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Based on observation and interview, the hospital failed to ensure two corridor doors could resist the passage of smoke, and that there was no impediment to the closing of a corridor door.

The deficiency had the potential to permit the passage of smoke, flame, or gases during a fire.

Findings:

Hollywood Campus

Basement

1.) On August 18, 2014 at 11:30 a.m., the doctors' break/locker room had a ¼" diameter penetration through the solid wood corridor door of at a fire rated exit corridor.

During an interview at the same time as the observation, the Disaster Coordinator stated that the corridor was a fire rated exit corridor.

This is a repeat deficiency; on 4/1/14, during a Sample Validation survey, the facility received a deficiency for having a corridor door in a condition that could not resist the passage of smoke.


First Floor

2.) At 12:25 p.m., the Urgent Care door at a fire exit corridor was held fully open by a bundled bandage with tape wedged between the top of the door and door frame.

This is a repeat deficiency; on 4/1/14 during a sampled validation survey the facility received a deficiency for having a corridor door that was impeded from closing.


Culver City Campus Pavilion

6th floor Unit C Psychiatric

3.) On 8/20/14 between 9:30 a.m. and 9:45 a.m., the Dutch corridor door at nurses station C had an aluminum floor threshold with no indication of a fire rating at the meeting edges of the upper and lower leaves. The door was not equipped with an astragal, a rabbet, or a bevel with the same fire rating as the door at the meeting edges of the upper and lower leaves. Closer observation revealed the labels that indicate the fire rating had been removed from the door and door frame.

During an interview at the same time as the observation, the Nursing director of P6 (Psychiatric 6) stated, the metal piece (threshold) was placed there yesterday (8/19/14).

This is a repeat deficiency; on 4/1/14 during a Sampled Validation survey, the facility received a deficiency for having a corridor Dutch door with no astragal.

Based on observation and interview, the hospital failed to ensure smoke barriers were maintained with a half hour fire resistance by having missing gypsum board at corridor smoke barrier wall, and a penetration through a construction separation wall.

The deficiency had the potential to reduce the time the corridor smoke barrier wall had to withstand a fire exposure, and permit the passage of smoke, flame, or gases through the construction separation wall during a fire.

Findings:

Van Nuys Campus

Station 2

1.) On 8/19/14, at Station 2 15 ft. a gypsum board was missing from one side of a corridor smoke barrier wall exposing the wood framing members. The area missing the gypsum board was located above the drop down ceiling, above the observation and dictation room, both of which had 20 minute rated fire doors.

At the same time as the interview, the Head Engineer stated that the wall was a 30 minute rated fire wall that needed to have dry wall on both sides of the wall.


Culver City Campus Pavilion

4th floor Rehabilitation Unit

2.) On 8/20/14 between 10:05 a.m. and 10:23 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 was a 3 foot by 5 foot section missing from the gypsum board barrier at the separation.

During an interview at the same time as the observation, the Corporate Director of Facilities stated that the gypsum board barrier was supposed to go all the way up to the ceiling.

This is a repeat deficiency; on 4/1/14 during a Sampled Validation survey, the facility received a deficiency for having unsealed penetrations through the gypsum board barrier at the construction separation between the back of the 4th floor and the rehabilitation unit at the front of the 4th floor.

Based on observation and interview, the hospital failed to ensure a cross corridor door automatically self closed when the fire alarm system was activated.

The deficiency had the potential to permit the passage of smoke, flame, or gases during a fire, and permit drafts which could spread fire rapidly.

Finding:

Hollywood Campus

First Floor

On August 18, 2014 at 12:37 p.m., a cross corridor door located on the first floor, between Urgent Care and the kitchen, failed to close upon activation of the fire alarm system. Closer observation revealed the magnetically held door released upon activation of the fire alarm system, but failed to close. Further observation revealed the door was stuck to the floor.

At the same time as the observation, the Corporate Director of Facilities stated that the door failed to close because of wax built up on the floor.

At 1:20 p.m., after the wax build up was removed from the floor, the door was retested by again activating the fire alarm system. The door released from the magnetic holder and closed.

This is a repeat deficiency; on 4/1/14 during a Sampled Validation survey, the facility received a deficiency for the same cross corridor door not closing during a test of the fire alarm system.

NFPA 72 National Fire Alarm Code, 1999 Edition

7-3.2 Testing. Testing shall be performed in accordance
with the schedules in Chapter 7 or more often if required by
the authority having jurisdiction. If automatic testing is performed
at least weekly by a remotely monitored fire alarm control
unit specifically listed for the application, the manual
testing frequency shall be permitted to be extended to annual.
Table 7-3.2 shall apply.

Exception: Devices or equipment that are inaccessible for safety considerations
(for example, continuous process operations, energized electrical
equipment, radiation, and excessive height) shall be tested during
scheduled shutdowns if approved by the authority having jurisdiction
but shall not be tested more than every 18 months.

Table 7-3.2 Testing Frequencies

5. Batteries - Central Station Facilities

c. Sealed Lead-Acid Type
1. Charger Test - Monthly, Quarterly
2. Discharge Test (30 minutes) - Monthly
3. Load Voltage Test - Monthly

6. Batteries - Fire Alarm System

c. Sealed Lead-Acid Type
1. Charger Test - Annually
2. Discharge Test (30 minutes) - Annually
3. Load Voltage Test - Semiannually

The Code was not met as evidenced by:

Culver City Campus

Based on document review, and interview, the hospital failed to ensure the batteries of the fire alarm system were tested at the frequencies indicated by NFPA 72.

The deficiency had the potential to not supply backup power to the fire alarm system.

Finding:

On August 21, 2014 at 10:30 a.m., during document review, there was no documented evidence the fire alarm system batteries were routinely tested.

During an interview, at the same time as the document review, the Lead Man stated that the fire alarm system had sealed lead acid batteries, and that the load voltage tests of the batteries was not being conducted.

NFPA 72 National Fire Alarm Code 1999 Edition

2-1.3.2 In all cases, initiating devices shall be supported independently of their attachment to the circuit conductor.

The Code was not met as evidenced by:

Based on observation and interview, the hospital failed to ensure that a required smoke detector (initiating device) was maintained as required by having a dismounted smoke head suspended by its electrical wires.

The deficiency had the potential to impair the operation of the initiating device circuit, conceivably resulting in loss of life or property because of fire alarm failure. Copper used in wiring conductors is not formulated to serve as a mechanical support. Copper fatigues over time if placed under mechanical stress, resulting in increasing brittleness and increasing electrical resistance. Ultimately, the fatigued conductor either breaks or its resistance becomes too high to allow the initiating device to function properly.

Finding:

Culver City Campus Pavilion

6th floor Unit C Psychiatric

On 8/20/14 between 9:30 a.m. and 9:45 a.m., in room 636, there was a smoke detector head that was detached from its base, supported only by its electrical wires.

During an interview at the same time as the observation, the Director of Engineering acknowledged the smoke detector head was supported by its wires, and stated the head would be repaired to be supported by its base or it would be replaced.

This is a repeat deficiency; on 4/1/14 during a Sampled Validation survey, the facility received a deficiency for having a smoke detector that was pulled of a wall.

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.

4-3.5.2.1(b)24. Even if they are considered empty, cylinders shall never be used as rollers, supports, or for any purpose other than that for which they are intended by the supplier.

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 (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.

These Standards was not met as evidenced by:

Based on observation and interview, the hospital failed to ensure oxygen cylinders were properly chained or supported in proper cylinder stands or carts.

The deficiency had the potential to create a mechanical hazard. If a cylinder falls, the valve could snap off and/or if the cylinder is cracked open and the cylinder has a sudden, uncontrollable release of its contents, it could be propelled rapidly and/or violently.

Findings:

Culver City Campus

Exterior Oxygen Cylinder Storage

On August 21, 2014 at 9:10 a.m. the following conditions existed at the exterior oxygen (O2) cylinder storage area.

1.) Two O2 (a non-flammable gas) cylinders were lying on their sides on the ground with a metal hand truck on top of them.

During an interview, at the same time as the observation, the Head Engineer stated that the cylinders should have been in racks, stands or secured by chains.

2.) One O2 cylinder was free standing and unsecured.

During an interview, at the same time as the observation, the Head Engineer stated that the cylinder should have been in a rack, stand or secured by a chain.

This is a repeat deficiency; on 4/1/14 during a Sample Validation survey, the facility received a deficiency for having free standing oxygen cylinders that were not supported or chained throughout the hospital, including the exterior oxygen storage area.

3.) One Argon (a non-flammable gas) cylinder was free standing unsecured.

During an interview, at the same time as the observation, the Head Engineer identified the cylinder as an argon cylinder and stated that the cylinder should have been in a rack, stand or secured by a chain.

4.) There were ten full O2 cylinders stored on the empty cylinder side of the cylinder storage area. A sign on the wall identified the section as the empty cylinder section of the O2 storage area.

During an interview, at the same time as the observation, the Head Engineer identified the cylinders as full cylinders and stated that the should been stored on the full side.

NFPA 70 National Electrical Code (NEC) 1999 Edition

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.

These requirements were not met as evidenced by:

Based on observation and interview, the hospital had an extension cord in use as permanent wiring.

The deficiency had the potential to present a fire safety hazard. The National Electrical Code (NEC) stipulates that temporary wiring is to be removed immediately upon completion of construction or other purpose (i.e. remodeling, maintenance, repair, and demolition) for which the wiring was installed.

Finding:

Culver City Campus

Single Story Building

On August 21, 2014, at 9:35 a.m., there was an extension cord being used as permanent wiring at the exterior west side of the single story building. A mini drop amplifier was connected to the extension cord.

During an interview, at the same time as the observation, the Lead Engineer stated that the extension cord should not have been in use as permanent wiring.

This is a repeat deficiency; on 4/1/14 during a Sampled Validation survey, the facility received a deficiency for using extension cords as permanent wiring.