HospitalInspections.org

Based on observation, the facility failed to maintain their interior finish. This was evidenced by penetrations in ceilings and walls. During a fire, this could allow smoke and flames to pass through the ceilings and walls and harm patients, visitors, and staff. This affected two of seven floors in the Culver City Pavilion building, and three of seven floors in the Hollywood Campus.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's interior finish and smoke barrier construction.

Culver City Pavilion, Third Floor:
1. On 1/22/19, at 4:33 p.m., in the Social Services Coordinator room, an unsealed penetration measuring approximately one inch in diameter went through the ceiling. Two cables passed through the hole.

Hollywood Campus:
2. On 1/24/19, at 9:07 a.m., in the Central Supply Room in the Basement, an unsealed penetration measuring approximately one inch in diameter went through the entrance wall.

3. At 9:49 a.m., in the Hot Water Storage Tank Room, off the Sixth Floor Nursing Office, five penetrations measuring approximately one inch went through the west wall.

4. At 10:07 a.m., in the Case Manager Office, Fifth Floor, an unsealed penetration measuring approximately two inches in diameter went through the southeast wall. A cable went through the penetration. The Life Safety Coordinator said it should have been capped.

Based on observation and interview, the facility failed to maintain the exit doors. This was evidenced by the failure to easily exit the facility after the exit doors were released upon the activation of the fire alarm system. This could result in a delay to evacuate the building resulting to injury. This affected one of two floors in the Van Nuys Campus.

7.2.1.4.5 Door Leaf Operating Forces.
7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:
(1) The opening forces for interior side-hinged or pivoted swinging door leaves without closers shall not exceed 5 lbf (22 N).
(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.
(3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided
in Chapters 22 and 23.
(4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9.
7.2.1.4.5.2 The forces specified in 7.2.1.4.5 shall be applied to the latch stile.
7.2.1.5 Locks, Latches, and Alarm Devices.
7.2.1.5.1 Door leaves shall be arranged to be opened readily from the egress side whenever the building is occupied.

Finding:

During a tour of the facility with the Hospital Staff on 1/24/19, the surveyor observed the facility's fire alarm system and doors.

Van Nuys Campus:
1. On 1/24/19, at 3:54 p.m., there was a door leaf that released from the magnetic device upon the activation of the fire alarm system. The door required more than 5 lb of pressure to open because it became stuck with the other door. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain the egress doors. This was evidenced by the failure to maintain egress doors free from impediments, and by the failure to secure a refrigerator located in the egress pathway. This could result in a delay to exit the facility during an emergency. This affected the basement in the Culver City Pavilion building, and one of six floors in the Hollywood Campus.

NFPA 101, Life Safety Code, 2012 Edition
19.2 Means of Egress Requirements
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
7.1.10.1* General. 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.
7.1.10.2.2 No obstruction by railings, barriers, or gates shall divide the means of egress into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's egress doors.

Culver City Pavilion, Basement:
1. On 1/23/19, at 4:46 p.m., there was an egress door blocked with a CAT Scan machine in the Operating Room Department. The Hospital Staff (Adm10) concurrently acknowledged the deficiency.

Hollywood Campus, First Floor:
2. On 1/24/19, at 11:38 a.m., there was a clinical refrigerator in the Laboratory that was not anchored to the ground to prevent it from tipping over, and there was a smaller refrigerator mounted on top. The height of the combined refrigerators was approximately 6-feet. The Hospital Staff (Adm23) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain their self-closing doors. This was evidenced by doors which failed to self-close and latch, and by doors propped open with wedges. During a fire, this could allow smoke and flames to pass through the open door and harm patients, visitors, and staff. This affected one of six floors in the Culver City Pavilion building, two of seven floors in the Culver City Tower building, one of one floor in the Van Nuys Campus, and the single story building attached to the Tower.

NFPA 101, Life Safety Code, 2012 Edition
19.2 Means of Egress Requirements.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.
7.1.10.1* General. 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.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's self-closing doors.

Culver City Pavilion, Fourth Floor:
1. On 1/22/19, at 4:10 p.m., in the Clean Utility room, the door failed to self-close and latch.

Culver City Tower, Basement:
2. On 1/23/19, at 9:20 a.m., in the Storage room (signed as the Radiation Room), a doorstop prevented the door from closing. The doorstop was placed there to supplement the kickstand, which was attached to the door and not able to hold it open.

Culver City Tower, Fourth Floor:
3. At 10:00 a.m., in the IT office, an electrical UPS unit was used as a doorstop.

4. At 10:03 a.m., in the Storage room, a computer stand was used as a doorstop.

Van Nuys Campus, First Floor:
5. On 1/24/19, at 3:15 p.m., the door from the Kitchen leading to the corridor failed to self-close and latch. The Engineer said the door needed adjustment.

6. At 3:18 p.m., the door from the Kitchen to the Dietary Office failed to self-close and latch.


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Culver City Single Story Attached to Tower
7. On 1/23/19, at 10 a.m., there was a door propped open with a plastic wedge in the Pathology Laboratory suite. The Hospital Staff (Adm19) concurrently acknowledged the deficiency and removed the wedge.

8. At 10:27 a.m., there was a door held open with a cement weight in the Facility Operation Center. The Hospital Staff (Adm19) concurrently acknowledged the deficiency and removed the weight.

9. At 10:35 a.m., there was a door held open with a wooden chair in the Human Resource conference room. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

10. At 10:47 a.m., there was door held open with a plastic wedge in the copy room adjacent to the restroom. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units which failed to illuminate when tested. During a fire or other emergency, this could cause confusion or delay in evacuation and could harm patients, visitors, and staff. This affected one of six floors in the Hollywood Campus, and one of six floors in the Culver City Pavilion building.

NFPA 101, Life Safety Code, 2012 Edition
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.
7.9.2.1* Emergency illumination shall be provided for a minimum of 11/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the end of 11/2 hours. A maximum to minimum illumination uniformity ratio of 40 to 1 shall not be exceeded.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 11/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's emergency lighting units.

Hollywood Campus, Fourth Floor:
1. On 1/24/19, at 10:24 a.m., the emergency light unit Number 17 on the southwest corridor, failed to illuminate when the test button was pressed. Staff interviewed said that management told them the unit was not working and that they should retrieve a portable light unit from the closet during an emergency.


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Culver City Pavilion, Fourth Floor:
2. On 1/23/19, at 9:22 a.m., the emergency lights were tested in the Kitchen Room and they failed to illuminate. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain the exit signs. This was evidenced by the failure to mark the exit door on the rooftop, and by the failure to have a direction of travel to the exit discharge. This could result in a delay and confusion to escape the building during an event of an emergency. This affected the one of six floors in the Culver City Pavilion building, and one of seven floors in the Culver City Tower building.

NFPA 101, Life Safety Code, 2012 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.
7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.
7.10.1.2.2* Horizontal components of the egress path within an exit enclosure shall be marked by approved exit or directional exit signs where the continuation of the egress path is not obvious.
7.10.1.3 Exit Door Tactile Signage. Tactile signage shall be provided to meet all of the following criteria, unless otherwise provided in 7.10.1.4:
(1) Tactile signage shall be located at each exit door requiring an exit sign.
(2) Tactile signage shall read as follows: EXIT.
(3) Tactile signage shall comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's exit signs.

Culver City Pavilion, Mechanical Roof:
1. On 1/22/19, at 3:26 p.m., there was no exit sign visible on the southwest exit door of the rooftop. The Hospital Staff (PO7) concurrently acknowledged the deficiency and stated he is not sure what happened to the sign.

Culver City Tower, First Floor:
2. On 1/23/19, at 10:45 a.m., the exit sign did not have a direction of travel to the exit discharge. The exit sign was located next to Radiology Room 5. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain the kitchen grease filters. This was evidenced by grease accumulation inside two of the filters. This could result in fire and injury to the entire facility. This affected one of six floors in the Hollywood Campus.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2.5.1 Cooking facilities shall be protected in accordance with 9.2.3, unless otherwise permitted by 19.3.2.5.2, 19.3.2.5.3, or 19.3.2.5.4.
9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 2011 Edition
13.6.2 All filters shall be cleaned or replaced in accordance with the manufacturer's instructions.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's kitchen grease filters.

Hollywood Campus, First Floor
1. On 1/24/19, at 10:47 a.m., there was grease accumulation on two out of the four kitchen hood grease filters. The Hospital Staff (Adm21) concurrently acknowledged the deficiency. The Hospital Staff (Adm22) stated they clean the filters every week and they are scheduled to clean them again on 1/27/19.

Based on observation, document review, and interview, the facility failed to maintain a fully functioning fire alarm system (FAS) as evidenced by an initiating device that failed to actuate. This could result in the delay to notify building occupants during a fire emergency. This affected six of six floors in the Hollywood Campus.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.1.5* 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 and Signaling Code.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
14.2.1.2.2 System defects and malfunctions shall be corrected.
23.8.1.1* Actuation Time. Actuation of alarm notification appliances or emergency voice communications, fire safety functions, and annunciation at the protected premises shall occur within 10 seconds after the activation of an initiating device.
23.18.3.4 The maximum allowable response delay from activation of an initiating device to receipt and display by the receiver/fire alarm control unit shall be 10 seconds.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the Fire Alarm System (FAS) and requested documentation.

Hollywood Campus, Roof:
On 1/24/19, at 12 p.m., the manual pull station that was activated by the stairwell exit, failed to sound an alarm throughout the building. The pull station was tested a second time at 12:05 p.m., and it failed to alarm throughout the building. The Hospital Staff (Adm4) concurrently acknowledged the deficiency. The annual fire alarm inspection report, dated 11/29/18, had identified the pull station as failing.

Based on observation and interview, the facility failed to maintain the automatic release device of fire doors. This was evidenced by the failure of the fire doors to release from the hold open device upon activation of the Fire Alarm System (FAS). This could result in the spread of smoke and fire to the next compartment during a fire. This affected one of six floors in the Culver City Pavilion building.

NFPA 101 - Life Safety Code, 2012 Edition
19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.
(5) The release by means of smoke detection of one door leaf in a stair enclosure results in closing all door leaves serving that stair.
9.6.1.5* 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 and Signaling Code.

NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition
14.2 General.
14.2.1.1.2 Inspection, testing, and maintenance programs shall verify correct operation of the system.
14.2.1.2 Impairments.
14.2.1.2.2 System defects and malfunctions shall be corrected.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's cross corridor doors.

Culver City Pavilion, Sixth Floor
1. On 1/23/19, at 1:41 p.m., the south and north fire doors did not release from hold open devices during the fire alarm system test in the Behavioral Health Unit. The Hospital Staff (VP2) concurrently acknowledged the deficiency.


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Culver City Pavilion, Sixth Floor:
2. On 1/23/19, at 2:04 p.m., all the fire doors in the Behavioral Health Unit did not release from their magnet hold open devices during the activation of the inspector's test valve, two smoke detectors, and a manual pull station. The Hospital Staff (Adm4) concurrently acknowledged the deficiency and said that he wants to do a complete reset of the entire fire alarm system. At 2:07 p.m., the facility's fire alarm vendor (Ven16) indicated that he had witnessed all doors releasing and working as designed when he tested the FAS on 12/4/18.

3. At 3:28 p.m., the FAS displayed troubles and Ven16 stated that he will need to complete a new program upgrade to clear all troubles that will take approximately 15 minutes.

4. At 3:43 p.m., the FAS continued to display the following trouble: "Ground Fault."

Culver City Pavilion, Basement:
5. At 4:27 p.m., the pair of cross corridor doors by the Fire Pump Control Room, failed to release from their magnet hold open devices during the activation of the inspector's test valve.

Culver City Pavilion:
6. On 1/25/19, at 8:29 a.m., the FAS continued to display the following trouble: "Ground Fault Datacard2."

Based on observation, record review, and interview, the facility failed to maintain their Water-Based Fire Protection Systems. This was evidenced by corrosion on the fire pump assembly, by failing to complete annual inspections, by the failure to maintain the sprinklers free from obstruction with a minimum of 18-inch clearance below the sprinkler's deflector, by the failure to maintain the sprinklers free of physical damage, debris, and corrosion, and by the failure to have three spare sprinklers and a wrench. This could cause delay or failure of the water-based sprinkler system during a fire and could harm patients, visitors, and staff. This affected two of seven floors in the Culver City Tower, the sub-basement and one of six floors in the Culver City Pavilion, one of one floor in the Van Nuys Campus, and the basement and one of six floors in the Hollywood Campus.

NFPA 101, Life Safety Code, 2012 Edition
9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level.
5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.
5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.

NFPA 13 - Standard for the Installation of Sprinkler Systems, 2010 Edition
6.2.9.1* A supply of at least six spare sprinklers (never fewer than six) shall be maintained on the premise so that any sprinklers that have operated or been damaged in any way can be promptly replaced.
6.2.9.6* One sprinkler wrench as specified by the sprinkler manufacturer shall be provided in the cabinet for each type of sprinkler installed to be used for the removal and installation of sprinklers in the system.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's sprinkler system.

Culver City Pavilion, Sub-Basement:
1. On 1/22/19, at 3:10 p.m., corrosion was observed on the pipe and assembly directly below the fire pump that needs to be addressed to prevent failure or damage to the fire pump system. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.

Hollywood Campus:
2. On 1/25/19, at 8:43 a.m., the facility failed to provide the annual inspection record for the sprinklers, the pipes, and the pipe hangers in accordance with NFPA 25. During an interview with Hospital Staff (Adm4), he stated that he only had the annual record showing the main drain test.


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Culver City Tower, Third Floor:
3. On 1/22/19, at 4:45 p.m., in the Intensive Care Unit's (ICU) Clean Utility Room, the sprinkler was contaminated with a foreign substance.

4. At 4:47 p.m., in the ICU Staff Lounge, the sprinkler was contaminated with a foreign substance.

Van Nuys Campus, First Floor:
5. On 1/24/19, at 2:37 p.m., in the Intake Office, the sprinkler was contaminated with a white foreign material.


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Culver City Pavilion, Sixth Floor:
6. On 1/22/19, at 4 p.m., there was a bent sprinkler deflector in Room 610. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

7. At 4:02 p.m., there was a bent sprinkler deflector in Room 614. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

8. At 4:14 p.m., there was a sprinkler head obstructed with two plastic bags in the patient belonging room. The bags were approximately 2 inches away from the deflector. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

9. At 4:23 p.m., there was a sprinkler head with corrosion in the stairway on the B-wing. The stairway was not enclosed and the sprinkler head was exposed to outdoor weather. The Hospital Staff (Adm19) concurrently acknowledged the deficiency and stated it was due to moisture.

10. At 4:28 p.m., there was a sprinkler missing the deflectors in Room 636. The room was used for single patient observation. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Culver City Tower, First Floor:
11. On 1/23/19, at 10:55 a.m., there was a sprinkler head obstructed with a cardboard box containing gauze sponges in a storage room located in the Emergency Department. The box was approximately 8 inches away from the deflector. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

12. At 10:59 a.m., the stock of spare sprinklers in the Main Room contained only three sprinklers and there was no wrench. The Hospital Staff (Adm19) concurrently acknowledged the deficiency and stated they should have six spares and the wrench.

Hollywood Campus, Basement:
13. On 1/24/19, at 9:01 a.m., there was a sprinkler deflector obstructed with plastic bags in a closet room located in the Operating Room Department. The bags were approximately 4 inches away from the deflector. The Hospital Staff (Adm10) concurrently acknowledged the deficiency.

Hollywood Campus, Third Floor:
14. At 9:40 a.m., there was a sprinkler head with debris accumulation in Room 305 Bed A. There was an air vent approximately 10 inches away from the sprinkler. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

15. At 9:55 a.m., there was a sprinkler escutcheon plate not flushed to the ceiling in the shower room across Room 307. There was approximately a ¼ inch gap between the ceiling and the plate. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by the failure to inspect an extinguisher one of the twelve months. This could result in the device to malfunction in the event of a fire. This affected the designated smoking area at the Hollywood Campus, and the single story building attached to the Tower in Culver City.

NFPA 101, Life Safety Code, 2012 Edition
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
7.2.4 Inspection Record Keeping.
7.2.4.3 Where at least monthly manual inspections are conducted, the date the manual inspection was performed the initials of the person performing the inspection shall be recorded.
7.2.4.4 Where manual inspections are conducted, records for manual inspections shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or by an electronic method.
7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's fire extinguishers.

Hollywood Campus:
1. On 1/24/19, at 9:40 a.m., the portable fire extinguisher in the designated smoking area, located on the West side of the exterior part of the building, was missing its annual service tag. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.


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Culver City Single Story Attached to Tower:
2. On 1/23/19, at 10:20 a.m., the tag on the fire extinguisher did not have a monthly inspection for December 2018. It was across the Facilities Operation Center. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain their corridor doors. This was evidenced by doors which failed to latch when closed, and by doors that were impeded from closing. During a fire, this could allow smoke and flames to pass through the open door and harm patients, visitors, and staff. This affected two of six floors in the Hollywood Campus, one of one floor in the Van Nuys Campus, one of six floors in the Culver City Pavilion, and one of six floors in the Hollywood campus.

NFPA 101 Life Safety Code, 2012 Edition
7.1.10.1* General. 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.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits or their access thereto, egress therefrom, or visibility thereof.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's corridor doors.

Hollywood Campus, Fifth Floor:
1. On 1/24/19, at 10:10 a.m., the door to patient sleeping room 510 was blocked from closing by a bed.

2. At 10:11 a.m., the door to patient sleeping room 508 did not latch when closed.

Hollywood Campus, Fourth Floor:
3. At 10:27 a.m., the door to patient sleeping room 406 did not latch when closed.

4. At 10:28 a.m., the door to patient sleeping room 404 did not latch when closed.

Van Nuys Campus:
5. At 3:25 p.m., the door to patient room 101 failed to latch when closed.


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Culver City Pavilion, Sixth Floor:
6. On 1/23/19, at 4:29 p.m., the Equipment Room door was obstructed with medical device equipment. The door led to the corridor. The Hospital Staff (Adm10) concurrently acknowledged the deficiency.

Hollywood Campus, Third Floor:
7. On 1/24/19, at 9:49 a.m., the door to Room 306 was obstructed with patient bed A. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain a 30-minute fire-rated smoke barrier wall. This was evidenced by an unsealed conduit in the smoke barrier wall. This could result in the spread of smoke and fire to the next compartment during a fire. This affected the single story building attached to the Tower in Culver City.

NFPA 101 - Life Safety Code, 2012 Edition
8.5 Smoke Barriers.
8.5.1* General. Where required by Chapters 11 through 43, smoke barriers shall be provided to subdivide building spaces for the purpose of restricting the movement of smoke.
8.5.2* Continuity.
8.5.2.1 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 by use of a combination thereof.
8.5.2.2 Smoke barriers shall be continuous through all concealed spaces, such as those found above a ceiling, including interstitial spaces.
8.5.2.3 A smoke barrier required for an occupied space below an interstitial space shall not be required to extend through the interstitial space, provided that the construction assembly forming the bottom of the interstitial space provides resistance to the passage of smoke equal to that provided by the smoke barrier.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor observed the facility's smoke barriers.

Culver City Single Story Attached to Tower:
1. On 1/25/19, at 9:25 a.m., there was a penetration in a metal conduit pipe approximately 1 inch in diameter. There was an orange protective sleeve and three satellite cables going through the conduit. The smoke barrier was located in the Intensive Outpatient Program. The Hospital Staff (Adm20) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain the electrical systems. This was evidenced by a broken Ground-Fault Circuit Interrupter (GFCI), by the failure to use covers on the electrical panel to prevent contact with energized parts, and by blocked access to the electrical and data room. This could result in electrical shock. This affected the single story attached to the Tower.

NFPA 101, Life Safety Code, 2012 Edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
110.56 Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.
230.95 Ground-Fault Protection of Equipment.
(C) Performance Testing. The ground-fault protection system shall be performance tested when first installed on site. The test shall be conducted in accordance with instructions that shall be provided with the equipment. A written record of this test shall be made and shall be available to the authority having jurisdiction.
314.28 Pull and Junction Boxes and Conduit Bodies.
Boxes and conduit bodies used as pull or junction boxes shall comply with 314.28(A) through (E).
(C) Covers. All pull boxes, junction boxes, and conduit bodies shall be provided with covers compatible with the box or conduit body construction and suitable for the conditions of use. Where used, metal covers shall comply with the grounding requirements of 250.110.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's electrical equipment.

Culver City Pavilion, First Floor:
1. On 1/22/19, at 4:46 p.m., the GFCI located in the woman's restroom by the laboratory, had a broken reset switch. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.


40597



Culver City Single Story Attached to Tower
2. On 1/23/19, at 10:22 a.m., there were two electrical panels missing three raceway knockouts adjacent to the Facilities Department. The Hospital Staff (Adm18) concurrently acknowledged the deficiency and stated the room is not in use.

Culver City Pavilion, Basement:
3. On 1/23/19, at 4:44 p.m., the door to the electrical and data room was blocked with a rolling cart in the Operating Room Department. The door was labeled "Do Not Block and Maintain 36-inch Clearance." The Hospital Staff (Adm10) concurrently acknowledged the deficiency.

Based on interview, the facility failed to ensure that staff had knowledge of the proper fire protection procedures, as evidenced by staff that could not determine the correct procedure to use in case of fire. This could cause confusion and delay during a fire, and result in injury to patients, visitors, and staff. This affected one of seven floors in the Culver City Outpatient Medical Plaza building.

NFPA 101 Life Safety Code, 2012 Edition
19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures devices.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors interviewed staff to determine their knowledge and usage of life safety equipment.

Culver City Outpatient Medical Plaza
1. At 1:20 p.m., Staff 24 in Suite 105 was interviewed on how she would respond to a fire in the building. She failed to recall how to contain a fire in the room and did not know if the building was equipped with a manual fire alarm pull station. The building was observed with two pull stations, one at each exit door outside of Suite 105. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.


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Culver City Outpatient Medical Plaza
2. At 1:27 p.m., Staff 25 was interviewed on what she would do in case of fire in a patient room. She failed to mention or identify the components of R.A.C.E. (Rescue, Alarm, Contain, Extinguish or Evacuate) or P.A.S.S. (Pull, Aim, Squeeze, Sweep) with a portable fire extinguisher. She failed to mention to shut the door after the patient is rescued.

Based on observation and interview, the facility failed to provide accurate evacuation plans posted on walls. This was evidenced by failing to include actual locations of fire alarm boxes on the posted evacuation plans. This could potentially delay the activation of a fire alarm. This affected one of seven floors in the Culver City Outpatient Medical Plaza building.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition
10.18.1.2* Floor plan drawings should be drawn to an indicated scale and should include the following.
(1) Evacuation routes.
(2) Location of fire alarm boxes.
(3) Location of fire extinguishers.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor observed the posted evacuation plans.

Culver City Outpatient Medical Plaza
1. On 1/23/19, at 1:28 p.m., the posted evacuation map located by Exam Room 3 in Suite 105, failed to mark the location of the fire alarm pull stations. The building was observed with two pull stations, one at each exit door outside of Suite 105. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.

Based on observation and record review, the facility failed to maintain smoking regulations. This was evidenced by no smoking signage missing from areas containing combustible liquids. This could lead to patients, visitors, or staff to smoke in prohibited areas that could cause fire and result in injury. This affected the exterior part of the building at Culver City Pavilion.

NFPA 101, Life Safety Code, 2012 Edition
19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.

Findings:

During a facility tour with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the no smoking signage and areas that shall prohibit smoking.

Culver City Pavilion, Ground Floor:
1. On 1/22/19, at 4:35 p.m., there were multiple cigarette butts (greater than 12) found throughout the back alley outside the kitchen area and around a kitchen grease collection container. The smoking policy titled SMP.007, indicated that smoking was restricted to designated smoking areas and it included a map found on page 4 that marked this location. The cigarette butts were found outside of the designated smoking area that was marked on the map. The area around the grease collection container did not display a signage to prohibit smoking. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.



40325



Culver City Pavilion, Ground Floor:
2. On 1/22/19, at 2:47 p.m., there was no sign prohibiting smoking, either on the fence or on the gate of the generator enclosure. The area contained the storage of diesel fuel for the generator. The Assistant Administrator acknowledged the finding.

Based on record review and interview, the facility failed to maintain their cryogenic bulk system. This was evidenced by the absence of an emergency oxygen supply connection and annunciatior. This could delay response to identifying and addressing problems with the oxygen supply that can result in injury to patients, staff, and visitors. This affected two of three buildings at the Culver City Campuses.

NFPA 99, Standard for Health Care Facilities, 2012 Edition
5.1.3.5.12.4* The bulk systems shall have a local signal that visibly indicates the operating status of the equipment and an indicator at all master alarms under the following conditions:
(1) When or at a predetermined set point before the main supply reaches an average day's supply, indicating low contents
(2) When or at a predetermined set point before the reserve supply begins to supply the system, indicating reserve is in use
(3) When or at a predetermined set point before the reserve supply contents fall to one day ' s average supply, indicating reserve low
(4) If the reserve is a cryogenic vessel, when or at a predetermined set point before the reserve internal pressure falls too low for the reserve to operate properly, indicating reserve failure
(5) Where there is more than one main supply vessel, when or at a predetermined set point before the secondary vessel begins to supply the system, indicating changeover
5.1.3.5.13* Emergency Oxygen Supply Connection (EOSC).
Emergency oxygen supply connections (EOSCs) shall be installed to allow connection of a temporary auxiliary source of supply for emergency or maintenance situations where any of the following conditions exist:
(1) The bulk cryogenic liquid central supply system is outside of and remote from the building that the oxygen supply serves.
(2) There is no connected oxygen reserve sufficient for an average day ' s supply within the building. (see 5.1.3.5.14 for requirements for such reserves).
(3) Multiple freestanding buildings are served from a single oxygen source such that damage to the interconnecting oxygen line could result in one or more buildings losing oxygen supply, in which case each building is required to be provided with a separate emergency connection.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor requested information on the cryogenic bulk system alarm annunciators.

Culver City Pavilion:
1. On 1/25/19, at 9:05 a.m., the cryogenic system was not equipped with an emergency oxygen supply connection (oxygen autofill port) and an annunciator. The Hospital Staff (Adm14) concurrently acknowledged the deficiency and stated that the construction is in progress. Adm14 explained that they plan to continue with this project soon after their applicable method of procedures (MOPs) receives approval for a planned shutdown to the oxygen supply system. This finding was previously cited during a Life Safety Code Survey conducted in September 2015 and July 2016.

Based on observation and interview, the facility failed to maintain the electrical systems. This was evidenced by the failure to maintain the integrity of the receptacles in patient care vicinities. This could result in failure of the receptacles or electrical shock. This affected one of seven floors in the Culver City Tower, and one of six floors in Hollywood Campus.

NFPA 101, Life Safety Code, 2012 Edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electric Code
314.21 Repairing Noncombustible Surfaces. Noncombustible surfaces that are broken or incomplete around boxes employing a flush-type cover or faceplate shall be repaired so there will be no gaps or open spaces greater than 3 mm (1/8 in.) at the edge of the box.
406.5 Receptacle Mounting. Receptacles shall be mounted in boxes or assemblies design for the purpose, and such boxes or assemblies shall be securely fastened in place unless otherwise permitted elsewhere in this Code.
(A) Boxes that are set back. Receptacles mounted in boxes that are set back from the finished surface as permitted in 314.20 shall be installed such that the mounting yoke or strap of the receptacle is held rigidly at the finished surface.
(B) Boxes that are flush. Receptacles mounted in boxes that are flush with the finished surface or project therefrom shall be installed such that the mounting yoke or strap of the receptacle is held rigidly against the box or box cover.
(C) Receptacles mounted on covers. Receptacles mounted to and supported by a cover shall be held rigidly against the cover by more than one screw or shall be a device assembly or box cover listed and identified for securing by a single screw.
(D) Position of receptacle faces. After installation, receptacle faces shall be flush with or project from faceplates of insulating material and shall project a minimum of 0.4 mm from metal faceplates.
(E) Receptacles in countertops and similar work surfaces in dwelling units. Receptacles shall not be installed in a face-up position in countertop or similar work surfaces.
(F) Exposed Terminals. Receptacles shall be enclosed so that live wiring terminals are not exposed to contact.
406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Finding:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor observed the facility's electrical systems.

Culver City Pavilion, Fourth Floor:
1. On 1/23/19, at 9:29 a.m., there was a receptacle that was not flush with the wall surface in Room 408. The receptacle was approximately a ¼ inch away from the wall, located behind the patient bed. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Hollywood Campus, Third Floor:
2. On 1/24/19, at 9:30 a.m., there was an electrical box with exposed wires in Room 301. It did not have a faceplate and it was next to a patient bed. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Hollywood Campus, First Floor:
3. On 1/24/19, at 11:22 a.m., there was a broken faceplate in the Urgent Care Unit. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by generators that were not monitored by remote alarm annunciators. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients. This affected two of three buildings at the Culver City Campuses.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition.
5.6.6 Remote Controls and Alarms. A remote, common audible alarm shall be provided as specified in 5.6.5.2(4) that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor requested information on the generators alarm annunciators.

Culver City Pavilion:
1. On 1/25/19, at 9:15 a.m., there was no remote alarm annunciator for Generator 2 (Manufactured by Kurz & Root Company, Model #KD400, 400 kW, 500 KVA) that was connected to the Pavilion building. The Hospital Staff (Adm4) concurrently acknowledged the deficiency. This finding was previously cited during a Life Safety Code Surveys conducted in September 2015 and July 2016.

Culver City Tower:
2. At 9:17 a.m., there was no remote alarm annunciator for Generator 3 (Manufactured by Electric Machinery, Serial #1R919231, 75 KVA) that was connected to the Tower building. The Hospital Staff (Adm4) concurrently acknowledged the deficiency. This finding was previously cited during a Life Safety Code Surveys conducted in September 2015 and July 2016.

Based on document review and interview, the facility failed to maintain the battery-powered emergency lighting units in the operating rooms. This was evidenced by the failure to inspect the emergency lighting units annually. This could result in failure of the emergency lights to operate during a power outage. This affected one of seven floors in the Hollywood Campus.

NFPA 99, Standard for Healthcare Facilities, 2012 Edition
6.3.2.2.11 Battery-Powered Lighting Units.
6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.
6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.
6.3.2.2.11.3 The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.
6.3.2.2.11.4 Units shall be capable of providing lighting for 11/2 hours.
6.3.2.2.11.5 Units shall be tested monthly for 30 seconds, and annually for 30 minutes.

Finding:

During document review with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor requested documentation for the facility's emergency lighting.

1. On 1/25/19, at 8:35 a.m., the annual inspection of the emergency lighting units for the operating rooms was not provided. The Hospital Staff (Adm4) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by power strips tensioned by the cords of electrical devices, by overloaded power strips, the use of multi-outlet adapters and extension cords in daisy chains, and a non-UL power strip. This could cause sparking, smoke, and fire, and could harm patients, visitors, and staff. This affected two of six floors in the Culver City Pavilion building, the Basement and one six floors in the Culver City Tower building, one of six floors in the Hollywood building, one of one floor in the Van Nuys building, and the single story attached to the Tower.

NFPA 101, Life Safety Code, 2012 Edition
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted in 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 to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(8)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage 400.10 Pull at Joints and Terminals. Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyor observed the facility's electrical equipment.

NFPA 99, Health Care Facilities Code, 2012 Edition
10.2.3.5 Cord Strain Relief.
10.2.3.5.1 Cord strain relief shall be provided at the attachment of the power cord to the appliance so that mechanical stress, either pull, twist, or bend, is not transmitted to internal connections.
10.2.3.5.2 A strain relief molded onto the cord shall be bonded to the jacket and shall be of compatible material.
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart-mounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2)* The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4)* The electrical and mechanical integrity of the assembly is regularly verified and documented.
(5)* Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe.

NFPA 70, National Electrical Code, 2011 Edition:
400.10 Pull at Joints and Terminals.
Flexible cords and cables shall be connected to devices and to fittings so that tension is not transmitted to joints or terminals.

Findings:

On 1/22-24/19, during a facility tour with the Assistant Administrator, the Vice President of Faculty Development, the Environmental Health and Safety Manager, the Chief Operations Officer, the Leadman, the Director of Environmental Services, the Nursing Administrator, the Engineer, the Chief Engineer and the Life Safety Coordinator, the power strips and electrical devices were observed.

Culver City Pavilion, Fifth Floor:
1. At 3:53 p.m., in the P5 Director's Office, a UL power strip was hanging in mid-air, held up by its power cord, which was connected to the duplex receptacle wall outlet. A laminator was connected to the power strip.

2. At 4:03 p.m., in the CDI office Room 544, a 12.5 A (amperes or amps, a unit measuring electric current flow drawn by equipment] Keurig coffeemaker and three computer monitors, 0.75 A each, 14.75 A total, were connected to a 15 A Tripp-Lite UL power strip. The maximum permissible ampere is 11.25 A [15 x .75]. The power strip was therefore overloaded by 3.5 A.

Culver City Tower, Basement:
3. At 9:13 a.m., in the EVS Breakroom in the Basement, a six-outlet adapter was connected to the duplex receptacle wall outlet. A refrigerator was plugged into the adapter.

Culver City Tower, Sixth Floor:
4. At 9:45 a.m., in the Day Room, an extension cord measuring approximately 50 feet in length was daisy-chained to a three-outlet adapter, which was connected by a cord measuring approximately 10 feet in length to the duplex receptacle wall outlet. A television, VCR and Blu-ray player were connected to the adapter.

5. At 9:48 a.m., in the Counseling Room, a computer and router were connected to a non-UL power strip, which was then connected to the duplex receptacle wall outlet.

Hollywood Campus, Sixth Floor:
6. At 9:32 a.m., in the Materials Management Office, a portable heater was connected to a 15 A (amperes or amps, a unit measuring electric current flow drawn by equipment) UL-listed power strip. The heater was 12.5 A. The maximum permissible ampere is 11.25 A [15 x .75]. The power strip was therefore overloaded by 1.25 A.

Note: Although the heater was connected with its power light illuminating, it was not switched on and therefore not subject to the temperature test as proscribed in NFPA 101, Life Safety Code, 2012 edition, 18.7.8.

7. At 9:56 a.m., in the Machine Shop, an extension cord connected one power strip to another power strip, in a daisy chain. The power strips were UL-listed.

Van Nuys Campus:
8. At 3:08 p.m., in the Administrative Assistant Office, three electrical devices were plugged into a six-outlet adapter which was connected to the duplex receptacle wall outlet.

9. At 3:09 p.m., also in the Administrative Assistant office, six electrical devices were connected to a Tripp-ex power strip, which was then connected to a six-outlet adapter, in a daisy-chain. The adapter was plugged into the duplex receptacle wall outlet.


40597



Culver City Pavilion, Sixth Floor:
10. On 1/22/19, at 4:11 p.m., there was a power strip plugged into a power strip. One of those power strips was taped to the floor and it was plugged directly into a red emergency receptacle. The Hospital Staff (Adm19) concurrently acknowledged the deficiency.

Culver City Single Story Attached to Tower:
11. On 1/25/19, at 9:13 a.m., there was a power adapter plugged into an orange extension cord. The extension cord was plugged directly in the wall receptacle. The Hospital Staff (Adm20) concurrently acknowledged the deficiency.

Based on observation and interview, the facility failed to maintain the medical gas storage. This was evidenced by the failure to separate a flammable tank from other oxygen cylinders. This could result in a fire and injury. This affected the outdoor storage area in the Culver City Tower building.

NFPA 101, Life Safety Code, 2012 Edition
19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

NFPA 99, Standard for Healthcare Facilities, 2012 Edition
5.3.6.20.9 No flammable materials, cylinders containing flammable gases, or containers containing flammable liquids shall be stored in rooms with gas cylinders
11.3.2.2 Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor

Findings:

During a tour of the facility with the Hospital Staff from 1/22/19 through 1/25/19, the surveyors observed the facility's medical gas storage.

Culver City Tower, Ground Floor:
On 1/22/19, at 2:53 p.m., there was a hydrogen tank mixed with several oxygen cylinders in an outdoor medical gas storage. The size of the hydrogen tank was approximately 15 cubic feet and it was within 2 feet from other oxygen cylinders. The Hospital Staff (Adm4) concurrently acknowledged the deficiency and removed the hydrogen tank from the storage area.