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Based on observation the hospital failed to ensure a corridor door could resist the passage of smoke and that there was no impediment to the closing of a corridor door by having a Dutch door without an astragal and a table placed in front of a door.

Doors protecting corridor openings play an integral role in interrupting the spread of smoke.

Findings:

Culver City campus

On March 26, 2014 between 10:53 a.m. and 3:20 p.m., the following conditions existed at the Culver City campus.

1. In the 6th floor, Unit C, an astragal was missing at the nurses' station corridor Dutch door.

2. In the Detox Unit, the kitchen corridor door was obstructed from closing by having a wood table placed in front of the door.

Based on observation, the hospital failed to ensure a chute (a vertical opening) had a one hour fire resistance by having a hole through the chute door.

Maintenance of the fire resistance of vertical openings is essential in the containment of smoke and fire.

Finding:

Culver City campus

On March 26, 2014, between 2:25 p.m. and 3:20 p.m., at the Detox Unit of the Culver City campus, there was an one inch diameter penetration through the soiled linen chute door.

Based on observation, the hospital failed to ensure smoke barriers were maintained with a half hour fire resistance by having penetrations through the walls.

Smoke barriers assist to limit the spread the movement of smoke, limit the number of occupants exposed to a single fire and create a safe relocation area. If left unsealed, fire, smoke and toxic gases driven by the heat and pressure of a fire may move through the penetrations and travel to other parts of the building.

Findings:

Van Nuys campus

1. On March 24, 2014 at 2:50 p.m., in Unit 1 of the Van Nuys campus, there was a 2 inch by 2 inch penetration through a ceiling at compartmentation above a cross corridor door by the men's common bathroom.

2. On March 25, 2014 in Unit 2 of the Van Nuys campus there was a penetration through a corridor separation wall by the Doctor Dictation Room.

Culver City campus

3. On March 28, 2014, between 9:30 a.m. and 10:45 a.m,. at the construction separation between the back of the 4th floor and the rehabilitation unit at the front of the 4th floor, there were eight unsealed penetrations through the gypsum board barrier at the separation.

During an interview, the Director of Engineering stated that besides being a dust barrier, the gypsum board barrier was also suppose to be a fire barrier.

A review of the hospitals policy and procedure titled "Interim Life Safety Policy (#EC5.50.1-3)" with an effective date of February 2011, stipulated that temporary construction partitions would be smoke tight and built of noncombustible or limited combustible materials.

Based on observation and interview, the facility failed to ensure that the only smoke compartment double doors available on the first floor closed upon activation of the fire alarm.

Finding:

Hollywood campus

On March 25, 2014, at 1:48 p.m., the evaluator observed the Life Safety Code system test. The building staff activated the smoke detector and the smoke barrier doors located on the ground floor did not close. This affected two smoke compartments.

An interview was held with Staff V and he stated that the door would be serviced as soon as possible.

Based on observation and interview, the facility failed to ensure that the exit access corridor was maintained clear and unobstructed at all times.

Finding:

Hollywood campus

On March 24, 2014, at 8:35 a.m., the evaluator inspected the 5th floor and observed one over bed table with a computer monitor and a staff seated on a chair located near the nurse station. The evaluator observed another table holding three computer monitors and three chairs located near room 507 and 506. The corridor width was eight feet and the table occupied 1.5 feet of corridor width.

On March 25, 2014, at 9:45 a.m., the evaluator inspected the fourth floor and observed a desk with four chairs installed into the fire exit access corridor located near room 406. The desk measured ten feet long and one and half wide, with four chairs.

An interview was held with staff V and he stated that he would address the above issue as soon as possible.

Based on observation and interview, the facility failed to ensure that all the fire exit signs pointed to the nearest fire exit at all times.

Finding:

Hollywood campus

On March 24, 2014, at 11:20 a.m., the evaluator conducted an inspection of the facility and observed a fire exit located near the elevator did not have n operational directional arrow. Without a directional arrow, an evacuee would go straight into a patient sleeping room.

An interview was held with staff V and he stated that the fire exit sign would be serviced as soon as possible.

NFPA 72 National Fire Alarm Code 1999 Edition

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

The standard was not met as evidenced by:

Based on observation and record review the hospital failed to maintain a smoke detector alarm annunciator and maintain a complete permanent record of a fire alarm inspection and test report, by having tape over the annunciator and having a fire alarm report with missing information.

Findings:

Culver City campus

1. On March 26, 2014, between 2:25 p.m. and 3:20 p.m., there was tape over the annunciator alarm for patient room smoke detectors at the Detox Unit nurse's station at the Culver City campus.

2. On March 31, 2014 between 12:50 p.m. and 2:14 p.m. record review revealed the hospitals fire alarm test report did not include the name of the person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number; name, address, and representative of approving agency(ies); Signatures of tester and approved authority representative.

Based on observation and record review the hospital failed to ensure that all required smoke detectors were maintained as required by not having documented evidence that the smoke detectors had sensitivity testing in the last five years, having a dismounted smoke head and a missing smoke head.

Smoke detectors that may be out of sensitivity range, that are dismounted and missing could delay or be ineffective in the detection of smoke.

Findings:

Van Nuys Campus

1. On March 25, 2014, between 11:00 a.m. and 2:45 p.m., during document review at the Van Nuys campus, there was no documented evidence of a five year smoke detector sensitivity test.

Culver City campus

2. On March 26, 2014, between 12:12 p.m. and 12:40 p.m., in room 632 in the 6th floor Unit C of the Culver City Campus, the smoke detector was pulled off the bathroom wall.

3. In room 630 in the 6th floor Unit C of the Culver City Campus, the smoke detector head was missing from the room.

Based on observation and interview, the hospital failed to maintain an automatic sprinkler system in operating order and failed to inspect and test the system routinely by having obstructions to sprinkler spray patterns, having missing hose valve caps and not periodically inspecting and testing the system.

Inspection, testing and maintenance of the fire sprinkler system is essential to ensure the system functions as designed during a fire emergency.

Findings:

Van Nuys campus

1. On March 24, 2014 at 11:45 a.m., in Unit 1 of the Van Nuys campus there were boxes stored to the ceiling in the medical records file room, bypassing the 18 inch space required between the top of storage and sprinkler head deflector.

Culver City campus

2. On March 26, 2014, between 11:15 a.m. and 11:45 a.m., in the 6th floor Unit A of the Culver City Campus, there was storage to the ceiling in the patient belongings storage room. bypassing the 18 inch space required between the top of storage and sprinkler head deflector.

3. On March 26, 2014, between 2:25 p.m. and 3:20 p.m., at the Detox Unit of the Culver City campus, the caps were missing from the wet standby pipe fire suppression system at stairwell landings.

On March 31, 2014, between 2:14 p.m. and 3:30 p.m., during an interview the Director of Engineering, it was stated that the caps were missing on every floor in both stairwells of the tower and that the wet pipe system was part of a new sprinkler project that was started six months ago, that the wet pipe system was replacing a dry stand-by pipe system, that the original installer was removed from the project in November and that a new company was contracted that is starting in two weeks.

The Director of Engineering provided a copy of a signed vendor quote dated March 4, 2014 to complete a fire sprinkler installation that was left incomplete by another fire protection company with scope of work, including providing cap and chains for all hose valves in stairwells.

4. On March 31, 2014, between 12:50 p.m. and 2:14 p.m., record review revealed there was no documented evidence that annual sprinkler tests were conducted at the Culver City campus. The only document provided was a vendor work order dated March 26, 2014 that indicated "An annual sprinkler test performance testing waterflow and tampers (walk through the buildings X3) Three buildings: A single story, Main Tower, and 3826 Delmas Terrace building. All three buildings were visually inspected waterflows and tampers were not tested due to test got canceled per building engineer." The notation on the work order indicated the testing was not completed.

At the same time as the review, the Director of Engineering stated that the annual sprinkler test was being conducted during the survey, that it was the first time an annual sprinkler test was being conducted and that he did not yet have the report including results and corrections.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition

1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

These standards were not met as evidenced by:

Based on observation, the facility failed to ensure a fire extinguisher was immediately available, accessible and unobstructed from view.

Portable fire extinguishers are intended as a first line of defense to cope with fires of limited size. For the fire extinguisher to do its job it must be accessible.

Finding:

Culver City campus

On March 31, 2014 at 9:04 a.m., in room 209, in the main laboratory at the 1st floor Pavilion of the Culver City campus, a fire extinguisher was obstructed from view and access by being mounted at a wall behind a computer monitor in a cubicle.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 1998 Edition

9-1.2.3 All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.

Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.

The standard was not met as evidenced by:

Based on observation, the facility failed to meet the requirement of NFPA 96 by not having a 16-inch space, or a steel or tempered glass baffle at a minimum 8 inches in height between the fryer and surface flames from adjacent cooking equipment.

Finding:

Van Nuys campus

On March 24, 2014, between 11:20 a.m. and 11:40 a.m., in the Kitchen of the Van Nuys campus, there was a deep fryer next to an open flame stove without benefit of 16 inch separation or 8 inch steel or tempered glass baffle.

Based on observation, interview and document review, the hospital failed to maintain full instant use of a means egress by having equipment placed along exit corridors and by having an exit door locked against egress.

Obstructions to full instant use of a means of egress may delay or impede an evacuation.

Findings:

Culver City campus

1. On March 28, 2014, between 2:00 p.m. and 2:20 p.m., in southwest and southeast telemetry units in the 2nd floor of the Culver City campus, there were wheeled equipment placed in the exit corridors, including two computers, four chairs, and one blood pressure machine in the southwest exit corridor and four computers and three chairs in the southeast exit corridor.

On March 31, 2014 at 2:14 p.m., review of a fire drill report dated February 25, 2014, and conducted on the 2nd floor pavilion, did not address the relocation of the wheeled equipment during a fire or similar emergency.

During an interview at the same time as the fire drill review, a security officer stated that when he had conducted fire drills in the Telemetry units of the 2nd floor pavilion, the equipment that was located on one side of the corridor, remained on one side of the corridor and was not relocated.

A review of the "Fire Response Plan policy (#LMP.003)" dated effective February 2011, and provided as the facility's fire safety plan, revealed it did not address the relocation of the wheeled equipment during a fire or similar emergency.

2. On March 31, 2014, between 10:00 a.m. and 10:10 a.m., on the 1st floor pavilion lobby in the 1st floor Pavilion at the Culver City campus, one of three exit doors (south exit) was locked and did not provide egress.

(1) NFPA 99 Health Care Facility, 1999 Edition, 4-3.1.1.8 (a) Cylinders. Cylinders shall be designed, constructed, tested, and maintained in accordance with 4-3.1.1.1(a) Cylinders in service shall be adequately secured. Cylinders in storage shall be secured and located to prevent them from falling or being knocked over.

This requirement was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that portable oxygen cylinders were secured at all times.

Finding:

Hollywood campus

On March 25, 2014, at 10:50 a.m., the evaluator inspected the facility basement area Sterilizer Room and observed a free standing E-Oxygen cylinder being stored in a corner.

The evaluator conducted an interview with staff V and he stated that the oxygen cylinder would be removed as soon as possible.

(2) NFPA 99 Health Care Facilities 1999 edition

4-3.5.2.2(b)(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85m3).

This requirement was not met as evidenced by:

Based on observation, the facility failed to ensure nonflammable gases were stored in accordance with NFPA (National Fire Protection Association) 99 by not segregating empty cylinders from full cylinders.

Findings:

Hollywood campus

On March 24, 2014, at 12:10 p.m., accompanied by staff V, the evaluator observed 10 full oxygen cylinders and 3 empty oxygen cylinders being stored and mixed together in an unlabeled oxygen storage room located in the respiratory area on the 6th floor.

The evaluator conducted an interview with staff V and he stated that the room would be identified and the oxygen cylinders separated, with an empty and full sign posted, as soon as possible.







16281

NFPA 99 Standard for Health Care Facilities 1999 Edition

4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).

(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

4-3.5.2.1(b)27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

8-6.2.4.5 A scheduled preventive maintenance program shall be followed.

8-6.5 Qualification and Training of Personnel. Equipment shall be serviced by qualified personnel only.

The Standard was not met as evidenced by

Based on observation, the facility failed to meet the requirements of NFPA 99 by chaining or supporting free standing cylinders in a stand or cart, and by not correcting deficiencies found during a medical gas and vacuum system test.

Findings:

Culver City Campus

1. On March 26, 2014, between 11:45 a.m. and 12:12 p.m., in the 6th floor Unit B of the Culver City Campus, there was a free standing oxygen cylinder located between a photocopy machine and a wall at the nurse's station. During an interview at the same time as the observation, the Director of Psychiatric Services stated the cylinder was for emergency use and should not have been there (between the photocopy machine and the wall).

2. On March 28, 2014, between 9:30 a.m. and 10:45 a.m., in the 4th floor physical therapy room of the Culver City campus, 1 of 4 free standing oxygen cylinders was not supported or chained.

3. On March 28, 2014, between 11:20 a.m. and 11:50 a.m., in the 3rd floor CCU of the Culver City campus, there was a free standing oxygen cylinder in the central supply closet, the cylinder was half full per its regulator gauge and was not supported or chained.

4. On March 31, 2014 at 10:15 a.m. there were two unsecured oxygen cylinders in the chain link oxygen storage area outside of the tower building of the Culver City campus. Neither cylinder was was supported or chained.

5. On March 31, 2014 at 12:50 p.m., record review revealed there was no documented evidence that deficiencies found during the medical gas and vacuum system test done on December 19, 2003 were corrected for the Culver City campus, including medical gas zone valves on the 1st, 2nd, 3rd and 5th floors; medical gas area alarm panels on the lower level, 2nd and 3rd floors; O2 and vacuum leaks, reduced flows, non-functioning audible signals, lights out, improper and missing labeling, missing tab, missing pull ring, warn valve bodies, missing screw, adapters with no latch, and missing faceplates throughout the hospital.

During an interview at the same time as the review, the Engineering Supervisor stated that he changes the O-rings when they are the cause of leaks, however that the remaining items that were not corrected were contracted out to be repaired, that the hospital had obtained quotes, and that no vendor had been contacted yet to complete the repairs.

Based on observation and interview, the facility failed to ensure that all electrical outlets were maintained in optimal condition at all times. Culver City location

Finding:

On March 31,2 014, at 11:45 a.m., the evaluator observed that the Gastrointestinal Service area's restroom electrical outlet did not have an electrical plate cover.

The evaluator conducted an interview with the staff V and he stated that the plate would be replaced as soon as possible.


16281

NFPA 70 National Electrical Code 1999 Edition

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

400-8. Uses not permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

400-9. Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by section 400-7(a). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400-4) No. 14 and larger shall permitted if conductors are spliced in accordance with Section 110-14-(b) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

410-56(e) 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 0.015 in. (0,381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

These requirements were not met as evidenced by:

Based on observation and interview, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by using extension cords as permanent wiring, and by having loose electrical receptacles and receptacles that had missing or damaged faceplates,

To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles, extension cords and/or power strips are often interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire. Damaged and or missing electrical receptacle coverplates can expose energized electrical parts creating a risk of electric shock, burn injuries and fire.


Findings:

Van Nuys campus

1. On March 24, 2014 at 12:20 a.m., in the Intake Department Room located in the basement of the Van Nuys campus extension cords were being daisy chained. There were two pieces of electrical equipment connected to a power strip which was connected to a second power strip along with four pieces of equipment which was connected to an extension cord which was connected to a third power strip along with four pieces of electrical equipment which, in turn, was connected to a wall mounted receptacle. On the other side of the room there were four pieces of electrical equipment connected to a power strip which was connected to an extension cord which was connected to a second extension cord which was connected to a three receptacle extension cord with two other pieces of electrical equipment which in turn was connected to a wall mounted receptacle. There was also a missing electrical cover plate at a wall mounted electrical receptacle.

2. On March 24, 2014, between 2:55 p.m. and 3:20 p.m., in the Outpatient Unit of the Van Nuys campus, there was an ungrounded household tap zip cord extension cord used to connect a snack vending machine and a soft drink vending machine to an electrical receptacle.

A review of the hospital's policy and procedure titled "Electrical Safety (#SF-035)" with an effective date of November 2001, it was stipulated that extension cords were not allowed for use in the hospital.

A review of the hospital's policy and procedure titled "Electrical Safety - Preventing Overload (#SF-040)" with an effective date of November 2001, it was stipulated that, when using extension cords, to use only one duplex receptacle to one extension cord, and to use extension cords only in emergencies and to never use them as a permanent source of electricity.

A review of the hospital's policy and procedure titled "Extension Cords (#SF-044)" with an effective date of November 2001, it was stipulated that the use of extension cords in non-emergency situations is discouraged, they must be constructed of hospital grade material, and they shall not be used as a substitute for fixed wiring.

3. On March 25, 2014, between 9:55 a.m. and 10:15 a.m., in Unit 2 of the Van Nuys campus, there was a loose electrical receptacle in room 207.

Culver City campus

4. On March 26, 2014, between 12:12 p.m. and 12:40 p.m., in room 630 in the 6th floor Unit D of the Culver City campus, there was a broken electrical cover plate exposing the side of the electrical receptacle in the wall.

5. On March 26, 2014 at 3:20 p.m., in room 682 in the Detox unit of the Culver City campus, there was a broken electrical cover plate exposing the space between the electrical receptacle and the wall.

6. On March 28, 2014, between 9:30 a.m. and 10:45 a.m., at the corridor by room 405 of 4th floor Culver City campus, there was a broken electrical coverplate exposing the sides of the electrical receptacle.

7. On March 28, 2014, between 12:10 p.m. and 2:00 p.m., in room 315B in the 3rd floor SDU at the Culver City campus, there was a loose electrical receptacle.

8. On March 28, 2014, between 2:00 p.m. and 2:20 p.m., in room 209 in the 2nd floor Southwest Telemetry unit at the Culver City campus, there was a loose electrical receptacle in the room.

9. On March 28, 2014, between 2:23 p.m. and 2:45 p.m. in room 222 in the 2nd floor Southeast Telemetry unit at the Culver City campus, there was a loose electrical receptacle in the room.

10. On March 31, 2014 at 9:52 a.m., in the pharmacy on the 1st floor Pavilion at the Culver City campus, an extension cord was placed over an exit door to connect a radio to an electrical receptacle.

Based on observation the hospital failed to ensure a corridor door could resist the passage of smoke and that there was no impediment to the closing of a corridor door by having a Dutch door without an astragal and a table placed in front of a door.

Doors protecting corridor openings play an integral role in interrupting the spread of smoke.

Findings:

Culver City campus

On March 26, 2014 between 10:53 a.m. and 3:20 p.m., the following conditions existed at the Culver City campus.

1. In the 6th floor, Unit C, an astragal was missing at the nurses' station corridor Dutch door.

2. In the Detox Unit, the kitchen corridor door was obstructed from closing by having a wood table placed in front of the door.

Based on observation, the hospital failed to ensure a chute (a vertical opening) had a one hour fire resistance by having a hole through the chute door.

Maintenance of the fire resistance of vertical openings is essential in the containment of smoke and fire.

Finding:

Culver City campus

On March 26, 2014, between 2:25 p.m. and 3:20 p.m., at the Detox Unit of the Culver City campus, there was an one inch diameter penetration through the soiled linen chute door.

Based on observation, the hospital failed to ensure smoke barriers were maintained with a half hour fire resistance by having penetrations through the walls.

Smoke barriers assist to limit the spread the movement of smoke, limit the number of occupants exposed to a single fire and create a safe relocation area. If left unsealed, fire, smoke and toxic gases driven by the heat and pressure of a fire may move through the penetrations and travel to other parts of the building.

Findings:

Van Nuys campus

1. On March 24, 2014 at 2:50 p.m., in Unit 1 of the Van Nuys campus, there was a 2 inch by 2 inch penetration through a ceiling at compartmentation above a cross corridor door by the men's common bathroom.

2. On March 25, 2014 in Unit 2 of the Van Nuys campus there was a penetration through a corridor separation wall by the Doctor Dictation Room.

Culver City campus

3. On March 28, 2014, between 9:30 a.m. and 10:45 a.m,. at the construction separation between the back of the 4th floor and the rehabilitation unit at the front of the 4th floor, there were eight unsealed penetrations through the gypsum board barrier at the separation.

During an interview, the Director of Engineering stated that besides being a dust barrier, the gypsum board barrier was also suppose to be a fire barrier.

A review of the hospitals policy and procedure titled "Interim Life Safety Policy (#EC5.50.1-3)" with an effective date of February 2011, stipulated that temporary construction partitions would be smoke tight and built of noncombustible or limited combustible materials.

Based on observation and interview, the facility failed to ensure that the only smoke compartment double doors available on the first floor closed upon activation of the fire alarm.

Finding:

Hollywood campus

On March 25, 2014, at 1:48 p.m., the evaluator observed the Life Safety Code system test. The building staff activated the smoke detector and the smoke barrier doors located on the ground floor did not close. This affected two smoke compartments.

An interview was held with Staff V and he stated that the door would be serviced as soon as possible.

Based on observation and interview, the facility failed to ensure that the exit access corridor was maintained clear and unobstructed at all times.

Finding:

Hollywood campus

On March 24, 2014, at 8:35 a.m., the evaluator inspected the 5th floor and observed one over bed table with a computer monitor and a staff seated on a chair located near the nurse station. The evaluator observed another table holding three computer monitors and three chairs located near room 507 and 506. The corridor width was eight feet and the table occupied 1.5 feet of corridor width.

On March 25, 2014, at 9:45 a.m., the evaluator inspected the fourth floor and observed a desk with four chairs installed into the fire exit access corridor located near room 406. The desk measured ten feet long and one and half wide, with four chairs.

An interview was held with staff V and he stated that he would address the above issue as soon as possible.

Based on observation and interview, the facility failed to ensure that all the fire exit signs pointed to the nearest fire exit at all times.

Finding:

Hollywood campus

On March 24, 2014, at 11:20 a.m., the evaluator conducted an inspection of the facility and observed a fire exit located near the elevator did not have n operational directional arrow. Without a directional arrow, an evacuee would go straight into a patient sleeping room.

An interview was held with staff V and he stated that the fire exit sign would be serviced as soon as possible.

NFPA 72 National Fire Alarm Code 1999 Edition

7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) *Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15) Disposition of problems identified during test (for example, owner notified, problem corrected/successfully retested, device abandoned in place)

The standard was not met as evidenced by:

Based on observation and record review the hospital failed to maintain a smoke detector alarm annunciator and maintain a complete permanent record of a fire alarm inspection and test report, by having tape over the annunciator and having a fire alarm report with missing information.

Findings:

Culver City campus

1. On March 26, 2014, between 2:25 p.m. and 3:20 p.m., there was tape over the annunciator alarm for patient room smoke detectors at the Detox Unit nurse's station at the Culver City campus.

2. On March 31, 2014 between 12:50 p.m. and 2:14 p.m. record review revealed the hospitals fire alarm test report did not include the name of the person performing the inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number; name, address, and representative of approving agency(ies); Signatures of tester and approved authority representative.

Based on observation and record review the hospital failed to ensure that all required smoke detectors were maintained as required by not having documented evidence that the smoke detectors had sensitivity testing in the last five years, having a dismounted smoke head and a missing smoke head.

Smoke detectors that may be out of sensitivity range, that are dismounted and missing could delay or be ineffective in the detection of smoke.

Findings:

Van Nuys Campus

1. On March 25, 2014, between 11:00 a.m. and 2:45 p.m., during document review at the Van Nuys campus, there was no documented evidence of a five year smoke detector sensitivity test.

Culver City campus

2. On March 26, 2014, between 12:12 p.m. and 12:40 p.m., in room 632 in the 6th floor Unit C of the Culver City Campus, the smoke detector was pulled off the bathroom wall.

3. In room 630 in the 6th floor Unit C of the Culver City Campus, the smoke detector head was missing from the room.

Based on observation and interview, the hospital failed to maintain an automatic sprinkler system in operating order and failed to inspect and test the system routinely by having obstructions to sprinkler spray patterns, having missing hose valve caps and not periodically inspecting and testing the system.

Inspection, testing and maintenance of the fire sprinkler system is essential to ensure the system functions as designed during a fire emergency.

Findings:

Van Nuys campus

1. On March 24, 2014 at 11:45 a.m., in Unit 1 of the Van Nuys campus there were boxes stored to the ceiling in the medical records file room, bypassing the 18 inch space required between the top of storage and sprinkler head deflector.

Culver City campus

2. On March 26, 2014, between 11:15 a.m. and 11:45 a.m., in the 6th floor Unit A of the Culver City Campus, there was storage to the ceiling in the patient belongings storage room. bypassing the 18 inch space required between the top of storage and sprinkler head deflector.

3. On March 26, 2014, between 2:25 p.m. and 3:20 p.m., at the Detox Unit of the Culver City campus, the caps were missing from the wet standby pipe fire suppression system at stairwell landings.

On March 31, 2014, between 2:14 p.m. and 3:30 p.m., during an interview the Director of Engineering, it was stated that the caps were missing on every floor in both stairwells of the tower and that the wet pipe system was part of a new sprinkler project that was started six months ago, that the wet pipe system was replacing a dry stand-by pipe system, that the original installer was removed from the project in November and that a new company was contracted that is starting in two weeks.

The Director of Engineering provided a copy of a signed vendor quote dated March 4, 2014 to complete a fire sprinkler installation that was left incomplete by another fire protection company with scope of work, including providing cap and chains for all hose valves in stairwells.

4. On March 31, 2014, between 12:50 p.m. and 2:14 p.m., record review revealed there was no documented evidence that annual sprinkler tests were conducted at the Culver City campus. The only document provided was a vendor work order dated March 26, 2014 that indicated "An annual sprinkler test performance testing waterflow and tampers (walk through the buildings X3) Three buildings: A single story, Main Tower, and 3826 Delmas Terrace building. All three buildings were visually inspected waterflows and tampers were not tested due to test got canceled per building engineer." The notation on the work order indicated the testing was not completed.

At the same time as the review, the Director of Engineering stated that the annual sprinkler test was being conducted during the survey, that it was the first time an annual sprinkler test was being conducted and that he did not yet have the report including results and corrections.

NFPA 10 Standard for Portable Fire Extinguishers 1998 Edition

1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Exception: In large rooms, and in certain locations where visual obstruction cannot be completely avoided, means shall be provided to indicate the location.

These standards were not met as evidenced by:

Based on observation, the facility failed to ensure a fire extinguisher was immediately available, accessible and unobstructed from view.

Portable fire extinguishers are intended as a first line of defense to cope with fires of limited size. For the fire extinguisher to do its job it must be accessible.

Finding:

Culver City campus

On March 31, 2014 at 9:04 a.m., in room 209, in the main laboratory at the 1st floor Pavilion of the Culver City campus, a fire extinguisher was obstructed from view and access by being mounted at a wall behind a computer monitor in a cubicle.

NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 1998 Edition

9-1.2.3 All deep fat fryers shall be installed with at least a 16-in. (406.4-mm) space between the fryer and surface flames from adjacent cooking equipment.

Exception: Where a steel or tempered glass baffle plate is installed at a minimum 8 in. (203 mm) in height between the fryer and surface flames of the adjacent appliance.

The standard was not met as evidenced by:

Based on observation, the facility failed to meet the requirement of NFPA 96 by not having a 16-inch space, or a steel or tempered glass baffle at a minimum 8 inches in height between the fryer and surface flames from adjacent cooking equipment.

Finding:

Van Nuys campus

On March 24, 2014, between 11:20 a.m. and 11:40 a.m., in the Kitchen of the Van Nuys campus, there was a deep fryer next to an open flame stove without benefit of 16 inch separation or 8 inch steel or tempered glass baffle.

Based on observation, interview and document review, the hospital failed to maintain full instant use of a means egress by having equipment placed along exit corridors and by having an exit door locked against egress.

Obstructions to full instant use of a means of egress may delay or impede an evacuation.

Findings:

Culver City campus

1. On March 28, 2014, between 2:00 p.m. and 2:20 p.m., in southwest and southeast telemetry units in the 2nd floor of the Culver City campus, there were wheeled equipment placed in the exit corridors, including two computers, four chairs, and one blood pressure machine in the southwest exit corridor and four computers and three chairs in the southeast exit corridor.

On March 31, 2014 at 2:14 p.m., review of a fire drill report dated February 25, 2014, and conducted on the 2nd floor pavilion, did not address the relocation of the wheeled equipment during a fire or similar emergency.

During an interview at the same time as the fire drill review, a security officer stated that when he had conducted fire drills in the Telemetry units of the 2nd floor pavilion, the equipment that was located on one side of the corridor, remained on one side of the corridor and was not relocated.

A review of the "Fire Response Plan policy (#LMP.003)" dated effective February 2011, and provided as the facility's fire safety plan, revealed it did not address the relocation of the wheeled equipment during a fire or similar emergency.

2. On March 31, 2014, between 10:00 a.m. and 10:10 a.m., on the 1st floor pavilion lobby in the 1st floor Pavilion at the Culver City campus, one of three exit doors (south exit) was locked and did not provide egress.

(1) NFPA 99 Health Care Facility, 1999 Edition, 4-3.1.1.8 (a) Cylinders. Cylinders shall be designed, constructed, tested, and maintained in accordance with 4-3.1.1.1(a) Cylinders in service shall be adequately secured. Cylinders in storage shall be secured and located to prevent them from falling or being knocked over.

This requirement was not met as evidenced by:

Based on observation and interview, the facility failed to ensure that portable oxygen cylinders were secured at all times.

Finding:

Hollywood campus

On March 25, 2014, at 10:50 a.m., the evaluator inspected the facility basement area Sterilizer Room and observed a free standing E-Oxygen cylinder being stored in a corner.

The evaluator conducted an interview with staff V and he stated that the oxygen cylinder would be removed as soon as possible.

(2) NFPA 99 Health Care Facilities 1999 edition

4-3.5.2.2(b)(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85m3).

This requirement was not met as evidenced by:

Based on observation, the facility failed to ensure nonflammable gases were stored in accordance with NFPA (National Fire Protection Association) 99 by not segregating empty cylinders from full cylinders.

Findings:

Hollywood campus

On March 24, 2014, at 12:10 p.m., accompanied by staff V, the evaluator observed 10 full oxygen cylinders and 3 empty oxygen cylinders being stored and mixed together in an unlabeled oxygen storage room located in the respiratory area on the 6th floor.

The evaluator conducted an interview with staff V and he stated that the room would be identified and the oxygen cylinders separated, with an empty and full sign posted, as soon as possible.







16281

NFPA 99 Standard for Health Care Facilities 1999 Edition

4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).

(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

4-3.5.2.1(b)27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

8-6.2.4.5 A scheduled preventive maintenance program shall be followed.

8-6.5 Qualification and Training of Personnel. Equipment shall be serviced by qualified personnel only.

The Standard was not met as evidenced by

Based on observation, the facility failed to meet the requirements of NFPA 99 by chaining or supporting free standing cylinders in a stand or cart, and by not correcting deficiencies found during a medical gas and vacuum system test.

Findings:

Culver City Campus

1. On March 26, 2014, between 11:45 a.m. and 12:12 p.m., in the 6th floor Unit B of the Culver City Campus, there was a free standing oxygen cylinder located between a photocopy machine and a wall at the nurse's station. During an interview at the same time as the observation, the Director of Psychiatric Services stated the cylinder was for emergency use and should not have been there (between the photocopy machine and the wall).

2. On March 28, 2014, between 9:30 a.m. and 10:45 a.m., in the 4th floor physical therapy room of the Culver City campus, 1 of 4 free standing oxygen cylinders was not supported or chained.

3. On March 28, 2014, between 11:20 a.m. and 11:50 a.m., in the 3rd floor CCU of the Culver City campus, there was a free standing oxygen cylinder in the central supply closet, the cylinder was half full per its regulator gauge and was not supported or chained.

4. On March 31, 2014 at 10:15 a.m. there were two unsecured oxygen cylinders in the chain link oxygen storage area outside of the tower building of the Culver City campus. Neither cylinder was was supported or chained.

5. On March 31, 2014 at 12:50 p.m., record review revealed there was no documented evidence that deficiencies found during the medical gas and vacuum system test done on December 19, 2003 were corrected for the Culver City campus, including medical gas zone valves on the 1st, 2nd, 3rd and 5th floors; medical gas area alarm panels on the lower level, 2nd and 3rd floors; O2 and vacuum leaks, reduced flows, non-functioning audible signals, lights out, improper and missing labeling, missing tab, missing pull ring, warn valve bodies, missing screw, adapters with no latch, and missing faceplates throughout the hospital.

During an interview at the same time as the review, the Engineering Supervisor stated that he changes the O-rings when they are the cause of leaks, however that the remaining items that were not corrected were contracted out to be repaired, that the hospital had obtained quotes, and that no vendor had been contacted yet to complete the repairs.

Based on observation and interview, the facility failed to ensure that all electrical outlets were maintained in optimal condition at all times. Culver City location

Finding:

On March 31,2 014, at 11:45 a.m., the evaluator observed that the Gastrointestinal Service area's restroom electrical outlet did not have an electrical plate cover.

The evaluator conducted an interview with the staff V and he stated that the plate would be replaced as soon as possible.


16281

NFPA 70 National Electrical Code 1999 Edition

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

400-8. Uses not permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

400-9. Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by section 400-7(a). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400-4) No. 14 and larger shall permitted if conductors are spliced in accordance with Section 110-14-(b) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.

410-56(e) 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 0.015 in. (0,381 mm) from metal faceplates. Faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

These requirements were not met as evidenced by:

Based on observation and interview, the facility failed to ensure electrical wiring and equipment was in accordance with NFPA 70 by using extension cords as permanent wiring, and by having loose electrical receptacles and receptacles that had missing or damaged faceplates,

To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles, extension cords and/or power strips are often interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire. Damaged and or missing electrical receptacle coverplates can expose energized electrical parts creating a risk of electric shock, burn injuries and fire.


Findings:

Van Nuys campus

1. On March 24, 2014 at 12:20 a.m., in the Intake Department Room located in the basement of the Van Nuys campus extension cords were being daisy chained. There were two pieces of electrical equipment connected to a power strip which was connected to a second power strip along with four pieces of equipment which was connected to an extension cord which was connected to a third power strip along with four pieces of electrical equipment which, in turn, was connected to a wall mounted receptacle. On the other side of the room there were four pieces of electrical equipment connected to a power strip which was connected to an extension cord which was connected to a second extension cord which was connected to a three receptacle extension cord with two other pieces of electrical equipment which in turn was connected to a wall mounted receptacle. There was also a missing electrical cover plate at a wall mounted electrical receptacle.

2. On March 24, 2014, between 2:55 p.m. and 3:20 p.m., in the Outpatient Unit of the Van Nuys campus, there was an ungrounded household tap zip cord extension cord used to connect a snack vending machine and a soft drink vending machine to an electrical receptacle.

A review of the hospital's policy and procedure titled "Electrical Safety (#SF-035)" with an effective date of November 2001, it was stipulated that extension cords were not allowed for use in the hospital.

A review of the hospital's policy and procedure titled "Electrical Safety - Preventing Overload (#SF-040)" with an effective date of November 2001, it was stipulated that, when using extension cords, to use only one duplex receptacle to one extension cord, and to use extension cords only in emergencies and to never use them as a permanent source of electricity.

A review of the hospital's policy and procedure titled "Extension Cords (#SF-044)" with an effective date of November 2001, it was stipulated that the use of extension cords in non-emergency situations is discouraged, they must be constructed of hospital grade material, and they shall not be used as a substitute for fixed wiring.

3. On March 25, 2014, between 9:55 a.m. and 10:15 a.m., in Unit 2 of the Van Nuys campus, there was a loose electrical receptacle in room 207.

Culver City campus

4. On March 26, 2014, between 12:12 p.m. and 12:40 p.m., in room 630 in the 6th floor Unit D of the Culver City campus, there was a broken electrical cover plate exposing the side of the electrical receptacle in the wall.

5. On March 26, 2014 at 3:20 p.m., in room 682 in the Detox unit of the Culver City campus, there was a broken electrical cover plate exposing the space between the electrical receptacle and the wall.

6. On March 28, 2014, between 9:30 a.m. and 10:45 a.m., at the corridor by room 405 of 4th floor Culver City campus, there was a broken electrical coverplate exposing the sides of the electrical receptacle.

7. On March 28, 2014, between 12:10 p.m. and 2:00 p.m., in room 315B in the 3rd floor SDU at the Culver City campus, there was a loose electrical receptacle.

8. On March 28, 2014, between 2:00 p.m. and 2:20 p.m., in room 209 in the 2nd floor Southwest Telemetry unit at the Culver City campus, there was a loose electrical receptacle in the room.

9. On March 28, 2014, between 2:23 p.m. and 2:45 p.m. in room 222 in the 2nd floor Southeast Telemetry unit at the Culver City campus, there was a loose electrical receptacle in the room.

10. On March 31, 2014 at 9:52 a.m., in the pharmacy on the 1st floor Pavilion at the Culver City campus, an extension cord was placed over an exit door to connect a radio to an electrical receptacle.