HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the walls and ceilings. This affected 1 of 10 stories in Building A, East Tower; 1 of 12 stories in Building A, West Tower; and Building K, and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/11/13, the building construction was observed.

Building A, East Tower:1. On 1/8/13 at 8:25 A.M., in EVS storage 24-03-099 on the 3rd floor, there were 6 penetrations approximately 1/2 inch in diameter in the back wall.

Building A, West Tower:
2. On 1/8/13 at 2:00 P.M., in EVS storage 22-06-054 on the 6th floor, there were 4 penetrations approximately 1 inch in diameter in the back wall.


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Building A, North Tower:
3. On 1/9/13 at 8:59 a.m., in the Engineering Shop on the Basement level, there was an approximately 1/2 inch diameter wall penetration around 1 of 2 air duct units.

Building K
4. On 1/9/13 at 2:30 p.m., in the wall above the door to Suite 140 by the Hyperbaric Chambers, there were two, approximately 1 inch wall penetrations, and an approximately 2 ½ inch wall penetration.

Based on observation, the facility failed to maintain their doors to resist the passage of fire and smoke as evidenced by doors that failed to positive latch. This affected 3 of 10 floors in Building A, East Tower, and 1 of 12 floors in Building A, West Tower. This could result in the migration of fire and smoke causing harm to patients, staff and visitors.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the facility doors were observed.

Building A, East Tower:
1. On 1/7/13 at 1:30 P.M., the door to Storage 24006-070 on the 6th floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

2. On 1/7/13 at 2:48 P.M., the door to the Physicians Work Room 24-04-086 on the 4th floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

3. On 1/8/13 at 10:10 A.M., the door to Blood Bank 24-B-062 on the Basement level was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

Building A, West Tower:
4. On 1/8/13 at 11:20 A.M., the door to the Transformer Closet in the Soiled Utility 22-10-063 on the 10th floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure due to tape placed over the latching mechanism.

Based on observation, the facility failed to maintain their fire rated smoke barrier doors on magnetic devices to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by smoke barrier doors that failed to latch upon closure. This affected 1 of 12 floors in Building A, West Tower, and 2 of 6 floors in Building B, and could result in the spread of smoke and/or fire from one compartment to another.

Findings:

During testing of the fire alarm system with Hospital Staff on 1/7/13 through 1/11/13, the smoke barrier doors were observed and tested.

Building A, West Tower:
1. On 1/10/13 at 10:16 A.M., 1 of 4 the smoke barrier doors to the Nursing Station on the 5th floor failed to positive latch after activation of a manual pull station.


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Building B
2. On 1/8/13 at 3:56 p.m., the smoke barrier door by elevator #3 on the 1st floor failed to latch on the left side during testing of the fire alarm system.

3. On 1/8/13 at 4:27 p.m., the smoke barrier door in the basement by the restroom failed to latch during testing of the fire alarm system.

Building A, East Tower
4. On 1/9/13 at 3:59 p.m., the smoke barrier door by Room 24-02-105 on the 2nd floor failed to latch on one side during testing of the fire alarm system.

5. On 1/9/13 at 4:15 p.m., the smoke barrier door by the Blood Bank in the basement failed to latch during testing of the fire alarm system.

Building A, North Tower
6. On 1/10/13 at 9:40 a.m., smoke barrier door 22-06-064 in the Nurses Station on the 6th floor failed to latch during testing of the fire alarm system.

Building A, Auxiliary Building
7. On 1/10/13 at 2:00 p.m., the smoke barrier door by the ESI treatment room on the 1st floor failed to close, leaving an approximately 1/2 inch opening.

8. On 1/10/13 at 2:31 p.m., the smoke barrier door by room 284 failed to close and latch.

9. On 1/10/13 at 2:35 p.m., the smoke barrier door by the west elevators on the 1st floor failed to close.

10. On 1/10/13 at 2:45 p.m., the left leaf of the double doors by the surgery waiting area failed to latch during testing of the fire alarm system.

11. On 1/10/13 at 3:31 p.m., the left leaf of the double doors by the South Parking failed to latch during testing of the fire alarm system.

Based on observation and interview, the facility failed to maintain their exits so that they were readily accessible at all times. This was evidenced by medical equipment that was stored in the exit corridors and in the exit access. This has the potential to cause harm to patients, staff and visitors in the event of an evacuation due to a fire. This affected 3 of 10 floors in Building A, East Tower.

Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/11/13, the corridors and exits were observed, and staff were interviewed.

Building A, East Tower:
1. On 1/8/13 at 10:00 A.M., in the Lab by Pathology 24-B-080 on the Basement level there were two, 5 foot by 5 foot plastic bins, a chair, a soiled linen cart, and a table stored in the corridor that was part of the egress path.

2. On 1/8/13 at 2:30 P.M., on the 5th floor by room 5W-002 there was a Computer on Wheels (COW) and Dialyses machine up against the fire doors that were part of the egress path.

Based on record review and interview, the facility failed to conduct fire drills at least quarterly on each shift. This was evidenced by incomplete records for fire drills for each shift, per quarter. This could result in all staff members not being familiar with their roles and responsibilities in the event of a fire, and affected Building A and Building B.

Findings:

During document review with the Hospital Staff on 1/7/13 through 1/11/13, the fire drill records were reviewed.

Building A
1. On 1/7/13 at 10:35 a.m., the records showed fire drills were not conducted for 1st quarter 2012 AM shift for the 1st floor Cafe staff, and the 5th floor East Tower staff.
For the 2nd quarter 2012, there were no records for the NOC shift for the main Operating Room, and Post Acute Care unit staff.

For the 3rd quarter 2012 AM shift, there were no records for the MOR and PACU staff.

For the 3rd quarter 2012, there were no records for the PM (evening) shift for Cafe staff on the 1st floor.

When interviewed on 1/7/13, Hospital staff 1 stated fire drills were done per department, and not per shift.

Building B:
2. On 1/8/13 at 9:50 a.m., the facility failed to provide records to show the fire drills were conducted for all staff for all quarters.

There were no records for the first quarter 2012, and the 2nd quarter 2012, AM shifts for 1st floor kitchen staff, Pharmacy and Radiology staff.

For the 3rd quarter 2012, there were no records for the PM and NOC shift fire drills for the Critical Care unit, Cardiology, Emergency Department, Radiology, Surgery and Laboratory staff.

There were no records for fire drills for the Critical Care unit, and the Emergency Department staff, for the 4th quarter 2012 PM shift.

When interviewed, Hospital Staff 2 stated the registered nurses work 12 hour shifts, and all other staff work three, 8 hour shifts (AM, PM, and NOC).

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Based on observation, document review and interview, the facility failed to provide effective warning of fire as evidenced by fire alarm system strobes, chimes and manual pull stations that failed to activate and alarm. This could result in potential harm to patients, visitors and staff if the fire alarm system devices failed to notify patients, visitors and staff of a fire in the facility. This affected Building A, North Tower, West Tower, Main Operating Rooms, and the Chemical Dependency Recovery Center.

During fire alarm testing with Hospital Staff on 1/7/13 through 1/11/13, the fire alarm system strobes, chimes and manual pull stations were observed, tested, and Hospital Staff was interviewed.

Building A, North Tower:
1. On 1/8/13 at 10:30 A.M., the 435 GNP Case Manager & Hospitalists room on the 4th floor had a chime/strobe device that had a napkin taped over it.

Building A, West Tower:
2. On 1/10/13 at 10:38 A.M., on the 3rd floor of the West Tower, all strobe/chime devices failed to emit an audible sound. The strobe portion of the device functioned. The 3rd floor was unoccupied. Hospital Staff stated that they plan begin to move employees into that area on 1/22/13. Hospital Staff stated that they had to download the file again for the audible devices. The file was downloaded, and Hospital Staff stated the audible and visual functionality of the strobe/chime devices were working on 1/11/13.

Building A, Main Operating Rooms:
3. On 1/10/13 at 2:30 P.M., 6 strobe/chime devices on the 1st floor, Pre-Post Procedure area failed to emit an audible sound. The strobe portion of the device functioned. Hospital Staff stated that they had to download the file again. The file was downloaded, and Hospital Staff stated the audible and visual functionality of the strobe/chime device were working on 1/11/13.

Building A, Chemical Dependency Recovery Center:
4. On 1/10/13 at 3:43 P.M., 2 manual pull stations, 2 strobe/chime devices and 1 hard wired smoke detector over the nursing station failed. No other devices were observed in the Chemical Dependency Recovery Center. Hospital Staff was asked what they would do for fire coverage in the absence of a functioning fire alarm system, and Hospital Staff stated that they would immediately begin a fire watch, which according to their policy and procedure was every 30 minutes. A fire watch log was posted, and a security guard designated by the faciltity for the fire watch rounds, was observed at the Nursing Station.

Hospital Staff stated that they did not know the Chemical Dependency Recovery Center was wired into the North Tower. The fire alarm system for the North Tower was completed on 11/30/12. Hospital Staff was asked when the last testing for the Chemical Dependency Recovery Center had been done, and staff stated 10/12.

Hospital Staff stated that they had to replace the one smoke detector, 2 strobe/chimes and 2 manual pull stations with a newer device due to the new wiring that was completed on 11/30/12. Documentation from the Office of Statewide Health Planning and Development (OSHPD) Construction Advisory Report dated 11/30/12, Project # P-2011-00199, stated that the project was 100% completed for fire alarm wiring for the North Tower.

The vendor completed the replacement of all devices in that area by 1/11/2013 in the morning. The smoke detector, 2 strobe/chimes and 2 manual pull stations were tested on 1/11/13, and all devices were audible and visible, and transmitted a signal to PBX and the third party monitoring company.

NFPA 101, 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.

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

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

Based on documentation, observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by the batteries in the Fire Alarm Control Panels (FACP) not tested and replaced according to NFPA 72 specifications, by audible devices that failed to activate during alarm testing, by the monitoring company not receiving signals from the FACP and PBX, and by a FACP that was obstructed by furniture. This could cause harm to patients and staff in the event of a fire, and affected Building A, East Tower, and Building B.

Findings:

During testing of the fire alarm system with Hospital Staff on 1/7/13 through 1/11/13, the fire alarms system was tested and observed, documents were reviewed, and staff was interviewed.

Building A, East Tower:
1. On 1/7/13 at 2:45 P.M., the two batteries in the FACP labeled PS.4B in Signal Room 24-04-104 on the 4th floor were dated 2/08.

2. On 1/8/13 at 8:40 A.M., two batteries in the FACP labeled PS.3B in Signal Room 24-03-103 on the 3rd floor did not have a date on them. Hospital Staff stated that they did not know when the batteries were installed.



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Building B
3. On 1/8/13 at 4:25 p.m., a fire alarm pull station was obstructed by a patient bed in the egress corridor of the basement by the Laboratory.

4. On 1/9/13 at 9:05 a.m., Hospital Staff 1 stated the fire alarm test conducted on 1/8/13 from 4:00 p.m. to 5:00 p.m., had failed to send signals to the third party monitoring company until approximately 1:00 a.m., on 1/9/13. At that time the Fire Department dispatched a fire truck to the hospital. Hospital Staff 1 stated they were notified during fire alarm testing on 1/8/13, that the phone lines were down. According to document review, the monitoring company received the fire alarm test signals by a delay of approximately 8 hours.

Building A
5. On 1/9/13 at 9:35 a.m., in the Bio-Med storage room on the Basement level, boxes of supplies and equipment obstructed access to the fire alarm power supply boxes.

6. On 1/10/13 at 4:15 p.m., two of two audio units by HVI corridor on the 1st floor failed to activate during alarm testing.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Based on document review, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to provide documentation of quarterly automatic sprinkler testing and inspection for 1 of 4 quarters. This could result in the failure of the automatic sprinkler system in the event of a fire, and affected Building L, Surgicare, Suite 100.

Findings:

During document review with the Hospital Staff on 1/7/13 through 1/11/13, the facility's automatic sprinkler system maintenance records were reviewed.

Building L, Surgicare, Suite 100:
On 1/11/13 at 10:30 A.M., the maintenance records were reviewed, and the facility failed to provide documentation that the automatic sprinkler testing and inspections were conducted for the 1st quarter, January, February and/or March, 2012.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinkler heads with escutcheon rings that were missing, sprinkler heads that were not free of debris, and sprinkler heads with less than 18 inches of clearance. This could result in the automatic sprinkler system not functioning as designed, and increased risk of injury to patients and staff. This affected 2 of 12 floors in Building A, West Tower, Building B and Building L.

NFPA 13 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, 2002 Edition
5.2.1.1.1
Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall).


Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/11/13, the automatic sprinkler system was observed.

Building A, West Tower:
1. On 1/8/13 at 4:00 P.M., in the Drug Room in the PACU on the 1st floor, there was an escutcheon ring hanging down from the ceiling, and created a penetration approximately 1/2 inch in the ceiling.

2. On 1/8/13 at 4:35 P.M., in the closet outside the Board Room on the 1st floor, there was a sprinkler missing an escutcheon ring.

3. On 1/9/13 at 9:10 A.M., in the Trash Room on the Basement level, there was 1 of 5 escutcheon rings missing.

4. On 1/10/13 at 2:50 P.M., in the Operating Room (OR) area on the 1st floor, the sprinkler between the sterilizer machines by OR 8 was hanging down from the ceiling approximately 1 1/2 inches, and created an approximately 1/2 inch penetration in the ceiling.

Building L, Surgicare, Suite 100:
5. On 1/11/13 at 10:00 A.M., the sprinkler head in the Electrical Room had blue plastic on it. The sprinkler head was directly above a trash bin that contained blue plastic bags filled with trash.




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Building B
6. On 1/8/13 at 11:16 a.m., in Room 5224 on the 5 th floor, 2 of 2 sprinkler heads were obstructed by staff locker cabinets that were approximately 12 inches directly below the sprinkler deflectors.

Building A
7. On 1/9/13 at 8:40 a.m., in the Engineer Staff Lounge on the Basement level, 1 of 4 sprinkler heads was covered in dust and/or debris.

8. On 1/9/13 at 9:20 a.m., in the Rehab Service office on the Basement level, 2 of 7 sprinkler heads were missing escutcheon rings.

9. On 1/9/13 at 9:40 a.m., in the Kitchen on Basement level, 1 of 2 sprinkler heads in refrigerator B had a built up of debris.

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.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

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 10 stories in Building A, East Tower and could result in a delay in access to the fire extinguisher resulting in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/8/13, the portable fire extinguishers were observed.

Building A, East Tower:
On 1/8/13 at 10:08 A.M., in the Lab on the Basement level, the fire extinguisher was impeded from immediate access by a 2 drawer cabinet, a monitor, a hard drive and a label printer.

NFPA 90 A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

Based on record review and interview, the facility failed to maintain their heating, ventilating, and air conditioning system as evidenced by fire dampers that were inaccessible, and were unable to be tested and/or inspected. This affected Building A, and could result in the spread of smoke and fire.

Findings:

During record review with Hospital Staff on 1/7/13 through 1/11/13, the damper testing and maintanence records were reviewed, and staff was interviewed.

Building A
On 1/7/13 at 2:30 p.m., records for testing of 1,411 fire/smoke dampers by an outside vendor on 3/21/11, indicated that 17 fire/smoke dampers were inaccessible, and maintenance and inspection could not be performed on them. The facility failed to provide records that the 17 fire/smoke dampers that were identified in the report dated 3/21/11, had been tested and maintained, and that there was accessibility for the dampers.

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

NFPA 99, Standard for Health Care Facilities, 1999 Edition
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a) 11e with respect to temperature limitations. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a) 11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b) 13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b) 27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b) 14.

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

4-3.5.2.2 (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.
4-3.5.2.1

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and interview, the facility failed to maintain the oxygen storage. This was evidenced by failing to ensure that the empty oxygen cylinders were individually secured, that the full and empty cylinders were separated, and not stored next to combustible materials and electrical outlets, and had the proper precautionary signs displayed. This could result in an increased risk of damage to an oxygen cylinder, or in an increased risk of fire, or in staff confusion or a delay in staff response to an emergency if did not know which cylinders were empty or full when responding to an emergency. This affected 4 of 10 stories in Building A, East Tower, 5 of 12 stories in Building A, West Tower and 1 of 3 stories in Building G.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the facility's oxygen storage areas were observed, and staff was interviewed.

Building A, East Tower:
1. On 1/7/13 at 1:20 P.M., Clean Utility room 24-06-122 on the 6th floor had 8 E-Tank oxygen cylinders with no sign to indicate if the cylinders were empty or full, and were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

2. On 1/7/13 at 2:35 P.M., Clean Utility room 24-04-090 on the 4th floor had 6 E-Tank oxygen cylinders with no sign to indicate if the cylinders were empty or full, and were stored in a room with no precautionary sign to indicate the room was used for oxygen storage. Five E-Tank oxygen cylinders had a red cap, and 1 did not. Nursing staff was interviewed, and asked how they identify the empty cylinders from the full ones, and staff said they had to look at the gauge in order to see which ones were full.

3. On 1/8/13 at 8:30 A.M., Clean Utility room 24-03-009 on the 3rd floor had 5 full E-Tank oxygen cylinders and 1 empty E-Tank cylinder stored together in a rack with no sign indicating which ones were empty or full. The metal rack was stored next to a cart with seizer pads and medical supplies. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

4. On 1/8/13 at 8:35 A.M., Clean Utility room 24-03-055 on the 3rd floor had 5 E-Tank oxygen cylinders stored together in a rack with no sign indicating which ones were full and/or empty. The metal rack was stored next to a linen cart. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

5. On 1/8/13 at 9:05 A.M., in the Equipment Processing room 24-02-088 on the 2nd floor there were 8 E-Tank oxygen cylinders stored in a rack with no sign indicating which ones were empty or full. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

Building A, West Tower:
6. On 1/8/13 at 1:30 P.M., Soiled Utility room 22-07-063 on the 7th floor had 1 E-Tank oxygen cylinder in a metal cart stored next to a 4 plug electrical outlet. The oxygen cylinder was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

7. On 1/8/13 at 1:38 P.M., Clean Utility room 22-07-034 on the 7th floor had 11 E-Tank oxygen cylinders in a metal cart stored next to a 2 plug electrical outlet. There was no sign by the tanks to indicate which ones were empty or full. The oxygen was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

8. On 1/8/13 at 2:05 P.M., Soiled Utility Biohazard room 22-06-063 on the 6th floor had 2 E-Tank oxygen cylinders in a metal cart stored next to a 2 plug electrical outlet. There was no sign by the cylinders to indicate which ones were empty or full. Hospital Staff stated that the gauge on the tanks indicated they were empty. The oxygen was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

9. On 1/8/13 at 2:09 P.M., in the Clean Utility Nourishment room 22-06-064 on the 6th floor there were 12 E-Tank oxygen cylinders in a metal cart stored next to a 4 plug electrical outlet and two fire alarm control panels. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

10. On 1/8/13 at 2:20 P.M., in the Biohazard Soiled Utility room 22-05-63 on the 5th floor there were 4 E-Tank oxygen cylinders in a metal cart stored next to a 2 plug electrical outlet and next to a chemo tub waste and 2 plastic bags with dirty rags and linen in them. There was no sign by the cylinders to indicate which ones were empty or full. Nursing Staff was asked if the tanks were empty or full, and the Nursing Staff stated that the gauge on 1 of 4 E-Tanks was 100% full. The Nursing Staff was asked if the E-cylinder would be used since it was full, and staff stated that it would not because any oxygen tanks in the "soiled utility" rooms were not used. The oxygen was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

11. On 1/8/13 at 2:35 P.M., Clean Utility Nourishment room 22-05-064 on the 5th floor had 12 E-Tank oxygen cylinders in a metal cart stored next to two fire alarm control panels and a 2 plug electrical outlet. There was no sign by the tanks to indicate which ones were empty or full. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

12. On 1/8/13 at 2:38 P.M., CCU Clean Supply Holding room 22-04-071 on the 4th floor had 7 E-Tank oxygen cylinders in a metal cart with no sign by the tanks to indicate which ones were empty or full. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

13. On 1/8/13 at 4:10 P.M., in PACU Hopper area on the 1st floor there were 10 E-Tank oxygen cylinders in a metal cart stored next to a biohazard tub and 2 soiled linen containers.

14. On 1/8/13 at 4:15 P.M., in the Main OR Pre/Post Procedure Unit Clean Utility room 29-01-139 on the 1st floor had 4 E-Tank oxygen cylinders stored next to a cart with plastic bags of tubing and medical supplies.

15. On 1/8/13 at 4:30 P.M., in Equipment Storage room 32-01-308 on the 1st floor there were 9 E-Tank oxygen cylinders stored next to bags of plastic tubing and medical supplies.

Building G:
16. On 1/9/13 at 12:15 P.M., in Suite 100 on the 1st floor there were 6 E-Tank oxygen cylinders with no sign to indicate if the tanks were empty or full.

Building A, West Tower:
17. On 1/10/13 at 10:01 A.M., by EVS 22-07-076 storage on the 7th floor there was 1 E-Tank oxygen cylinder on the floor leaning against the wall. Nursing staff stated the gauge indicated it was 1/3 full.

Building A, Main Operating Rooms:
18. On 1/10/13 at 2:45 P.M., in the Outback Surgical Equipment 26-01-214 on the 1st floor there were 7 carbon dioxide, 2 nitros oxide, 1 compressed air and 2 E-Tank oxygen cylinders in a metal cart with no sign by the tanks to indicate which ones were empty or full. The cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.



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Hospital B
19. On 1/8/13 at 1:40 p.m., in the Emergency Room Supply Room 1643, there were 6 E-Tank Oxygen cylinders stored within 5 feet of combustible supplies. The empty and full E-cylinders were stored in the same crate.

Hospital A
20. On 1/9/13 at 9:20 a.m., an E-Tank Oxygen cylinder was taped to an IV pole and placed among supply boxes in the Bio-Med storage room on basement level.

NFPA 101, Life Safety Code, 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on document review and interview, the facility failed to maintain the relative humidity level equal to or greater than 35%. This was evidenced by documentation that some of the humidity levels for Operating Rooms 2, 3, and 4 for the months of January 2013 and November 2012 fell below the required level of 35%, and the facility failed to provide a policy and procedure for the Operating Room Relative Humidity and what to do in the event the relative humidity fell below the facility's humidity standard. This could result in an increased risk of fire in the operating rooms, resulting in potential harm to patients and staff. This affected Building L, Surgicare, Suite 100.

Findings:

During document review with Hospital Staff on 1/7/13 through 1/11/13, the humidity levels of Operating Room 2, 3 and 4 were reviewed, and staff was interviewed.

Relative humidity is checked by the facility at 6:00 A.M. Documentation provided was based on a 6:00 A.M. reading/documentation provided by the facility. Operating Room 1 is not in use per Hospital Staff. When interviewed, the Director stated that the facility's policy and procedure for relative humidity is between 30% and 60%. The Director was asked if the facility continued with surgery on the days the humidity fell below the facility's requirement of 30% range, and the Director stated that they did continue with surgery. When asked if they document any corrections to the relative humidity, the Director stated that they did not.

Hoag Hospital Relative Humidity/Temperature Log" for OR 2, 3 and 4:
1. Humidity levels documented on 11/12/12 for OR 2 was 33%, and OR 4 was 28%.
2. Humidity levels documented on 11/13/12 for OR 2 was 33%, and OR 4 was 28%.
3. Humidity levels documented on 1/2//13 for OR 2 was 31%, OR 3 was 32%, and OR 4 was 26%.
4. Humidity levels documented on 1/3/13 for OR 2 was 34%, and OR 4 was 32%.
5. Humidity levels documented on 1/4/13 for OR 2 was 34%, and OR 4 was 31%.
6. Humidity levels documented on 1/11//13 for OR 2 was 34%, OR 3 was 34%, and OR 4 was 29%.

NFPA 101 Life Safety Code 2000 Edition
4.5.7 Maintenance. 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 maintained unless the Code exempts such maintenance.

Based on observation and interview, the facility failed to maintain the dryers in the laundry room. This was evidenced by a built-up of lint in a dryer. This affected Building A, and could result in an increased risk of a fire and potentially cause injury to patients and staff.

Findings:

During tour of facility with Hospital Staff 1 on 1/7/13 through 1/11/13, the laundry room was observed.

Building A
On 1/9/13 at 10:11 a.m., in the Laundry room in the Basement, there was a build up of lint on top of the lint screen shelf, and in the back of the dryer.

NFPA 99 (1999 Edition) 3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

NFPA 70 (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
(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

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by the use of a surge protector to provide additional outlets in place of fixed wired receptacles. This affected 1 of 10 floors at Building A, East Tower and could result in an increased risk of an electrical fire.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the facility electrical wiring and equipment was observed.

Building A, East Tower:
On 1/7/13 at 1:38 P.M., there was a surge protector used to extend power to a refrigerator in Room 24-06-166 on the 6th floor.

Based on observation, the facility failed to ensure the Alcohol Based Hand Rub (ABHR) dispensers were installed away from ignition sources. This was evidenced by an ABHR mounted above an electrical switch. This could result in a fire, and increase the risk of injury to patients, visitors and staff. This affected 1 of 5 smoke comparments.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the ABHR dispensers were observed.

Building A, East Tower:
On 1/8/13 at 10:05 A.M., in the Histology area on the Basement level there was an ABHR dispenser mounted above an electrical light switch.

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the walls and ceilings. This affected 1 of 10 stories in Building A, East Tower; 1 of 12 stories in Building A, West Tower; and Building K, and could result in the spread of smoke or fire to other locations in the facility.

Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/11/13, the building construction was observed.

Building A, East Tower:1. On 1/8/13 at 8:25 A.M., in EVS storage 24-03-099 on the 3rd floor, there were 6 penetrations approximately 1/2 inch in diameter in the back wall.

Building A, West Tower:
2. On 1/8/13 at 2:00 P.M., in EVS storage 22-06-054 on the 6th floor, there were 4 penetrations approximately 1 inch in diameter in the back wall.


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Building A, North Tower:
3. On 1/9/13 at 8:59 a.m., in the Engineering Shop on the Basement level, there was an approximately 1/2 inch diameter wall penetration around 1 of 2 air duct units.

Building K
4. On 1/9/13 at 2:30 p.m., in the wall above the door to Suite 140 by the Hyperbaric Chambers, there were two, approximately 1 inch wall penetrations, and an approximately 2 ½ inch wall penetration.

Based on observation, the facility failed to maintain their doors to resist the passage of fire and smoke as evidenced by doors that failed to positive latch. This affected 3 of 10 floors in Building A, East Tower, and 1 of 12 floors in Building A, West Tower. This could result in the migration of fire and smoke causing harm to patients, staff and visitors.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the facility doors were observed.

Building A, East Tower:
1. On 1/7/13 at 1:30 P.M., the door to Storage 24006-070 on the 6th floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

2. On 1/7/13 at 2:48 P.M., the door to the Physicians Work Room 24-04-086 on the 4th floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

3. On 1/8/13 at 10:10 A.M., the door to Blood Bank 24-B-062 on the Basement level was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

Building A, West Tower:
4. On 1/8/13 at 11:20 A.M., the door to the Transformer Closet in the Soiled Utility 22-10-063 on the 10th floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure due to tape placed over the latching mechanism.

Based on observation, the facility failed to maintain their fire rated smoke barrier doors on magnetic devices to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by smoke barrier doors that failed to latch upon closure. This affected 1 of 12 floors in Building A, West Tower, and 2 of 6 floors in Building B, and could result in the spread of smoke and/or fire from one compartment to another.

Findings:

During testing of the fire alarm system with Hospital Staff on 1/7/13 through 1/11/13, the smoke barrier doors were observed and tested.

Building A, West Tower:
1. On 1/10/13 at 10:16 A.M., 1 of 4 the smoke barrier doors to the Nursing Station on the 5th floor failed to positive latch after activation of a manual pull station.


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Building B
2. On 1/8/13 at 3:56 p.m., the smoke barrier door by elevator #3 on the 1st floor failed to latch on the left side during testing of the fire alarm system.

3. On 1/8/13 at 4:27 p.m., the smoke barrier door in the basement by the restroom failed to latch during testing of the fire alarm system.

Building A, East Tower
4. On 1/9/13 at 3:59 p.m., the smoke barrier door by Room 24-02-105 on the 2nd floor failed to latch on one side during testing of the fire alarm system.

5. On 1/9/13 at 4:15 p.m., the smoke barrier door by the Blood Bank in the basement failed to latch during testing of the fire alarm system.

Building A, North Tower
6. On 1/10/13 at 9:40 a.m., smoke barrier door 22-06-064 in the Nurses Station on the 6th floor failed to latch during testing of the fire alarm system.

Building A, Auxiliary Building
7. On 1/10/13 at 2:00 p.m., the smoke barrier door by the ESI treatment room on the 1st floor failed to close, leaving an approximately 1/2 inch opening.

8. On 1/10/13 at 2:31 p.m., the smoke barrier door by room 284 failed to close and latch.

9. On 1/10/13 at 2:35 p.m., the smoke barrier door by the west elevators on the 1st floor failed to close.

10. On 1/10/13 at 2:45 p.m., the left leaf of the double doors by the surgery waiting area failed to latch during testing of the fire alarm system.

11. On 1/10/13 at 3:31 p.m., the left leaf of the double doors by the South Parking failed to latch during testing of the fire alarm system.

Based on observation and interview, the facility failed to maintain their exits so that they were readily accessible at all times. This was evidenced by medical equipment that was stored in the exit corridors and in the exit access. This has the potential to cause harm to patients, staff and visitors in the event of an evacuation due to a fire. This affected 3 of 10 floors in Building A, East Tower.

Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/11/13, the corridors and exits were observed, and staff were interviewed.

Building A, East Tower:
1. On 1/8/13 at 10:00 A.M., in the Lab by Pathology 24-B-080 on the Basement level there were two, 5 foot by 5 foot plastic bins, a chair, a soiled linen cart, and a table stored in the corridor that was part of the egress path.

2. On 1/8/13 at 2:30 P.M., on the 5th floor by room 5W-002 there was a Computer on Wheels (COW) and Dialyses machine up against the fire doors that were part of the egress path.

Based on record review and interview, the facility failed to conduct fire drills at least quarterly on each shift. This was evidenced by incomplete records for fire drills for each shift, per quarter. This could result in all staff members not being familiar with their roles and responsibilities in the event of a fire, and affected Building A and Building B.

Findings:

During document review with the Hospital Staff on 1/7/13 through 1/11/13, the fire drill records were reviewed.

Building A
1. On 1/7/13 at 10:35 a.m., the records showed fire drills were not conducted for 1st quarter 2012 AM shift for the 1st floor Cafe staff, and the 5th floor East Tower staff.
For the 2nd quarter 2012, there were no records for the NOC shift for the main Operating Room, and Post Acute Care unit staff.

For the 3rd quarter 2012 AM shift, there were no records for the MOR and PACU staff.

For the 3rd quarter 2012, there were no records for the PM (evening) shift for Cafe staff on the 1st floor.

When interviewed on 1/7/13, Hospital staff 1 stated fire drills were done per department, and not per shift.

Building B:
2. On 1/8/13 at 9:50 a.m., the facility failed to provide records to show the fire drills were conducted for all staff for all quarters.

There were no records for the first quarter 2012, and the 2nd quarter 2012, AM shifts for 1st floor kitchen staff, Pharmacy and Radiology staff.

For the 3rd quarter 2012, there were no records for the PM and NOC shift fire drills for the Critical Care unit, Cardiology, Emergency Department, Radiology, Surgery and Laboratory staff.

There were no records for fire drills for the Critical Care unit, and the Emergency Department staff, for the 4th quarter 2012 PM shift.

When interviewed, Hospital Staff 2 stated the registered nurses work 12 hour shifts, and all other staff work three, 8 hour shifts (AM, PM, and NOC).

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Based on observation, document review and interview, the facility failed to provide effective warning of fire as evidenced by fire alarm system strobes, chimes and manual pull stations that failed to activate and alarm. This could result in potential harm to patients, visitors and staff if the fire alarm system devices failed to notify patients, visitors and staff of a fire in the facility. This affected Building A, North Tower, West Tower, Main Operating Rooms, and the Chemical Dependency Recovery Center.

During fire alarm testing with Hospital Staff on 1/7/13 through 1/11/13, the fire alarm system strobes, chimes and manual pull stations were observed, tested, and Hospital Staff was interviewed.

Building A, North Tower:
1. On 1/8/13 at 10:30 A.M., the 435 GNP Case Manager & Hospitalists room on the 4th floor had a chime/strobe device that had a napkin taped over it.

Building A, West Tower:
2. On 1/10/13 at 10:38 A.M., on the 3rd floor of the West Tower, all strobe/chime devices failed to emit an audible sound. The strobe portion of the device functioned. The 3rd floor was unoccupied. Hospital Staff stated that they plan begin to move employees into that area on 1/22/13. Hospital Staff stated that they had to download the file again for the audible devices. The file was downloaded, and Hospital Staff stated the audible and visual functionality of the strobe/chime devices were working on 1/11/13.

Building A, Main Operating Rooms:
3. On 1/10/13 at 2:30 P.M., 6 strobe/chime devices on the 1st floor, Pre-Post Procedure area failed to emit an audible sound. The strobe portion of the device functioned. Hospital Staff stated that they had to download the file again. The file was downloaded, and Hospital Staff stated the audible and visual functionality of the strobe/chime device were working on 1/11/13.

Building A, Chemical Dependency Recovery Center:
4. On 1/10/13 at 3:43 P.M., 2 manual pull stations, 2 strobe/chime devices and 1 hard wired smoke detector over the nursing station failed. No other devices were observed in the Chemical Dependency Recovery Center. Hospital Staff was asked what they would do for fire coverage in the absence of a functioning fire alarm system, and Hospital Staff stated that they would immediately begin a fire watch, which according to their policy and procedure was every 30 minutes. A fire watch log was posted, and a security guard designated by the faciltity for the fire watch rounds, was observed at the Nursing Station.

Hospital Staff stated that they did not know the Chemical Dependency Recovery Center was wired into the North Tower. The fire alarm system for the North Tower was completed on 11/30/12. Hospital Staff was asked when the last testing for the Chemical Dependency Recovery Center had been done, and staff stated 10/12.

Hospital Staff stated that they had to replace the one smoke detector, 2 strobe/chimes and 2 manual pull stations with a newer device due to the new wiring that was completed on 11/30/12. Documentation from the Office of Statewide Health Planning and Development (OSHPD) Construction Advisory Report dated 11/30/12, Project # P-2011-00199, stated that the project was 100% completed for fire alarm wiring for the North Tower.

The vendor completed the replacement of all devices in that area by 1/11/2013 in the morning. The smoke detector, 2 strobe/chimes and 2 manual pull stations were tested on 1/11/13, and all devices were audible and visible, and transmitted a signal to PBX and the third party monitoring company.

NFPA 101, 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.

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

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

Based on documentation, observation and interview, the facility failed to maintain their fire alarm system. This was evidenced by the batteries in the Fire Alarm Control Panels (FACP) not tested and replaced according to NFPA 72 specifications, by audible devices that failed to activate during alarm testing, by the monitoring company not receiving signals from the FACP and PBX, and by a FACP that was obstructed by furniture. This could cause harm to patients and staff in the event of a fire, and affected Building A, East Tower, and Building B.

Findings:

During testing of the fire alarm system with Hospital Staff on 1/7/13 through 1/11/13, the fire alarms system was tested and observed, documents were reviewed, and staff was interviewed.

Building A, East Tower:
1. On 1/7/13 at 2:45 P.M., the two batteries in the FACP labeled PS.4B in Signal Room 24-04-104 on the 4th floor were dated 2/08.

2. On 1/8/13 at 8:40 A.M., two batteries in the FACP labeled PS.3B in Signal Room 24-03-103 on the 3rd floor did not have a date on them. Hospital Staff stated that they did not know when the batteries were installed.



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Building B
3. On 1/8/13 at 4:25 p.m., a fire alarm pull station was obstructed by a patient bed in the egress corridor of the basement by the Laboratory.

4. On 1/9/13 at 9:05 a.m., Hospital Staff 1 stated the fire alarm test conducted on 1/8/13 from 4:00 p.m. to 5:00 p.m., had failed to send signals to the third party monitoring company until approximately 1:00 a.m., on 1/9/13. At that time the Fire Department dispatched a fire truck to the hospital. Hospital Staff 1 stated they were notified during fire alarm testing on 1/8/13, that the phone lines were down. According to document review, the monitoring company received the fire alarm test signals by a delay of approximately 8 hours.

Building A
5. On 1/9/13 at 9:35 a.m., in the Bio-Med storage room on the Basement level, boxes of supplies and equipment obstructed access to the fire alarm power supply boxes.

6. On 1/10/13 at 4:15 p.m., two of two audio units by HVI corridor on the 1st floor failed to activate during alarm testing.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

Based on document review, the facility failed to maintain their automatic sprinkler system. This was evidenced by the failure to provide documentation of quarterly automatic sprinkler testing and inspection for 1 of 4 quarters. This could result in the failure of the automatic sprinkler system in the event of a fire, and affected Building L, Surgicare, Suite 100.

Findings:

During document review with the Hospital Staff on 1/7/13 through 1/11/13, the facility's automatic sprinkler system maintenance records were reviewed.

Building L, Surgicare, Suite 100:
On 1/11/13 at 10:30 A.M., the maintenance records were reviewed, and the facility failed to provide documentation that the automatic sprinkler testing and inspections were conducted for the 1st quarter, January, February and/or March, 2012.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinkler heads with escutcheon rings that were missing, sprinkler heads that were not free of debris, and sprinkler heads with less than 18 inches of clearance. This could result in the automatic sprinkler system not functioning as designed, and increased risk of injury to patients and staff. This affected 2 of 12 floors in Building A, West Tower, Building B and Building L.

NFPA 13 1999 edition
5-5.6 Clearance to Storage. The clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater.

NFPA 25, 2002 Edition
5.2.1.1.1
Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall).


Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/11/13, the automatic sprinkler system was observed.

Building A, West Tower:
1. On 1/8/13 at 4:00 P.M., in the Drug Room in the PACU on the 1st floor, there was an escutcheon ring hanging down from the ceiling, and created a penetration approximately 1/2 inch in the ceiling.

2. On 1/8/13 at 4:35 P.M., in the closet outside the Board Room on the 1st floor, there was a sprinkler missing an escutcheon ring.

3. On 1/9/13 at 9:10 A.M., in the Trash Room on the Basement level, there was 1 of 5 escutcheon rings missing.

4. On 1/10/13 at 2:50 P.M., in the Operating Room (OR) area on the 1st floor, the sprinkler between the sterilizer machines by OR 8 was hanging down from the ceiling approximately 1 1/2 inches, and created an approximately 1/2 inch penetration in the ceiling.

Building L, Surgicare, Suite 100:
5. On 1/11/13 at 10:00 A.M., the sprinkler head in the Electrical Room had blue plastic on it. The sprinkler head was directly above a trash bin that contained blue plastic bags filled with trash.




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Building B
6. On 1/8/13 at 11:16 a.m., in Room 5224 on the 5 th floor, 2 of 2 sprinkler heads were obstructed by staff locker cabinets that were approximately 12 inches directly below the sprinkler deflectors.

Building A
7. On 1/9/13 at 8:40 a.m., in the Engineer Staff Lounge on the Basement level, 1 of 4 sprinkler heads was covered in dust and/or debris.

8. On 1/9/13 at 9:20 a.m., in the Rehab Service office on the Basement level, 2 of 7 sprinkler heads were missing escutcheon rings.

9. On 1/9/13 at 9:40 a.m., in the Kitchen on Basement level, 1 of 2 sprinkler heads in refrigerator B had a built up of debris.

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.
1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

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 10 stories in Building A, East Tower and could result in a delay in access to the fire extinguisher resulting in the spread of smoke and/or fire.

Findings:

During a tour of the facility with the Hospital Staff on 1/7/13 through 1/8/13, the portable fire extinguishers were observed.

Building A, East Tower:
On 1/8/13 at 10:08 A.M., in the Lab on the Basement level, the fire extinguisher was impeded from immediate access by a 2 drawer cabinet, a monitor, a hard drive and a label printer.

NFPA 90 A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.1 A service opening shall be provided in air ducts adjacent to each fire damper, smoke damper, and smoke detector. The opening shall be large enough to permit maintenance and resetting of the device.
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection device(s) within.

Based on record review and interview, the facility failed to maintain their heating, ventilating, and air conditioning system as evidenced by fire dampers that were inaccessible, and were unable to be tested and/or inspected. This affected Building A, and could result in the spread of smoke and fire.

Findings:

During record review with Hospital Staff on 1/7/13 through 1/11/13, the damper testing and maintanence records were reviewed, and staff was interviewed.

Building A
On 1/7/13 at 2:30 p.m., records for testing of 1,411 fire/smoke dampers by an outside vendor on 3/21/11, indicated that 17 fire/smoke dampers were inaccessible, and maintenance and inspection could not be performed on them. The facility failed to provide records that the 17 fire/smoke dampers that were identified in the report dated 3/21/11, had been tested and maintained, and that there was accessibility for the dampers.

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

NFPA 99, Standard for Health Care Facilities, 1999 Edition
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a) 11e with respect to temperature limitations. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a) 11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b) 13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b) 27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b) 14.

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

4-3.5.2.2 (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.
4-3.5.2.1

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation and interview, the facility failed to maintain the oxygen storage. This was evidenced by failing to ensure that the empty oxygen cylinders were individually secured, that the full and empty cylinders were separated, and not stored next to combustible materials and electrical outlets, and had the proper precautionary signs displayed. This could result in an increased risk of damage to an oxygen cylinder, or in an increased risk of fire, or in staff confusion or a delay in staff response to an emergency if did not know which cylinders were empty or full when responding to an emergency. This affected 4 of 10 stories in Building A, East Tower, 5 of 12 stories in Building A, West Tower and 1 of 3 stories in Building G.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the facility's oxygen storage areas were observed, and staff was interviewed.

Building A, East Tower:
1. On 1/7/13 at 1:20 P.M., Clean Utility room 24-06-122 on the 6th floor had 8 E-Tank oxygen cylinders with no sign to indicate if the cylinders were empty or full, and were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

2. On 1/7/13 at 2:35 P.M., Clean Utility room 24-04-090 on the 4th floor had 6 E-Tank oxygen cylinders with no sign to indicate if the cylinders were empty or full, and were stored in a room with no precautionary sign to indicate the room was used for oxygen storage. Five E-Tank oxygen cylinders had a red cap, and 1 did not. Nursing staff was interviewed, and asked how they identify the empty cylinders from the full ones, and staff said they had to look at the gauge in order to see which ones were full.

3. On 1/8/13 at 8:30 A.M., Clean Utility room 24-03-009 on the 3rd floor had 5 full E-Tank oxygen cylinders and 1 empty E-Tank cylinder stored together in a rack with no sign indicating which ones were empty or full. The metal rack was stored next to a cart with seizer pads and medical supplies. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

4. On 1/8/13 at 8:35 A.M., Clean Utility room 24-03-055 on the 3rd floor had 5 E-Tank oxygen cylinders stored together in a rack with no sign indicating which ones were full and/or empty. The metal rack was stored next to a linen cart. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

5. On 1/8/13 at 9:05 A.M., in the Equipment Processing room 24-02-088 on the 2nd floor there were 8 E-Tank oxygen cylinders stored in a rack with no sign indicating which ones were empty or full. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

Building A, West Tower:
6. On 1/8/13 at 1:30 P.M., Soiled Utility room 22-07-063 on the 7th floor had 1 E-Tank oxygen cylinder in a metal cart stored next to a 4 plug electrical outlet. The oxygen cylinder was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

7. On 1/8/13 at 1:38 P.M., Clean Utility room 22-07-034 on the 7th floor had 11 E-Tank oxygen cylinders in a metal cart stored next to a 2 plug electrical outlet. There was no sign by the tanks to indicate which ones were empty or full. The oxygen was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

8. On 1/8/13 at 2:05 P.M., Soiled Utility Biohazard room 22-06-063 on the 6th floor had 2 E-Tank oxygen cylinders in a metal cart stored next to a 2 plug electrical outlet. There was no sign by the cylinders to indicate which ones were empty or full. Hospital Staff stated that the gauge on the tanks indicated they were empty. The oxygen was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

9. On 1/8/13 at 2:09 P.M., in the Clean Utility Nourishment room 22-06-064 on the 6th floor there were 12 E-Tank oxygen cylinders in a metal cart stored next to a 4 plug electrical outlet and two fire alarm control panels. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

10. On 1/8/13 at 2:20 P.M., in the Biohazard Soiled Utility room 22-05-63 on the 5th floor there were 4 E-Tank oxygen cylinders in a metal cart stored next to a 2 plug electrical outlet and next to a chemo tub waste and 2 plastic bags with dirty rags and linen in them. There was no sign by the cylinders to indicate which ones were empty or full. Nursing Staff was asked if the tanks were empty or full, and the Nursing Staff stated that the gauge on 1 of 4 E-Tanks was 100% full. The Nursing Staff was asked if the E-cylinder would be used since it was full, and staff stated that it would not because any oxygen tanks in the "soiled utility" rooms were not used. The oxygen was stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

11. On 1/8/13 at 2:35 P.M., Clean Utility Nourishment room 22-05-064 on the 5th floor had 12 E-Tank oxygen cylinders in a metal cart stored next to two fire alarm control panels and a 2 plug electrical outlet. There was no sign by the tanks to indicate which ones were empty or full. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

12. On 1/8/13 at 2:38 P.M., CCU Clean Supply Holding room 22-04-071 on the 4th floor had 7 E-Tank oxygen cylinders in a metal cart with no sign by the tanks to indicate which ones were empty or full. The oxygen cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.

13. On 1/8/13 at 4:10 P.M., in PACU Hopper area on the 1st floor there were 10 E-Tank oxygen cylinders in a metal cart stored next to a biohazard tub and 2 soiled linen containers.

14. On 1/8/13 at 4:15 P.M., in the Main OR Pre/Post Procedure Unit Clean Utility room 29-01-139 on the 1st floor had 4 E-Tank oxygen cylinders stored next to a cart with plastic bags of tubing and medical supplies.

15. On 1/8/13 at 4:30 P.M., in Equipment Storage room 32-01-308 on the 1st floor there were 9 E-Tank oxygen cylinders stored next to bags of plastic tubing and medical supplies.

Building G:
16. On 1/9/13 at 12:15 P.M., in Suite 100 on the 1st floor there were 6 E-Tank oxygen cylinders with no sign to indicate if the tanks were empty or full.

Building A, West Tower:
17. On 1/10/13 at 10:01 A.M., by EVS 22-07-076 storage on the 7th floor there was 1 E-Tank oxygen cylinder on the floor leaning against the wall. Nursing staff stated the gauge indicated it was 1/3 full.

Building A, Main Operating Rooms:
18. On 1/10/13 at 2:45 P.M., in the Outback Surgical Equipment 26-01-214 on the 1st floor there were 7 carbon dioxide, 2 nitros oxide, 1 compressed air and 2 E-Tank oxygen cylinders in a metal cart with no sign by the tanks to indicate which ones were empty or full. The cylinders were stored in a room with no precautionary sign to indicate the room was used for oxygen storage.



29566

Hospital B
19. On 1/8/13 at 1:40 p.m., in the Emergency Room Supply Room 1643, there were 6 E-Tank Oxygen cylinders stored within 5 feet of combustible supplies. The empty and full E-cylinders were stored in the same crate.

Hospital A
20. On 1/9/13 at 9:20 a.m., an E-Tank Oxygen cylinder was taped to an IV pole and placed among supply boxes in the Bio-Med storage room on basement level.

NFPA 101, Life Safety Code, 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Based on document review and interview, the facility failed to maintain the relative humidity level equal to or greater than 35%. This was evidenced by documentation that some of the humidity levels for Operating Rooms 2, 3, and 4 for the months of January 2013 and November 2012 fell below the required level of 35%, and the facility failed to provide a policy and procedure for the Operating Room Relative Humidity and what to do in the event the relative humidity fell below the facility's humidity standard. This could result in an increased risk of fire in the operating rooms, resulting in potential harm to patients and staff. This affected Building L, Surgicare, Suite 100.

Findings:

During document review with Hospital Staff on 1/7/13 through 1/11/13, the humidity levels of Operating Room 2, 3 and 4 were reviewed, and staff was interviewed.

Relative humidity is checked by the facility at 6:00 A.M. Documentation provided was based on a 6:00 A.M. reading/documentation provided by the facility. Operating Room 1 is not in use per Hospital Staff. When interviewed, the Director stated that the facility's policy and procedure for relative humidity is between 30% and 60%. The Director was asked if the facility continued with surgery on the days the humidity fell below the facility's requirement of 30% range, and the Director stated that they did continue with surgery. When asked if they document any corrections to the relative humidity, the Director stated that they did not.

Hoag Hospital Relative Humidity/Temperature Log" for OR 2, 3 and 4:
1. Humidity levels documented on 11/12/12 for OR 2 was 33%, and OR 4 was 28%.
2. Humidity levels documented on 11/13/12 for OR 2 was 33%, and OR 4 was 28%.
3. Humidity levels documented on 1/2//13 for OR 2 was 31%, OR 3 was 32%, and OR 4 was 26%.
4. Humidity levels documented on 1/3/13 for OR 2 was 34%, and OR 4 was 32%.
5. Humidity levels documented on 1/4/13 for OR 2 was 34%, and OR 4 was 31%.
6. Humidity levels documented on 1/11//13 for OR 2 was 34%, OR 3 was 34%, and OR 4 was 29%.

NFPA 101 Life Safety Code 2000 Edition
4.5.7 Maintenance. 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 maintained unless the Code exempts such maintenance.

Based on observation and interview, the facility failed to maintain the dryers in the laundry room. This was evidenced by a built-up of lint in a dryer. This affected Building A, and could result in an increased risk of a fire and potentially cause injury to patients and staff.

Findings:

During tour of facility with Hospital Staff 1 on 1/7/13 through 1/11/13, the laundry room was observed.

Building A
On 1/9/13 at 10:11 a.m., in the Laundry room in the Basement, there was a build up of lint on top of the lint screen shelf, and in the back of the dryer.

NFPA 99 (1999 Edition) 3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

NFPA 70 (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
(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

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by the use of a surge protector to provide additional outlets in place of fixed wired receptacles. This affected 1 of 10 floors at Building A, East Tower and could result in an increased risk of an electrical fire.

Findings:

During a tour of the facility with Hospital Staff on 1/7/13 through 1/11/13, the facility electrical wiring and equipment was observed.

Building A, East Tower:
On 1/7/13 at 1:38 P.M., there was a surge protector used to extend power to a refrigerator in Room 24-06-166 on the 6th floor.