plastics and papers stored in the same room. The distance between the cylinders and combustibles supplies were less than 5-feet. The door to the supply room was not equipped with the appropriate signage.

Third Floor - Shirley Eye Center - 3/8/13

4. At 4:01 p.m., there were three unsecured (free standing) cylinders of varying sizes in the oxygen storage area. At 4:02 p.m., interview with engineer staff failed to identify the contents of the cylinders.

Based on observation, the facility failed to properly store their medical gas cylinders. This was evidenced by exceeding 300 cubic feet of medical gas stored outside an area that meets all storage requirements. This could increase the risk of fire and cause harm to patients, visitors, and staff. This affected 1 of 4 floors of the Sulpizio Cardiovascular Center and 1 of 3 floors at the Moores Cancer Center.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
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)
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.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for non Flammable gases less than 3000 ft (85 m 3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (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, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Center for Medicare and Medicaid Services S&C-07-10-LSC, dated January 12, 2007, states: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured. An individual container of medical gas placed in a patient room for 'as needed' (but regular) individual use is not required to be stored in an enclosure, when properly secured."

Findings:

During a facility tour with Engineering Staff from 3/5/13 to 3/12/13, the medical gas cylinders and their storage areas were observed.

Second Floor - Sulpizio Cardiovascular Center - 3/11/13

At 9:40 a.m., the Anesthesia Workroom in the OR had 17 medical gas cylinders (15 oxygen and 2 nitrous) that measured approximately 24 cubic feet each. This amount exceeded the 300 cubic feet of nonflammable medical gas that may be maintained outside of storage. Combustible materials that included mask, nasal cannulas, and plastics were stored on top of the cylinders.


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First Floor - Moores Cancer Center - 3/8/13

At 3:20 p.m., piped-in oxygen storage room had 8 H-cylinders (measuring approximately 250 cubic feet each) stored in the room. The light outlet measured approximately 4-feet from the floor, less than the 5-feet minimum requirement.

Based on observation and record review, the facility failed to maintain their piped in medical gas system. This was evidenced by oxygen leaking from a wall outlet regulator, failure to correct discrepancies noted in the most recent medical gas system inspection report, by an emergency shut-off valve that was obstructed, and signs missing for oxygen valves. This failure could increase the risk of fire and could result in a delay in access to the shut-off valve during an emergency. This affected 3 of 4 floors at Thornton Hospital and 2 of 12 floors of the Main Hospital at Hillcrest.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

4-3.5.3 Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the records for the inspection of the piped in medical gas was reviewed and the system was observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 9:35 a.m., the wall outlet regulator labeled as oxygen in ICU Room 12 (#2-202) could be heard leaking while the regulator was turned off.

2. At 3:15 p.m., the medical gas piping system inspection report, dated 12/21/2012, was reviewed. That report indicated that 23 of 29 discrepancies had not been repaired in the following areas: I.C.U.3, I.C.U.5, O.R.1D, O.R.2C, O.R.3A O.R.5C, O.R.6A, O.R.6C, O.R.7A, O.R.8A, O.R.9A, O.R.9E, O.R.10B, O.R.10E, O.R.11D, Room 213, Room 256A, Room 257B, Zone Valve O.R.3, Zone Valve O.R.9, Zone Valve O.R.10, Zone Valve O.R.11, and Room 368. Engineering Staff 98 stated that the 23 items had not been corrected.


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Second Floor - Main Hospital at Hillcrest - 3/7/13

3. At 1:59 p.m., the medical gas emergency shut-off valve, outside Room 9 in the SICU, was obstructed by a gurney.


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Basement - Main Hospital at Hillcrest - 3/7/13

4. At 2:10 p.m., by room L-216, the door sign stated piped in oxygen valve was located in the ceiling of the room. The room's ceiling was not equipped with a sign identifying the location of the oxygen valve.

Based on observation, the facility failed to properly maintain duct penetrations. This was evidenced by penetrations through fire/smoke barriers walls that were sealed with non-rated fire material and unlisted method. This had the potential to allow the spread of fire, resulting in injury to patients, visitors and staff. This affected 2 of 4 floors at Thornton Hospital.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the fire/smoke barriers were observed.

Third Floor - Thornton Hospital - 3/5/13

1. At 3:36 p.m., the fire wall separating the smoke compartments between the vestibule and the patient sleeping areas were observed to have its penetrations sealed by a piece of dry wall, measuring approximately 4-inches by 4-inches, screwed on top of a dry wall and foam type material around it. The wall was observed above the ceiling tiles directly above the cross corridor doors by Room 300. The building's floor plans identified the wall rating to be 1 hour. Engineering Staff 95 could not provide evidence that the method used was a listed and approved fire-stopping system. The Inspector of Records (person responsible for overseeing all alterations, modifications, and additions to the hospital building) was interviewed and he stated that the foam type material is not allowed to be used in the hospital and that the dry wall should have been anchored from stud to stud.

Second Floor - Thornton Hospital - 3/6/13

2. At 9:42 a.m., the fire wall separating the smoke compartments, located in Corridor 2-C10, was observed to have its penetrations sealed with a foam type material. The wall was observed above the ceiling tiles directly above the cross corridor doors entrance into the ICU Unit 2-231. The building's floor plans identified the wall rating to be 1 hour. Engineering Staff 95 provided a data sheet with information on the foam material used, "One-Component Polyurethane Foam Sealant HC." The product was listed as "Extremely Flammable" and that "toxic gases/fumes may be given off during burning." The Inspector of Records was interviewed and he stated that the product is not allowed to be used in the hospital.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by electrical panels that were obstructed and with combustible materials stored against equipment. This could result in an increased risk of fire. This affected 1 of 4 of the Sulpizio Cardiovascular Center.

NFPA 70, National Electric Code, 1999 Edition.
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the electrical wiring and equipment were observed.

Second Floor - Sulpizio Cardiovascular Center - 3/11/13

At 9:48 a.m., the electrical room 2-405A located in the OR was observed that have combustible material stored in front of the electrical panel and on top of the electrical equipment. The combustible material included cardboard boxes (measuring approximately 2-feet x 2-feet x 2-feet) containing cables.

Based on observation, record review, and interview, the facility failed to maintain electrical safety. This was evidenced by incomplete documentation for annual tension and polarity testing, by electrical boxes with no covers, by the use of surge protectors and extension cords to plug appliances, by daisy chaining of surge protectors and extension cords, and by electrical panels that were obstructed. This could result in an increased risk of an electrical fire. This affected 11 of 12 floors of the Main Hospital at Hillcrest, 1 of 4 floors at Thornton Hospital, and 1 of 2 floors of the West Wing at Hillcrest.

NFPA 70, National Electric Code, 1999 Edition.
110-12 Mechanical Execution of Work. Electrical Equipment shall be installed in a neat and workman like manner,(a) Unused openings, Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
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.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas
(d) 3. Polarity of Receptacles. Each receptacle shall be wired in accordance with NFPA 70, National Electrical Code, to ensure correct polarity.
(f) Wet Locations.
1.* Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
Exception No. 1: Patient beds, toilets, bidets, and wash basins shall not be required to be considered wet locations.
Exception No. 2: In existing construction, the requirements of 3-3.2.1.2(f)1 are not required when written inspection procedure, acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital, to indicate that equipment-grounding conductors for 120-V, single-phase, 15- and 20-A receptacles, equipment connected by cord and plug, and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and applicable performance requirements of this chapter. The procedure shall include electrical continuity tests of all required equipment, grounding conductors, and their connections. These tests shall be conducted as follows.
Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested:
(a) When first installed
(b) Where there is evidence of damage
(c) After any repairs, or
(d) At intervals not exceeding 6 months
3-3.3.2.5 Test Equipment. Electrical safety test instruments shall be tested periodically, but not less than annually, for acceptable performance.
3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Findings:

During a facility tour with Engineering Staff from 3/5/13 to 3/12/13, the electrical wiring and equipment were observed.

Main Hospital at Hillcrest - 3/5/13

1. At 11:31 a.m., records for annual tension and polarity testing of electrical receptacles were provided. There records indicated that not all patient care area receptacles were tested. During an interview at 11:34 a.m., Engineering Staff 101 stated that only receptacles in critical care areas were tested annually. All other receptacles in general care areas were visually inspected every six months.

Eleventh Floor - Main Hospital at Hillcrest - 3/6/13

2. At 9:41 a.m., there was a six-plug surge protector plugged into another six-plug surge protector in the 11 West Charge Nurse Office.

Tenth Floor - Main Hospital at Hillcrest - 3/6/13

3. At 9:54 a.m., there was a refrigerator and a six-plug surge protector plugged into another six-plug surge protector, in the Nurse Manager Office, Room 10-311.

Ninth Floor - Main Hospital at Hillcrest - 3/6/13

4. At 10:41 a.m., there was a six-plug surge protector plugged into a three-plug extension cord, in Doctors Sleep Room 9-305.

5. At 11:15 a.m., there was a six-plug surge protector plugged into a six-plug surge protector in Room 9-260.

Seventh Floor - Main Hospital at Hillcrest - 3/6/13

6. At 1:51 p.m., there was a coffee maker plugged into a three-plug extension cord in the 7 West Staff Lounge, Room 728.

Third Floor - Main Hospital at Hillcrest - 3/7/13

7. At 9:31 a.m., there was an approximately 16-inch by 12-inch electrical box with no cover in Electrical Room 3-301.

First Floor - Main Hospital at Hillcrest - 3/7/13

8. At 2:35 p.m., there were two "volunteer check-in" computer work stations plugged into a three-plug extension cord in the Cafeteria.

9. At 3:10 p.m., there was a refrigerator in a six-plug surge protector in Suite 1-138, Image Services Administration.

First Floor - Main Hospital at Hillcrest - 3/8/13

10. At 8:59 a.m., Electrical Panel FH 12123 was blocked by a trash receptacle outside of the pharmacy.


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Second Floor - Thornton Hospital - 3/6/13

11. At 9:01 a.m., there were items stored up against the electrical panel in room 2-C28.

12. At 10:01 a.m., there was a yellow extension cord in the Cardiac EP Lab 2. The lab technician was interviewed on 3/11/13 at 2:04 p.m., she stated that they had been using the extension cord to plug in the carto machine (equipment used for mapping the heart). Rust was observed on the metal hinges to the port covers and the technician stated that it had been due to the extension cord being there for a long time. Engineering Staff 95 stated that the room had not been one of the rooms assessed, after complaint #314117, to ensure that enough receptacle outlets were installed to eliminate the use of extension cords and multi-outlet adapters in patient care areas.


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West Wing at Hillcrest - 3/5/13

13. At 3:44 p.m., the record showed tension and polarity was not done for the West Wing receptacles.

Basement - Main Hospital at Hillcrest - 3/7/13

14. At 3:38 p.m., in the kitchen, a refrigerator was plugged into an orange extension cord.

First Floor- Main Hospital at Hillcrest - 3/7/13

15. At 3:53 p.m., a computer and the accessories on a desk and a chair blocked access to the electrical panel 1EPK in the kitchen office.

Based on observation, the facility failed to ensure that ABHR dispensers were not installed near ignition sources. This was evidenced by ABHR dispensers that were installed directly over electrical outlets. This affected 2 of 12 floors of the Main Hospital at Hillcrest and could result in an increased risk of a fire.

Findings:

During a facility tour from 3/5/13 to 3/12/13, the ABHR dispensers were observed.

Second Floor - Main Hospital at Hillcrest - 3/7/13

1. At 10:50 a.m., there was an ABHR dispenser installed approximately 3-feet directly over an electrical outlet in PACU.

2. At 11:26 a.m., there was an ABHR dispenser installed approximately 2-feet directly over an electrical outlet in the Blood Lab, Room 2-140.

First Floor - Main Hospital at Hillcrest - 3/7/13

3. At 3:22 p.m., there was an ABHR dispenser installed approximately 2-feet directly over an electrical outlet near the copier in Room 1103.

Based on observation, the facility failed to maintain the integrity of the building construction. This was evidenced by unsealed penetrations in the facility's walls that could result in the spread of fire and smoke. This had the potential for injury to patients and staff with burns and/or smoke inhalation in the event of a fire. This affected 1 of 4 floors at Thornton Hospital.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the facility's walls and ceilings were observed.

Second Floor - Thornton Hospital - 3/6/13

At 8:36 a.m., there were 2 penetrations on the wall to Patient Room 208 (#2-445). Each penetration measured approximately 1/2-inch diameter.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor walls as evidenced by penetrations on corridor walls. 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 4 floors at Thornton Hospital.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the corridor walls were observed.

Second Floor - Thornton Hospital - 3/6/13

At 9:53 a.m., there was a penetration on the corridor wall in Corridor 2-C03. The penetration was observed above the drop down ceiling above the door entrance into Corridor 2-116. The penetration surrounded a conduit and it measured approximately 1/2-inch diameter. The building's floor plans identified the wall rating to be 1 hour.

Based on observation, the facility failed to maintain their doors, as evidenced by doors that failed to close and latch, and doors held open by a wedge. This could result in the rapid spread of smoke and fire. This affected 2 of 12 floors of the Main Hospital at Hillcrest and 1 of 2 floors of the West Wing at Hillcrest.

Findings:

During a facility tour with the hospital staff from 3/5/13 to 3/12/13, the doors were observed.

Basement - Main Hospital at Hillcrest - 3/8/13

1. At 8:34 a.m., the door to the Occupational Physical and Speech Therapy Room, Door 1-411, released from its magnetic hold-open device upon activation of the fire alarm system. The door failed to close and latch leaving an approximately 1 inch gap between the door and door frame.

Second Floor - Main Hospital at Hillcrest - 3/8/13

2. At 9:19 a.m., the door to the SICU Storage Room, Door 1-411, released from its magnetic hold-open device upon activation of the fire alarm system. The door closed but failed to latch.



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First Floor - Behavioral Unit, West Wing at Hillcrest - 3/5/13

3. At 2:15 p.m., the corridor door was held open with a plastic wedge positioned under door leaf. Interview with the Head Nurse, she stated the door needs to stay open, so staff can monitor the patients effectively. The door was rated 20 minutes per label.

Based on observation, the facility failed to maintain their vertical openings. This was evidenced by unsealed conduits going through the floors. This could result in the spread of smoke and fire from one floor to the other, in the event of a fire. This affected 2 of 3 floors of the Hyperbaric Medicine & Wound Healing Center in Encinitas.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the vertical openings were observed.

Second Floor - Hyperbaric Medicine & Wound Healing Center in Encinitas - 3/8/13

At 1:26 p.m., there were five conduits penetrating the ceiling in the room containing the Fire Control Panel. The conduits did not have fire stop to seal the opening within the tube that measured approximately 2-inches each.

Based on observation and interview, the facility failed to maintain their vertical openings. This was evidenced by unsealed conduits penetrating floors. This could result in the spread of smoke and fire from one floor to the other, in the event of a fire. This affected 4 of 12 floors of the Main Hospital at Hillcrest.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the vertical openings were observed.

Tenth Floor - Main Hospital at Hillcrest - 3/6/13

1. At 10:21 a.m., there was an approximately 4 inch conduit, with an approximately 1 inch bundle of wires going through, in the ceiling of IT Closet 10-257. The conduit was not sealed around the bundle of wires.

During an interview at 10:22 a.m., Engineering Staff 96 stated that the conduit penetrates the eleventh floor.


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First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 2:25 p.m., there were four conduits penetrating the ceiling in Room 1-335B. The conduits did not have fire stop to seal the opening within the tube. The tube had a bundle of cables running through it and the unsealed opening measured approximately 3-inches.

3. At 2:30 p.m., there were two conduits penetrating the ceiling in Room 1-335A. The conduits did not have fire stop to seal the opening within the tube. The unsealed opening measured approximately 3-inches.

4. At 2:37 p.m., there was a penetration on the ceiling in the Telecom Room 1-529. The opening had a bundle of cables running through it and it measured approximately 3-inches.

Based on observation and interview, the facility failed to maintain their smoke barrier doors. This was evidenced by smoke barrier doors that failed to release from hold-open devices and automatically close upon activation of the fire alarm system. This could result in the spread of smoke and fire, in the event of a fire. This affected 1 of 12 floors of the Main Hospital at Hillcrest.

Findings:

During a facility tour with the Engineering Staff on 3/8/13, the smoke barrier doors were observed.

Second Floor - Main Hospital at Hillcrest - 3/8/13

At 9:31 a.m., the two smoke barrier doors into the OR and one smoke barrier door into PACU were held open by electronic hold-open devices. The doors failed to close upon activation of the fire alarm system and remained open to their fullest extent.

During an interview at 9:32 a.m., Engineering Staff 96 stated that the hold-open devices are designed to close the identified doors upon activation of the fire alarm system.

Based on observation, the facility failed to maintain exit signs. This was evidenced by an exit sign that did not clearly identify the exit that was not readily apparent. This could potentially delay evacuation during a fire and result in injury to patients, visitors, and staff. This affected 1 of 3 floors of the Hyperbaric Medicine & Wound Healing Center in Encinitas.

NFPA 101, Life Safety Code, 2000 Edition
7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the exits and exit signs were observed.

Second Floor - Hyperbaric Medicine & Wound Healing Center - 3/8/13

At 1:15 p.m., the signage installed in the 2nd floor corridor by the door to Stairwell-2 read "stair 2 emergency down" and the door did not lead to the exit discharge. The pathway to the exit discharge was through a door adjacently located from the door to Stairwell-2.

Based on observation, the facility failed to maintain smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, potentially harming patients, visitors, and staff. This affected 1 of 4 floors at Thornton Hospital and 1 of 2 floors of the West Wing at Hillcrest.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the smoke barrier walls were observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 9:20 a.m., the smoke barrier wall in Corridor 2-C50, had a penetration on the wall. The penetration was observed above the drop down ceiling above the door entrance into the Pre-Op Area Suite 2-034. The penetration measured approximately 2-inches by 3-inches. The building's floor plans identified the wall rating to be 1 hour.

2. At 9:27 a.m., the smoke barrier wall in Corridor 2-C50, had a penetration on the wall. The penetration was observed above the drop down ceiling by Room 2-030. There was a pipe sleeve that penetrated the wall with no fire stop material within the pipe that measured approximately 1/2-inch. The building's floor plans identified the wall rating to be 1 hour.


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First Floor - Behavioral Unit, West Wing at Hillcrest - 3/5/13

3. At 2:10 p.m., the two hour fire wall had multiple penetrations ranging in sizes approximately 1/2-inch to 1-inch circular penetrations and a 4-inch square penetrations.

4. At 2:12 p.m., the smoke barrier wall to the Behavioral Unit had approximately 8 by 16 inches sheet-rack opening and another 1/2-inch penetration in the smoke barrier wall.

Based on observation, the facility failed to maintain smoke barrier walls. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, potentially harming patients, visitors, and staff. This affected 1 of 4 floors of the Sulpizio Cardiovascular Center.

NFPA 101, Life Safety Code, 2000 Edition
8.3.2 Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from a floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the smoke barrier walls were observed.

Second Floor - Sulpizio Cardiovascular Center - 3/5/13

At 2:04 p.m., the smoke barrier wall located by the entrance into the Procedure and Treatment Unit had penetrations on the wall. The penetrations were observed from the corridor in the inter space above the ceiling by Patient Room 1. The penetrations were found inside conduits with no fire stop.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by smoke barrier doors that failed to latch. This finding could result in the spread of smoke from one smoke compartment to another and increase the risk of injury to patients and staff, in the event of a fire. This affected 1 of 3 floors at the Moores Cancer Center.

Findings:

During the facility tour with engineering staff from 3/5/13 to 3/11/13, the smoke barrier doors were observed.

First Floor - Moores Cancer Center - 3/8/13

1. At 2:58 p.m., the smoke barrier double doors by pharmacy and Infusion failed to latch upon activation of the fire alarm system.

2. At 3:01 p.m., the smoke barrier double doors by Imagining failed to close and latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain their fire doors to prevent the passage of smoke. This was evidenced by rolling doors that were obstructed from closing and cross corridor doors that failed to positive latch upon activation of the fire alarm system. 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 1 of 4 floors at Thornton Hospital, 3 of 12 floors of the Main Hospital at Hillcrest, 1 of 4 floors of the South Wing at Hillcrest, 1 of 5 floors of the Medical Office North at Hillcrest, and 1 of 3 floors at the Shiley Eye Center.

NFPA 101, Life Safety Code, 2000 Edition
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.

Findings:

During a facility tour with the Engineering Staff on 3/5/13 to 3/12/13, the fire doors were observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 9:10 a.m., the rolling door that opened into the corridor from Room 2-028 had items obstructing the pathway of the door. The items included a box of gloves, cariwipes, and a spray bottle.

First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 1:55 p.m., the rolling door #021675 that opened into the waiting area of the Emergency Department had items obstructing the pathway of the door. The items included two basin trays.

Second Floor - Main Hospital at Hillcrest - 3/8/13

3. At 9:33 a.m., 1 of 2 cross-corridor fire doors, located by Room 2-115, failed to close and positive latch upon activation of the fire alarm system. The door was held open by an electronic hold-open device.


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Basement - Main Hospital at Hillcrest - 3/8/13

4. At 8:41 a.m., the smoke barrier doors by Radiology classroom failed to latch upon activation of the fire alarm system.

First Floor- Main Hospital at Hillcrest - 3/8/13

5. At 8:59 a.m., smoke barrier doors to the cafeteria/ kitchen held open with the electronic automatic closing devices failed to latch upon activation of the fire alarm system.

First Floor - South Wing at Hillcrest - 3/8/13

6. At 9:08 a.m., the gift shop smoke barrier doors were held open with the electronic automatic closing device. One leaf failed to release and close upon activation of the fire alarm system.

7. At 9:11 a.m., double doors, by admission desk in lobby area, held open with the electronic automatic closing device failed to close and latch upon activation of the fire alarm system.

Second Floor - Medical Office North (MON) at Hillcrest - 3/8/13

8. At 9:23 a.m., the smoke barrier doors by Cardiac Cath Laboratory failed to latch.

Third Floor - Shiley Eye Center - 3/11/13

9. At 11:59 a.m., the smoke barrier doors by Room 337 and soiled utility room failed to latch upon activation of the fire alarm system.

Based on observation, the facility failed to maintain its hazardous areas as evidenced by penetrations on walls to rooms identified as hazardous areas. This had the potential to allow the spread of smoke and fire, resulting in injury to patients, visitors and staff. This affected 1 of 3 floors at the Shiley Eye Center.

Findings:

During a facility tour with hospital staff on 3/5/13 to 3/12/13, hazardous areas were observed.

Third Floor - Shiley Eye Center- 3/11/13

At 11:56 a.m., the walls and ceiling in the room containing the hot water heater had multiple penetrations that measured approximately 1/2-inch each. Three penetrations were observed around conduits going through the ceilings and three penetrations on the wall.

Based on observation, the facility failed to maintain stairways used as exits. This was evidenced by multiple items being stored underneath the stairwell and a stairway with a missing signage. This had the potential for interfering with egress during a fire emergency and delay evacuating patients, staff, and visitors. This affected 3 of 3 floors at the Shiley Eye Center and 1 of 12 floors of the Main Hospital at Hillcrest .

NFPA 101, Life Safety Code, 2000 Edition
7.2.2.5.3 Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.

7.2.2.5.4 Stair Identification Signs. Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the stairwells were observed.

First Floor - Shiley Eye Center - 3/11/13

1. At 11:41 a.m., Stairwell-2 had several items stored underneath the stairs on the 1st Floor. These items included wheeled stands, chairs, and boxes.


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Eleventh Floor - Main Hospital at Hillcrest - 3/6/13

2. At 9:11 a.m., there was no sign in the Link Stairwell identifying the Eleventh Floor and indicating that the exit discharge was on the First Floor.

Based on observation, the facility failed to ensure that exits were readily accessible. This was evidenced obstructions found in the pathway leading to the public way from an exit door. This had the potential to delay egress in the event of a fire, resulting in injury to visitors and staff. This affected 1 of 4 floors at Thornton Hospital.

NFPA 101, Life Safety Code, 2000 Edition
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.7.1 Exits shall terminate directly at a public way or at an exterior exit discharge. Yards, courts, open spaces, or other portions of the exit discharge shall be of required width and size to provide all occupants with a safe access to a public way.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the exits, exit access, and exit discharges were observed.

Basement - Thornton Hospital- 3/6/13

At 1:13 p.m., the exit door from the mechanical room L-311 had multiple linen carts obstructing the pathway leading to the public way. The linen carts were found throughout the the soiled dock L-C15 and the way to reach the exit was not evident. A staff member working in the dock stated that they typically only clear the area from carts during surveys.

Based on record review, observation, and interview, the facility failed to maintain their battery-powered emergency lights and exit signs. This was evidenced by incomplete documentation for testing the emergency lights and no documentation for testing the exit signs. This could result in the failure of the emergency lights in anesthetizing locations and other areas of the hospital, in the event of a power outage. This affected 12 of 12 floors of the Main Hospital at Hillcrest, 4 of 4 floors at Thornton Hospital, and the MRI Outpatient Services at Hillcrest .

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.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.
7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

NFPA 99, 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).

Findings:

During record review from 3/5/13 to 3/12/13, records for testing the battery-powered emergency lights and the battery-powered exit signs were requested and were reviewed.

Main Hospital at Hillcrest - 3/5/13

1. At 3:49 p.m., records for annual 90-minute testing of emergency lights in OR 1 to OR 9, on 10/19/12, were provided. There were no records for monthly testing of the lights and no records for testing the emergency lights in two of two Labor and Delivery rooms.
During an interview at 3:50 p.m., Engineering Staff 101 stated that there were no other records for testing emergency lights.

Main Hospital at Hillcrest - 3/6/13

2. During an interview at 11:00 a.m., Engineering Staff 96 and Engineering Staff 101 stated that the battery-powered exit signs throughout the facility were also backed up by the generator. They stated that there were no records for testing the battery-powered exit signs that were observed on every floor.

Second Floor - Main Hospital at Hillcrest - 3/7/13

3. At 1:52 p.m., battery back-up emergency lights were observed in the SICU and in the laboratories. There were no records provided for testing these lights.

First Floor - Main Hospital at Hillcrest - 3/7/13

4. At 3:37 p.m., battery back-up emergency lights were observed in the kitchen dry storage room. There were no records provided for testing these lights.

Seventh Floor - Main Hospital at Hillcrest - 3/8/13

5. At 10:01 a.m., all the light fixtures at the Senior Behavioral Health Department were equipped with red test buttons. During an interview at 10:02 a.m., Engineering Staff 96 stated that the buttons indicated that the lights were equipped with battery back-up. There were no records for testing these lights.




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First and Second Floor - Thornton Hospital - 3/6/13

6. At 10:16 a.m., the battery powered emergency lighting unit installed in Stairwell 3, between the 1st and 2nd floor, failed to illuminate when tested with the test button.

First Floor - Main Hospital at Hillcrest - 3/7/13

7. At 2:40 p.m., the two battery powered emergency lights installed in the Cath Lab, Room 1-531, failed to illuminate when tested with the test buttons. During an interview with Safety Staff 93, he confirmed that they failed to maintain the batteries to the emergency lights.

Thornton Hospital - 3/7/13

8. At 11:57 a.m., the records for the annual 90-minute testing of emergency lights were provided for battery powered emergency lights installed throughout the facility. Engineering Staff 95 stated that they only check the battery powered emergency lights semi-annually because it is too labor-intensive to be checking them every 30 days.


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MRI Outpatient Services at Hillcrest - 3/6/13

9. At 9:04 a.m., the record showed facility failed to perform the 90 minutes annual test for the battery powered emergency lights (bug lights). Interview with Safety Staff 93 stated facility failed to do 90 minutes annual test for the bugs lights in the MRI buildings and other departments of the Hospitals such as Basement of the Main Building Hillcrest.

Based on observation, the facility failed to maintain exit signs to continuously illuminate. This was evidenced by exit signs installed that did not illuminate. This could potentially delay evacuation in the event of a power outage and an emergency evacuation. This affected 1 of 4 floors at Thornton Hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the exit signs were observed.

Third Floor - Thornton Hospital - 3/5/13

At 3:47 p.m., the exit sign installed by the exit door next to Patient Room 307 (#3-247), failed to illuminate.

Based on observation and interview, the facility failed to instruct their staff on their role to protect their patients, in the event of an emergency. This was evidenced by the staff's lack of familiarity with the dedicated patient audio/strobe fire alarm device located at the nurse's station. This could result in delay of notification of the location of the fire and possible harm to patients and staff, in the event of a fire. This affected 1 of 4 floors of the Sulpizio Cardiovascular Center.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During the facility tour with the Engineering Staff on 3/5/13 through 3/11/13, the facility fire alarm system was tested and staff were interviewed to determine their knowledge of the patient room audio alarm devices at the nurse's station.

Third Floor - Sulpizio Cardiovascular Center - 3/11/13

At 9:13 a.m., a smoke detector in a patient room 302 was activated. The audio/strobe device at the nurse's station alarmed with a distinct sound. At 9:15 a.m., 7 of 7 staff interviewed could not recall ever hearing or seeing the patient room audio/strobe alarm that was activated. Staff stated that they did not receive any training and were not given information on their unit being equipped with a dedicated patient room audio/strobe system.

Based on staff interviews and record review, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire and the facility failed to ensure that the fire alarm system is activated during fire drills conducted between 6 a.m. to 9 p.m. This had the potential for staff members to not properly respond to a fire that could result in harm to patients, staff, and visitors. This affected 12 of 12 floors of the Main Hospital at Hillcrest and 1 of 4 floors at Thornton Hospital.


NFPA 101, Life Safety Code, 2000 Edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system
Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During a tour of the facility with the Engineering Staff from 3/5/13 to 3/12/13, facility staffs were interviewed to determine their knowledge of their fire emergency procedures and the usage of life safety equipments, and the fire drill records were reviewed.

Second Floor - Thornton Hospital - 3/11/13

At 10:36 a.m., the custodial staff was asked how she would respond to a fire in her working area. The staff member could not describe how to transmit a fire alarm signal by activating the closest manual fire alarm box.


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Main Hospital at Hillcrest - 3/5/13

At 1:24 p.m., the records for two fire drills conducted on 5/17/12, at 12:45 p.m. during the AM shift and at 4 p.m. during the PM shift, indicated that the fire alarm system was not activated during the drills.

Based on observation and record review, the facility failed to ensure that the fire alarm system was properly maintained. This was evidenced by a manual pull station installed with no tool to remove its protective glass cover, an initiating device that did not immediately alarm throughout the building after activation, fire alarms not heard throughout the entire building, audible/visual devices that failed to function, and no smoke or heat detection device installed in rooms containing fire alarm panels . This had the potential for occupants to not be alerted of a fire, resulting in harm to patients, visitors and staff. This affected 1 of 12 floors of the Main Hospital, 2 of 4 floors at Thornton Hospital, 1 of 2 floors of the West Wing, 1 of 5 floors of the Medical Office North, and 1 of 4 floors of the South Wing.

NFPA 101, Life Safety Code, 2000 Edition
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.2 Notification shall be provided by audible and visible signals in accordance with 9.6.3.3 through 9.6.3.12.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.2.2 Actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 20 seconds after the activation of an initiating device.
Effective on January 1, 2002, actuation of alarm notification appliances or emergency voice communications and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit (s) to provide notification of fire at that location.
Exception: Where ambient conditions prohibit installation of automatic smoke detection, automatic heat detection shall be permitted.

Findings:

During a tour of the facility with the Engineering Staff from 3/5/13 to 3/12/13, the fire alarm system was tested and documents for the system were reviewed.

Third Floor - Thornton Hospital - 3/5/13

1. At 4:12 p.m., the manual fire alarm pull station installed in the Elevator Lobby 3-C08 had a glass cover with no tool readily available to break the glass.

Basement - Medical Office North (MON) at Hillcrest - 3/8/13

2. At 8:42 a.m., the fire alarm pull station M3-29 that was installed by the stairwell in the MON (also known as OPC) did not actuate throughout the building for more than 20 seconds.

Basement - Thornton Hospital - 3/11/13

3. At 10:17 a.m., a smoke detector was activated in the basement's corridor. The fire alarm could not be heard in the clean linen storage room L-120 while the radio was on. No audible and no visual fire alarm devices where observed in the room.


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First Floor - Main Hospital at Hillcrest - 3/8/13

4. At 8:54 a.m., there were combination audible/visual fire alarm notification devices in the Emergency Department. The strobe on the device in the corridor outside ED Room 1-417, and the chime on the device in the corridor outside ED Bathroom 1-448, failed to activate during fire alarm testing.

First Floor - West Wing at Hillcrest - 3/8/13

5. At 8:54 a.m., there were combination audible/visual fire alarm notification devices in the Psychiatric Unit. The strobe and chime on the device in the corridor outside Room 1 failed to activate during fire alarm testing.


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Basement - Medical Office North (MON) at Hillcrest - 3/5/13

6. At 3:24 p.m., the fire alarm panel (sub panel) was mounted in the telecom room OPC0-01. The room was not equipped with a smoke detector.

Second Floor - South Wing at Hillcrest - 3/7/13

7. At 9:50 a.m., the fire alarm panel (sub panel) was mounted in the tele-com room 2-205. The room was not equipped with a smoke detector.

Based on observation, the facility failed to ensure that their manual fire alarm pull stations were easily accessible to allow for quick activation of fire alarm. This was evidenced by manual fire alarm pull stations and Argon System abort switches that were obstructed from view, batteries in fire control panel exceeding their replacement period, and unlabeled dedicated devices. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff. This affected 4 of 4 floors of the Sulpizio Cardiovascular Center, 3 of 3 floors of the Hyperbaric Medicine & Wound Healing Center in Encinitas, and 1 of 3 floors at the Moores Cancer Center.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.
9.6.2.6 Each manual fire alarm box on a system shall be accessible, unobstructed, and visible.

NFPA 72, National Fire Alarm Code, 1999 Edition
Table 7-3.2 Testing Frequencies
6. Batteries - Fire Alarm Systems d. Sealed Lead-Acid Type 1. Charger Test (Replace battery every 4 years.)

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the the fire alarm system was observed.

Fourth Floor - Sulpizio Cardiovascular Center - 3/5/13

1. At 11:58 a.m., the abort switches for the Argon System located in the Data Center was obstructed by multiple boxes placed in front of them.

Second Floor - Sulpizio Cardiovascular Center - 3/5/13

2. At 2:20 p.m., the two sealed lead-acid batteries for Fire Control Panels 2A and 2B were not dated.

First Floor - Sulpizio Cardiovascular Center - 3/5/13

3. At 2:55 p.m., there were two manual fire alarm pull stations by the door entrance into the main lobby that were obstructed by potted plants. The fire alarm pull stations were not visible.

Second Floor - Hyperbaric Medicine & Wound Healing Center - 3/8/13

4. At 1:24 p.m., the two sealed lead-acid batteries for the Fire Control Panel were dated 5/2007, exceeding their 4 year replacement period.

Third Floor - Sulpizio Cardiovascular Center - 3/11/13

5. At 9:13 a.m., the dedicated strobe light with chime device installed by the nurses station was not labeled to identify the areas affected when the alarm activates. Nursing staff did not know that the alarm was due to a smoke detector activated in a room located by the nurses station.


29566


First Floor- Moores Cancer Center - 3/8/13

6. At 2:25 p.m., a pull station was blocked by the newly construction security cubicle in the lobby area.

Based on observation and interview, the facility failed to maintain their smoke detectors. This was evidenced by a smoke detector that was covered with plastic, a smoke detector hanging from the ceiling, and smoke detectors with no record of sensitivity testing. This could result in a delay in notification during a fire. This affected 2 of 12 floors of the Main Hospital, 4 of 4 floors of the Medical Office South, and the MRI Outpatient Services at Hillcrest.

Findings:

During a facility tour from 3/5/13 to 3/8/13, the smoke detectors were observed.

Seventh Floor - Main Hospital at Hillcrest - 3/6/13

1. At 2:04 p.m., the smoke detector in Room 707B, in the Senior Behavioral Health Department, was entirely obstructed by an orange plastic cover. During an interview at 2:05 p.m., Engineering Staff 101 stated there were repairs done in the area approximately one week before.

Second Floor - Main Hospital at Hillcrest - 3/7/13

2. At 10:30 a.m., the smoke detector in Operating Room 9 was hanging by its electrical wires approximately 2 inches from the ceiling.


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Medical Office South (MOS) at Hillcrest - 3/5/13

3. At 3:50 p.m., the were no recorded documents of smoke detectors sensitivity test for 147 of 147 smoke detectors.

MRI Outpatient Services at Hillcrest - 3/5/13

4. At 3:54 p.m., the were no recorded documents of smoke detectors sensitivity test for 26 of 26 smoke detectors.

During an interview with the Engineering staff 95 on 3/12/13, at 9:35 a.m., he stated that his understanding of the regulations was that smoke detectors that are old and cannot be tested for sensitivity do not need to be tested for sensitivity. The smoke detectors were more than 10 years old and the facility failed to show documentation of sensitivity or nuisance alarms.

Based on document review and observation, the facility failed to maintain their sprinkler tamper alarm. This was evidenced by a Post Indicator Valve (PIV) tamper switch and an Outside Stem & Yoke (OS&Y) tamper switch that did not report to the central monitoring station. This had the potential to have a delayed response to the tampering of the sprinkler system, increasing the risk of injury to patients, visitors and staff. This affected 12 of 12 floors of the Main Hospital and the MRI Outpatient Services at Hillcrest.

NFPA 72, National Fire Alarm Code, 1999 Edition
1-5.4.4 Distinctive Signals. Fire Alarms, Supervisory signals, and trouble signals shall be distinctively and descriptively annunciated .
3-8.3.3.1.3 Signals shall distinctively indicate the particular function (e.g., valve position, temperature, or pressure) of the system that is off-normal and also indicate its restoration to normal.
3-8.3.4.2 The integrity of each fire suppression system actuating device and its circuit shall be supervised in accordance with 1-5.8.1 and with other applicable NFPA standards.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
9-3.4.3 Valve supervisory switches shall be tested semiannually. A distinctive signal shall indicate movement from the valve's normal position during either the first two revolutions of a hand wheel or when the stem of the valve has moved one fifth of the distance from its normal position. The signal shall not be restored at any valve position except the normal position.

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the fire sprinkler system was tested and documents were reviewed.

Main Hospital at Hillcrest - 3/8/13

1. At 10:54 a.m., the PIV, labeled "200 West Arbor," tamper alarm was tested by turning the valve handle for more than three revolutions. No signal was received at the fire control panel and no signal was received at the central monitoring station.


29566


MRI Outpatient Services at Hillcrest - 3/6/13

2. At 9:53 a.m., the OS&Y valve failed to send a supervisor signal to the Private Branch Exchange (PBX), the facility's central monitoring.

Based on document review and observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by an Inspectors Test Valve (ITV) that failed to report to the central monitoring station. This could result in the failure of notifying the fire department in the event that the sprinkler system activates during a fire. This deficient practice affected all staff and patients in the Hyperbaric Medicine & Wound Healing Center.

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.
5-2.6.1.5.1 Test signals initiated by the subscriber, including those for the benefit of an authority having jurisdiction, shall be acknowledged by central station personnel whenever the subscriber or authority inquires.
5-2.6.1.5.2 Any test signal not received by the central station shall be investigated immediately and action shall be taken to reestablish system integrity.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the sprinkler system devices were observed and the records for the system were reviewed.

Hyperbaric Medicine & Wound Healing Center in Encinitas - 3/8/13

At 1:52 p.m., the ITV was tested and an alarm activated within 28 seconds. The event history report was not immdediately available to review. When the event history report from the central monitoring company was reviewed, it did not show that an alarm was received during the time the ITV device was tested. All other devices tested were listed in the central monitoring company's event history report.

Based on observation and record review, the facility failed to maintain their automatic sprinkler system. This was evidenced by incomplete testing of the waterflow alarms, by missing escutcheon rings, paint or debris on sprinkler heads, 18-inches clearance not maintained from deflectors of sprinklers, and failure to provide sprinkler head. This could result in a delay in extinguishing a fire. This affected 12 of 12 floors of the Main Hospital at Hillcrest, 3 of 4 floors at Thornton Hospital, 2 of 2 floors of the West Wing, 2 of 5 floors of the Medical Office North (MON), and 1 of 4 floors of the South Wing.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
2.2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
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.

NFPA 13, Standard for the Installation of Sprinkler Systems, 1999 Edition
5-5.6. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

Findings:

During a facility tour with Engineering Staff from 3/5/13 to 3/12/13, the automatic sprinkler system was observed and inspection documents were requested.

Main Hospital at Hillcrest - 3/5/13

1. At 1:55 p.m., documentation provided for testing of the sprinkler system on 10/19/12 by an outside vendor listed all the tamper switches were tested. The document did not indicate that any of the waterflow alarms were tested during that quarter.

First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 3:36 p.m., two of four sprinkler heads in Walk-in Freezer 1 were missing escutcheon rings.


29626


Second Floor - Thornton Hospital - 3/6/13

3. At 8:42 a.m., a sprinkler head in the pantry by Patient Room 219 was missing its escutcheon ring.

4. At 8:54 a.m., the sprinkler head in Patient Room 255 had heavy accumulation of dust and debris.

First Floor - Thornton Hospital - 3/6/13

5. At 11:03 a.m., the sprinkler head in the electric room, located by the entrance into the Radiology Department from the waiting area, had paint on its deflector.

Basement - Thornton Hospital - 3/6/13

6. At 1:35 p.m., a sprinkler head in the Pharmacy Room L-206 was missing its escutcheon ring.

7. At 1:36 p.m., a sprinkler head in the Central Supply L-011 was missing its escutcheon ring.

8. At 1:50 p.m., the sprinkler heads in the Storage Room L-101 had multiple boxes stored less than 18-inches from the spray pattern of the sprinkler heads.

First Floor - Main Hospital at Hillcrest - 3/7/13

9. At 2:10 p.m., there was no sprinkler head in the closet, Room 1-405. Engineering Staff 96 stated that the closet space was part of the ED project remodel.

10. At 2:12 p.m., a sprinkler head in the corridor by Room 1-405 was missing its escutcheon ring.

11. At 2:50 p.m., a sprinkler head in the Radiology Reading Room 1-610 was missing its escutcheon ring.


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First Floor - West Wing at Hillcrest - 3/5/13

12. At 1:30 p.m., room 446 (storage room) had paint or plaster on the sprinkler head.

Basement - West Wing at Hillcrest - 3/5/13

13. At 2: 35 p.m., in room 446 A, the sprinkler escutcheon ring was removed from around the sprinkler and the opening extended. The extended opening had data cords running through it.

Second Floor - Cardiac Catheterization Suite in MON at Hillcrest - 3/7/13

14. At 8:30 a.m.,boxes of supplies on the top shelf blocked three sprinklers head. The boxes were position approximately 14-inches from the sprinklers

Third Floor - Ortho Suite in MON at Hillcrest - 3/7/13

15. At 9:30 a.m., one of two storage closet was not equipped with a sprinkler head. The room measured 12 square feet. The rest of the suite was sprinklered except for that storage room in the egress path of the suite. Interview with Safety Staff 93, he had no knowledge if the closet was a new addition.

Third Floor - South Wing at Hillcrest - 3/7/13

16. At 9:41 a.m., the insulation surround the supply air duct was on the sprinkler pipe in the Mechanical Room 3-307 A.

Basement - Main Hospital at Hillcrest - 3/7/13

17. At 2:50 p.m., the clean linen room, B-436 A, the sprinkler had the wrong type of escutcheon plate.

Based on observation, the facility failed to maintain portable fire extinguishers readily accessible. This was evidenced by a fire extinguishers that were obscured from view and were obstructed and not accessible to allow for the quick response to a fire. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors, and staff. This affected 2 of 4 floors at Thornton Hospital and 1 of 3 floors at the Shiley Eye Center.

NFPA 101, Life Safety Code, 2000 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
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.
Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

Findings:

During a facility tour from 3/5/13 to 3/8/13, the fire extinguishers were observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 8:58 a.m., the fire extinguisher in Room 2-C31 was obstructed from being readily accessible.

2. At 9:06 a.m., the fire extinguisher in the PACU Room 2-050 was obstructed from being readily accessible.

First Floor - Thornton Hospital - 3/6/13

3. At 10:47 a.m., the k-type fire extinguisher in the kitchen Room 1-309 was obscured from view by a sink. A kitchen staff was asked to locate the closest k-type fire extinguisher and walked past it when trying to locate one. There was no signage pointing to the mounted fire extinguisher.

Third Floor - Shiley Eye Center- 3/11/13

4. At 12:09 a.m., the fire extinguisher in the OR by Room 315 was obstructed by a wheeled cart and was not readily accessible.

Based on record review and interview, the facility failed to maintain their dampers. This was evidenced by no records for testing two dampers. This could result in the spread of smoke and fire, in the event of a fire. This affected 2 of 12 floors in the Main Hospital at Hillcrest.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Center for Medicare and Medicaid Services S&C-10-04-LSC, dated October 30 2009, states: "After due consideration of State survey agency findings and conclusions of the National Fire Protection Association (NFPA), we are issuing a categorical waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of 6 years rather than 4 years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital ' s testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protectives and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The 6-year testing interval shall commence on the date of the last documented damper test."

Findings:

During record review on 3/5/13, records for damper testing were requested.

Main Hospital at Hillcrest - 3/5/13

1. At 2:36 p.m., records indicated that dampers throughout the hospital were tested in May 2010. Corresponding work orders for any repairs required by the vendor were provided. For Damper 6-11, on the sixth floor, the vendor indicated "damper could not be tested, conduit in the way, damper rusted open." The paperwork indicated that the corresponding work order number was FH-49343. Records for that work order were not provided.

2. At 2:38 p.m., For Damper 9-5, on the ninth floor, the vendor indicated "damper could not be tested. Statement of Commission. Need to enlarge access door in ductwork." The paperwork indicated that the corresponding work order number was FH-49349. The work order indicated that the damper was not tested because there was a "pipe in the way."

During an interview at 2:40 p.m., Engineering Staff 102 stated that records of Work Order FH-49343 could not be found and therefore the status of repair and testing of Damper 6-11 could not be established. He also confirmed that Damper 9-5 was not tested.

Based on observation, record review, and interview, the facility failed to maintain their cooking facilities. This was evidenced by incomplete maintenance of the hood exhaust systems in the kitchen and grease laden deposits on the kitchen hoods. This could cause injury to patients, staff, and visitors in the event of a fire. This affected 1 of 12 floors in the Main Hospital at Hillcrest.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
7-10.1 Portable fire extinguishers shall be installed in kitchen cooking areas in accordance with NFPA 10, Standard for Portable Fire Extinguishers. Such extinguishers shall use agents that saponify upon contact with hot grease such as sodium bicarbonate and potassium bicarbonate dry chemical and potassium carbonate solutions. Class B gas-type portables such as CO2 and halon shall not be permitted in kitchen cooking areas. Manufacturer's recommendations shall be followed.
8-3.1 Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with powder or other substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1
Table 8-3.1 - Type or Volume of Cooking: Systems serving high-volume cooking operations such as 24-hour cooking, charbroiling or wok cooking.
Frequency: Quarterly

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the kitchen was observed.

Main Hospital at Hillcrest - 3/5/13

1. At 3:30 p.m., records indicated that the exhaust hoods at the Hillcrest kitchen were inspected and cleaned semi-annually, on 9/20/12 and 3/22/12. Inspite of the cleaning schedule, the kitchen hood was still observed to have accumulation of grease due to the frequency of use.


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First Floor - Main Hospital at Hillcrest - 3/7/13

2. At 1:45 p.m., the cooking appliances (stove, deep fryer, and grill for charbroiling) under the suppression hood the suppression pipes and filters had a built up of grease, running streaks that form a puddle at the edge of the hood and filters. During an interview with the head kitchen staff at 1:47 p.m., he stated that the kitchen staff does a lot of deep frying of foods and charbroiling on the grill. Kitchen staff cooked approximately 1200 to 1400 meals daily, Mondays through Fridays, for breakfasts and lunches. Kitchen staff stated the kitchen exhaust system gets cleaned every six months by a vendor.

Based on observation, the facility failed to ensure that portable space heaters were not used in patient care smoke compartments. This was evidenced by one portable space heater that was plugged into a surge-protector and was not used in accordance with manufacturer specifications. This affected 1 of 12 floors in the Main Hospital at Hillcrest and could result in an increased risk of a fire.

Findings:

During a facility tour with the engineering satff from 3/5/13 to 3/8/13, portable space heaters were observed.

Second Floor - Main Hospital at Hillcrest - 3/7/13

At 2:01 p.m., there was a portable space heater plugged into a six-plug surge protector in the Labor and Deliver/Burn Unit/ Trauma Admissions Office. A warning sticker on the side of the heater stated: "risk of fire-keep combustible materials such as furniture, paper, clothes and curtains at least 3-feet (0.9m) from the front of the heater and away from the sides and rears." The heater was found under a desk, less than 3-feet away from combustibles, in the admissions office.

Based on observation, the facility failed to maintain means of egress continuously free from obstructions. This was evidenced by items obstructing the exit pathways. This had the potential to delay egress in the event of an emergency evacuation, resulting in injury to patients, visitors and staff. This affected 2 of 12 floors of the Main Hospital, 1 of 2 floors of the West Wing, 1 of 4 floors of the Medical Office South (MOS), and 1 of 4 floors of the South Wing.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/8/13, the exits, exit access, and exit discharges were observed.

First Floor - West Wing at Hillcrest - 3/5/13

1. At 1:26 p.m., a cart was stored by the exit door of the egress path by the Care Coordinator's office.

First Floor - Bio-Med, Main Hospital at Hillcrest - 3/5/13

2. At 1:39 p.m., four gurneys and two patient beds stored in the egress path by the exit door. During an interview with Bio-Med staff at 1:40 p.m., he stated the beds and the gurneys were in a assembly line and waiting to be repaired and stored in the egress path until closing time (approximately 4:30 p.m.) for Bio-Med staffs.

Third Floor - OWN Clinic, MOS - 3/6/13

3. At 11:25 a.m., a patient wheelchair scale blocked the exit door (3-305) of the suit to the reception area and egress path exit.

Third Floor - South Wing at Hillcrest - 3/7/13

4. At 8:55 a.m., the exit door of conference room 3-10 was block with furniture (desk and chairs).

Basement - Main Hospital at Hillcrest - 3/7/13

5. At 2:57 p.m., there were three industrial size approximately 60 gallons trash bins, four trash cans, and 32 gallons trash bins blocked and stored in the egress corridor from the entrance of the morgue to smoke barrier doors.

6. At 3:01 p.m., three 32-gallon bins and two portable trays blocked the egress corridor by Room L- 437.

Based on observation, the facility failed to ensure that soiled linen and trash receptacles with capacities greater than 32 gallons were attended when not stored in a room protected as a hazardous area. This was evidenced by one trash receptacle with a capacity of more than 32 gallons that was unattended in the corridor. This affected 1 of 12 floors in the Main Hospital at Hillcrest and could result in an increased risk of a fire.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/8/13, soiled linen and trash receptacles were observed.

First Floor - Main Hospital at Hillcrest

1. At 8:10 a.m., on 3/6/13, there was an approximately 125-gallon green trash receptacle outside the pharmacy. The receptacle was unattended.

2. At 8:59 a.m., on 3/8/13, there was an approximately 125-gallon green trash receptacle outside the pharmacy. The receptacle was approximately 50% filled with combustible trash and was unattended. During an interview at 9:00 a.m., Engineering Staff 96 stated that the receptacle was the same one observed on 3/6/12 and staff were told to remove it from the corridor.

Based on observation, the facility failed to properly store their medical gas cylinders. This was evidenced by exceeding 300 cubic feet of medical gas stored outside an area meeting storage requirements and oxygen cylinders that were not individually secured. This could cause harm to patients, visitors, and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 1 of 12 floors of the Main Hospital, 1 of 4 floors of the Medical Office South (MOS), 1 of 5 floors of the Medical Office North (MON), and 1 of 3 floors at the Shiley Eye Center.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
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)
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Center for Medicare and Medicaid Services S&C-07-10-LSC, dated January 12, 2007, states: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured. An individual container of medical gas placed in a patient room for 'as needed' (but regular) individual use is not required to be stored in an enclosure, when properly secured."

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the medical gas cylinders and their storage areas were observed.

First Floor- Main Hospital at Hillcrest - 3/7/13

1. At 1:50 p.m., the room identified as SA/SB/SC in the Emergency Department had 17 oxygen cylinders that measured approximately 24 cubic feet each. This amount exceeded the 300 cubic feet of nonflammable medical gas that may be maintained outside of storage.

2. At 2:16 p.m., the MRI corridor had an oxygen cylinder that was laying on the ground and not individually secured. The cylinder measured approximately 24 cubic feet.



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Hyperbaric Chamber, MON at Hillcrest - 3/5/13

2. At 2:40 p.m., piped-in oxygen storage room had six H-sized (measuring approximately 250 cubic feet each) cylinders secured with one chain and an E-sized (measuring approximately 24 cubic feet) cylinder hung from the same chain. The cylinders were not individually secured

Third Floor - OWN Clinic, MOS at Hillcrest - 3/6/13

3. At 11:20 a.m., there were 10 E-sized (measuring approximately 24 cubic feet each) oxygen cylinder and one 10 liters of cryogenic container of liquid nitrogen stored in the central supply room. The room measured 15-feet by 7-feet and had combustible supplies of plastics and papers stored in the same room. The distance between the cylinders and combustibles supplies were less than 5-feet. The door to the supply room was not equipped with the appropriate signage.

Third Floor - Shirley Eye Center - 3/8/13

4. At 4:01 p.m., there were three unsecured (free standing) cylinders of varying sizes in the oxygen storage area. At 4:02 p.m., interview with engineer staff failed to identify the contents of the cylinders.

Based on observation, the facility failed to properly store their medical gas cylinders. This was evidenced by exceeding 300 cubic feet of medical gas stored outside an area that meets all storage requirements. This could increase the risk of fire and cause harm to patients, visitors, and staff. This affected 1 of 4 floors of the Sulpizio Cardiovascular Center and 1 of 3 floors at the Moores Cancer Center.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Health Care Facilities, 1999 Edition
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)
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.
7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

8-3.1.11 Storage Requirements.
8-3.1.11.2 Storage for non Flammable gases less than 3000 ft (85 m 3)
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustible or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (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, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

Center for Medicare and Medicaid Services S&C-07-10-LSC, dated January 12, 2007, states: "Up to 300 cubic feet of nonflammable medical gas may be accessible as operational supply rather than storage, when properly secured. An individual container of medical gas placed in a patient room for 'as needed' (but regular) individual use is not required to be stored in an enclosure, when properly secured."

Findings:

During a facility tour with Engineering Staff from 3/5/13 to 3/12/13, the medical gas cylinders and their storage areas were observed.

Second Floor - Sulpizio Cardiovascular Center - 3/11/13

At 9:40 a.m., the Anesthesia Workroom in the OR had 17 medical gas cylinders (15 oxygen and 2 nitrous) that measured approximately 24 cubic feet each. This amount exceeded the 300 cubic feet of nonflammable medical gas that may be maintained outside of storage. Combustible materials that included mask, nasal cannulas, and plastics were stored on top of the cylinders.


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First Floor - Moores Cancer Center - 3/8/13

At 3:20 p.m., piped-in oxygen storage room had 8 H-cylinders (measuring approximately 250 cubic feet each) stored in the room. The light outlet measured approximately 4-feet from the floor, less than the 5-feet minimum requirement.

Based on observation and record review, the facility failed to maintain their piped in medical gas system. This was evidenced by oxygen leaking from a wall outlet regulator, failure to correct discrepancies noted in the most recent medical gas system inspection report, by an emergency shut-off valve that was obstructed, and signs missing for oxygen valves. This failure could increase the risk of fire and could result in a delay in access to the shut-off valve during an emergency. This affected 3 of 4 floors at Thornton Hospital and 2 of 12 floors of the Main Hospital at Hillcrest.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

4-3.5.3 Gas Systems Recordkeeping-Level 1. Prior to the use of any medical gas piping system for patient care, the responsible authority of the facility shall ensure that all tests required in 4-3.4.1 have been successfully conducted and permanent records of the test maintained in the facility files.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the records for the inspection of the piped in medical gas was reviewed and the system was observed.

Second Floor - Thornton Hospital - 3/6/13

1. At 9:35 a.m., the wall outlet regulator labeled as oxygen in ICU Room 12 (#2-202) could be heard leaking while the regulator was turned off.

2. At 3:15 p.m., the medical gas piping system inspection report, dated 12/21/2012, was reviewed. That report indicated that 23 of 29 discrepancies had not been repaired in the following areas: I.C.U.3, I.C.U.5, O.R.1D, O.R.2C, O.R.3A O.R.5C, O.R.6A, O.R.6C, O.R.7A, O.R.8A, O.R.9A, O.R.9E, O.R.10B, O.R.10E, O.R.11D, Room 213, Room 256A, Room 257B, Zone Valve O.R.3, Zone Valve O.R.9, Zone Valve O.R.10, Zone Valve O.R.11, and Room 368. Engineering Staff 98 stated that the 23 items had not been corrected.


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Second Floor - Main Hospital at Hillcrest - 3/7/13

3. At 1:59 p.m., the medical gas emergency shut-off valve, outside Room 9 in the SICU, was obstructed by a gurney.


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Basement - Main Hospital at Hillcrest - 3/7/13

4. At 2:10 p.m., by room L-216, the door sign stated piped in oxygen valve was located in the ceiling of the room. The room's ceiling was not equipped with a sign identifying the location of the oxygen valve.

Based on observation, the facility failed to properly maintain duct penetrations. This was evidenced by penetrations through fire/smoke barriers walls that were sealed with non-rated fire material and unlisted method. This had the potential to allow the spread of fire, resulting in injury to patients, visitors and staff. This affected 2 of 4 floors at Thornton Hospital.

Findings:

During a facility tour with the Engineering Staff from 3/5/13 to 3/12/13, the fire/smoke barriers were observed.

Third Floor - Thornton Hospital - 3/5/13

1. At 3:36 p.m., the fire wall separating the smoke compartments between the vestibule and the patient sleeping areas were observed to have its penetrations sealed by a piece of dry wall, measuring approximately 4-inches by 4-inches, screwed on top of a dry wall and foam type material around it. The wall was observed above the ceiling tiles directly above the cross corridor doors by Room 300. The building's floor plans identified the wall rating to be 1 hour. Engineering Staff 95 could not provide evidence that the method used was a listed and approved fire-stopping system. The Inspector of Records (person responsible for overseeing all alterations, modifications, and additions to the hospital building) was interviewed and he stated that the foam type material is not allowed to be used in the hospital and that the dry wall should have been anchored from stud to stud.

Second Floor - Thornton Hospital - 3/6/13

2. At 9:42 a.m., the fire wall separating the smoke compartments, located in Corridor 2-C10, was observed to have its penetrations sealed with a foam type material. The wall was observed above the ceiling tiles directly above the cross corridor doors entrance into the ICU Unit 2-231. The building's floor plans identified the wall rating to be 1 hour. Engineering Staff 95 provided a data sheet with information on the foam material used, "One-Component Polyurethane Foam Sealant HC." The product was listed as "Extremely Flammable" and that "toxic gases/fumes may be given off during burning." The Inspector of Records was interviewed and he stated that the product is not allowed to be used in the hospital.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by electrical panels that were obstructed and with combustible materials stored against equipment. This could result in an increased risk of fire. This affected 1 of 4 of the Sulpizio Cardiovascular Center.

NFPA 70, National Electric Code, 1999 Edition.
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Findings:

During a facility tour with hospital staff from 3/5/13 to 3/12/13, the electrical wiring and equipment were observed.

Second Floor - Sulpizio Cardiovascular Center - 3/11/13

At 9:48 a.m., the electrical room 2-405A located in the OR was observed that have combustible material stored in front of the electrical panel and on top of the electrical equipment. The combustible material included cardboard boxes (measuring approximately 2-feet x 2-feet x 2-feet) containing cables.

Based on observation, record review, and interview, the facility failed to maintain electrical safety. This was evidenced by incomplete documentation for annual tension and polarity testing, by electrical boxes with no covers, by the use of surge protectors and extension cords to plug appliances, by daisy chaining of surge protectors and extension cords, and by electrical panels that were obstructed. This could result in an increased risk of an electrical fire. This affected 11 of 12 floors of the Main Hospital at Hillcrest, 1 of 4 floors at Thornton Hospital, and 1 of 2 floors of the West Wing at Hillcrest.

NFPA 70, National Electric Code, 1999 Edition.
110-12 Mechanical Execution of Work. Electrical Equipment shall be installed in a neat and workman like manner,(a) Unused openings, Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
110-26. Spaces About Electrical Equipment. Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.
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.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas
(d) 3. Polarity of Receptacles. Each receptacle shall be wired in accordance with NFPA 70, National Electrical Code, to ensure correct polarity.
(f) Wet Locations.
1.* Wet location patient care areas shall be provided with special protection against electric shock. This special protection shall be provided by a power distribution system that inherently limits the possible ground-fault current due to a first fault to a low value, without interrupting the power supply; or by a power distribution system in which the power supply is interrupted if the ground-fault current does, in fact, exceed a value of 6 mA.
Exception No. 1: Patient beds, toilets, bidets, and wash basins shall not be required to be considered wet locations.
Exception No. 2: In existing construction, the requirements of 3-3.2.1.2(f)1 are not required when written inspection procedure, acceptable to the authority having jurisdiction, is continuously enforced by a designated individual at the hospital, to indicate that equipment-grounding conductors for 120-V, single-phase, 15- and 20-A receptacles, equipment connected by cord and plug, and fixed electrical equipment are installed and maintained in accordance with NFPA 70, National Electrical Code, and applicable performance requirements of this chapter. The procedure shall include electrical continuity tests of all required equipment, grounding conductors, and their connections. These tests shall be conducted as follows.
Fixed receptacles, equipment connected by cord and plug, and fixed electrical equipment shall be tested:
(a) When first installed
(b) Where there is evidence of damage
(c) After any repairs, or
(d) At intervals not exceeding 6 months
3-3.3.2.5 Test Equipment. Electrical safety test instruments shall be tested periodically, but not less than annually, for acceptable performance.
3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Findings:

During a facility tour with Engineering Staff from 3/5/13 to 3/12/13, the electrical wiring and equipment were observed.

Main Hospital at Hillcrest - 3/5/13

1. At 11:31 a.m., records for annual tension and polarity testing of electrical receptacles were provided. There records indicated that not all patient care area receptacles were tested. During an interview at 11:34 a.m., Engineering Staff 101 stated that only receptacles in critical care areas were tested annually. All other receptacles in general care areas were visually inspected every six months.

Eleventh Floor - Main Hospital at Hillcrest - 3/6/13

2. At 9:41 a.m., there was a six-plug surge protector plugged into another six-plug surge protector in the 11 West Charge Nurse Office.

Tenth Floor - Main Hospital at Hillcrest - 3/6/13

3. At 9:54 a.m., there was a refrigerator and a six-plug surge protector plugged into another six-plug surge protector, in the Nurse Manager Office, Room 10-311.

Ninth Floor - Main Hospital at Hillcrest - 3/6/13

4. At 10:41 a.m., there was a six-plug surge protector plugged into a three-plug extension cord, in Doctors Sleep Room 9-305.

5. At 11:15 a.m., there was a six-plug surge protector plugged into a six-plug surge protector in Room 9-260.

Seventh Floor - Main Hospital at Hillcrest - 3/6/13

6. At 1:51 p.m., there was a coffee maker plugged into a three-plug extension cord in the 7 West Staff Lounge, Room 728.

Third Floor - Main Hospital at Hillcrest - 3/7/13

7. At 9:31 a.m., there was an approximately 16-inch by 12-inch electrical box with no cover in Electrical Room 3-301.

First Floor - Main Hospital at Hillcrest - 3/7/13

8. At 2:35 p.m., there were two "volunteer check-in" computer work stations plugged into a three-plug extension cord in the Cafeteria.

9. At 3:10 p.m., there was a refrigerator in a six-plug surge protector in Suite 1-138, Image Services Administration.

First Floor - Main Hospital at Hillcrest - 3/8/13

10. At 8:59 a.m., Electrical Panel FH 12123 was blocked by a trash receptacle outside of the pharmacy.


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Second Floor - Thornton Hospital - 3/6/13

11. At 9:01 a.m., there were items stored up against the electrical panel in room 2-C28.

12. At 10:01 a.m., there was a yellow extension cord in the Cardiac EP Lab 2. The lab technician was interviewed on 3/11/13 at 2:04 p.m., she stated that they had been using the extension cord to plug in the carto machine (equipment used for mapping the heart). Rust was observed on the metal hinges to the port covers and the technician stated that it had been due to the extension cord being there for a long time. Engineering Staff 95 stated that the room had not been one of the rooms assessed, after complaint #314117, to ensure that enough receptacle outlets were installed to eliminate the use of extension cords and multi-outlet adapters in patient care areas.


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West Wing at Hillcrest - 3/5/13

13. At 3:44 p.m., the record showed tension and polarity was not done for the West Wing receptacles.

Basement - Main Hospital at Hillcrest - 3/7/13

14. At 3:38 p.m., in the kitchen, a refrigerator was plugged into an orange extension cord.

First Floor- Main Hospital at Hillcrest - 3/7/13

15. At 3:53 p.m., a computer and the accessories on a desk and a chair blocked access to the electrical panel 1EPK in the kitchen office.