HospitalInspections.org

Based on record review and interview, the facility failed to develop and maintain the emergency preparedness program. This was evidenced by an incomplete risk assessment utilizing the all hazard approach. This could result in not having the necessary planning and preparation in place to adequately protect the health and safety of the patients within the Main Building, the Partial Hospitalization Program, and Laguna Woods.

Findings:

During record review and interview with staff on 7/23/19 through 7/24/19, the emergency preparedness program was reviewed.

At 12:57 p.m. on 7/23/19, the risk assessment titled, "Hazard Vulnerability Analysis" for the emergency preparedness program failed to include information regarding elopement. Upon interview, MS1 and MS2 confirmed the facility housed patients at high risk of elopement and they confirmed the finding.

Based on record review and interview, the facility failed to develop and maintain the emergency preparedness program. This was evidenced by an incomplete communication plan. This could result in not having the necessary planning and preparation in place to adequately protect the health and safety of the patients within the Main Building, the Partial Hospitalization Program, and Laguna Woods.


Findings:

During record review and interview with staff on 7/23/19 through 7/24/19, the emergency preparedness program was reviewed.

At 10:22 a.m. on 7/24/19, the facility failed to include a means of providing information about the facility's occupancy, needs, and its ability to provide assistance in the event of an emergency. Upon interview, MS1, MS2, and ES stated the facility utilizes California Health Alert Network (CAHAN). In the document titled, "EOC-309A CHCM Utility Resources and Emergency Contact Information" there was no information regarding the facility's use of CAHAN.

Based on record review and interview, the facility failed to develop and maintain the emergency preparedness training program. This was evidenced by incomplete training progran and no documentation of the training conducted to staff. This could result in not having the necessary planning and preparation in place to adequately protect the health and safety of the patients within the Main Building, the Partial Hospitalization Program, and Laguna Woods.


Findings:

During record review and interview with staff on 7/23/19 through 7/24/19, the emergency preparedness program was reviewed.

At 2:30 p.m. on 7/24/19, the training and testing programs failed to have policy for initial training in emergency preparedness for new and existing staff. Upon further review, the training materials only covered earthquake emergency preparedness and no additional policies or procedures were included in the training and testing programs. Upon interview, MS1 and MS2 confirmed the finding.

Based on observation and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the wall. This affected one of three buildings and could result in the passage of fire and smoke in the event of a fire.

Findings:

During a tour of the facility and interview with staff on 7/22/19 through 7/24/19, the building construction was observed.

At 1:55 p.m. on 7/22/19, the Infection Control Office bathroom was observed with a 2 inch in diameter penetration behind the door. Upon interview, MS1 stated it looked like the door knob created the penetration.

Based on record review and interview, the facility failed to maintain the emergency lighting. This was evidenced by incomplete maintenance and testing. This affected one of three buildings and could result in the delay of evacuating during an emergency.

NFPA 101 Life Safety Code, 2012 Edition
39.2.9 Emergency Lighting.
39.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9 in any building where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of discharge.
(3) The occupancy is subject to 1000 or more total occupants.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.
7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1 (2)
(2) *The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1 (1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.


Findings:

During record review and interview with staff on 7/22/19 through 7/24/19, the emergency lighting records were requested and reviewed.

Laguna Woods Partial Hospitalization Program

At 10:30 a.m. on 7/23/19, the facility failed to maintain records for an annual 90 minute functional test of the emergency lighting. The last test was done on 1/7/2013. Upon interview, PD confirmed the finding.

Based on observation, document review, and interview, the facility failed to maintain the exit signs. This was evidenced by failure to perform the required monthly functional test of the battery-powered exit signs. This affected two of three buildings, and could result in delayed evacuation.


NFPA 101, Life Safety Code, 2012 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

39.2.1.1 All means of egress shall be in accordance with Chapter 7 and this chapter.

7.10.9.2 Testing. Exit signs connected to, or provided with, a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment.
7.9.3.1 Required emergency lighting systems shall be tested in accordance with one of the three options offered by 7.9.3.1.1, 7.9.3.1.2, or 7.9.3.1.3.

7.9.3.1.1 Testing of required emergency lighting systems shall be permitted to be conducted as follows:
(1) Functional testing shall be conducted monthly, with a minimum of 3 weeks and a maximum of 5 weeks between tests, for not less than 30 seconds, except as otherwise permitted by 7.9.3.1.1(2).
(2)*The test interval shall be permitted to be extended beyond 30 days with the approval of the authority having jurisdiction.
(3) Functional testing shall be conducted annually for a minimum of 1 1/2 hours if the emergency lighting system is battery powered.
(4) The emergency lighting equipment shall be fully operational for the duration of the tests required by 7.9.3.1.1(1) and (3).
(5) Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.


Findings:

During a tour of the facility, document review, and interview with the ES and MS2, the exit signs were observed and document reviewed.

MAIN CAMPUS and MAIN CAMPUS PARTIAL HOSPITALIZATION PROGRAM

1. At 12:36 p.m. on 7/22/19, the facility failed to perform the required 30 seconds monthly functional test for the battery-powered exit signs. The record provided did not indicate the exit signs were tested for 30 seconds. When interviewed, the MS2 confirmed the finding and stated that the exit signs were tested for 20 seconds. This finding was also confirmed by the ES.


40394



Laguna Woods Partial Hospitalization Program

2. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for an annual 90 minute functional test of the exit signs. The last test was done on 1/7/2013. Upon interview, PD confirmed the finding.

3. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for an annual 90 minute functional test of the exit signs. The last test was done on 1/7/2013. Upon interview, PD confirmed the finding.

4. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for 12 of 12 monthly 30 second functional tests of the exit signs. The last test was done on 1/7/2013. Upon interview, PD confirmed the finding.

5. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for 12 of 12 monthly visual inspections of the exit signs. The last recorded visual inspection was done on 1/7/2013. Upon interview, PD confirmed the finding.

Based on document review and interview, the facility failed to maintain the fire alarm system (FAS). This was evidenced by the failure to correct the deficiencies noted during test and inspections and by incomplete maintenance and testing records. This could result in the ineffective operation of the FAS in the event of an emergency or fire, and affected two of three buildings.

NFPA 101, Life Safety Code, 2012 Edition
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with section 9.6

39.3.4 Detection, Alarm, and Communications Systems.
39.3.4.1 General. A fire alarm system in accordance with Section 9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height.
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

9.6 Fire Detection, Alarm, and Communications Systems.
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.
9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.


NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition

14 Inspection, Testing, and Maintenance
14.4 Testing
Table 14.4.5 Testing Frequencies
6. Batteries - fire alarm systems
(d) Sealed lead-acid type
(1) Charger test (replace battery within 5 years after manufacturer or more frequently as needed.) - Annually
(2) Discharge test (30 minutes) - Annually
(3) Load voltage test - Semiannually

INSPECTION, TESTING, AND MAINTENANCE, Table 14.3.1

14.6.2.4* A 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 14.6.2.4:
(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
(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) Functional test of mass notification system control units
(13) Functional test of signal transmission to mass notification systems
(14) Functional test of ability of mass notification system to silence fire alarm notification appliances
(15) Tests of intelligibility of mass notification system speakers
(16) Other tests as required by the equipment manufacturer ' s published instructions
(17) Other tests as required by the authority having jurisdiction
(18) Signatures of tester and approved authority representative
(19) Disposition of problems identified during test (e.g., system owner notified, problem corrected/successfully retested, device abandoned in place)

Findings:

On 7/22/2019, the FAS maintenance document were reviewed.

MAIN CAMPUS

1. At 11:40 a.m. on 7/22/19, the inspection and testing report provided dated 7/18/19, indicated that "Phone line #2 fault signal did not report to the monitoring company when disconnecting it from the panel. It did report a restoral signal when reconnecting the phone line to the panel". When interviewed, the ES stated that it has not been repaired and the vendor was contacted to schedule the repair.

2. At 1:25 p.m. on 7/22/19, the annual inspection and testing report provided dated 1/28/19, did not indicate if the sealed lead-acid batteries to the Fire Alarm Control Panel (FACP) were tested for minimum of 30 minute discharge test. When interviewed, the ES contacted the vendor and vendor stated that batteries were tested for load test. The ES further stated that the vendor will be in the facility to conduct battery testing on 7/25/19.


40394


Laguna Woods Partial Hospitalization Program

3. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for two of two semi-annual load voltage tests for the sealed lead-acid batteries within the Fire Alarm Control Panel (FACP). Upon interview, PD confirmed the finding.

4. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for an annual charger test for the sealed lead-acid batteries within the FACP. Upon interview, PD confirmed the finding.

5. At 10:30 a.m. on 7/23/19, the facility failed to maintain records for an annual 30-minute discharge test for the sealed lead-acid batteries within the FACP. Upon interview, PD confirmed the finding.

Based on record review and interview, the facility failed to maintain the smoke detectors. This was evidenced by no written evidence smoke detector sensitivity testing. This affected one of three buildings and could result in the delay in notification in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition
39.3.4.1 General. A fire alarm system in accordance with Section 9.6 shall be provided in all business occupancies where any one of the following conditions exists:
(1) The building is three or more stories in height
(2) The occupancy is subject to 100 or more occupants above or below the level of exit discharge.
(3) The occupancy is subject to 1000 or more total occupants.

9.6.2.10 Smoke Alarms.
9.6.2.10.1 General.
9.6.2.10.1.1 Where required by another section of this Code, single-station and multiple-station smoke alarms shall be in accordance with NFPA 72, National Fire Alarm and Signaling Code, unless otherwise provided in 9.6.2.10.1.2, 9.6.2.10.1.3, or 9.6.2.10.1.4.

NFPA 72 National Fire Alarm and Signaling Code, 2010 Edition
14.4 Testing.
14.4.5.3* In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.
14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.


Findings:

During record review and interview with staff on 7/22/19 through 7/24/19, the smoke detector records were reviewed.

Laguna Woods Partial Hospitalization Program
At 10:30 a.m. on 7/23/19, the facility failed to maintain records for smoke detector sensitivity testing. At the time of survey, the last test was unknown. Upon interview, PD confirmed the finding.

Based on observation and interview, the facility failed to maintain the supervisory signal-initiating devices. This was evidenced by the failure of the sprinkler control valves to initiate a distinctive supervisory alarm within the first two revolutions of the handwheel or within one-fifth of the travel distance. This affected one of three buildings, and could result in a delayed alarm identification and notification of a suspension in water supplied to the automatic fire sprinkler system.


NFPA 101, Life Safety Code, 2012 Edition.
19.3.5 Extinguishment Requirements.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise
permitted by 19.3.5.5.
9.7 Automatic Sprinklers and Other Extinguishing Equipment.
9.7.2 Supervision.
9.7.2.1* Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

NFPA 72, National Fire Alarm Code, 2010 Edition
Chapter 10 Fundamentals
10.1 Application.
10.1.1 The basic functions of a complete fire alarm or signaling system shall comply with the requirements of this chapter.
10.1.2 The requirements of this chapter shall apply to systems, equipment, and components addressed in Chapters 12, 14, 17, 18, 21, 23, 24, 26 and 27.
10.2 Purpose. The purpose of fire alarm and signaling systems shall be primarily to provide notification of alarm, supervisory, and trouble conditions; to alert the occupants; to summon aid; and to control emergency control functions.

Table 14.4.2.2
Valve shall be operated and signal receipt shall be verified to be within the first two revolutions of the handwheel or within one-fifth of the travel distance, or per the manufacturer ' s published instructions.


Findings:

During fire alarm system testing and interview with the ES and MS1 on 7/24/19, the control valve supervisory alarm signal was observed.

MAIN CAMPUS

Between 9:43 a.m. and 9:46 a.m., the left valve for the outside stem and yolk (OS&Y) valve located in front of the building was exercised. There were no signal received at the fire alarm panel (FACP) within the first two revolutions of the handwheel or within one-fifth of the travel distance. The FACP received a supervisory signal on the 5th revolutions of the handwheel. The OS&Y was for the main campus sprinkler system. When interviewed, the ES and MS1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by incomplete maintenance of the automatic sprinkler system. This affected two of three buildings and could result in the ineffective operation of the automatic sprinkler system in the event of a fire.

Findings:

During a tour of the facility and interview with staff on 7/22/19, the automatic sprinkler system was observed.

1. At 11:19 a.m., the foyer in the Main Building Adolescent Unit was observed with a penetration next to the escutcheon ring on one sprinkler. The penetration was approximately 2 inches long by 2 centimeters wide. Upon interview, MS1 confirmed the finding.

2. At 11:21 a.m., the Dayroom in the Main Building Adolescent Unit was observed with one of seven pendent style sprinklers missing an escutcheon ring. Upon interview, MS1 confirmed the finding.

3. At 11:25 a.m., the Nurse Station in the Main Building Adolescent Unit was observed with a pendent style sprinkler covered in foreign materials. Upon interview, MS1 confirmed the finding.

4. At 11:45 a.m., the facility was observed with sidewall sprinklers throughout. Upon investigation, the facility failed to maintain any spare sidewall sprinklers. Upon interview, MS1 confirmed the usage of sidewall sprinklers and confirmed the finding.

5. At 12:05 p.m., the Social Services Office in the Main Building East Unit was observed with one of three pendent style sprinklers covered in foreign materials. Upon interview, MS1 confirmed the finding.

6. At 12:07 p.m., the Reception Area in the Partial Hospitalization Program (PHP) was observed with two of 10 fallen escutcheon rings on the pendent style sprinklers. Upon interview, MS1 confirmed the finding.

7. At 12:13 p.m., the Main Dining Hall in the PHP was observed with two of 15 fallen escutcheon rings on the pendent style sprinklers. Upon interview, MS1 confirmed the finding.

8. At 12:15 p.m., Group Room 1 in the PHP was observed with a penetration next to the escutcheon ring on one of two pendent style sprinklers. The penetration was approximately 2 inches long by 2 centimeters wide. Upon interview, MS1 confirmed the finding.

9. At 12:18 p.m., Group Room 3 in the PHP was observed with one of three fallen escutcheon rings on the pendent style sprinklers. Upon interview, MS1 confirmed the finding.

10. At 1:17 p.m., the Condiment Station in the Main Building Kitchen was observed with one of three pendent style sprinklers missing an escutcheon ring. Upon interview, MS1 confirmed the finding.

11. At 1:26 p.m., the Kitchen hallway in the Main Building was observed with one of four pendent style sprinklers covered in foreign materials. Upon interview, MS1 confirmed the finding.

12. At 2:03 p.m., the Administration Conference Room doorway in the Main Building was observed with a penetration next to the escutcheon ring on a pendent style sprinkler. The penetration was approximately 2 inches long by 2 centimeters wide. Upon interview, MS1 confirmed the finding.

13. At 2:07 p.m., the Administration Conference Room Storage Room in the Main Building was observed with a pendent style sprinkler covered in foreign materials. Upon interview, MS1 confirmed the finding.




31203

MAIN CAMPUS and MAIN CAMPUS PARTIAL HOSPITALIZATION PROGRAM

14. At 12:00 p.m., the five year certification for the automatic sprinkler system was over due. The last service was conducted on 2/18/2014. When interviewed, ES confirmed the finding.

Based on document review and interview, the facility failed to protect their patients in the event that the automatic fire sprinkler system went out of service. This was evidenced by the failure to provide a written policy to protect their patients in the event that the automatic fire sprinkler system went out of service for more than 10 hours in a 24-hour period. This affected one of three buildings and could result in a delay in notification in the event of an emergency with the automatic fire sprinkler system.

Findings:

During document review and interview with staff, the facility's fire watch policy and procedure for the automatic fire sprinkler system were requested.

MAIN CAMPUS

1. At 1:52 p.m. on 7/22/19, the facility did not provide a fire watch policy in the event that the automatic fire sprinkler system went out of service for more than 10 hours in a 24 hour period, at time of survey. The policy provided titled "Fire Watch" read "Immediately establish and maintain Fire Watch continuously for twenty-four (24) hours a day until the fire alarm and warning system has been serviced and restored to proper operating condition". The fire watch policy did not mention the sprinkler system. When interviewed, the ES stated that the policy is also for the sprinkler system.



40394

Laguna Woods Partial Hospitalization Program

2. At 10:33 a.m. on 7/23/19, the fire watch policy failed to address notification of the authority having jurisdiction in the event that the automatic sprinkler system is out of service. Upon interview, PD confirmed the finding.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers. This was evidenced by incomplete maintenance of the portable fire extinguishers. This affected one of three buildings and could result in the delay or malfunction of fire extinguishment in the event of a fire.



Finding:

During a tour of the facilities and interview with staff on 7/22/19 through 7/24/19, the fire extinguishers were observed.

At 2:53 p.m. on 7/22/19, the Maintenance Shop was observed with two unsecured portable fire extinguishers sitting on the floor. Upon interview, MS1 confirmed the finding.

Based on observation and interview, the facility failed to maintain the corridor doors. This was evidenced by corridor doors that failed to close and latch. This affected one of three buildings and could result in the delay of evacuating during an emergency.

Findings:

During a tour of the facilities and interview with staff on 7/22/19 through 7/24/19, the corridor doors were observed.

1. At 11:34 a.m. on 7/22/19, the door to the Dayroom in the Main Building South Unit was obstructed by a garbage can. The door was equip with a self-closer and was obstructed from closing at the time of survey. Upon interview, MS1 confirmed the finding.

2. At 11:43 a.m. on 7/22/19, the door to the Clean Linen Closet in the Main Building East Unit failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon interview, MS1 confirmed the finding.

3. At 11:45 a.m. on 7/22/19, the door to the Clean Linen Closet in the Main Building West Unit failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon interview, MS1 confirmed the finding.

4. At 12:01 p.m. on 7/22/19, the door to the Medication Room in the Main Building East Unit was propped open with a door stop. The door was equip with a self-closer but was obstructed at the time of survey. Upon interview, MS1 confirmed the finding.

5. At 1:26 p.m. on 7/22/19, the Kitchen hallway door in the Main Building was propped open with a door stop. The door was equip with a self-closer but was obstructed at the time of survey. Upon interview, MS1 confirmed the finding.

6. At 1:28 p.m. on 7/22/19, the door to the Laundry Room in the Main Building failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon further inspection, the strike plate was stuffed with paper towels to prevent the door from latching. Upon interview, MS1 confirmed the finding.

7. At 1:34 p.m. on 7/22/19, the door to the Cafeteria in the Main Building failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon interview, MS1 confirmed the finding.

8. At 1:36 p.m. on 7/22/19, the door to the Eyewash Station in the Main Building Kitchen hallway failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon further inspection, the strike plate was stuffed with paper towels to prevent the door from latching. Upon interview, MS1 confirmed the finding.

9. At 1:41 p.m. on 7/22/19, the door to the Main Laboratory Entrance in the Main Building failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon interview, MS1 confirmed the finding.

10. At 1:52 p.m. on 7/22/19, the door to the Emergency Supplies Closet in the Main Building Laboratory hallway failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon interview, MS1 confirmed the finding.

11. At 2:14 p.m. on 7/22/19, the door to the Emergency Supplies Closet in the Main Building Administration hallway failed to latch. The door was equip with a self-closer and was tested three times by staff and failed to latch each time. Upon interview, MS1 confirmed the finding.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by an obstructed electrical panel. This affected one of three buildings and could result in the spread of fire and smoke in the event of a fire.

Findings:

During a tour of the facilities and interview with staff on 7/22/19 through 7/24/19, the utilities were observed.

At 11:38 a.m. on 7/22/19, electrical panel EP in the Main Building South Dayroom was obstructed by a table. Upon interview, MS1 confirmed the finding.

Based on document review and interview, the facility failed to ensure that all personnel on all shifts were familiar with the use of the facility's emergency and disaster plans and procedures. This was evidenced by the failure to provide fire drill record for all shifts once per quarter and by failure to include transmission of a fire alarm during the quarterly fire drills. This could result in staff to ineffectively protect patients in the event of an actual fire and could result in injury. This affected one of three buildings.

Findings:

During document review and interview with staff, the fire drill records were reviewed.

MAIN CAMPUS

1. At 11:19 a.m. on 7/22/19, the facility failed to provide documentation for one of twelve fire drills. The facility failed to provide the NOC shift fire drill during the second quarter (April/May/June 2019).

There were two fire drills that were conducted that did not include transmission of a fire alarm. There were no fire alarm transmission during the PM shift second quarter 2019 and AM shift fourth quarter 2018. When interviewed, the ES confirmed the finding.




40394

Laguna Woods Partial Hospitalization Program

2. At 10:33 a.m. on 7/23/19, the fire drill records indicated a fire drill was missing in the third quarter of 2018. Upon interview, PD confirmed the finding.

Based on observation and interview, the facility failed to maintain fire safety in the designated smoking area. This was evidenced by cigarette butts being disposed on the ground and by the failure to provide safety-type ashtray in the designated smoking areas. This could result in the increased risk of fire, and affected the two of two designated smoking areas.

Finding:

During a tour of the facility and interview with the ES on 7/23/19, the designated smoking areas were observed.

1. At 8:35 a.m., there were over two dozen cigarette butts observed on the ground in the designated smoking area. The designated smoking area was near the West unit and PHP campus The ashtray provided for disposal of cigarette butts had no cover. The ashtray was open and had black sand. There was no safety-type ashtray with cover in the designated smoking area. When interviewed, the ES stated that housekeeping of the smoking area is once or twice a day. The ES further stated that there are night meetings for the outpatients and would smoke during break.

2. At 10:50 a.m., there was no safety-type ashtray with cover in the designated smoking area. The designated smoking area was in front of the medical office building. There were two open ashtray provided without cover. When interviewed, the ES confirmed the finding.

Based on observation and interview, the facility failed to prevent the use of space heaters. This was evidenced by the use of a portable space heater. This affected one of three buildings and could result in the malfunction of the portable space heater and fire.

Finding:

During a tour of the facilities and interview with staff on 7/22/19 through 7/24/19, the portable space heaters were observed.

At 10:58 a.m. on 7/22/19, the Access Department in the Main Building was observed with a portable space heater stored on the floor under a desk approximately 1 foot from combustible items. Upon investigation, the manufacturer's instructions stated to keep combustibles at least 3 feet away from the front, sides, and rear of the heater. Upon interview, MS1 confirmed the finding.

Based on observation and interview, the facility failed to ensure the essential electric system alarm annunciator were visible. This was evidenced by the failure to maintain the alarm annunciator unobstructed from view. This affected one of three buildings and could result in delay of notification in the event of a malfunction.

Findings:

During a tour of the facility and interview with the ES on 7/23/19, the alarm annunciator was observed.

MAIN CAMPUS

At 11:00 a.m., the generator remote alarm annunciator in the Med Surge Nurse Station was observed. There was a parked crash cart that was approximately 5 foot tall and covered the annunciator. The alarm annunciator was not visible. The ES moved the crash cart to observe the annunciator. This finding was confirmed by the ES.

Based on document review and interview, the facility failed to maintain the emergency generator. This was evidenced by the failure to perform monthly conductance test to the generator battery. This could result in the ineffective operation of the generator in the event of an emergency and affected two of three buildings.

NFPA 101 Life Safety Code, 2012 Edition
19.5 Building Services
19.5.1 Utilities
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
Section 9.1 Utilities

39.5 Building Services.
39.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.

9.1.3 Emergency Generators and Standby Power Systems. Where required for compliance with this Code, emergency generators and standby power systems shall comply with 9.1.3.1 and 9.1.3.2.
9.1.3.1 Emergency generators and standby power systems shall be installed, tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.

NFPA 110, Standard for Emergency and Standby Power Systems, 2010 Edition

8.3.7.1 Maintenance of lead-acid batteries shall include the monthly testing and recording of electrolyte specific gravity. Battery conductance testing shall be permitted in lieu of the testing of specific gravity when applicable or warranted.


Findings:

During document review and interview with the ES on 7/23/19, the document was requested.

MAIN CAMPUS and MAIN CAMPUS PARTIAL HOSPITALIZATION PROGRAM

At 8:43 a.m., the facility failed to provide document for the monthly conductance test of the battery in the generator. The 150 kW diesel powered generator was equipped with one maintenance free battery. When interviewed, the ES stated that the battery was maintenance free and he did not know of the monthly conductance test.

Based on observation and interview, the facility failed to maintain electrical safety. This was evidenced by power strips connected to each other. This affected one of three buildings and could result in the ignition of a fire.

Findings:

During the tour of the facilities and interview with staff on 7/22/19 through 7/24/19, the electrical wiring and equipment was observed.

1. At 11:02 a.m., the House Supervisor's Office in the Main Building was observed with two power strips plugged in to each other. At the time of survey, six devices were plugged into the power strips. Upon interview, MS1 confirmed the finding.

2. At 11:05 a.m., the Doctor's Lounge in the Main Building was observed with two power strips plugged in to each other. At the time of survey, seven devices were plugged into the power strips. Upon interview, MS1 confirmed the finding.

3. At 12:00 p.m., the Medication Room in the Main Building East Unit was observed with two power strips plugged in to each other. At the time of survey, six devices were plugged into the power strips. Upon interview, MS1 confirmed the finding.

4. At 12:24 p.m., the Doctor's Room in the Main Building Medicine Surgery Unit was observed with two power strips plugged in to each other. At the time of survey, eight devices were plugged into the power strips. Upon interview, MS1 confirmed the finding.

5. At 1:23 p.m., the Server Room in the Main Building Kitchen hallway was observed with a suspended power strip. Upon interview, MS1 confirmed the finding.

6. At 1:57 p.m., the Medical Staff Services Office in the Main Building was observed with an extension cord. At the time of survey, one device was plugged into the extension cord. Upon interview, MS1 confirmed the finding.

7. At 2:08 p.m., the Chief Executive Officer's Office in the Main Building was observed with two power strips plugged in to each other. At the time of survey, six devices were plugged into the power strips. Upon interview, MS1 confirmed the finding.

8. At 2:11 p.m., the Cardiopulmonary Office in the Main Building was observed with two power strips plugged in to each other. At the time of survey, eight devices were plugged into the power strips. Upon interview, MS1 confirmed the finding.

Based on observation and interview, the facility failed to properly store oxygen cylinders. This was evidenced by failure to properly maintain the bulk oxygen system and oxygen cylinders. This affected one of three buildings and could cause harm to patients in the event that the oxygen system or cylinders caught fire.

NFPA 99 Health Care Facilities Code, 2012 Edition
11.6.5.4 Cylinders stored in the open shall be protected as follows:
(1) Against extremes of weather and from the ground beneath to prevent rusting.
(2) During winter, against accumulations of ice or snow
(3) During summer, screened against continuous exposure to direct rays of the sun in those localities where extreme temperatures prevail


Findings:

During a tour of the facilities and interview with staff on 7/22/19, the oxygen storage location was observed and document requested.

MAIN CAMPUS

1. At 10:30 a.m., the oxygen storage location was observed with no protection from extreme weather. The outdoor location was constructed of cinder blocks and a chain link fence with no roof or covering. Upon interview, MS1 confirmed the finding.


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2. At 3:25 p.m., the policy and procedure titled "Handling & Storage of Gases and Oxygen" and Medical Gas/Cylinder Safety" were reviewed. The policies did not include storage was planned so cylinders were used in order which they are received from the supplier. When interviewed, the QI/RMA confirmed the finding and stated that the policy did not include which cylinders are used first.

Based on observation, document review, and interview, the facility failed to maintain medical gas safety. This was evidenced by the failure to provide annual training on bulk cryogenic system operations. This affected one of three buildings and could result in the unsafe handling and use of the medical gas equipment.


NFPA 99, Health Care Facilities, 2012 Edition

11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual training on its operation.

Findings:

During a tour of the facility, document review, and interview, with the ES on 7/23/19, the bulk system were observed and document requested.

MAIN CAMPUS

At 9:00 a.m., the facility was observed with bulk system that consisted of liquid oxygen, nitrous oxide cylinders, various sizes of medical gas, and manifolds. The bulk system was located in back of the main campus. There were no documentation provided of annual training of the bulk system by the supplier. The ES stated that training was last provided on 4/2017. There were no training records provided for 2018. When interviewed, the ES stated that the vendor was notified to schedule training for staff.