HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 3 of 5 buildings which could result in the spread of smoke or fire to other locations in the facility.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2) on 3/3/14 through 3/7/14, the building construction was observed.

In Patient Tower
3/3/14

1. At 3:12 p.m., there was an approximately 3/4 unsealed conduit pipe in the wall near elevator 3 on the 6th floor.

In Patient Tower
3/5/14

2. At 2:47 a.m., there was an approximately three inch round unsealed penetration in the ceiling near door 2M102B.


21101

Clinic Tower
3/5/14

3. At 9:12 a.m., in room 2A413 there was an approximately 8 inch by 5 inch cut out in the ceiling with red, white and blue wires running through the penetration.

Out Patient Building
3/5/14

4. At 11:22 a.m., there were two approximately 1/2 inch penetrations in the wall next to the copier in the Manage Care Offices.

5. At 12:20 p.m., there was an approximately 2 1/2 inch penetration in the wall above the copy machine in the VIP Forensic Clinic room 3P-61.

6. At 1:48 p.m., there was an approximately 4 inch penetration in the ceiling around a sprinkler pipe that was exposed in the corridor outside of room 3P-61A.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by doors that were impeded from closing and doors that failed to latch. This affected 3 of 5 buildings which had the potential to allow the migration of smoke.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2), on 3/3/14 through 3/7/14, the doors were observed.

In Patient Tower
3/3/14

1. At 1:42 p.m., the self-closing corridor door to to room 7P214 failed to fully close and latch without assistance.

2. At 2:27 p.m., the door to to room C6A125 was impeded from closing with a wedge under the door.

In Patient Tower
3/4/13

3. At 9:37 a.m., the door to room 1J211 was impeded from closing with a wooden wedge under the door.

4. At 9:48 a.m., the door self-closure mechanism to room 1F104B was disconnected. The door was not self closing as designed.

5. At 10:31 a.m., the self-closing door to the electrical room 1R170 was not latching when tested.

6. At 10:39 a.m., the self-closing door to room 1N216 was impeded from closing with a wooden wedge under the door.

6. At 10:42 a.m., the door to room 1N215, Jail, to the jail holding area was impeded from closing with a bed in front of the door.

7. At 10:50 a.m., the self-closing door to room 1R117, Sally Port Office, was not latching when tested. The door was hitting the latching hardware and prevented the door from closing.

8. At 1:48 p.m., the door to room 2N230 was impeded from closing with a rubber wedge.

9. At 1:50 p.m., the door to room 2N128 was impeded from closing with a rubber wedge under the door.

In Patient Tower
3/5/14

10. At 11:26 a.m., the self-closing door to room 5K310 was not latching when tested.

D&T Tower
3/6/14

11. At 8:26 a.m., the clean work room 5C415 door was impeded from closing with a large medical item in front of the door path.

12. At 9:58 a.m., the self-closing inside door to Operating Room 12 was not latching when tested.

13. At 1:48 p.m., the door to room 7A121 was not latching when tested in the Micro Lab.


21101

Clinic Tower
3/3/14

14. At 1:29 p.m., the door to room 7B411 was impeded from closing by a wedge placed under the door.

15. At 1:42 p.m., the door to room A7D109, staff lounge, was impeded from closing by a wedge placed under the door.

Based on observation, the facility failed to maintain their automatic closing fire doors. This was evidenced by doors connected to the fire alarm system that failed to close and positive latch when tested. This affected 1 of 5 buildings and could allow the spread of smoke or flames in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
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, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door 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 release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the doors held open by magnetic hold-open devices, were tested.

D&T Tower
3/6/14

At 9:18 a.m., the door to room 5E214 was not latching when tested. The door was connected to the fire alarm system.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by unsealed penetrations. The penetrations could result in the reduction in staff ability to protect in place. This affected 1 of 5 buildings.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the smoke barrier walls were observed.

In Patient Tower
3/5/14

1. At 10:51 a.m., there was an approximately 2 inch by 1/4 inch unsealed penetration above the JCI box in the 5H429A smoke barrier wall.

2. At 11:12 a.m., there were two unsealed penetrations in the smoke barrier wall near door 5H402A. One penetration was approximately 2 inches by 2 inches and the other was approximately 2 inches by 1/4 inches.

3. At 2:17 p.m., there was an approximately 4 inch by 3 inch square unsealed penetration in the smoke barrier wall near Room 3H414.

4. At 2:39 p.m., there was an approximately 4 inch by 5 inch unsealed penetration in the smoke barrier wall 2R105. The penetration was above the smoke damper.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors and roll down down doors that failed to self-close, a roll down door that was impeded, and smoke barrier doors that failed to latch. This could fail to contain smoke and fire during a fire. This affected 3 of 5 buildings.

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.

7.2.1.14 Horizontal Sliding Doors.
Horizontal sliding doors shall be permitted in means of egress, provided that the following criteria are met:
(1) The door is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf (67 N).
(3) The force required to operate the door in the direction of door travel is not more than 30 lbf (133 N) to set the door in motion and is not more than 15 lbf (67 N) to close the door or open it to the minimum required width.
(4) The door is operable with a force not more than 50 lbf (222 N) when a force of 250 lbf (1110 N) is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of fewer than 50.
(5) The door assembly complies with the fire protection rating and, where rated, is self-closing or automatic-closing by means of smoke detection in accordance with 7.2.1.8,
and is installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.


Findings:

During a tour of the facility with the Administrator of Facilities Management Operations (AFMO), and the Safety Officer on 3/3/14 through 3/7/14, the facility smoke barrier doors were tested.

In Patient Tower
3/5/14

1. At 8:37 a.m., the south smoke barrier door 3M104A was not latching when tested.

2. At 1:40 p.m., the smoke barrier door 4R105A was not closing and latching when tested.

3. At 3:05 p.m., the right smoke barrier door 1L264A was not latching when tested.

D&T Tower
3/6/14

4. At 8:15 a.m., 7 of 7 roll down smoke barrier doors failed to close when tested. The following doors failed, 1st floor corridor to ER East 1E204, 5th floor OHFD #45 5E303B, 5th floor OHFD #44 5E302A, 4th floor main corridor to IPT PHFD, 4th floor back corridor to IPT OHFD, 3rd floor Main corridor leading to IPT OHFP, and 1st floor mechanical corridor.

At 8:17 a.m., the AFMO said during an interview that the doors are being repaired today. The doors started having problems last week and he scheduled a vendor to come out and repair them as quickly as he could.

5. At 10:22 a.m., the west smoke barrier door 3E228 failed to latch when tested.

Clinic Tower
3/6/14

6. At 1:40 p.m., the the roll down door in the Micro Lab was impeded from closing with a phone, radio antenna, electrical cord, and a plastic box that was in the door path.

7 At 2:33 p.m., the south smoke barrier door near elevator 24 on the second floor failed to latch when tested.

8. At 2:35 p.m., the smoke barrier door 2B300 failed to latch when tested.

Based on observation, the facility failed to maintain their emergency lighting units. This was evidenced by an emergency light that failed to illuminate when tested. This affected 1 of 5 building and could result in darkness during a power failure.

NFPA 101, Life Safety Code, 2000 Edition
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 1.5 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.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the emergency lighting units were tested.

In Patient Tower
3/4/14

At 3:24 p.m., the emergency light in room 3M112 failed to illuminate when the power was disconnected.

Based on document review, and interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by a staff member that did not have access to a fire extinguisher, staff that did not know the protocols for a fire emergency and no documentation for a second quarter fire drill. This affected 2 of 5 buildings, and could result in facility staff not being prepared to respond to an emergency fire evacuation.

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 a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2) on 3/3/14 through 3/7/14, staff members were interviewed, and documents were reviewed.

In Patient Tower
3/4/14

1. At 10:01 a.m., Psychiatric Emergency Room staff members 1 through 9 were interviewed and asked to show their key to the padlock on the fire extinguisher in the Psychiatric Emergency Room. Staff 1 and Staff 2 did not have their key in their possession. One person had her key in her car and the other person had her key in her locker. Staff 3 and Staff 4 did not have a key assigned to them. Four of nine staff were unable to open the fire extinguisher cabinet.

In Patient Tower
3/4/13 through 3/7/14

2. At 10:59 a.m., through 3:30 p.m., Sixteen staff members were interviewed and asked what actions would they take if they discovered a small trash can fire in a patient room with one patient in the room. Four of sixteen staff did not know the code phrase for fire, Code Red, SAFE, Safety, close door, Activate alarm/dial ext 111, Fight fire (optional), Evacuate, and PASS, Pull the pin, Aim hose at the base of the fire, Squeeze the handle, Sweep side to side. Three of four staff would yell fire during a fire emergency.


21101


Augustus F. Hawkins
3/4/14

3. At 11:50 a.m., the facility failed to provide documentation for the second quarter, April, May, June 2013, AM fire drill. During an interview, staff acknowledged the missing documentation and stated there were no additional records for review.

Based on observation the facility failed to maintain the fire alarm system as evidenced by the failure to keep impediments from obstructing manual fire alarm pull station devices from access, obstructed chime/strobes, and a strobe that failed to illuminate when tested. This could delay activation of the fire alarm system. This affected 2 of 5 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer, on 3/3/14 through 3/7/14, the fire alarm system components were observed.

In Patient Tower
3/4/14

1. At 8:43 a.m. the emergency pull station alarm activation device near the Facility Supply Chain entrance 1P314B was impeded from immediate access with boxes in front of the device.

2. At 9:16 a.m., the strobe/chime was impeded from view in the Kitchen Room 1H311 with boxes in front and both sides of the device.

D&T Tower
3/6/14

3. At 1:32 p.m., the strobe Sig 11-2 near Room 1D420-2 was not flashing during fire alarm testing.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinklers that were covered with foreign matter, missing escutcheon rings, an impeded sprinkler and failure to provide documentation for the five year certification of the automatic sprinkler system. This could result in the failure of the sprinkler system in the event of a fire. This affected 5 of 5 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

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.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, 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.
2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

9-2.8.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-4.1.2 Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

9-4.2 Check Valves.
9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

9-5.1.2 A full flow test shall be conducted on each valve at 5- year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be made in accordance with the manufacturer ' s instructions.


Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and the Safety Manager (team 2) on 3/3/14 through 3/7/14, the sprinkler system was tested, documents were reviewed, and staff were interviewed.

In Patient Tower
3/3/14

1. At 11:23 a.m., the sprinkler head in the Nourishment Room C8A107 was approximately 80% covered with foreign matter.

2. At 11:31 a.m., there were paper products approximately 11 inches away from the sprinkler head in the Clerical Supply Room 8A.

3. At 11:38 a.m., there were two boxes approximately 4 inches away from the sprinkler head in Room 8N119-8C.

In Patient Tower
3/4/14

4. At 2:43 p.m., there was 1 of 4 sprinklers at Nursing Station 4A that was covered approximately 85% with foreign matter.

5. At 4:02 p.m., there were two of two sprinklers in Room 3R317 that were covered approximately 80% with foreign matter.



21101

Clinic Tower
3/3/14

6. At 1:22 p.m., there were boxes stored approximately 6 inches away from the sprinkler head in Room A7A114.

Augustus F. Hawkins
3/4/14

7. At 11:30 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the facility sprinkler system. The report dated 2/01/2011, had deficiencies and failed the sprinkler system. The facility provided additional documentation for the repairs that were noted on the 2/01/2011 sprinkler report. There was no documented evidence for the 5 year inspection passing once the repairs were completed.

Clinic Tower
3/5/14

8. At 10:31 a.m., 3 of 7 sprinklers above the check-in area of the pharmacy were contaminated with dust and debris.

Out Patient Building
3/5/14

9. At 2:09 p.m., 1 of 2 sprinkler escutcheon rings in room 3P-61B had a gap and was not flush with the ceiling.

10. At 3:06 p.m., in room 1P-75, there were four escutcheon rings missing.

11. At 3:08 p.m., 2 of 2 sprinkler escutcheon rings were missing in room 1P-75A-1.

Augustus F. Hawkins
3/6/14

12. At 3:15 p.m.,. during document review the facility provided a copy of the 5 year certification report dated 3/6/14, for Augustus F. Hawkins Building. The inspection report passed and certified the sprinkler system for the Augustus F. Hawkins Building.

In Patient Tower
3/6/14

13. At 9:11 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. The report dated 11/14/13, had deficiencies and noted that the sprinkler system failed. During an interview, facility staff stated the repairs were completed. There was no documented evidence for the 5 year inspection passing once the repairs were completed.

D & T Tower
3/6/14

14. At 9:16 a.m.,there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. The report dated 11/14/13, had deficiencies and noted that the sprinkler system failed. During an interview, facility staff stated the repairs were completed. There was no documented evidence for the 5 year inspection passing once the repairs were completed.

Clinic Tower
3/6/14

15. At 9:20 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. There were deficiencies on the report dated 11/14/13, and noted that the sprinkler system failed during the test. During an interview, facility staff stated the repairs were completed. There was no documented evidence for the 5 year inspection passing once the repairs were completed.


Out Patient Building
3/6/14

16. At 9:40 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. During an interview, facility staff provided documentation and stated the sprinkler system is tested by an outside vendor quarterly. There was no documented evidence of a current 5 year Inspection , Testing and Maintenance certification report for the sprinkler system.

Based on observation, the facility failed to maintain their portable fire extinguishers as evidenced by a portable fire extinguisher that was obstructed from immediate access. This affected 1 of 5 buildings and could result in a delay in access to the fire extinguisher resulting in the spread of smoke and/or fire.

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.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the portable fire extinguishers were observed.

In Patient Tower
3/4/14

At 9:02 a.m., the fire extinguisher was impeded from access with a 800 gallon laundry cart in front of the device on the east wall of room 1L214, Laundry Storage.

Based on observation, the facility failed to maintain the oxygen storage as evidenced by unsecured oxygen cylinders and by a light switch in an oxygen storage room less than 5 feet above the above the floor. This could increase the risk of an electrical fire. This affected 1 of 5 buildings.

NFPA 101, 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
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)

3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

4. The electrical 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.

5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer 1, and the Health and Safety Manager on 3/3/14 through 3/7/14, the oxygen storage was observed.

Clinic Tower
3/3/14

1. At 3:11 p.m., the light switch in oxygen storage room A4B118 was installed less than 5 feet from the floor. There were 14 E oxygen cylinders in the room at the time of survey.

2. At 3:18 p.m., there were 3 E oxygen cylinders and 2 D oxygen cylinders laying on the floor unsecured in room 4A311/A4B122.

Based on observation, the facility failed to maintain accessibility to their emergency oxygen shut off valves as evidenced by impediments in front of emergency oxygen valves. This could delay personnel from shutting off oxygen during a fire emergency. This affected 1 of 5 buildings.

NFPA 101, 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, Standard for Healthcare 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.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled ' ' SOURCE VALVE FOR The (SOURCE NAME). ' '
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the emergency oxygen shut off valves were observed.

In Patient Tower
3/5/14

1. At 8:46 a.m., the emergency oxygen shut off valve near Room 3P118, was impeded from access with a cart and boxes in front of the device.

2. At 8:52 a.m., the emergency oxygen shut off valve near 3P121, was impeded from access with two carts in front of the device.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords or multi-outlet plug adapters, multi-outlet extension cords in multi-outlet extension cords, medical equipment in multi-outlet extension cords, utilizing extension cords as permanent wiring, an electrical outlet missing a cover plate, and impeded electrical panels. This affected 4 of 5 buildings, and could result in an electrical fire.

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

NFPA 70, National Electrical Code, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2) on 3/3/14 thru 3/7/14, the electrical equipment and wiring were observed.

In Patient Tower
3/3/14

1. At 2:05 p.m., there was an orange extension cord plugged into a multi-plug power strip in use in Room 7N180.

2. At 2:11 p.m., there was a microwave and refrigerator that was plugged into a multi-plug power strip in Room C6A101.

3. At 3:47 p.m., there was a multi-plug power strip plugged in another multi-plug power strip plugged into a refrigerator in Room 6R325.

In Patient Tower
3/4/14

4. At 8:40 a.m., there was an orange extension cord in use near the grease transfer box on the dock of the In Patient Tower.

5. At 8:47 a.m., there were three electrical panels in the Facility Supply Chain that were impeded from access with four carts full of boxes.

6. At 8:49 a.m., there was a refrigerator plugged into a multi-plug power strip in the Facility Supply Chain office.

7. At 10:26 a.m., there was an electrical outlet on the west wall of Room 1K170 that was missing a cover plate.

8. At 1:25 p.m., there was a multi-plug power strip that was plugged into another multi-plug power strip in Room 2R124.

9. At 1:40 p.m., there was a six plug adapter in use in waiting room 2N225.

10. At 1:56 p.m., there was a refrigerator that was plugged into a multi-plug power strip in Room 5P221.

In Patient Tower
3/5/14

11. At 8:40 a.m., there was a medical bed, and assorted medical equipment plugged into a multi-plug power strip in Operating Room 3P126 (OR 2).

D&T Tower
3/6/14

12. At 1:53 p.m., there was a refrigerator plugged into a multi-plug power strip in the Micro Lab. Refrigerator LA County number 599364 #33833.


21101

Clinic Tower
3/3/14

13. At 2:23 p.m., there was a white extension cord and a brown extension cord in use in the Surgical Services Department located on the 6th floor.

Clinic Tower
3/5/14

14. At 9:48 a.m., there was a microwave plugged into a power strip and not directly into the wall receptacle in room 2A312.

15. At 10:28 a.m., there was a microwave plugged into a power strip that was plugged into an orange extension cord in room 1A212, Pt. Billing inquiry Dept.

Out Patient Building
3/5/14

16. At 11:01 a.m.,there was a power strip plugged into a power strip in use in the Doctors conference room 529.

17. At 11:13 a.m., there was a power strip plugged into a power strip and in use in the Doctors conference room 561.

18. At 11:19 a.m., there was a brown extension cord in use in the Manage Care offices room 5P-47, in office 3 .

19. At 11:58 a.m., there was a power strip plugged into another power strip that was in use in the Laboratory Registration room 4P-51.

20. At 2:59 p.m.,there was a refrigerator plugged into a power strip that was plugged into an other power strip and in use in room 1P-73.

21. At 3:06 p.m., there was a refrigerator plugged into a power strip and not directly into the wall receptacle in room 1P-75.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers. This was evidenced by alcohol based hand rub dispensers (ABHR) mounted above ignition sources (electrical outlets). This affected 4 of 5 buildings, and could result in an alcohol based hand rub ignited fire.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2), the alcohol based hand rub dispensers in the facility were observed.

In Patient Tower
3/3/14

1. At 11:17 a.m., there was an ABHR mounted over an electrical outlet outside of Room C8A148.

2. At 2:34 p.m., there was an ABHR mounted over an electrical outlet outside of Room 6P217.

3. At 2:50 p.m., there was an ABHR mounted over an electrical outlet outside of Room 6R110.

4. At 2:59 p.m., there was an ABHR mounted over an electrical outlet outside of Room 6R310.

D&T Tower
3/6/14

5. At 9:52 a.m., there was an ABHR mounted over an electrical outlet outside of Operating Rooms 15 and 12 (Two).


21101

Augustus F. Hawkins
3/4/14

6. At 9:21 a.m., the ABHR was installed above an electrical outlet in Interview room 2177.

7. At 9:41 a.m., the ABHR was installed above an electrical outlet in the conference room 2112.

Clinic Tower
3/3/14

8. At 2:34 p.m., the ABHR was installed above an electrical outlet in the corridor of A5C.

9. At 3:00 p.m., the ABHR was installed above an electrical outlet in the reception area 4A150.

10. At 3:46 p.m., the ABHR was installed above an electrical outlet in the Pediatrics Cast room A3D129.

Clinic Tower
3/5/14

11. At 9:25 a.m., the ABHR was installed above an electrical outlet in room 2B415.

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This affected 3 of 5 buildings which could result in the spread of smoke or fire to other locations in the facility.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.4 Each exterior wall of frame construction and all interior stud partitions shall be firestopped to cut off all concealed draft openings, both horizontal and vertical, between any cellar or basement and the first floor. Such firestopping shall consist of wood not less than 2 in. (5 cm) (nominal) thick or shall be of noncombustible material.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2) on 3/3/14 through 3/7/14, the building construction was observed.

In Patient Tower
3/3/14

1. At 3:12 p.m., there was an approximately 3/4 unsealed conduit pipe in the wall near elevator 3 on the 6th floor.

In Patient Tower
3/5/14

2. At 2:47 a.m., there was an approximately three inch round unsealed penetration in the ceiling near door 2M102B.


21101

Clinic Tower
3/5/14

3. At 9:12 a.m., in room 2A413 there was an approximately 8 inch by 5 inch cut out in the ceiling with red, white and blue wires running through the penetration.

Out Patient Building
3/5/14

4. At 11:22 a.m., there were two approximately 1/2 inch penetrations in the wall next to the copier in the Manage Care Offices.

5. At 12:20 p.m., there was an approximately 2 1/2 inch penetration in the wall above the copy machine in the VIP Forensic Clinic room 3P-61.

6. At 1:48 p.m., there was an approximately 4 inch penetration in the ceiling around a sprinkler pipe that was exposed in the corridor outside of room 3P-61A.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by doors that were impeded from closing and doors that failed to latch. This affected 3 of 5 buildings which had the potential to allow the migration of smoke.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2), on 3/3/14 through 3/7/14, the doors were observed.

In Patient Tower
3/3/14

1. At 1:42 p.m., the self-closing corridor door to to room 7P214 failed to fully close and latch without assistance.

2. At 2:27 p.m., the door to to room C6A125 was impeded from closing with a wedge under the door.

In Patient Tower
3/4/13

3. At 9:37 a.m., the door to room 1J211 was impeded from closing with a wooden wedge under the door.

4. At 9:48 a.m., the door self-closure mechanism to room 1F104B was disconnected. The door was not self closing as designed.

5. At 10:31 a.m., the self-closing door to the electrical room 1R170 was not latching when tested.

6. At 10:39 a.m., the self-closing door to room 1N216 was impeded from closing with a wooden wedge under the door.

6. At 10:42 a.m., the door to room 1N215, Jail, to the jail holding area was impeded from closing with a bed in front of the door.

7. At 10:50 a.m., the self-closing door to room 1R117, Sally Port Office, was not latching when tested. The door was hitting the latching hardware and prevented the door from closing.

8. At 1:48 p.m., the door to room 2N230 was impeded from closing with a rubber wedge.

9. At 1:50 p.m., the door to room 2N128 was impeded from closing with a rubber wedge under the door.

In Patient Tower
3/5/14

10. At 11:26 a.m., the self-closing door to room 5K310 was not latching when tested.

D&T Tower
3/6/14

11. At 8:26 a.m., the clean work room 5C415 door was impeded from closing with a large medical item in front of the door path.

12. At 9:58 a.m., the self-closing inside door to Operating Room 12 was not latching when tested.

13. At 1:48 p.m., the door to room 7A121 was not latching when tested in the Micro Lab.


21101

Clinic Tower
3/3/14

14. At 1:29 p.m., the door to room 7B411 was impeded from closing by a wedge placed under the door.

15. At 1:42 p.m., the door to room A7D109, staff lounge, was impeded from closing by a wedge placed under the door.

Based on observation, the facility failed to maintain their automatic closing fire doors. This was evidenced by doors connected to the fire alarm system that failed to close and positive latch when tested. This affected 1 of 5 buildings and could allow the spread of smoke or flames in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
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, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door 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 release service in NFPA 72, National Fire Alarm Code®.
(4) Upon loss of power to the hold-open device, the hold open mechanism is released and the door becomes self closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the doors held open by magnetic hold-open devices, were tested.

D&T Tower
3/6/14

At 9:18 a.m., the door to room 5E214 was not latching when tested. The door was connected to the fire alarm system.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls. This was evidenced by unsealed penetrations. The penetrations could result in the reduction in staff ability to protect in place. This affected 1 of 5 buildings.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the smoke barrier walls were observed.

In Patient Tower
3/5/14

1. At 10:51 a.m., there was an approximately 2 inch by 1/4 inch unsealed penetration above the JCI box in the 5H429A smoke barrier wall.

2. At 11:12 a.m., there were two unsealed penetrations in the smoke barrier wall near door 5H402A. One penetration was approximately 2 inches by 2 inches and the other was approximately 2 inches by 1/4 inches.

3. At 2:17 p.m., there was an approximately 4 inch by 3 inch square unsealed penetration in the smoke barrier wall near Room 3H414.

4. At 2:39 p.m., there was an approximately 4 inch by 5 inch unsealed penetration in the smoke barrier wall 2R105. The penetration was above the smoke damper.

Based on observation, the facility failed to maintain the smoke barrier doors as evidenced by smoke barrier doors and roll down down doors that failed to self-close, a roll down door that was impeded, and smoke barrier doors that failed to latch. This could fail to contain smoke and fire during a fire. This affected 3 of 5 buildings.

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.

7.2.1.14 Horizontal Sliding Doors.
Horizontal sliding doors shall be permitted in means of egress, provided that the following criteria are met:
(1) The door is readily operable from either side without special knowledge or effort.
(2) The force that, when applied to the operating device in the direction of egress, is required to operate the door is not more than 15 lbf (67 N).
(3) The force required to operate the door in the direction of door travel is not more than 30 lbf (133 N) to set the door in motion and is not more than 15 lbf (67 N) to close the door or open it to the minimum required width.
(4) The door is operable with a force not more than 50 lbf (222 N) when a force of 250 lbf (1110 N) is applied perpendicularly to the door adjacent to the operating device, unless the door is an existing horizontal sliding exit access door serving an area with an occupant load of fewer than 50.
(5) The door assembly complies with the fire protection rating and, where rated, is self-closing or automatic-closing by means of smoke detection in accordance with 7.2.1.8,
and is installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition
15-2.4.3 All horizontal or vertical sliding and rolling fire doors shall be inspected and tested annually to check for proper operation and full closure. Resetting of the release mechanism shall be done in accordance with the manufacturer's instructions. A written record shall be maintained and shall be made available to the authority having jurisdiction.


Findings:

During a tour of the facility with the Administrator of Facilities Management Operations (AFMO), and the Safety Officer on 3/3/14 through 3/7/14, the facility smoke barrier doors were tested.

In Patient Tower
3/5/14

1. At 8:37 a.m., the south smoke barrier door 3M104A was not latching when tested.

2. At 1:40 p.m., the smoke barrier door 4R105A was not closing and latching when tested.

3. At 3:05 p.m., the right smoke barrier door 1L264A was not latching when tested.

D&T Tower
3/6/14

4. At 8:15 a.m., 7 of 7 roll down smoke barrier doors failed to close when tested. The following doors failed, 1st floor corridor to ER East 1E204, 5th floor OHFD #45 5E303B, 5th floor OHFD #44 5E302A, 4th floor main corridor to IPT PHFD, 4th floor back corridor to IPT OHFD, 3rd floor Main corridor leading to IPT OHFP, and 1st floor mechanical corridor.

At 8:17 a.m., the AFMO said during an interview that the doors are being repaired today. The doors started having problems last week and he scheduled a vendor to come out and repair them as quickly as he could.

5. At 10:22 a.m., the west smoke barrier door 3E228 failed to latch when tested.

Clinic Tower
3/6/14

6. At 1:40 p.m., the the roll down door in the Micro Lab was impeded from closing with a phone, radio antenna, electrical cord, and a plastic box that was in the door path.

7 At 2:33 p.m., the south smoke barrier door near elevator 24 on the second floor failed to latch when tested.

8. At 2:35 p.m., the smoke barrier door 2B300 failed to latch when tested.

Based on observation, the facility failed to maintain their emergency lighting units. This was evidenced by an emergency light that failed to illuminate when tested. This affected 1 of 5 building and could result in darkness during a power failure.

NFPA 101, Life Safety Code, 2000 Edition
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 1.5 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.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the emergency lighting units were tested.

In Patient Tower
3/4/14

At 3:24 p.m., the emergency light in room 3M112 failed to illuminate when the power was disconnected.

Based on document review, and interview, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by a staff member that did not have access to a fire extinguisher, staff that did not know the protocols for a fire emergency and no documentation for a second quarter fire drill. This affected 2 of 5 buildings, and could result in facility staff not being prepared to respond to an emergency fire evacuation.

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 a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2) on 3/3/14 through 3/7/14, staff members were interviewed, and documents were reviewed.

In Patient Tower
3/4/14

1. At 10:01 a.m., Psychiatric Emergency Room staff members 1 through 9 were interviewed and asked to show their key to the padlock on the fire extinguisher in the Psychiatric Emergency Room. Staff 1 and Staff 2 did not have their key in their possession. One person had her key in her car and the other person had her key in her locker. Staff 3 and Staff 4 did not have a key assigned to them. Four of nine staff were unable to open the fire extinguisher cabinet.

In Patient Tower
3/4/13 through 3/7/14

2. At 10:59 a.m., through 3:30 p.m., Sixteen staff members were interviewed and asked what actions would they take if they discovered a small trash can fire in a patient room with one patient in the room. Four of sixteen staff did not know the code phrase for fire, Code Red, SAFE, Safety, close door, Activate alarm/dial ext 111, Fight fire (optional), Evacuate, and PASS, Pull the pin, Aim hose at the base of the fire, Squeeze the handle, Sweep side to side. Three of four staff would yell fire during a fire emergency.


21101


Augustus F. Hawkins
3/4/14

3. At 11:50 a.m., the facility failed to provide documentation for the second quarter, April, May, June 2013, AM fire drill. During an interview, staff acknowledged the missing documentation and stated there were no additional records for review.

Based on observation the facility failed to maintain the fire alarm system as evidenced by the failure to keep impediments from obstructing manual fire alarm pull station devices from access, obstructed chime/strobes, and a strobe that failed to illuminate when tested. This could delay activation of the fire alarm system. This affected 2 of 5 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Chapter 7 Inspection, Testing, and Maintenance
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.
7-1.1.2 System defects and malfunctions shall be corrected. If a defect or malfunction is not corrected at the conclusion of system inspection, testing, or maintenance, the system owner or the owner's designated representative shall be informed of the impairment in writing within 24 hours.
7-1.2 The owner or the owner's designated representative shall be responsible for inspection, testing, and maintenance of the system and alterations or additions to this system. The delegation of responsibility shall be in writing, with a copy of such delegation provided to the authority having jurisdiction upon request.

NFPA 101, Life Safety Code, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer, on 3/3/14 through 3/7/14, the fire alarm system components were observed.

In Patient Tower
3/4/14

1. At 8:43 a.m. the emergency pull station alarm activation device near the Facility Supply Chain entrance 1P314B was impeded from immediate access with boxes in front of the device.

2. At 9:16 a.m., the strobe/chime was impeded from view in the Kitchen Room 1H311 with boxes in front and both sides of the device.

D&T Tower
3/6/14

3. At 1:32 p.m., the strobe Sig 11-2 near Room 1D420-2 was not flashing during fire alarm testing.

Based on observation, document review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinklers that were covered with foreign matter, missing escutcheon rings, an impeded sprinkler and failure to provide documentation for the five year certification of the automatic sprinkler system. This could result in the failure of the sprinkler system in the event of a fire. This affected 5 of 5 buildings.

NFPA 101, Life Safety Code, 2000 Edition
9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.
Exception No. 1: NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted for use as specifically referenced in Chapters 24 through 33 of this Code.
Exception No. 2: NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes, shall be permitted for use as provided in Chapters 24, 26, 32, and 33 of this Code.

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.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

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.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign material, 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.
2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

9-2.8.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-4.1.2 Alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

9-4.2 Check Valves.
9-4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition.

9-5.1.2 A full flow test shall be conducted on each valve at 5- year intervals and shall be compared to previous test results. If adjustments are necessary, they shall be made in accordance with the manufacturer ' s instructions.


Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and the Safety Manager (team 2) on 3/3/14 through 3/7/14, the sprinkler system was tested, documents were reviewed, and staff were interviewed.

In Patient Tower
3/3/14

1. At 11:23 a.m., the sprinkler head in the Nourishment Room C8A107 was approximately 80% covered with foreign matter.

2. At 11:31 a.m., there were paper products approximately 11 inches away from the sprinkler head in the Clerical Supply Room 8A.

3. At 11:38 a.m., there were two boxes approximately 4 inches away from the sprinkler head in Room 8N119-8C.

In Patient Tower
3/4/14

4. At 2:43 p.m., there was 1 of 4 sprinklers at Nursing Station 4A that was covered approximately 85% with foreign matter.

5. At 4:02 p.m., there were two of two sprinklers in Room 3R317 that were covered approximately 80% with foreign matter.



21101

Clinic Tower
3/3/14

6. At 1:22 p.m., there were boxes stored approximately 6 inches away from the sprinkler head in Room A7A114.

Augustus F. Hawkins
3/4/14

7. At 11:30 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the facility sprinkler system. The report dated 2/01/2011, had deficiencies and failed the sprinkler system. The facility provided additional documentation for the repairs that were noted on the 2/01/2011 sprinkler report. There was no documented evidence for the 5 year inspection passing once the repairs were completed.

Clinic Tower
3/5/14

8. At 10:31 a.m., 3 of 7 sprinklers above the check-in area of the pharmacy were contaminated with dust and debris.

Out Patient Building
3/5/14

9. At 2:09 p.m., 1 of 2 sprinkler escutcheon rings in room 3P-61B had a gap and was not flush with the ceiling.

10. At 3:06 p.m., in room 1P-75, there were four escutcheon rings missing.

11. At 3:08 p.m., 2 of 2 sprinkler escutcheon rings were missing in room 1P-75A-1.

Augustus F. Hawkins
3/6/14

12. At 3:15 p.m.,. during document review the facility provided a copy of the 5 year certification report dated 3/6/14, for Augustus F. Hawkins Building. The inspection report passed and certified the sprinkler system for the Augustus F. Hawkins Building.

In Patient Tower
3/6/14

13. At 9:11 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. The report dated 11/14/13, had deficiencies and noted that the sprinkler system failed. During an interview, facility staff stated the repairs were completed. There was no documented evidence for the 5 year inspection passing once the repairs were completed.

D & T Tower
3/6/14

14. At 9:16 a.m.,there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. The report dated 11/14/13, had deficiencies and noted that the sprinkler system failed. During an interview, facility staff stated the repairs were completed. There was no documented evidence for the 5 year inspection passing once the repairs were completed.

Clinic Tower
3/6/14

15. At 9:20 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. There were deficiencies on the report dated 11/14/13, and noted that the sprinkler system failed during the test. During an interview, facility staff stated the repairs were completed. There was no documented evidence for the 5 year inspection passing once the repairs were completed.


Out Patient Building
3/6/14

16. At 9:40 a.m., there was no documented evidence provided for the current 5 year Inspection, Testing and Maintenance of the sprinkler system. During an interview, facility staff provided documentation and stated the sprinkler system is tested by an outside vendor quarterly. There was no documented evidence of a current 5 year Inspection , Testing and Maintenance certification report for the sprinkler system.

Based on observation, the facility failed to maintain their portable fire extinguishers as evidenced by a portable fire extinguisher that was obstructed from immediate access. This affected 1 of 5 buildings and could result in a delay in access to the fire extinguisher resulting in the spread of smoke and/or fire.

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.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the portable fire extinguishers were observed.

In Patient Tower
3/4/14

At 9:02 a.m., the fire extinguisher was impeded from access with a 800 gallon laundry cart in front of the device on the east wall of room 1L214, Laundry Storage.

Based on observation, the facility failed to maintain the oxygen storage as evidenced by unsecured oxygen cylinders and by a light switch in an oxygen storage room less than 5 feet above the above the floor. This could increase the risk of an electrical fire. This affected 1 of 5 buildings.

NFPA 101, 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
4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)

3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.

4. The electrical 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.

5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer 1, and the Health and Safety Manager on 3/3/14 through 3/7/14, the oxygen storage was observed.

Clinic Tower
3/3/14

1. At 3:11 p.m., the light switch in oxygen storage room A4B118 was installed less than 5 feet from the floor. There were 14 E oxygen cylinders in the room at the time of survey.

2. At 3:18 p.m., there were 3 E oxygen cylinders and 2 D oxygen cylinders laying on the floor unsecured in room 4A311/A4B122.

Based on observation, the facility failed to maintain accessibility to their emergency oxygen shut off valves as evidenced by impediments in front of emergency oxygen valves. This could delay personnel from shutting off oxygen during a fire emergency. This affected 1 of 5 buildings.

NFPA 101, 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, Standard for Healthcare 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.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled ' ' SOURCE VALVE FOR The (SOURCE NAME). ' '
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, and the Safety Officer on 3/3/14 through 3/7/14, the emergency oxygen shut off valves were observed.

In Patient Tower
3/5/14

1. At 8:46 a.m., the emergency oxygen shut off valve near Room 3P118, was impeded from access with a cart and boxes in front of the device.

2. At 8:52 a.m., the emergency oxygen shut off valve near 3P121, was impeded from access with two carts in front of the device.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by high powered appliances that were plugged into surge protected multi-outlet extension cords or multi-outlet plug adapters, multi-outlet extension cords in multi-outlet extension cords, medical equipment in multi-outlet extension cords, utilizing extension cords as permanent wiring, an electrical outlet missing a cover plate, and impeded electrical panels. This affected 4 of 5 buildings, and could result in an electrical fire.

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

NFPA 70, National Electrical Code, 1999 Edition
240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8 Unless specifically permitted in Section 400-7, flexible cord 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
(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

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

Article 110-26(a)(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 30 in. (762 mm), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

Findings:

During a tour of the facility with the Administrator of Facilities Management Operations, the Safety Officer (team 1), the Safety Officer 1, and the Health and Safety Manager (team 2) on 3/3/14 thru 3/7/14, the electrical equipment and wiring were observed.

In Patient Tower
3/3/14

1. At 2:05 p.m., there was an orange extension cord plugged into a multi-plug power strip in use in Room 7N180.

2. At 2:11 p.m., there was a microwave and refrigerator that was plugged into a multi-plug power strip in Room C6A101.

3. At 3:47 p.m., there was a multi-plug power strip plugged in another multi-plug power strip plugged into a refrigerator in Room 6R325.

In Patient Tower
3/4/14

4. At 8:40 a.m., there was an orange extension cord in use near the grease transfer box on the dock of the In Patient Tower.

5. At 8:47 a.m., there were three electrical panels in the Facility Supply Chain that were impeded from access with four carts full of boxes.

6. At 8:49 a.m., there was a refrigerator plugged into a multi-plug power strip in the Facility Supply Chain office.

7. At 10:26 a.m., there was an electrical outlet on the west wall of Room 1K170 that was missing a cover plate.

8. At 1:25 p.m., there was a multi-plug power strip that was plugged into another multi-plug power strip in Room 2R124.

9. At 1:40 p.m., there was a six plug adapter in use in waiting room 2N225.

10. At 1:56 p.m., there was a refrigerator that was plugged into a multi-plug power strip in Room 5P221.

In Patient Tower
3/5/14

11. At 8:40 a.m., there was a medical bed, and assorted medical equipment plugged into a multi-plug power strip in Operating Room 3P126 (OR 2).

D&T Tower
3/6/14

12. At 1:53 p.m., there was a refrigerator plugged into a multi-plug power strip in the Micro Lab. Refrigerator LA County number 599364 #33833.


21101

Clinic Tower
3/3/14

13. At 2:23 p.m., there was a white extension cord and a brown extension cord in use in the Surgical Services Department located on the 6th floor.

Clinic Tower
3/5/14

14. At 9:48 a.m., there was a microwave plugged into a power strip and not directly into the wall receptacle in room 2A312.

15. At 10:28 a.m., there was a microwave plugged into a power strip that was plugged into an orange extension cord in room 1A212, Pt. Billing inquiry Dept.

Out Patient Building
3/5/14

16. At 11:01 a.m.,there was a power strip plugged into a power strip in use in the Doctors conference room 529.

17. At 11:13 a.m., there was a power strip plugged into a power strip and in use in the Doctors conference room 561.

18. At 11:19 a.m., there was a brown extension cord in use in the Manage Care offices room 5P-47, in office 3 .

19. At 11:58 a.m., there was a power strip plugged into another power strip that was in use in the Laboratory Registration room 4P-51.

20. At 2:59 p.m.,there was a refrigerator plugged into a power strip that was plugged into an other power strip and in use in room 1P-73.

21. At 3:06 p.m., there was a refrigerator plugged into a power strip and not directly into the wall receptacle in room 1P-75.