HospitalInspections.org

Based on observation, record review, and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls, by the use of nonrated paneling and insulation in the attic of a Type I building, and by missing sheetrock in the wall of the stairwell of a partially sprinklered building. This could result in the faster spread of fire and smoke, increasing the risk of injury to patients. This affected two of six floors in the Pavilion, one of two stairwells in the Tower, and one of six floors in the Hollywood Building.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

Findings:

During the facility tour with staff from 12/14/15 to 12/18/15, the walls and ceilings were observed.

Pavilion
First Floor:

1. At 12:36 p.m., on 12/14/15, there was a 5 inch diameter exhaust hose connection penetrating the ceiling of the Pavilion Conference Room. The attic could be observed through the opening caused by the hose connection. This connection was previously attached to the exhaust hose of the portable air conditioner observed during the Life Safety Code survey in September 2015.

Pavilion
Sixth Floor:

2. At 12:53 p.m., on 12/14/15, two ceiling tiles adjacent to the nurses station in the 6C corridor were completely wet.

During an interview at 12:53 p.m., Floor Technician 1 stated that he noticed the wet tiles at 6:50 a.m. and that nursing staff submitted a work order. A copy of Work Request No. 236232 was provided.

At 8:33 a.m., on 12/15/15, the ceiling tiles were replaced but there were two wet spots observed on the new tiles. The tiles were removed by facilities staff and a pipe above the tiles was wrapped in a light colored plastic bag. There was a 1 foot by 1 foot wooden panel near the pipe on the concrete roof above the drop ceiling.

During an interview at 9:34 a.m., on 12/15/15, when shown a picture of the pipe and wood panel in the 6C attic, the Project Manager (PM1) stated that wood paneling should not be used for a Type I building.

At 9:56 a.m., on 12/18/15, the pipe was still insulated with the plastic bag and the wood panel was still present.

Pavilion
First Floor:

3. At 3:49 p.m., on 12/14/15, there was an approximately 2 foot by 2 foot penetration in the wall behind the steam pipe in the kitchen closet. The pipe penetrated the floor into the basement and there was an approximately 2 inch penetration in the floor around the pipe. The basement was visible through the penetration.

During an interview at 3:50 p.m., the Director of Facilities Services (DFS1) stated that the steam line was recently repaired. He stated that the pipe still needed to be insulated to cover the hole in the floor and the wall still needed to be patched.

Hollywood
First Floor:

4. At 12:20 p.m., on 12/17/15, there was an approximately 2 foot by 1 foot rectangular hole in the concrete corridor wall into the dietary suite (cafeteria and kitchen). The penetration was observed above the attic access panel in the corridor outside the cafeteria.


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Tower:

5. At 4:15 p.m., on 12/16/15, there was approximately 4 feet by 4 feet opening in the wall of the east stairwell on the first floor. The opening exposed metal-like poles and meshed wiring.

During an interview at 4:16 p.m., the Chief Operating Officer (COO) stated he believed the opening was done for seismic testing of the building.

During an interview at 10:55 a.m., on 12/18/15, PM 1 confirmed the opening was done for seismic testing of the building.

Approved plans for the seismic testing from the Office of Statewide Health Planning and Development (OSHPD), dated 5/20/14, were provided by PM1. Under the "KEYNOTES" section of the approved plans, the facility was to restore the wall back to its original fire/smoke integrity after seismic testing.

The facility failed to restore the wall back to its original integrity as stated in the approved plans from the authority having jurisdiction.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that were obstructed from closing and by doors that failed to latch. This affected one of six floors in the Pavilion and two of six floors in the Hollywood Building. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to patients due to smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff from 12/14/15 to 12/18/15, the corridor doors were observed.

Pavilion
Sixth Floor:

1. At 4:09 p.m., on 12/15/15, the door to Room 622 was obstructed from closing by a rolled up towel positioned by the door leaf. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Hollywood
Fourth Floor:

2. At 10:17 a.m., on 12/17/15, the self-closing door to the shower room near Stairwell 1 failed to latch.

3. At 10:26 a.m., on 12/17/15, the self-closing door to the shower room near Room 408 failed to latch.

Hollywood
Fifth Floor:

4. At 10:36 a.m., on 12/17/15, the self-closing door to the storage room across from Room 507 failed to latch.

Based on observation, the facility failed to maintain the fire resistance rating of the smoke barrier walls. This was evidenced by penetrations in one smoke barrier wall. This finding affected one of seven floors in the Tower. This deficient practice could result in the faster spread of smoke and fire between smoke compartments and the increased risk of injury to patients, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

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

Findings:

During the facility tour with staff from 12/14/15 to 12/18/15, the smoke barrier walls were observed.

Tower
First Floor:

1. At 9:30 a.m., on 12/18/15, there was a 1 inch penetration around wires and a 1/2 inch penetration around a conduit in the attic smoke barrier wall, by the housekeeping closet outside the emergency department overflow.

There was a dime size penetration on the opposite side of the wall.

The above findings were acknowledged by the Director of Facilities Services (DFS1).

Based on observation and interview, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to close and latch upon activation of the fire alarm system. This affected six of six floors and the basement of the Pavilion. These findings could result in the faster spread of smoke and fire from one smoke compartment to another. This could result in the increased risk of injury to patients, visitors, and staff, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers' installation instructions and shall be adjusted to function as described in the listing.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the smoke barrier doors were observed during fire alarm testing. The fire alarm vendor was present for fire alarm testing.

Pavilion
First Floor:
1. At 10:18 a.m., on 12/16/15, the smoke barrier double doors to the kitchen were held open with electronic automatic-closing devices. The smoke barrier double doors failed to close and latch upon activation of a fire alarm device. A floor mat obstructed the doors from closing and latching.

Second Floor:
2. At 10:21 a.m., on 12/16/15, the smoke barrier double doors by Room 209 were held open with magnetic automatic-closing devices. One leaf failed to close and latch upon activation of a fire alarm device. The fire alarm vendor stated that it was due to a malfunctioning magnetic holder.

Third Floor:
3. At 10:50 a.m., on 12/16/15, the smoke barrier double doors by Room 332 were held open with magnetic automatic-closing devices. The doors failed to close and latch upon activation of a fire alarm device.

4. At 10:56 a.m., on 12/16/15, the smoke barrier double doors by Room 310 were held open with magnetic automatic-closing devices. One leaf failed to release from the magnetic holder upon activation of a fire alarm device.

Fourth Floor:
5. At 11:04 a.m., on 12/16/15, the smoke barrier double doors by Room 433 were held open with magnetic automatic-closing devices. The double doors failed to close and latch upon activation of a fire alarm device.

Fifth Floor:
6. At 11:11 a.m., on 12/16/15, the smoke barrier double doors by Room 509 were held open with magnetic automatic-closing devices. One leaf failed to close upon activation of a fire alarm device. There were drag marks on the floor beneath the door frame.

During an interview at 11:12 a.m., the Chief Operating Officer (COO) observed that the door leaf that failed to close was hanging lower from the top of the door frame than the door leaf that successfully closed.

Sixth Floor:
7. At 11:31 a.m., on 12/16/15, the smoke barrier double doors by Room 601 were held open with magnetic automatic-closing devices. The smoke barrier double doors failed to close and latch upon activation of a fire alarm device.

Basement:
8. At 2:33 p.m., on 12/16/15, the smoke barrier double doors to the entrance of the Tunnel were held open with magnetic automatic-closing devices. The smoke barrier double doors failed to close and latch upon activation of a fire alarm device. The smoke barrier doors were tested 3 times and failed.

The above findings were acknowledged by the fire alarm vendor and COO.

Based on record review and interview, the facility failed to ensure that emergency lighting is provided in the egress stairwells. This was evidenced by staff that were unfamiliar with the presence of emergency lights in the stairwell and by the absence of documentation of monthly inspections of emergency lights in the stairwells. This affected the Pavilion and Tower stairwells and could result in the increased risk of injury in the event of dim or no lighting during an evacuation.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the
following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

NFPA 70, National Electrical Code, 1999 Edition.
517-42. Automatic Connection to Life Safety Branch.
The life safety branch shall be installed and connected to the alternate source of power so that all functions specified herein shall be automatically restored to operation within 10 seconds after the interruption of the normal source. No functions other than those listed in (a) through (g) shall be connected to the life safety branch. The life safety branch shall supply power for the following lighting, receptacles, and equipment.
(a) Illumination of Means of Egress. Illumination of means of egress as is necessary for corridors, passageways, stairways, landings, and exit doors and all ways of approach to exits. Switching arrangement to transfer patient corridor lighting from general illumination circuits shall be permitted
providing only one of two circuits can be selected and both circuits cannot be extinguished at the same time.


Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the stairwells were observed.

Culver City Campus:

1. The facility failed to provide documentation to show that emergency lights were inspected in the stairway enclosures of the Tower and Pavilion and connection of the lights in the stairwells to emergency power could not be verified by documentation. This finding was previously cited during a Life Safety Code Survey conducted in September 2015 under K046. During the September survey, facilities staff were unsure if the stairwells were equipped with emergency lighting.

During an interview at 3:24 p.m., on 12/15/15, the Plant Operations Lead Staff (PO1) was asked if the stairwells were equipped with emergency lights and if they would be continuously illuminated during a power outage. PO1 stated that the lights were hooked up to the generator power but there were no records of inspecting them monthly.

During an interview at 4:05 p.m., on 12/17/15, the Facilities Operations Manager did not readily know if the stairwells were equipped with emergency lights.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by emergency lights that failed when tested and by no records of testing the battery-powered emergency lights. This affected the offsite Spine Clinic. This could result in a delay in evacuation due to limited visibility, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the
following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the emergency lights were observed and maintenance logs were requested.

Outpatient Spine Clinic:

1. At 1:44 p.m., on 12/15/15, the battery-powered emergency lighting unit, in the exit hallway outside Exam Room 3, failed to illuminate when tested by the Plant Operations Lead Staff (PO1).

2. At 1:52 p.m., on 12/15/15, testing records of the battery-powered emergency lights were requested. On 12/18/15, at 8:26 a.m., records of annual 90 minute testing (conducted 9/17/15) of the emergency lights in the common areas outside the Spine Clinic were provided. There were no records of monthly and annual testing the battery-powered emergency lights in the Spine Clinic.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by one exit sign with battery-operated emergency illumination that failed when tested, by one exit sign that was not illuminated, and by no records of testing the exit signs. This affected the offsite Spine Clinic and the basement of the Pavilion. This could result in a delay in evacuation, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.4 Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11
through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

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. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the exit signs were observed and maintenance records were requested.

Outpatient Spine Clinic:

1. At 1:52 p.m., on 12/15/15, records of monthly and annual testing of the exit signs were not provided.

2. At 2:02 p.m., on 12/15/15, the exit sign outside Exam Room 1 was equipped with battery-powered emergency illumination. The exit sign failed to illuminate when tested by Plant Operations Lead Staff (PO1).

3. At 2:06 p.m., on 12/15/15, the exit sign in the waiting area was not illuminated. PO1 removed the cover and the bulbs in the exit sign were not lit.


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Pavilion
Basement:

4. At 3:34 p.m., on 12/17/15, the exit sign in the back of the Microbiology Laboratory was not illuminated.

Based on observation, record review, and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire and other emergencies. This was evidenced by the failure of security staff to implement their fire response procedures during a Code Red (the facility's code word for fire) and by staff that were unfamiliar with the facility's evacuation procedures. This was also evidenced by no records of semi-annual disaster drills conducted at the Van Nuys Building. This affected the safety of patients in the Pavilion and Van Nuys Building. These deficient practices could result in a delay in staff response in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.
19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.11 Hospitals shall comply with the provisions of Chapter 11 for disaster planning, as appropriate.

Chapter 11 Health Care Emergency Preparedness
11-5.3.6 Security. Security plans shall be developed that address facility access, crowd control, security staff needs, and traffic control.

11-5.3.8 Staff Education. Each health care facility shall implement an educational program. This program shall include an overview of the components of the emergency preparedness plan and concepts of the Incident Command System. Education concerning the staff's specific duties and responsibilities shall be conducted upon reporting to their assigned departments or position. General overview education of the Emergency Preparedness Plan and the Incident Command System shall be conducted at the time of hire. Department/staff specific education shall be conducted upon reporting to their assignments or position and annually thereafter.

11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, a Code Red incident occurred and staff response was observed.

Pavilion:

1. At 12:40 p.m., on 12/14/15, the fire alarm system was activated. An overhead announcement "Code Red Pavilion Sixth Floor" was made by the facility's automatic paging system. PBX staff also made an overhead announcement "Room 633 Code Red."

At 12:42 p.m., on the first floor, two security staff with fire extinguishers and four hospital staff entered the elevator. The elevator stopped at every floor before reaching the sixth floor.

During an interview at 12:42 p.m., Security Staff (SS2) stated that they did not have the "autokey" that allows the elevator to go directly to the sixth floor.

At 12:45 p.m., two engineering staff arrived to Room 633 and determined that the cause of the fire alarm activation was due to a patient that broke the smoke detector in the bathroom.

During an interview at 12:46 p.m., SS2 stated that only the dispatcher and the security supervisor had the autokey for the elevator. She stated that security staff is trained not use the elevator during Code Red events and to use the stairs instead.

During an interview at 1:05 p.m., Security Staff/Dispatcher (SS1) stated that during a Code Red event, security staff are supposed to recall the elevators and block people from using them until the Code Red is cleared. He stated that it was the hospital's policy that responding security staff are trained to use the stairs and not the elevators.

Van Nuys:

2. At 12:02 p.m., on 12/16/15, there were no records of disaster drills conducted at the Van Nuys facility.

During an interview at 12:03 p.m., the disaster coordinator stated that disaster drills are held semi-annually at the Hollywood facility and Van Nuys staff are called over the phone and told to respond.

Review of the staff participation list for the earthquake drill on 6/11/15 at Hollywood indicated that only one staff from Van Nuys participated in the drill.


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Pavilion:

3. The facility's evacuation policy was reviewed and indicated that partial evacuation was to a safe area behind smoke barrier doors. The policy also indicated that staff should be familiar with horizontal evacuation and vertical evacuation.

During an interview at 10:44 a.m., on 12/16/15, a Registered Nurse stated she was unfamiliar with the terms partial evacuation, horizontal evacuation, and vertical evacuation and or the purpose of the smoke barrier doors in an evacuation.

During an interview at 11:50 a.m., on 12/16/15, a Mental Health Technician stated he was unfamiliar with the terms partial evacuation, horizontal evacuation, and vertical evacuation or what would be a safe area (behind smoke barrier doors) for a partial evacuation.

Based on document review and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by no records of a fire drill conducted at the Culver Medical Plaza where the offsite Spine Clinic is located, by a Pavilion fire drill that was not attended by majority of staff, and by staff that were not aware of their responsibilities in the event of a fire. This could result in improper staff response in the event of a fire and an increased risk of injury to patients. This affected the Culver City Campus and the Spine Clinic.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

39.7.1 Drills. In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.

39.7.2 Extinguisher Training. Designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers.

4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.

4.7.2 Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

4.7.5 Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the fire drill records were reviewed and staff were interviewed about fire response procedures.

Outpatient Spine Clinic:

1. At 1:53 p.m., on 12/15/15, the fire drill records were requested. No fire drill records were provided for the Spine Clinic as of 8:25 a.m. on 12/18/15.


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Pavilion:
2. At 11:12 a.m., on 12/18/15, the facility's fire drill policy, in the disaster manual, indicated that at least 90 percent of hospital staff would participate in the fire drills.

At 9:20 a.m., on 12/15/15, records showed that one fire drill was conducted in October 2015 at 9:10 p.m. in the Transitional Care Unit. The sign-in sheet indicated that only five staff participated. Records showed that this was the only fire drill conducted since the last Life Safety Code Survey in September 2015.

During an interview at 2:21 p.m., on 12/16/15, the Director of Laboratory Services confirmed that laboratory staff do not participate in facility-wide drills.

During an interview at 11:10 a.m., on 12/18/15, the Vice President of Facilities Services confirmed that only five staff signatures were on the fire drill's participation sign-in sheet.

The facility failed to ensure that 90% of staff participated in the fire drill per their policy.

3. The fire response plan indicated that, in the event of a fire, staff would follow R.A.C.E. (rescue, alarm, confine, extinguish/evacuate) procedures. The policy stated that staff are to rescue patients in immediate danger, notify the hospital by activating a pull station and dialing extension 5555 (PBX), confine the fire by closing the doors, and extinguish small fires with a fire extinguisher.

Facility staff were asked what they would do in the event of a fire:

a. During an interview at 10:44 a.m., on 12/16/15, a Registered Nurse (RN1) from the third floor stated that she would rescue the patient, close the door, pull the alarm, and sweep over the fire with a fire extinguisher if she could. She was not familiar with where on the fire she should aim the fire extinguisher and she was unfamiliar with the policy to dial the operator.

b. During an interview at 11:18 a.m., on 12/16/15, a Registered Nurse (RN2) from the surgical department stated that she would shout for help, pull the fire alarm, close the doors, and wait for further information. She was unfamiliar with the entire R.A.C.E. procedures and the facility's policy to dial the operator.

c. During an interview at 11:48 a.m., on 12/16/15, a Psychiatric Technician stated that he would get the patients out of the room and down the stairs, and call out code red. He was unfamiliar with the entire R.A.C.E. procedure sequence and the facility's policy.

d. During an interview at 3:05 p.m., on 12/16/15, security staff at the fire alarm panel stated that she was unfamiliar with the difference between a fire alarm and the supervisory tamper alarm. She incorrectly stated the supervisory tamper alarm was a smoke detector being activated.

e. During an interview at 3:43 p.m., on 12/16/15, Registered Nurse (RN3) stated she would dial 5555, call out code red, close the doors, and not open the doors if they were hot. She was unfamiliar with the entire R.A.C.E. sequence.

Facility staff were unfamiliar with life safety procedures and equipment.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in reliable operating condition. This was evidenced by fire alarm devices that exhibited trouble conditions, the failure of fire alarm notification devices, and by an area where the fire alarms could not be heard. This was also evidenced by the failure to arrange for smoke detector testing at Van Nuys and fire alarm testing at the two offsite clinics. This affected the Tower, the Pavilion, the Van Nuys Building, the Hollywood Building, and two offsite clinics. This could result in delay in notification and response, in the event of a fire, and could result in the increased risk of injury.

NFPA 101, Life Safety Code, 2000 Edition.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

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.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 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 Code.

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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-1.3.3 Initiating devices shall be installed in all areas where required by other NFPA codes and standards or the authority having jurisdiction. Each installed initiating device shall be accessible for periodic maintenance and testing.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the fire alarm system was observed.

Pavilion
Basement:

1. At 11:15 a.m., on 12/14/15, the following devices exhibited trouble conditions at the main fire alarm control panels (FACPs):

a. Tower 2 waiting room duct detector
b. Pavilion 1 smoke detector outside pharmacy
c. Tower 2nd, 4th, and 7th floor notification appliance circuit (NAC) expanders.

During an interview at 1:03 p.m., on 12/14/15, Facilities Operations Manager (FOM1) stated that the vendor was called to investigate the troubles. He stated that the vendor told him via telephone that the NAC expanders are connected to the notification horns and strobes.

The trouble signals were already acknowledged and silenced.

At 8:31 a.m., on 12/15/15, the three troubles were still exhibited on the FACP.

Penthouse:

2. At 8:49 a.m., on 12/15/15, the combination horn/strobe fire alarm notification device, near the cooling tower, was observed. The audible horn was covered with painters tape on both sides of the strobe.

At 10:06 a.m., on 12/18/15, one side of the speaker was still covered with blue painters tape.

Offsite IOP and Spine Clinics:

3. At 2:05 p.m., on 12/15/15, the Vice President of Business Development (VPBD1) and the Vice President of Facilities Services were asked to arrange for fire alarm testing to be conducted at the offsite clinics on Friday morning (12/18/15) as part of the validation survey.

During an interview at 8:21 a.m., on 12/18/15, VPBD1 stated that we cannot conduct fire alarm testing at the offsite facilities. Maintenance Staff at the Culver Medical Plaza (CMP Maint1) stated that they needed a couple of weeks notice to arrange for alarm testing. Functionality of the fire alarm system was not observed.

Van Nuys:

4. At 10:52 a.m., on 12/15/15, the Director of Facilities Services (DFS2) and Maintenance Staff (VN Maint 1) stated that there was no aerosol smoke to test the smoke detectors during the survey. Functionality of the smoke detectors were not observed.

Hollywood
Basement:

5. At 9:07 a.m., the smoke detector in the FACP room/Radiology Office failed to alarm when tested with aerosol smoke.


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Pavilion
Third Floor:

6. At 10:53 a.m., on 12/16/15, maintenance staff tested the smoke detector in Room 315A and the visual notification light in the corridor above the room's door failed upon activation of the smoke detector. The corridor notification lights are designed to indicate which patient room smoke detector is activated.

Penthouse:

7. At 12:05 p.m., on 12/16/15, one of the strobe and chime notification devices in the mechanical room failed to annunciate upon activation of a fire alarm device.

Tower
Seventh Floor:

8. At 3:50 p.m., on 12/16/15, no audible fire alarm could be heard in the Mechanical Room upon activation of a fire alarm device. The Chief Operating Officer (COO) acknowledged the finding.

Based on observation and interview, the facility failed to ensure that a local alarm will sound when the sprinkler control valves are closed. This was evidenced by the failure of the local supervisory audible alarm at the fire alarm subpanel in the telephone exchange box (PBX) room. This affected the entire Hollywood Building. This could result in a delayed response, in the event of closure of the sprinkler valves, and an increased risk of failure of the sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

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 Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. 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, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the supervised sprinkler control valves were observed.


Hollywood:

1. At 3:08 p.m., on 12/17/15, the sprinkler control valves on the riser of the sprinkler system were supervised by tamper switches designed to send a trouble signal to the fire alarm panel upon closure of the valves. The sprinkler control valve on the first floor was closed and a visual supervisory notification light was activated at the fire alarm subpanel in PBX. No audible alarm could be heard at the panel in PBX.

During an interview at 3:09 p.m., the Director of Facilities Services (DFS2), the Disaster Coordinator, and the Chief Engineer (CE1) all confirmed that an audible trouble signal could not be heard. CE1 stated that PBX is manned 24 hours a day and respond to trouble lights from the fire alarm panels, medical gas panels, and generator panels located in their office.

At 3:11 p.m., the sprinkler control valve on the second floor was closed and only a visual notification light at the PBX panel was activated. There was no audible alarm.

Based on observation, record review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by the failure to provide records of repairing deficiencies noted during an inspection, by the failure to conduct a five-year test more than one year after it was due, by corroded sprinkler heads, by sprinkler heads that were not free of foreign materials, and by fire department connections that failed to rotate smoothly. This affected two of three buildings in the Culver City Campus and the Van Nuys Building. These deficient practices could result in a delay in extinguishing a fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

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

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

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the sprinkler system was observed and maintenance records were reviewed.

Culver City Campus:
1. At 11:20 a.m., on 12/15/15, records of an inspection of the sprinkler system conducted by a vendor on 9/28/15 was reviewed. Under the Deficiencies and Comments section, it was noted that the waterflow switch corresponding to System Riser ID 1 did not report to the fire alarm control panel (FACP) and the tamper corresponding to System Riser ID 1 did not report to the FACP. Records of repairing the deficiencies were not provided.

Pavilion
Basement:
2. At 3:42 p.m., on 12/15/15, there were two pest strips attached to the sprinkler pipe in the trash chute room. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

3. At 3:45 p.m., on 12/15/15, there was a corroded sprinkler head in the trash chute room. The Chief Operating Officer (COO) acknowledged that the sprinkler head had turned green.

Van Nuys:
4. At 2:59 p.m., on 12/16/15, records indicated the most recent five year inspection was conducted in May 2009. The five year inspection was due in May 2014.

During an interview at 3:00 p.m., the director of facilities services (DFS2) stated that the five year was scheduled for 12/21/15. He attributed the delay due to a change in vendors.


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Pavilion:
5. At 2:15 p.m., on 12/16/15, there were four corroded sprinkler heads in the front entrance exterior overhang. This finding was previously cited during a Life Safety Code Survey conducted in September 2015. The COO acknowledged the sprinklers heads were green and the sprinkler heads had rusty escutcheon rings.

Single Story Building:
6. At 2:13 p.m., on 12/16/15, the fire department connection (FDC) facing Delmas Terrace, failed to rotate freely when tested by the fire alarm vendor.

Pavilion
Basement:
7. At 10:25 a.m., on 12/17/15, there were two corroded sprinkler heads in the Decontamination Room and a white foreign substance on the sprinkler head in the Sterilization Room of Central Sterile.

Based on observation and interview, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers with obstructed access, by the failure to provide all staff with keys to locked fire extinguisher cabinets in the acute psychiatric facility, and by fire extinguishers that were overdue for an annual service. This affected the safety of patients in the Van Nuys Building and the offsite Spine Clinic. This could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

4-3.2 Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the fire extinguishers were observed.

Outpatient Spine Clinic:

1. At 1:39 p.m., on 12/15/15, access to the fire extinguisher in the front office was blocked by a recycling bin.

2. At 1:47 p.m., on 12/15/15, the service tag on the fire extinguisher, located in the exit hallway outside of Exam Room 3, indicated that it was last annually serviced on 9/27/14. The extinguisher was due to be serviced again in September 2015.

Van Nuys:

3. At 8:39 a.m., on 12/16/15, housekeeping staff (VN EVS1) did not have the key to the locked fire extinguisher cabinets.

At 8:57 a.m., on 12/16/15, mental health worker (VN MHW1) did not have the key to the locked fire extinguisher cabinets.

4. At 9:10 a.m., on 12/16/15, access to the fire extinguisher in the storage cage was obstructed by stacked furniture.

Based on observation and interview, the facility failed to maintain their smoking areas. This was evidenced by no safety-type ashtrays in one designated smoking area. This affected the smoking area at the Hollywood Building and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or
oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read
NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During the tour of the facility with staff from 12/14/15 to 12/18/15, the designated smoking areas were observed.

Hollywood:

1. At 8:30 a.m., on 12/17/15, the smoking area in the west parking lot was not provided with safety type ashtrays. There were cigarette butts in open top ceramic planters filled with pebbles.

During an interview at 8:31 a.m., the Director of Facilities Services (DFS2) stated that the safety-type ashtrays were stolen so the planters were used because they were too heavy to steal.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air-conditioning (HVAC) systems. This was evidenced by the failure to provide adequate central heating to the patient rooms, by the failure to test dampers every four years, by the failure to repair dampers that failed inspections, by the use of a portable air conditioner, and by the failure to maintain that air conditioner in accordance with manufacturer guidelines. This was also evidenced by leaks in the hot water tanks and by a boiler that exhibited a low water pressure alarm. This affected the entire Pavilion, the basement of the Tower, three of six floors in the Hollywood Building, and four of four smoke compartments in the Van Nuys Building, These deficient practices could result in the increased risk of injury to patients due to lack of heating capabilities and the faster spread of smoke and fire due to incomplete maintenance of the dampers.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.
2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.
2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.
2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.
2-3.1.3 All air duct materials shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the air duct.
2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.
3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the HVAC systems were observed and maintenance records were reviewed.

Pavilion:
1A. At 10:00 a.m., on 12/15/15, records indicated that the facility has used a temporary air handler unit since March 2015. The facility was granted a permit on 12/9/15 from the Office of Statewide Health Planning and Development (OSHPD) to begin installation of the new air handler unit.

During an interview at 10:27 a.m., on 12/15/15, the Project Manager (PM2) in charge of restoration of the air handler installation (OSHPD Project #S151262-19-00) stated that the temporary air handler fed the air in the patient rooms of the Pavilion. He stated that he has heard complaints about the rooms being too cold since last Tuesday (12/8/15). PM2 stated that a possible solution to adding central heat to the rooms was to add a heating coil to the temporary air handler unit until the new permanent air handler was installed. PM2 estimated that the new air handler would be installed in approximately five to six months.

During an interview at 4:07 p.m., on 12/15/15, the Vice President of Facilities Services stated that the facility will be adding a heating coil to the temporary air handling unit to provide central heat to the rooms.

During an interview at 8:32 a.m., on 12/16/15, the Regional Compliance Officer (RCO) from OSHPD stated that the facility must provide heat between 70 to 75°F per state regulations. He stated that if the facility needed to add a heating coil to the HVAC system then the current system was not providing enough heat.

Observations, record review, and interviews showed that the facility failed to provide a working central heating system.

Ambient temperatures and temperatures from the supply air vents in the rooms were recorded:

12/15/15
a. At 4:05 p.m., Plant Operations Lead Staff (PO1) recorded the temperature in Room 628 with a handheld thermometer. The temperature in the room was 68.5°F and the thermostat in the room was set to "warm." During an interview at 4:05 p.m., the patient in the room stated that the room was too cold and has been cold for three days.

During an interview at 4:06 p.m., PO1 stated that there was no way to add heat to the room and the thermostat only turned off the cold air when it is set to warm.

b. At 4:19 p.m., PO1 measured the temperature in Room 630. The temperature was 67.2°F. The thermostat in the room had a broken lever and PO1 could not adjust it.

c. At 4:21 p.m., PO1 measured the temperature in Room 634 to be 67°F.

d. At 4:30 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 302 to be 61.6°F.

e. At 4:35 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 311 to be 66.2°F.

f. At 4:37 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 314A to be 63.8°F.

g. At 4:40 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 315A to be 67.8°F.

h. At 4:45 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 207 to be 67.6°F. The room's thermostat was set to warm.

i. At 4:47 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 206 to be 60°F. The thermostat in the room had no operating button to adjust the settings. During an interview, the patient in the room stated that the room was cold.

12/17/15
j. At 9:15 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 209 to be 68.6°F. During an interview, the patient in the room stated it was cold.

k. At 9:18 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 201 to be 63.4°F. During an interview, the patient in the room stated the room was chilly.

l. At 9:25 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 204 to be 62.2°F.

m. At 9:30 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 220 to be 62.2°F. During an interview, the patient in the room stated it was cold.

n. At 9:35 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 243 to be 61.3°F.

o. At 9:38 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 241 to be 61.6°F. During an interview, the patient in the room stated it was cold.

p. At 9:45 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 226 to be 58°F.

The Director of Emergency Services acknowledged that she could feel the chill in the North West wing of the second floor (patient room wing). She stated the rooms in that wing were much cooler than some of the other rooms.

1B. At 4:49 p.m., on 12/15/15, records of room temperatures recorded by staff in the Pavilion were reviewed. The logs showed that staff were recording ambient room temperatures three times daily (at 6:30 a.m., 12:00 p.m., and 7:00 p.m.) and the acceptable temperature range on the log was listed as 68 to 75°F. The logs were reviewed for temperatures below 68°F:

Sixth Floor:
a. Room temperatures fell below 68°F in 25 of 40 patient rooms on 12/15/15, with the lowest temperature of 64.4°F recorded at 12:00 p.m. in Room 633.

b. Room temperatures fell below 68°F in 8 of 40 patient rooms on 12/14/15, with the lowest temperature of 67.4°F recorded at 12:00 p.m. in Room 638.

c. Room temperatures fell below 68°F in 25 of 40 patient rooms on 12/13/15, with the lowest temperature of 65.2°F recorded at 6:30 a.m. in Rooms 631 and 632.

d. Room temperatures fell below 68°F in 6 of 40 patient rooms on 12/12/15, with the lowest temperature of 67°F recorded at 12:00 p.m. in Room 638.

e. Room temperatures fell below 68°F in 18 of 40 patient rooms on 12/2/15, with the lowest temperature of 66.5°F recorded at 6:30 a.m. in Room 639.

Fifth Floor:
a. Room temperatures fell below 68°F in 15 of 41 patient rooms on 12/13/15, with the lowest temperature of 66.1°F recorded at 6:30 a.m. in Rooms 536 and 540.

b. Room temperatures fell below 68°F in 8 of 41 patient rooms on 12/1/15, with the lowest temperature of 66.8°F recorded at 8:00 a.m. in Room 527.

Fourth Floor:
a. Room temperatures fell below 68°F in 8 of 19 patient rooms on 12/13/15, with the lowest temperature of 67.3°F recorded at 6:30 a.m. in Room 424.

b. Room temperatures fell below 68°F in 19 of 19 patient rooms on 12/12/15, with the lowest temperature of 65.4°F recorded at 6:30 a.m. in Room 406.

Second Floor (Unit P2):
a. Room temperatures fell below 68°F in 30 of 44 patient rooms on 12/12/15, with the lowest temperature of 65.2°F recorded at 6:30 a.m. in Rooms 223 and 230.

b. Room temperatures fell below 68°F in 20 of 44 patient rooms on 12/12/15, with the lowest temperature of 66.5°F recorded at 6:30 a.m. in Rooms 225 and 228.

1C. On 12/17/15, hospital staff at Pavilion recorded temperatures in patient rooms at 2:00 a.m., 4:00 a.m., and 6:00 a.m. Those temperature logs were reviewed:

a. In P6 (Sixth Floor), temperatures in 15 of 40 patient rooms remained below 68°F from 2 a.m. to 6 a.m. with the lowest temperature of 65.2°F recorded at 2:00 a.m. in Room 635.

b. In P5 (Fifth Floor), temperatures in 12 of 41 patient rooms remained below 68°F from 2 a.m. to 6 a.m. with the lowest temperature of 65.8°F recorded at 6:00 a.m. in Room 534.

c. In P2 (Second Floor), temperatures in 9 of 44 patient rooms remained below 68°F from 2 a.m. to 6 a.m. with the lowest temperature of 64.5°F recorded at 6:00 a.m. in Rooms 224, 225, and 226.

Per these observations, log reviews, and interviews, the facility failed to ensure that their HVAC system was capable of providing central heating to the patient rooms.

Tower:
2. At 2:33 p.m., on 12/14/15, the Director of Facilities Services (DFS1) stated that the facility did not elect to use any categorical waivers. The facility did not provide documentation of a categorical waiver (per Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 10-04-LSC, dated 10/30/09) allowing for a six year damper testing frequency.

At 11:04 a.m., on 12/15/15, records indicated that fire damper testing was conducted on 11/4/10 in the Tower and Pavilion. All dampers in the Pavilion were tested this year as part of an HVAC restoration project but there were no records of testing the Tower fire dampers since 2010. Without utilization of a categorical waiver, the dampers were due to be tested in November 2014.

3. At 11:04 a.m., on 12/15/15, records indicated that five dampers (#2-003, #2-004, #2-005, #2-006, and #2-008) in the second floor of the Tower failed testing on 11/4/10. There were no records of repairing the dampers.

Van Nuys:
4. At 8:07 a.m., on 12/16/15, there was a temporary portable air handler connected to the temporary portable chiller in the west parking lot. The portable chiller was cited during the last Life Safety Code Survey in September. The portable chiller, on a wheeled portable flat bed in the west parking lot, did not have an OSHPD permit.

An invoice from the HVAC vendor indicated that the temporary chiller was installed on 7/17/15.

At 11:37 a.m., a kitchen temperature log indicated that the portable air handler has been installed since 9/30/15. Records indicated that an application for an OSHPD permit was submitted but no permit had been issued for the use of the temporary chiller and air handler.

During an interview at 11:55 a.m., the Project Manager (PM1) stated that there was no OSHPD permit for this equipment yet.

5. At 12:15 p.m., on 12/16/15, the mechanical blue prints of the HVAC system showed that the facility was protected by fusible link fire dampers.
At 12:20 p.m., the Fire/Smoke Damper Inspection log indicated that maintenance staff (VN Maint 2) inspected the dampers from 1/6/15 to 4/2/15.

During an interview at 12:28 p.m., VN Maint 2 stated that he just cleans the ducts but does not exercise the dampers. There were no records of operating the dampers every four years.


Hollywood:
6. At 3:19 p.m., on 12/16/15, records indicated that a fire damper inspection was conducted on 5/28/15. The records showed that two dampers (Urgent Care Office First Floor and CCU Third Floor) were not tested because they could not be accessed. One damper failed to close (Fifth Floor corridor adjacent to Room 510) because it was obstructed by a pipe. There were no records or repairing the three deficiencies noted by the vendor.

During an interview at 3:20 p.m., the Chief Engineer (CE1) stated that the facility was aware of the issues and was working with the vendor to provide access to those dampers.

Hollywood
First Floor:
7. At 12:00 p.m., on 12/17/15, there was a portable air conditioner (AC) in the laboratory. It was vented into the return exhaust vent which was covered with a thin piece of vinyl. The AC's air filter had a thick accumulation of dust and dirt.

During an interview at 12:01 p.m., CE1 stated that the filter was cleaned every month.

The AC's manufacturer's manual recommended that the air filter be cleaned once a week.

At 4:02 p.m., the Director of Facilities Services (DFS2) stated that the portable AC has been in the laboratory for approximately one year.


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Pavilion
Basement:
8. At 4:05 p.m., on 12/14/15, there was a leaking pipe in the ceiling of Mechanical Room 1. The facilities operations manager acknowledged the finding.

9. At 3:25 p.m., on 12/15/15, there was an audible alarm activated in the basement near Mechanical Room 1.

During an interview at 3:26 p.m., PO1 stated that one of the two boilers was leaking and that caused the low water pressure alarm to activate.

10. At 3:27 p.m., on 12/15/15, the hot water tank was leaking and the electrical hot water circulating tank was also leaking.

During an interview at 3:28 p.m., PO1 stated that this hot water tank serviced the surgery suite in the basement.

Tower
Basement:
11. At 8:42 a.m., on 12/18/15, there was a leaking pipe in the ceiling by the door into the mechanical room.

During an interview at 8:43 a.m., DFS1 acknowledged the leaking pipe was from the hot water tank.

Based on observation and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by no filters in one kitchen hood and by grease-laden deposits on the kitchen hood and suppression system equipment. This affected one of seven floors in the Pavilion and one of six floors in the Hollywood Building. This could result in the increased risk of a grease fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Findings:

During a tour of the facility with staff from 12/14/15 to 12/18/15, the commercial cooking equipment was observed.

Pavilion
First Floor:

1. At 3:51 p.m., on 12/14/15, the kitchen hood above the stove was not equipped with grease filters. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview at 3:52 p.m., the Director of Facilities Services (DFS1) stated that custom built filters were ordered for the hood and stated he could provide documentation of the order.

Records of ordering the grease filters were requested from DFS1 on 12/14/15 (at 3:52 p.m.) and 12/15/15 (at 11:30 a.m.) but were not provided.

Hollywood
First Floor:

2. At 2:55 p.m., on 12/17/15, there was grease dripping from the kitchen hood filters above the stove. When the filters were removed, the inside of the hood and the fusible link were approximately 50% covered with grease laden deposits. The back of the filters above the griddle were completely covered with grease laden deposits. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Based on observation, the facility failed to ensure that portable space heaters used in non-sleeping staff areas complied with the requirements of NFPA 101. This was evidenced by no manufacturer's specifications indicating that the temperature of the portable space heater used in one staff office did not have heating element temperatures exceeding 212°F. This affected the basement of the Pavilion and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Findings:

During a tour of the facility with staff from 12/14/15 to 12/18/15, the public box exchange (PBX) room was observed.

Pavilion
Basement:

1. At 2:46 p.m., on 12/16/15, a portable fan space heater was turned on and located on the floor of the PBX room. The label on the portable fan space heater indicated power consumption was 750/1500 W.

The facility failed to provide manufacturer's specifications of the portable heater to show that the temperature of the heating elements did not exceed 212°F.

Based on observation and interview, the facility failed to ensure that means of egress are free from obstructions. This was evidenced by items obstructing the egress paths and corridors. This could result in the delay in evacuation and the increased risk of injury to the patients and staff during an emergency. This affected the basement of the Tower and two of six floors and basement of the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.6.1 General. Walking surfaces in the means of egress shall comply with 7.1.6.2 through 7.1.6.4.
Exception: Existing walking surfaces shall be permitted where approved by the authority having jurisdiction.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the egress paths were observed.

Pavilion
Basement:
1. At 3:58 p.m., on 12/14/15, there was a modular table system stored in the egress corridor, across from the exit sign, in the back of Medical Records.

Second Floor:
2. At 10:32 a.m., on 12/16/15, there were workstation on wheels (WOWs) along the egress corridors.

During an interview at 10:33 a.m., the charge nurse on the floor stated that the WOWs and their chairs were stored in the corridor even when unattended by staff.

Sixth Floor:
3. At 11:35 a.m., on 12/16/15, there was a telephone in a wooden cabinet mounted on the wall of the egress corridor by Room 617. The wooden cabinet protruded approximately 12 inches from the wall into the egress corridor and blocked usage of the handrail. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Tower
Basement:

4. At 8:48 a.m., on 12/18/15, there was a desk with office supplies and a storage box with paper in the egress corridor, by the piped-in oxygen gas shut-off valve.

5. At 8:50 a.m., on 12/18/15, there was an industrial-sized laundry receptacle stored in the egress corridor near Housekeeping.

Based on observation and interview, the facility failed to ensure that highly flammable decorations were not used. This was evidenced by the presence of two live cut Christmas trees. This could result in the faster spread of smoke and fire due to the dry vegetation. This affected one of four smoke compartments in the Van Nuys building and one of six floors in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the lobby area was observed.

Pavilion
First Floor:

1. At 4:36 p.m., on 12/14/15, there was an approximately 8 foot tall live cut Christmas tree in the lobby near the security desk. The tree was cut at the roots and dry.

During an interview at 4:37 p.m., the Director of Facilities Services (DFS1) stated that the tree was flame resistant and the facility had documentation from the local fire marshal to show this.

There was a folded red tag that was stapled at the bottom of the tree but was not legible. DFS1 stated that this was the certificate from the fire marshal about the tree's flame resistance and he had a copy he could provide.

A copy of the flame resistance certificate was not provided.


29665


Van Nuys:

2. At 8:55 a.m., on 12/16/15, there was an approximately 6 foot tall live cut Christmas tree in the front lobby/waiting room. The tree was cut at the roots and dry.

Based on observation and interview, the facility failed to maintain the storage of their soiled linen and trash receptacles. This was evidenced by a trash collection room door that failed to latch. This affected the basement of the Pavilion and could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the soiled linen and trash collection rooms were observed.

Pavilion
Basement:

1. At 3:40 p.m., on 12/15/15, the self-closing door to the trash chute room failed to latch. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview at 3:41 p.m., Plant Operations Lead Staff (PO1) stated that the latch hardware required adjustment.

Based on observation, the facility failed to maintain their medical gas cylinder storage. This was evidenced by four medical gas cylinders that were not individually secured. This affected the basement of the Pavilion and could result in the increased risk of injury, in the event a cylinder is knocked over.

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
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the medical gas cylinders were observed.

Pavilion
Basement:

1. At 3:47 p.m., on 12/14/15, there were four nitrous oxide H-cylinders that were chained together, and not individually secured, in the nitrous oxide piped-in medical gas room.

Based on observation and interview, the facility failed to maintain their piped-in medical gas systems. This was evidenced by the absence of an emergency oxygen supply connection. This affected the patients in the Pavilion and could result in the delay in emergency response and the increased risk of hazardous conditions.

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
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-3.1.1.8 General Requirements for Gas Central Supply Systems. Piped oxygen and medical air shall not be piped to or used for, any purpose except for use in patient care applications.
(h)Emergency Oxygen Supply Connection. Where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system an inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled "EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET." This connection shall be installed downstream of the shutoff valve on the main supply line (see 4-3.1.2.3(b)) and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the piped-in medical gas system was observed.

Pavilion:

1. At 9:05 a.m., on 12/15/15, the cryogenic system was not equipped with an emergency oxygen supply connection (oxygen autofill port). This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview, the Director of Facilities Services (DFS2) stated that the facility was in the process of obtaining approval for a project to add an autofill port.

Based on record review and interview, the facility failed to maintain the relative humidity levels in the anesthetizing locations. This was evidenced by records of the humidity levels falling below 35% during procedures in operating rooms (ORs) and by ORs that were not equipped with a means to mechanically increase humidity levels. This was also evidenced by the adoption of policies to lower the humidity in ORs below 35% without providing documentation of a categorical waiver in accordance with Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 13-25-LSC. This affected all the ORs in the Pavilion and all the ORs in the Hollywood Building. This could result in the increased risk of a fire and the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 5 Environmental Systems
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.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures.

Findings:

During document review with staff from 12/14/15 to 12/18/15, the humidity logs were reviewed.

Pavilion and Hollywood:
1. At 10:33 a.m., on 12/15/15, the "Operating Procedure Rooms Temperature and Humidity Monitoring" Policy (#SUR.048) stated that the facility would follow the Association of periOperative Registered Nurses (AORN) standard recommended humidity range of 30 to 60%.

The policy stated that it was applicable to the Culver City Campus and Hollywood Campus.

At 12:37 p.m., on 12/14/15, the Pavilion "OR Temperature and Humidity Monitoring Sheet" logs were reviewed. The top portion of the log indicated that the desired humidity range was 20 to 60%.

At 2:33 p.m., on 12/14/15, the Director of Facilities Services (DFS1) stated that the facility did not elect to use any categorical waivers. The facility did not provide documentation of a categorical waiver per Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 13-25-LSC, dated 4/19/13 to lower relative humidity in the anesthetizing locations to 20%.

Pavilion
Basement:
2. At 2:34 p.m., on 12/14/15, the humidity monitoring sheets indicated that humidity levels in the ORs fell below 35% immediately preceding procedures during the following dates and times:

a. On 12/7/15 at 7:00 a.m., the humidity was recorded as 23.9% before a procedure in OR 2.

b. On 12/7/15 at 12:00 p.m., the humidity was recorded as 29% before a procedure in OR 2.

c. On 12/7/15 at 6:00 a.m., the humidity was recorded as 28% before a procedure in OR 3.

d. On 12/7/15 at 6:00 a.m., the humidity was recorded as 24% before a procedure in OR 4.

e. On 12/7/15 at 7:00 a.m., the humidity was recorded as 25.5% before a procedure in OR 5.

Hollywood
Basement:
3. At 4:30 p.m., on 12/16/15, there were no humidity controls observed in ORs 1, 2, and 3. Humidity logs showed that humidity levels fell below 35% in the ORs (see Deficiency 4).

During an interview at 5:20 p.m., on 12/17/15, the Director of Facilities Services (DFS2) stated that the ORs were not equipped with an air handling system that could mechanically raise the humidity levels. He stated that humidity in the ORs depends on the outside humidity levels.

4. At 4:56 p.m., on 12/17/15, records indicated that humidity levels in the OR fell below 35% immediately preceding procedures during the following dates and times:

a. On 11/17/15 at 6:00 p.m., the humidity was recorded as 10% before a procedure in OR 1.

b. On 11/17/15 at 7:00 p.m., the humidity was recorded as 12% before a procedure in OR 1.

c. On 11/17/15 at 6:00 a.m., the humidity was recorded as 10% before a procedure in OR 3

d. On 11/17/15 at 6:00 p.m., the humidity was recorded as 18% before a procedure in OR 3.

e. On 11/20/15 at 12:00 p.m., the humidity was recorded as 24% before a procedure in OR 3.

f. On 11/23/15 at 7:30 a.m., the humidity was recorded as 10% before a procedure in OR 1.

g. On 12/1/15 at 6:00 a.m., the humidity was recorded as 18.5% before a procedure in OR 3.

h. On 12/2/15 at 6:00 a.m., the humidity was recorded as 16.9% before a procedure in OR 1

i. On 12/2/15 at 10:30 a.m., the humidity was recorded as 22% before a procedure in OR 1.

j. On 12/3/15 at 7:30 a.m., the humidity was recorded as 15% before a procedure in OR 3.

k. On 12/3/15 at 10:30 a.m., the humidity was recorded as 13.8% before a procedure in OR 3.

"Operating Procedure Rooms Temperature and Humidity Monitoring" Policy (#SUR.048) stated that the facility will follow the Association of periOperative Registered Nurses (AORN) standard recommended humidity range of 30 to 60%.

Section 1.7 of the policy stated, "if temperature and humidity cannot be controlled within specified levels, all scheduled procedures for that specific room will be canceled."

During an interview at 5:35 p.m., two surgical staff confirmed that cases were not canceled because of the low humidity readings.

Based on observation, the facility failed to maintain their oxygen storage areas. This was evidenced by the absence of precautionary signage in one oxygen storage area. This affected one of six floors in the Pavilion and could result in the failure to take the proper precautions required for an oxygen storage room.

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
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(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.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(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.

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

Findings:

During facility tour with staff from 12/14/15 to 12/18/15, the facility was observed.

Pavilion Building
Fourth Floor:

1. At 9:57 a.m., on 12/17/15, there were oxygen cylinders stored in the rehabilitation gym. The door to the rehabilitation gym was not labeled with a precautionary sign.

The above finding was acknowledged by Director of Emergency Services.

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by generators that were not monitored by remote alarm annunciators, by a generator enclosure that was not equipped with battery-powered emergency lights, and by one generator with an inoperable block heater. This affected three of three buildings at the Culver City Campus and the Van Nuys Building. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 70 , National Electrical Code, 1999 Edition
700-12 The annunciator shall indicate alarm condition of the emergency or auxiliary power source as follows:
(a)Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b)Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

3-5.5.2 (d) Battery powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2 (d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6.1 A remote,, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During tour of facility with staff from 12/14/15 to 12/18/15, the generators and generator components were observed.

Culver City Campus:

1. At 4:21 p.m., on 12/14/15, there were no remote alarm annunciators for three of three generators at Culver City. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview at 4:22 p.m., Plant Operations Lead Staff (PO1) confirmed that the generators did not have remote alarm annunciators.

2. At 1:04 p.m., on 12/15/15, records indicated that a load bank test was conducted for the North Ramp generator on 12/11/15. Per the Emergency Generator Test Run Log, the North Ramp generator is a 400 kW (kilowatt) diesel generator that supplies emergency power to the surgical basement in Pavilion. The vendor noted in his findings that the block heater was not working and needed to be replaced. There were no records of repairing the block heater.

Van Nuys:

3. At 10:34 a.m., on 12/16/15, there was no battery-powered emergency lighting in the generator room.

4. At 11:19 a.m., on 12/16/15, there was a low fuel sensor alarm for the generator's main diesel tank at the Unit 2 nurses station but no remote alarm annunciator. The Director of Facilities Services (DFS2) confirmed this finding. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Based on observation, record review, and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of a compromised power strip, by an electrical box with a broken cover, and by the rewiring of electrical circuits without approval from the authority having jurisdiction. This affected one of four smoke compartments in the Van Nuys Building and two of two stairwells in the Hollywood Building. These deficient practices could result in the increased risk of an electrical fire and an increased risk of malfunction of essential electrical equipment. This could result in the increased risk of harm to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

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

NFPA 70, National Electrical Code, 1999 Edition.
Section 90-4 Enforcement. This Code is intended to be suitable for mandatory application by governmental bodies that exercise legal jurisdiction over electrical installations and for use by insurance inspectors. The authority having jurisdiction for enforcement of the Code will have the responsibility for making interpretations of the rules for deciding on the approval of equipment and materials, and for granting the special permission contemplated in a number of the rules. The authority having jurisdiction may waive specific requirements in this Code or permit alternate methods where it is assured that equivalent objectives can be achieved by establishing and maintaining effective safety. This Code may require new products, constructions, or materials that may not yet be available at the time the Code is adopted. In such event, the authority having jurisdiction may permit the use of the products, constructions, or materials that comply with the most recent previous edition of this Code adopted by the jurisdiction.

90-7 Examination of Equipment for Safety. For specific items of equipment and materials referred to in this Code, examinations for safety made under standard conditions will provide a basis for approval where the record is made generally available through promulgation by organization properly equipped and qualified for experimental testing, inspections of the run of goods at factories, and service-value determination through field inspections. This avoids the necessity for repetition of examinations by different examiners, frequently with inadequate facilities for such work, and the confusion that would result from conflicting reports as to the suitability of devices and materials examined for a given purpose.
It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations or damage, if the equipment has been listed by a qualified electrical testing laboratory that is recognized as having the facilities described above and that require suitability for installation in accordance with this Code.

110-3. Examination, Identification, Installation, and Use of Equipment.
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
(b) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures, into which persons enter for installation and maintenance.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

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

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the electrical wiring was observed.

Pavilion
First Floor:

1. At 9:53 a.m., on 12/15/15, there was a 4 inch by 4 inch electrical box with a broken cover in the Green Room. The wiring in the electrical box was exposed.

Van Nuys:

2. At 10:05 a.m., on 12/16/15, the medication dispenser in the Unit 2 Medication Room was plugged into a six-plug power strip. The insulation on the power strip cord was ripped and wiring was exposed.

Hollywood
East and West Stairwells:

3. At 10:38 a.m., on 12/17/15, records indicated that a contractor rewired the stairwell light circuits on 10/23/15 so that they are serviced by the generator.

During an interview at 10:39 a.m., the Director of Facilities (DFS2) stated that, after the last Life Safety Code Survey, it was discovered that the stairwell lights are not hooked up to the generator and the stairwells were dark during a power outage. He stated that this contractor was hired to amend that issue. He said that the rewiring of the lighting and emergency circuits was not approved by the Office of Statewide Health Planning and Development.

Based on observation, document review, and interview, the facility failed to maintain their elevators. This was evidenced by the failure to ensure conveyance permits are current for the elevators. This was also evidenced by the failure to provide maintenance records for two elevators and the failure to provide repair records for the Phase II fire fighter service of one elevator. This affected the elevators in the Pavilion and the Tower. This could result in the increased risk of malfunction of the elevators and possible harm to patients, visitors, and staff.

NFPA 101 Life Safety Code, 2000 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and test as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators

Findings:

During record review with staff from 12/14/15 to 12/18/15, the elevator inspection records were reviewed.

Culver City Campus:

1. At 12:20 p.m., on 12/17/15, records indicated that the facility failed to ensure elevator conveyance permits were current since 9/2014. Reports sent to the facility from the State of California Department of Industrial Relations Division of Occupational Safety and Health (CDIRDOSH) were reviewed:

a. The facility received a notice, dated 2/1/15, of an overdue payment for a 12/23/14 inspection of Elevator Conveyance Permit #050929. The notice had a compliance date of 2/16/15.

b. The facility received a notice, dated 10/7/14, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #050930.

c. The facility received a notice, dated 10/7/14, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #065766.

d. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/15 inspection of Elevator Conveyance Permit #050902.

e. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #051351.

e. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #036094.

f. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 Inspection of Elevator Conveyance Permit #036088.

g. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #050901.

Documents indicated that payments were made by the facility for Elevator Conveyance Permits 036088, 05090, 036094, 051351, and 050902 on 7/23/15, after receiving final notices of shutdown from CDIRDOSH.

At 9:04 a.m., on 12/18/15, Elevator Conveyance Permit #036088 had an expiration date of 9/30/14.

During an interview at 9:05 a.m., the Director of Facilities Services (DFS1) stated that the final notices were paid and the facility was waiting for CDIRDOSH to send in current permit.

During a telephone interview at 3:45 p.m., on 12/22/15, staff at CDIRDOSH stated that the facility is current for 2014 conveyance permits but not for 2015. She stated this was due to the delinquency in compliance and payment for the 9/2014 inspection.

2. At 12/18/15, at 10:00 a.m., the facility failed to provide documents to show maintenance inspections were conducted for Elevators 050930 and 051351.

3. At 12/18/15, at 10:15 a.m., a vendor indicated in December 2014 and 1/25/15 that the Phase II fire fighter service for Elevator 065766 did not function. There were no records of repairing the deficiency noted by the vendor.

Based on observation and interview, the facility failed to ensure the Alcohol Based Hand Rub (ABHR) dispensers were not installed above or adjacent to an ignition source. This was evidenced by ABHR dispensers that were installed directly above electrical switches or outlets. This could result in the increased risk of an electrical fire and affected two of six floors in the Hollywood Building.

Findings:

During a facility tour from 12/14/15 to 12/18/15, the Alcohol Based Hand Rub (ABHR) dispensers were observed throughout the facility.

Hollywood
Fourth Floor:

1. At 11:46 a.m., on 12/17/15, the ABHR dispenser in the corridor outside Room 404 was installed directly over an electrical outlet. The packaging indicated that the solution consisted of 85% ethyl alcohol.

2. At 11:47 a.m., on 12/17/15, the ABHR dispenser in Room 407 was installed directly over a light switch. The packaging indicated that the solution consisted of 85% ethyl alcohol.

During an interview at 11:48 a.m., the Director of Facilities Services (DFS2) confirmed the findings and stated that the dispensers were recently installed by a vendor.

Fifth Floor:

3. At 12:24 p.m., on 12/17/15, the ABHR dispenser in the corridor outside Room 504 was installed directly over an emergency outlet. The packaging indicated that the solution consisted on 85% ethyl alcohol.

Based on observation, record review, and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by penetrations in the walls, by the use of nonrated paneling and insulation in the attic of a Type I building, and by missing sheetrock in the wall of the stairwell of a partially sprinklered building. This could result in the faster spread of fire and smoke, increasing the risk of injury to patients. This affected two of six floors in the Pavilion, one of two stairwells in the Tower, and one of six floors in the Hollywood Building.

NFPA 101, Life Safety Code, 2000 Edition
19.1.6.2 Health care occupancies shall be limited to the types of building construction shown in Table 19.1.6.2. (See 8.2.1.)
19.1.6.3 All interior walls and partitions in buildings of Type I or Type II construction shall be of noncombustible or limited-combustible materials.
8.2.3.1.1 Floor-ceiling assemblies and walls used as fire barriers, including supporting construction, shall be of a design that has been tested to meet the conditions of acceptance of NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. Fire barriers shall be continuous in accordance with 8.2.2.2.

Findings:

During the facility tour with staff from 12/14/15 to 12/18/15, the walls and ceilings were observed.

Pavilion
First Floor:

1. At 12:36 p.m., on 12/14/15, there was a 5 inch diameter exhaust hose connection penetrating the ceiling of the Pavilion Conference Room. The attic could be observed through the opening caused by the hose connection. This connection was previously attached to the exhaust hose of the portable air conditioner observed during the Life Safety Code survey in September 2015.

Pavilion
Sixth Floor:

2. At 12:53 p.m., on 12/14/15, two ceiling tiles adjacent to the nurses station in the 6C corridor were completely wet.

During an interview at 12:53 p.m., Floor Technician 1 stated that he noticed the wet tiles at 6:50 a.m. and that nursing staff submitted a work order. A copy of Work Request No. 236232 was provided.

At 8:33 a.m., on 12/15/15, the ceiling tiles were replaced but there were two wet spots observed on the new tiles. The tiles were removed by facilities staff and a pipe above the tiles was wrapped in a light colored plastic bag. There was a 1 foot by 1 foot wooden panel near the pipe on the concrete roof above the drop ceiling.

During an interview at 9:34 a.m., on 12/15/15, when shown a picture of the pipe and wood panel in the 6C attic, the Project Manager (PM1) stated that wood paneling should not be used for a Type I building.

At 9:56 a.m., on 12/18/15, the pipe was still insulated with the plastic bag and the wood panel was still present.

Pavilion
First Floor:

3. At 3:49 p.m., on 12/14/15, there was an approximately 2 foot by 2 foot penetration in the wall behind the steam pipe in the kitchen closet. The pipe penetrated the floor into the basement and there was an approximately 2 inch penetration in the floor around the pipe. The basement was visible through the penetration.

During an interview at 3:50 p.m., the Director of Facilities Services (DFS1) stated that the steam line was recently repaired. He stated that the pipe still needed to be insulated to cover the hole in the floor and the wall still needed to be patched.

Hollywood
First Floor:

4. At 12:20 p.m., on 12/17/15, there was an approximately 2 foot by 1 foot rectangular hole in the concrete corridor wall into the dietary suite (cafeteria and kitchen). The penetration was observed above the attic access panel in the corridor outside the cafeteria.


29566


Tower:

5. At 4:15 p.m., on 12/16/15, there was approximately 4 feet by 4 feet opening in the wall of the east stairwell on the first floor. The opening exposed metal-like poles and meshed wiring.

During an interview at 4:16 p.m., the Chief Operating Officer (COO) stated he believed the opening was done for seismic testing of the building.

During an interview at 10:55 a.m., on 12/18/15, PM 1 confirmed the opening was done for seismic testing of the building.

Approved plans for the seismic testing from the Office of Statewide Health Planning and Development (OSHPD), dated 5/20/14, were provided by PM1. Under the "KEYNOTES" section of the approved plans, the facility was to restore the wall back to its original fire/smoke integrity after seismic testing.

The facility failed to restore the wall back to its original integrity as stated in the approved plans from the authority having jurisdiction.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that were obstructed from closing and by doors that failed to latch. This affected one of six floors in the Pavilion and two of six floors in the Hollywood Building. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to patients due to smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the facility tour with staff from 12/14/15 to 12/18/15, the corridor doors were observed.

Pavilion
Sixth Floor:

1. At 4:09 p.m., on 12/15/15, the door to Room 622 was obstructed from closing by a rolled up towel positioned by the door leaf. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Hollywood
Fourth Floor:

2. At 10:17 a.m., on 12/17/15, the self-closing door to the shower room near Stairwell 1 failed to latch.

3. At 10:26 a.m., on 12/17/15, the self-closing door to the shower room near Room 408 failed to latch.

Hollywood
Fifth Floor:

4. At 10:36 a.m., on 12/17/15, the self-closing door to the storage room across from Room 507 failed to latch.

Based on observation, the facility failed to maintain the fire resistance rating of the smoke barrier walls. This was evidenced by penetrations in one smoke barrier wall. This finding affected one of seven floors in the Tower. This deficient practice could result in the faster spread of smoke and fire between smoke compartments and the increased risk of injury to patients, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.3 and shall have a fire resistance rating of not less than 1/2 hour.

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

Findings:

During the facility tour with staff from 12/14/15 to 12/18/15, the smoke barrier walls were observed.

Tower
First Floor:

1. At 9:30 a.m., on 12/18/15, there was a 1 inch penetration around wires and a 1/2 inch penetration around a conduit in the attic smoke barrier wall, by the housekeeping closet outside the emergency department overflow.

There was a dime size penetration on the opposite side of the wall.

The above findings were acknowledged by the Director of Facilities Services (DFS1).

Based on observation and interview, the facility failed to maintain its smoke barrier doors. This was evidenced by smoke barrier doors that failed to close and latch upon activation of the fire alarm system. This affected six of six floors and the basement of the Pavilion. These findings could result in the faster spread of smoke and fire from one smoke compartment to another. This could result in the increased risk of injury to patients, visitors, and staff, in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers' installation instructions and shall be adjusted to function as described in the listing.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the smoke barrier doors were observed during fire alarm testing. The fire alarm vendor was present for fire alarm testing.

Pavilion
First Floor:
1. At 10:18 a.m., on 12/16/15, the smoke barrier double doors to the kitchen were held open with electronic automatic-closing devices. The smoke barrier double doors failed to close and latch upon activation of a fire alarm device. A floor mat obstructed the doors from closing and latching.

Second Floor:
2. At 10:21 a.m., on 12/16/15, the smoke barrier double doors by Room 209 were held open with magnetic automatic-closing devices. One leaf failed to close and latch upon activation of a fire alarm device. The fire alarm vendor stated that it was due to a malfunctioning magnetic holder.

Third Floor:
3. At 10:50 a.m., on 12/16/15, the smoke barrier double doors by Room 332 were held open with magnetic automatic-closing devices. The doors failed to close and latch upon activation of a fire alarm device.

4. At 10:56 a.m., on 12/16/15, the smoke barrier double doors by Room 310 were held open with magnetic automatic-closing devices. One leaf failed to release from the magnetic holder upon activation of a fire alarm device.

Fourth Floor:
5. At 11:04 a.m., on 12/16/15, the smoke barrier double doors by Room 433 were held open with magnetic automatic-closing devices. The double doors failed to close and latch upon activation of a fire alarm device.

Fifth Floor:
6. At 11:11 a.m., on 12/16/15, the smoke barrier double doors by Room 509 were held open with magnetic automatic-closing devices. One leaf failed to close upon activation of a fire alarm device. There were drag marks on the floor beneath the door frame.

During an interview at 11:12 a.m., the Chief Operating Officer (COO) observed that the door leaf that failed to close was hanging lower from the top of the door frame than the door leaf that successfully closed.

Sixth Floor:
7. At 11:31 a.m., on 12/16/15, the smoke barrier double doors by Room 601 were held open with magnetic automatic-closing devices. The smoke barrier double doors failed to close and latch upon activation of a fire alarm device.

Basement:
8. At 2:33 p.m., on 12/16/15, the smoke barrier double doors to the entrance of the Tunnel were held open with magnetic automatic-closing devices. The smoke barrier double doors failed to close and latch upon activation of a fire alarm device. The smoke barrier doors were tested 3 times and failed.

The above findings were acknowledged by the fire alarm vendor and COO.

Based on record review and interview, the facility failed to ensure that emergency lighting is provided in the egress stairwells. This was evidenced by staff that were unfamiliar with the presence of emergency lights in the stairwell and by the absence of documentation of monthly inspections of emergency lights in the stairwells. This affected the Pavilion and Tower stairwells and could result in the increased risk of injury in the event of dim or no lighting during an evacuation.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the
following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

NFPA 70, National Electrical Code, 1999 Edition.
517-42. Automatic Connection to Life Safety Branch.
The life safety branch shall be installed and connected to the alternate source of power so that all functions specified herein shall be automatically restored to operation within 10 seconds after the interruption of the normal source. No functions other than those listed in (a) through (g) shall be connected to the life safety branch. The life safety branch shall supply power for the following lighting, receptacles, and equipment.
(a) Illumination of Means of Egress. Illumination of means of egress as is necessary for corridors, passageways, stairways, landings, and exit doors and all ways of approach to exits. Switching arrangement to transfer patient corridor lighting from general illumination circuits shall be permitted
providing only one of two circuits can be selected and both circuits cannot be extinguished at the same time.


Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the stairwells were observed.

Culver City Campus:

1. The facility failed to provide documentation to show that emergency lights were inspected in the stairway enclosures of the Tower and Pavilion and connection of the lights in the stairwells to emergency power could not be verified by documentation. This finding was previously cited during a Life Safety Code Survey conducted in September 2015 under K046. During the September survey, facilities staff were unsure if the stairwells were equipped with emergency lighting.

During an interview at 3:24 p.m., on 12/15/15, the Plant Operations Lead Staff (PO1) was asked if the stairwells were equipped with emergency lights and if they would be continuously illuminated during a power outage. PO1 stated that the lights were hooked up to the generator power but there were no records of inspecting them monthly.

During an interview at 4:05 p.m., on 12/17/15, the Facilities Operations Manager did not readily know if the stairwells were equipped with emergency lights.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by emergency lights that failed when tested and by no records of testing the battery-powered emergency lights. This affected the offsite Spine Clinic. This could result in a delay in evacuation due to limited visibility, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the
following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the emergency lights were observed and maintenance logs were requested.

Outpatient Spine Clinic:

1. At 1:44 p.m., on 12/15/15, the battery-powered emergency lighting unit, in the exit hallway outside Exam Room 3, failed to illuminate when tested by the Plant Operations Lead Staff (PO1).

2. At 1:52 p.m., on 12/15/15, testing records of the battery-powered emergency lights were requested. On 12/18/15, at 8:26 a.m., records of annual 90 minute testing (conducted 9/17/15) of the emergency lights in the common areas outside the Spine Clinic were provided. There were no records of monthly and annual testing the battery-powered emergency lights in the Spine Clinic.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by one exit sign with battery-operated emergency illumination that failed when tested, by one exit sign that was not illuminated, and by no records of testing the exit signs. This affected the offsite Spine Clinic and the basement of the Pavilion. This could result in a delay in evacuation, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.

7.10.4 Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11
through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

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. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the exit signs were observed and maintenance records were requested.

Outpatient Spine Clinic:

1. At 1:52 p.m., on 12/15/15, records of monthly and annual testing of the exit signs were not provided.

2. At 2:02 p.m., on 12/15/15, the exit sign outside Exam Room 1 was equipped with battery-powered emergency illumination. The exit sign failed to illuminate when tested by Plant Operations Lead Staff (PO1).

3. At 2:06 p.m., on 12/15/15, the exit sign in the waiting area was not illuminated. PO1 removed the cover and the bulbs in the exit sign were not lit.


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Pavilion
Basement:

4. At 3:34 p.m., on 12/17/15, the exit sign in the back of the Microbiology Laboratory was not illuminated.

Based on observation, record review, and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire and other emergencies. This was evidenced by the failure of security staff to implement their fire response procedures during a Code Red (the facility's code word for fire) and by staff that were unfamiliar with the facility's evacuation procedures. This was also evidenced by no records of semi-annual disaster drills conducted at the Van Nuys Building. This affected the safety of patients in the Pavilion and Van Nuys Building. These deficient practices could result in a delay in staff response in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2000 Edition.
4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

19.7.2 Procedure in Case of Fire.
19.7.2.1 For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel. The basic response required of staff shall include the removal of all occupants directly involved with the fire emergency, transmission of an appropriate fire alarm signal to warn other building occupants and summon staff, confinement of the effects of the fire by closing doors to isolate the fire area, and the relocation of patients as detailed in the health care occupancy's fire safety plan.

19.7.2.2 A written health care occupancy fire safety plan shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.11 Hospitals shall comply with the provisions of Chapter 11 for disaster planning, as appropriate.

Chapter 11 Health Care Emergency Preparedness
11-5.3.6 Security. Security plans shall be developed that address facility access, crowd control, security staff needs, and traffic control.

11-5.3.8 Staff Education. Each health care facility shall implement an educational program. This program shall include an overview of the components of the emergency preparedness plan and concepts of the Incident Command System. Education concerning the staff's specific duties and responsibilities shall be conducted upon reporting to their assigned departments or position. General overview education of the Emergency Preparedness Plan and the Incident Command System shall be conducted at the time of hire. Department/staff specific education shall be conducted upon reporting to their assignments or position and annually thereafter.

11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, a Code Red incident occurred and staff response was observed.

Pavilion:

1. At 12:40 p.m., on 12/14/15, the fire alarm system was activated. An overhead announcement "Code Red Pavilion Sixth Floor" was made by the facility's automatic paging system. PBX staff also made an overhead announcement "Room 633 Code Red."

At 12:42 p.m., on the first floor, two security staff with fire extinguishers and four hospital staff entered the elevator. The elevator stopped at every floor before reaching the sixth floor.

During an interview at 12:42 p.m., Security Staff (SS2) stated that they did not have the "autokey" that allows the elevator to go directly to the sixth floor.

At 12:45 p.m., two engineering staff arrived to Room 633 and determined that the cause of the fire alarm activation was due to a patient that broke the smoke detector in the bathroom.

During an interview at 12:46 p.m., SS2 stated that only the dispatcher and the security supervisor had the autokey for the elevator. She stated that security staff is trained not use the elevator during Code Red events and to use the stairs instead.

During an interview at 1:05 p.m., Security Staff/Dispatcher (SS1) stated that during a Code Red event, security staff are supposed to recall the elevators and block people from using them until the Code Red is cleared. He stated that it was the hospital's policy that responding security staff are trained to use the stairs and not the elevators.

Van Nuys:

2. At 12:02 p.m., on 12/16/15, there were no records of disaster drills conducted at the Van Nuys facility.

During an interview at 12:03 p.m., the disaster coordinator stated that disaster drills are held semi-annually at the Hollywood facility and Van Nuys staff are called over the phone and told to respond.

Review of the staff participation list for the earthquake drill on 6/11/15 at Hollywood indicated that only one staff from Van Nuys participated in the drill.


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Pavilion:

3. The facility's evacuation policy was reviewed and indicated that partial evacuation was to a safe area behind smoke barrier doors. The policy also indicated that staff should be familiar with horizontal evacuation and vertical evacuation.

During an interview at 10:44 a.m., on 12/16/15, a Registered Nurse stated she was unfamiliar with the terms partial evacuation, horizontal evacuation, and vertical evacuation and or the purpose of the smoke barrier doors in an evacuation.

During an interview at 11:50 a.m., on 12/16/15, a Mental Health Technician stated he was unfamiliar with the terms partial evacuation, horizontal evacuation, and vertical evacuation or what would be a safe area (behind smoke barrier doors) for a partial evacuation.

Based on document review and interview, the facility failed to ensure that staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by no records of a fire drill conducted at the Culver Medical Plaza where the offsite Spine Clinic is located, by a Pavilion fire drill that was not attended by majority of staff, and by staff that were not aware of their responsibilities in the event of a fire. This could result in improper staff response in the event of a fire and an increased risk of injury to patients. This affected the Culver City Campus and the Spine Clinic.

NFPA 101 Life Safety Code, 2000 Edition
19.7.1.2 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9 p.m. (2100 hours) and 6 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to exterior of the building.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

39.7.1 Drills. In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below the street level, employees and supervisory personnel shall be periodically instructed in accordance with Section 4.7 and shall hold drills periodically where practicable.

39.7.2 Extinguisher Training. Designated employees of business occupancies shall be periodically instructed in the use of portable fire extinguishers.

4.7.1 Where Required. Emergency egress and relocation drills conforming to the provisions of this Code shall be conducted as specified by the provisions of Chapters 11 through 42, or by appropriate action of the authority having jurisdiction. Drills shall be designed in cooperation with the local authorities.

4.7.2 Drill Frequency. Emergency egress and relocation drills, where required by Chapters 11 through 42 or the authority having jurisdiction, shall be held with sufficient frequency to familiarize occupants with the drill procedure and to establish conduct of the drill as a matter of routine. Drills shall include suitable procedures to ensure that all persons subject to the drill participate.

4.7.5 Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

4.7.6 Relocation Area. Drill participants shall relocate to a predetermined location and remain at such location until a recall or dismissal signal is given.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the fire drill records were reviewed and staff were interviewed about fire response procedures.

Outpatient Spine Clinic:

1. At 1:53 p.m., on 12/15/15, the fire drill records were requested. No fire drill records were provided for the Spine Clinic as of 8:25 a.m. on 12/18/15.


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Pavilion:
2. At 11:12 a.m., on 12/18/15, the facility's fire drill policy, in the disaster manual, indicated that at least 90 percent of hospital staff would participate in the fire drills.

At 9:20 a.m., on 12/15/15, records showed that one fire drill was conducted in October 2015 at 9:10 p.m. in the Transitional Care Unit. The sign-in sheet indicated that only five staff participated. Records showed that this was the only fire drill conducted since the last Life Safety Code Survey in September 2015.

During an interview at 2:21 p.m., on 12/16/15, the Director of Laboratory Services confirmed that laboratory staff do not participate in facility-wide drills.

During an interview at 11:10 a.m., on 12/18/15, the Vice President of Facilities Services confirmed that only five staff signatures were on the fire drill's participation sign-in sheet.

The facility failed to ensure that 90% of staff participated in the fire drill per their policy.

3. The fire response plan indicated that, in the event of a fire, staff would follow R.A.C.E. (rescue, alarm, confine, extinguish/evacuate) procedures. The policy stated that staff are to rescue patients in immediate danger, notify the hospital by activating a pull station and dialing extension 5555 (PBX), confine the fire by closing the doors, and extinguish small fires with a fire extinguisher.

Facility staff were asked what they would do in the event of a fire:

a. During an interview at 10:44 a.m., on 12/16/15, a Registered Nurse (RN1) from the third floor stated that she would rescue the patient, close the door, pull the alarm, and sweep over the fire with a fire extinguisher if she could. She was not familiar with where on the fire she should aim the fire extinguisher and she was unfamiliar with the policy to dial the operator.

b. During an interview at 11:18 a.m., on 12/16/15, a Registered Nurse (RN2) from the surgical department stated that she would shout for help, pull the fire alarm, close the doors, and wait for further information. She was unfamiliar with the entire R.A.C.E. procedures and the facility's policy to dial the operator.

c. During an interview at 11:48 a.m., on 12/16/15, a Psychiatric Technician stated that he would get the patients out of the room and down the stairs, and call out code red. He was unfamiliar with the entire R.A.C.E. procedure sequence and the facility's policy.

d. During an interview at 3:05 p.m., on 12/16/15, security staff at the fire alarm panel stated that she was unfamiliar with the difference between a fire alarm and the supervisory tamper alarm. She incorrectly stated the supervisory tamper alarm was a smoke detector being activated.

e. During an interview at 3:43 p.m., on 12/16/15, Registered Nurse (RN3) stated she would dial 5555, call out code red, close the doors, and not open the doors if they were hot. She was unfamiliar with the entire R.A.C.E. sequence.

Facility staff were unfamiliar with life safety procedures and equipment.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in reliable operating condition. This was evidenced by fire alarm devices that exhibited trouble conditions, the failure of fire alarm notification devices, and by an area where the fire alarms could not be heard. This was also evidenced by the failure to arrange for smoke detector testing at Van Nuys and fire alarm testing at the two offsite clinics. This affected the Tower, the Pavilion, the Van Nuys Building, the Hollywood Building, and two offsite clinics. This could result in delay in notification and response, in the event of a fire, and could result in the increased risk of injury.

NFPA 101, Life Safety Code, 2000 Edition.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

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.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 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 Code.

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.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-1.3.3 Initiating devices shall be installed in all areas where required by other NFPA codes and standards or the authority having jurisdiction. Each installed initiating device shall be accessible for periodic maintenance and testing.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the fire alarm system was observed.

Pavilion
Basement:

1. At 11:15 a.m., on 12/14/15, the following devices exhibited trouble conditions at the main fire alarm control panels (FACPs):

a. Tower 2 waiting room duct detector
b. Pavilion 1 smoke detector outside pharmacy
c. Tower 2nd, 4th, and 7th floor notification appliance circuit (NAC) expanders.

During an interview at 1:03 p.m., on 12/14/15, Facilities Operations Manager (FOM1) stated that the vendor was called to investigate the troubles. He stated that the vendor told him via telephone that the NAC expanders are connected to the notification horns and strobes.

The trouble signals were already acknowledged and silenced.

At 8:31 a.m., on 12/15/15, the three troubles were still exhibited on the FACP.

Penthouse:

2. At 8:49 a.m., on 12/15/15, the combination horn/strobe fire alarm notification device, near the cooling tower, was observed. The audible horn was covered with painters tape on both sides of the strobe.

At 10:06 a.m., on 12/18/15, one side of the speaker was still covered with blue painters tape.

Offsite IOP and Spine Clinics:

3. At 2:05 p.m., on 12/15/15, the Vice President of Business Development (VPBD1) and the Vice President of Facilities Services were asked to arrange for fire alarm testing to be conducted at the offsite clinics on Friday morning (12/18/15) as part of the validation survey.

During an interview at 8:21 a.m., on 12/18/15, VPBD1 stated that we cannot conduct fire alarm testing at the offsite facilities. Maintenance Staff at the Culver Medical Plaza (CMP Maint1) stated that they needed a couple of weeks notice to arrange for alarm testing. Functionality of the fire alarm system was not observed.

Van Nuys:

4. At 10:52 a.m., on 12/15/15, the Director of Facilities Services (DFS2) and Maintenance Staff (VN Maint 1) stated that there was no aerosol smoke to test the smoke detectors during the survey. Functionality of the smoke detectors were not observed.

Hollywood
Basement:

5. At 9:07 a.m., the smoke detector in the FACP room/Radiology Office failed to alarm when tested with aerosol smoke.


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Pavilion
Third Floor:

6. At 10:53 a.m., on 12/16/15, maintenance staff tested the smoke detector in Room 315A and the visual notification light in the corridor above the room's door failed upon activation of the smoke detector. The corridor notification lights are designed to indicate which patient room smoke detector is activated.

Penthouse:

7. At 12:05 p.m., on 12/16/15, one of the strobe and chime notification devices in the mechanical room failed to annunciate upon activation of a fire alarm device.

Tower
Seventh Floor:

8. At 3:50 p.m., on 12/16/15, no audible fire alarm could be heard in the Mechanical Room upon activation of a fire alarm device. The Chief Operating Officer (COO) acknowledged the finding.

Based on observation and interview, the facility failed to ensure that a local alarm will sound when the sprinkler control valves are closed. This was evidenced by the failure of the local supervisory audible alarm at the fire alarm subpanel in the telephone exchange box (PBX) room. This affected the entire Hollywood Building. This could result in a delayed response, in the event of closure of the sprinkler valves, and an increased risk of failure of the sprinkler system.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

19.3.5.2 Where this Code permits exceptions for fully sprinklered buildings or smoke compartments, the sprinkler system shall meet the following criteria:
(1) It shall be in accordance with Section 9.7.
(2) It shall be electrically connected to the fire alarm system.
(3) It shall be fully supervised.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

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 Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. 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, 1999 Edition
2-9 Supervisory Signal-Initiating Devices.
2-9.1 Control Valve Supervisory Signal-Initiating Device.
2-9.1.1 Two separate and distinct signals shall be initiated: one indicating movement of the valve from its normal position and the other indicating restoration of the valve to its normal position. The off-normal signal shall be initiated during the first two revolutions of the hand wheel or during one-fifth of the travel distance of the valve control apparatus from its normal position. The off-normal signal shall not be restored at any valve position except normal.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the supervised sprinkler control valves were observed.


Hollywood:

1. At 3:08 p.m., on 12/17/15, the sprinkler control valves on the riser of the sprinkler system were supervised by tamper switches designed to send a trouble signal to the fire alarm panel upon closure of the valves. The sprinkler control valve on the first floor was closed and a visual supervisory notification light was activated at the fire alarm subpanel in PBX. No audible alarm could be heard at the panel in PBX.

During an interview at 3:09 p.m., the Director of Facilities Services (DFS2), the Disaster Coordinator, and the Chief Engineer (CE1) all confirmed that an audible trouble signal could not be heard. CE1 stated that PBX is manned 24 hours a day and respond to trouble lights from the fire alarm panels, medical gas panels, and generator panels located in their office.

At 3:11 p.m., the sprinkler control valve on the second floor was closed and only a visual notification light at the PBX panel was activated. There was no audible alarm.

Based on observation, record review, and interview, the facility failed to maintain their sprinkler system. This was evidenced by the failure to provide records of repairing deficiencies noted during an inspection, by the failure to conduct a five-year test more than one year after it was due, by corroded sprinkler heads, by sprinkler heads that were not free of foreign materials, and by fire department connections that failed to rotate smoothly. This affected two of three buildings in the Culver City Campus and the Van Nuys Building. These deficient practices could result in a delay in extinguishing a fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

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

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

2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.1.2 Unacceptable obstructions to spray patterns shall be corrected.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.


9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the sprinkler system was observed and maintenance records were reviewed.

Culver City Campus:
1. At 11:20 a.m., on 12/15/15, records of an inspection of the sprinkler system conducted by a vendor on 9/28/15 was reviewed. Under the Deficiencies and Comments section, it was noted that the waterflow switch corresponding to System Riser ID 1 did not report to the fire alarm control panel (FACP) and the tamper corresponding to System Riser ID 1 did not report to the FACP. Records of repairing the deficiencies were not provided.

Pavilion
Basement:
2. At 3:42 p.m., on 12/15/15, there were two pest strips attached to the sprinkler pipe in the trash chute room. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

3. At 3:45 p.m., on 12/15/15, there was a corroded sprinkler head in the trash chute room. The Chief Operating Officer (COO) acknowledged that the sprinkler head had turned green.

Van Nuys:
4. At 2:59 p.m., on 12/16/15, records indicated the most recent five year inspection was conducted in May 2009. The five year inspection was due in May 2014.

During an interview at 3:00 p.m., the director of facilities services (DFS2) stated that the five year was scheduled for 12/21/15. He attributed the delay due to a change in vendors.


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Pavilion:
5. At 2:15 p.m., on 12/16/15, there were four corroded sprinkler heads in the front entrance exterior overhang. This finding was previously cited during a Life Safety Code Survey conducted in September 2015. The COO acknowledged the sprinklers heads were green and the sprinkler heads had rusty escutcheon rings.

Single Story Building:
6. At 2:13 p.m., on 12/16/15, the fire department connection (FDC) facing Delmas Terrace, failed to rotate freely when tested by the fire alarm vendor.

Pavilion
Basement:
7. At 10:25 a.m., on 12/17/15, there were two corroded sprinkler heads in the Decontamination Room and a white foreign substance on the sprinkler head in the Sterilization Room of Central Sterile.

Based on observation and interview, the facility failed to maintain their fire extinguishers. This was evidenced by fire extinguishers with obstructed access, by the failure to provide all staff with keys to locked fire extinguisher cabinets in the acute psychiatric facility, and by fire extinguishers that were overdue for an annual service. This affected the safety of patients in the Van Nuys Building and the offsite Spine Clinic. This could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition.
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.

1-6.5 Cabinets housing fire extinguishers shall not be locked.
Exception: Where fire extinguishers are subject to malicious use, locked cabinets shall be permitted to be used, provided they include means of emergency access.

4-3.2 Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or " hefting "
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

4-4.1 Frequency. Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the fire extinguishers were observed.

Outpatient Spine Clinic:

1. At 1:39 p.m., on 12/15/15, access to the fire extinguisher in the front office was blocked by a recycling bin.

2. At 1:47 p.m., on 12/15/15, the service tag on the fire extinguisher, located in the exit hallway outside of Exam Room 3, indicated that it was last annually serviced on 9/27/14. The extinguisher was due to be serviced again in September 2015.

Van Nuys:

3. At 8:39 a.m., on 12/16/15, housekeeping staff (VN EVS1) did not have the key to the locked fire extinguisher cabinets.

At 8:57 a.m., on 12/16/15, mental health worker (VN MHW1) did not have the key to the locked fire extinguisher cabinets.

4. At 9:10 a.m., on 12/16/15, access to the fire extinguisher in the storage cage was obstructed by stacked furniture.

Based on observation and interview, the facility failed to maintain their smoking areas. This was evidenced by no safety-type ashtrays in one designated smoking area. This affected the smoking area at the Hollywood Building and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or
oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read
NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

Findings:

During the tour of the facility with staff from 12/14/15 to 12/18/15, the designated smoking areas were observed.

Hollywood:

1. At 8:30 a.m., on 12/17/15, the smoking area in the west parking lot was not provided with safety type ashtrays. There were cigarette butts in open top ceramic planters filled with pebbles.

During an interview at 8:31 a.m., the Director of Facilities Services (DFS2) stated that the safety-type ashtrays were stolen so the planters were used because they were too heavy to steal.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air-conditioning (HVAC) systems. This was evidenced by the failure to provide adequate central heating to the patient rooms, by the failure to test dampers every four years, by the failure to repair dampers that failed inspections, by the use of a portable air conditioner, and by the failure to maintain that air conditioner in accordance with manufacturer guidelines. This was also evidenced by leaks in the hot water tanks and by a boiler that exhibited a low water pressure alarm. This affected the entire Pavilion, the basement of the Tower, three of six floors in the Hollywood Building, and four of four smoke compartments in the Van Nuys Building, These deficient practices could result in the increased risk of injury to patients due to lack of heating capabilities and the faster spread of smoke and fire due to incomplete maintenance of the dampers.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.
2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.
2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.
2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.
2-3.1.3 All air duct materials shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the air duct.
2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.
3-4.5.4 Dampers shall close against the maximum calculated airflow of that portion of the air duct system in which they are installed. Fire dampers shall be tested in accordance with UL 555, Standard for Safety Fire Dampers. Smoke dampers shall be tested in accordance with UL 555S, Standard for Safety Smoke Dampers.
3-4.6.1 The locations and mounting arrangement of all fire dampers, smoke dampers, ceiling dampers, and fire protection means of a similar nature required by this standard shall be shown on the drawings of the air duct system.
3-4.7 Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the HVAC systems were observed and maintenance records were reviewed.

Pavilion:
1A. At 10:00 a.m., on 12/15/15, records indicated that the facility has used a temporary air handler unit since March 2015. The facility was granted a permit on 12/9/15 from the Office of Statewide Health Planning and Development (OSHPD) to begin installation of the new air handler unit.

During an interview at 10:27 a.m., on 12/15/15, the Project Manager (PM2) in charge of restoration of the air handler installation (OSHPD Project #S151262-19-00) stated that the temporary air handler fed the air in the patient rooms of the Pavilion. He stated that he has heard complaints about the rooms being too cold since last Tuesday (12/8/15). PM2 stated that a possible solution to adding central heat to the rooms was to add a heating coil to the temporary air handler unit until the new permanent air handler was installed. PM2 estimated that the new air handler would be installed in approximately five to six months.

During an interview at 4:07 p.m., on 12/15/15, the Vice President of Facilities Services stated that the facility will be adding a heating coil to the temporary air handling unit to provide central heat to the rooms.

During an interview at 8:32 a.m., on 12/16/15, the Regional Compliance Officer (RCO) from OSHPD stated that the facility must provide heat between 70 to 75°F per state regulations. He stated that if the facility needed to add a heating coil to the HVAC system then the current system was not providing enough heat.

Observations, record review, and interviews showed that the facility failed to provide a working central heating system.

Ambient temperatures and temperatures from the supply air vents in the rooms were recorded:

12/15/15
a. At 4:05 p.m., Plant Operations Lead Staff (PO1) recorded the temperature in Room 628 with a handheld thermometer. The temperature in the room was 68.5°F and the thermostat in the room was set to "warm." During an interview at 4:05 p.m., the patient in the room stated that the room was too cold and has been cold for three days.

During an interview at 4:06 p.m., PO1 stated that there was no way to add heat to the room and the thermostat only turned off the cold air when it is set to warm.

b. At 4:19 p.m., PO1 measured the temperature in Room 630. The temperature was 67.2°F. The thermostat in the room had a broken lever and PO1 could not adjust it.

c. At 4:21 p.m., PO1 measured the temperature in Room 634 to be 67°F.

d. At 4:30 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 302 to be 61.6°F.

e. At 4:35 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 311 to be 66.2°F.

f. At 4:37 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 314A to be 63.8°F.

g. At 4:40 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 315A to be 67.8°F.

h. At 4:45 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 207 to be 67.6°F. The room's thermostat was set to warm.

i. At 4:47 p.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 206 to be 60°F. The thermostat in the room had no operating button to adjust the settings. During an interview, the patient in the room stated that the room was cold.

12/17/15
j. At 9:15 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 209 to be 68.6°F. During an interview, the patient in the room stated it was cold.

k. At 9:18 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 201 to be 63.4°F. During an interview, the patient in the room stated the room was chilly.

l. At 9:25 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 204 to be 62.2°F.

m. At 9:30 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 220 to be 62.2°F. During an interview, the patient in the room stated it was cold.

n. At 9:35 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 243 to be 61.3°F.

o. At 9:38 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 241 to be 61.6°F. During an interview, the patient in the room stated it was cold.

p. At 9:45 a.m., PO1 measured the temperature of the air coming out of the supply air vent in Room 226 to be 58°F.

The Director of Emergency Services acknowledged that she could feel the chill in the North West wing of the second floor (patient room wing). She stated the rooms in that wing were much cooler than some of the other rooms.

1B. At 4:49 p.m., on 12/15/15, records of room temperatures recorded by staff in the Pavilion were reviewed. The logs showed that staff were recording ambient room temperatures three times daily (at 6:30 a.m., 12:00 p.m., and 7:00 p.m.) and the acceptable temperature range on the log was listed as 68 to 75°F. The logs were reviewed for temperatures below 68°F:

Sixth Floor:
a. Room temperatures fell below 68°F in 25 of 40 patient rooms on 12/15/15, with the lowest temperature of 64.4°F recorded at 12:00 p.m. in Room 633.

b. Room temperatures fell below 68°F in 8 of 40 patient rooms on 12/14/15, with the lowest temperature of 67.4°F recorded at 12:00 p.m. in Room 638.

c. Room temperatures fell below 68°F in 25 of 40 patient rooms on 12/13/15, with the lowest temperature of 65.2°F recorded at 6:30 a.m. in Rooms 631 and 632.

d. Room temperatures fell below 68°F in 6 of 40 patient rooms on 12/12/15, with the lowest temperature of 67°F recorded at 12:00 p.m. in Room 638.

e. Room temperatures fell below 68°F in 18 of 40 patient rooms on 12/2/15, with the lowest temperature of 66.5°F recorded at 6:30 a.m. in Room 639.

Fifth Floor:
a. Room temperatures fell below 68°F in 15 of 41 patient rooms on 12/13/15, with the lowest temperature of 66.1°F recorded at 6:30 a.m. in Rooms 536 and 540.

b. Room temperatures fell below 68°F in 8 of 41 patient rooms on 12/1/15, with the lowest temperature of 66.8°F recorded at 8:00 a.m. in Room 527.

Fourth Floor:
a. Room temperatures fell below 68°F in 8 of 19 patient rooms on 12/13/15, with the lowest temperature of 67.3°F recorded at 6:30 a.m. in Room 424.

b. Room temperatures fell below 68°F in 19 of 19 patient rooms on 12/12/15, with the lowest temperature of 65.4°F recorded at 6:30 a.m. in Room 406.

Second Floor (Unit P2):
a. Room temperatures fell below 68°F in 30 of 44 patient rooms on 12/12/15, with the lowest temperature of 65.2°F recorded at 6:30 a.m. in Rooms 223 and 230.

b. Room temperatures fell below 68°F in 20 of 44 patient rooms on 12/12/15, with the lowest temperature of 66.5°F recorded at 6:30 a.m. in Rooms 225 and 228.

1C. On 12/17/15, hospital staff at Pavilion recorded temperatures in patient rooms at 2:00 a.m., 4:00 a.m., and 6:00 a.m. Those temperature logs were reviewed:

a. In P6 (Sixth Floor), temperatures in 15 of 40 patient rooms remained below 68°F from 2 a.m. to 6 a.m. with the lowest temperature of 65.2°F recorded at 2:00 a.m. in Room 635.

b. In P5 (Fifth Floor), temperatures in 12 of 41 patient rooms remained below 68°F from 2 a.m. to 6 a.m. with the lowest temperature of 65.8°F recorded at 6:00 a.m. in Room 534.

c. In P2 (Second Floor), temperatures in 9 of 44 patient rooms remained below 68°F from 2 a.m. to 6 a.m. with the lowest temperature of 64.5°F recorded at 6:00 a.m. in Rooms 224, 225, and 226.

Per these observations, log reviews, and interviews, the facility failed to ensure that their HVAC system was capable of providing central heating to the patient rooms.

Tower:
2. At 2:33 p.m., on 12/14/15, the Director of Facilities Services (DFS1) stated that the facility did not elect to use any categorical waivers. The facility did not provide documentation of a categorical waiver (per Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 10-04-LSC, dated 10/30/09) allowing for a six year damper testing frequency.

At 11:04 a.m., on 12/15/15, records indicated that fire damper testing was conducted on 11/4/10 in the Tower and Pavilion. All dampers in the Pavilion were tested this year as part of an HVAC restoration project but there were no records of testing the Tower fire dampers since 2010. Without utilization of a categorical waiver, the dampers were due to be tested in November 2014.

3. At 11:04 a.m., on 12/15/15, records indicated that five dampers (#2-003, #2-004, #2-005, #2-006, and #2-008) in the second floor of the Tower failed testing on 11/4/10. There were no records of repairing the dampers.

Van Nuys:
4. At 8:07 a.m., on 12/16/15, there was a temporary portable air handler connected to the temporary portable chiller in the west parking lot. The portable chiller was cited during the last Life Safety Code Survey in September. The portable chiller, on a wheeled portable flat bed in the west parking lot, did not have an OSHPD permit.

An invoice from the HVAC vendor indicated that the temporary chiller was installed on 7/17/15.

At 11:37 a.m., a kitchen temperature log indicated that the portable air handler has been installed since 9/30/15. Records indicated that an application for an OSHPD permit was submitted but no permit had been issued for the use of the temporary chiller and air handler.

During an interview at 11:55 a.m., the Project Manager (PM1) stated that there was no OSHPD permit for this equipment yet.

5. At 12:15 p.m., on 12/16/15, the mechanical blue prints of the HVAC system showed that the facility was protected by fusible link fire dampers.
At 12:20 p.m., the Fire/Smoke Damper Inspection log indicated that maintenance staff (VN Maint 2) inspected the dampers from 1/6/15 to 4/2/15.

During an interview at 12:28 p.m., VN Maint 2 stated that he just cleans the ducts but does not exercise the dampers. There were no records of operating the dampers every four years.


Hollywood:
6. At 3:19 p.m., on 12/16/15, records indicated that a fire damper inspection was conducted on 5/28/15. The records showed that two dampers (Urgent Care Office First Floor and CCU Third Floor) were not tested because they could not be accessed. One damper failed to close (Fifth Floor corridor adjacent to Room 510) because it was obstructed by a pipe. There were no records or repairing the three deficiencies noted by the vendor.

During an interview at 3:20 p.m., the Chief Engineer (CE1) stated that the facility was aware of the issues and was working with the vendor to provide access to those dampers.

Hollywood
First Floor:
7. At 12:00 p.m., on 12/17/15, there was a portable air conditioner (AC) in the laboratory. It was vented into the return exhaust vent which was covered with a thin piece of vinyl. The AC's air filter had a thick accumulation of dust and dirt.

During an interview at 12:01 p.m., CE1 stated that the filter was cleaned every month.

The AC's manufacturer's manual recommended that the air filter be cleaned once a week.

At 4:02 p.m., the Director of Facilities Services (DFS2) stated that the portable AC has been in the laboratory for approximately one year.


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Pavilion
Basement:
8. At 4:05 p.m., on 12/14/15, there was a leaking pipe in the ceiling of Mechanical Room 1. The facilities operations manager acknowledged the finding.

9. At 3:25 p.m., on 12/15/15, there was an audible alarm activated in the basement near Mechanical Room 1.

During an interview at 3:26 p.m., PO1 stated that one of the two boilers was leaking and that caused the low water pressure alarm to activate.

10. At 3:27 p.m., on 12/15/15, the hot water tank was leaking and the electrical hot water circulating tank was also leaking.

During an interview at 3:28 p.m., PO1 stated that this hot water tank serviced the surgery suite in the basement.

Tower
Basement:
11. At 8:42 a.m., on 12/18/15, there was a leaking pipe in the ceiling by the door into the mechanical room.

During an interview at 8:43 a.m., DFS1 acknowledged the leaking pipe was from the hot water tank.

Based on observation and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by no filters in one kitchen hood and by grease-laden deposits on the kitchen hood and suppression system equipment. This affected one of seven floors in the Pavilion and one of six floors in the Hollywood Building. This could result in the increased risk of a grease fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

Findings:

During a tour of the facility with staff from 12/14/15 to 12/18/15, the commercial cooking equipment was observed.

Pavilion
First Floor:

1. At 3:51 p.m., on 12/14/15, the kitchen hood above the stove was not equipped with grease filters. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview at 3:52 p.m., the Director of Facilities Services (DFS1) stated that custom built filters were ordered for the hood and stated he could provide documentation of the order.

Records of ordering the grease filters were requested from DFS1 on 12/14/15 (at 3:52 p.m.) and 12/15/15 (at 11:30 a.m.) but were not provided.

Hollywood
First Floor:

2. At 2:55 p.m., on 12/17/15, there was grease dripping from the kitchen hood filters above the stove. When the filters were removed, the inside of the hood and the fusible link were approximately 50% covered with grease laden deposits. The back of the filters above the griddle were completely covered with grease laden deposits. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Based on observation, the facility failed to ensure that portable space heaters used in non-sleeping staff areas complied with the requirements of NFPA 101. This was evidenced by no manufacturer's specifications indicating that the temperature of the portable space heater used in one staff office did not have heating element temperatures exceeding 212°F. This affected the basement of the Pavilion and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.8 Portable Space-Heating Devices. Portable space-heating devices shall be prohibited in all health care occupancies.
Exception: Portable space-heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements of such devices do not exceed 212°F (100°C).

Findings:

During a tour of the facility with staff from 12/14/15 to 12/18/15, the public box exchange (PBX) room was observed.

Pavilion
Basement:

1. At 2:46 p.m., on 12/16/15, a portable fan space heater was turned on and located on the floor of the PBX room. The label on the portable fan space heater indicated power consumption was 750/1500 W.

The facility failed to provide manufacturer's specifications of the portable heater to show that the temperature of the heating elements did not exceed 212°F.

Based on observation and interview, the facility failed to ensure that means of egress are free from obstructions. This was evidenced by items obstructing the egress paths and corridors. This could result in the delay in evacuation and the increased risk of injury to the patients and staff during an emergency. This affected the basement of the Tower and two of six floors and basement of the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.6.1 General. Walking surfaces in the means of egress shall comply with 7.1.6.2 through 7.1.6.4.
Exception: Existing walking surfaces shall be permitted where approved by the authority having jurisdiction.
7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.
7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the egress paths were observed.

Pavilion
Basement:
1. At 3:58 p.m., on 12/14/15, there was a modular table system stored in the egress corridor, across from the exit sign, in the back of Medical Records.

Second Floor:
2. At 10:32 a.m., on 12/16/15, there were workstation on wheels (WOWs) along the egress corridors.

During an interview at 10:33 a.m., the charge nurse on the floor stated that the WOWs and their chairs were stored in the corridor even when unattended by staff.

Sixth Floor:
3. At 11:35 a.m., on 12/16/15, there was a telephone in a wooden cabinet mounted on the wall of the egress corridor by Room 617. The wooden cabinet protruded approximately 12 inches from the wall into the egress corridor and blocked usage of the handrail. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Tower
Basement:

4. At 8:48 a.m., on 12/18/15, there was a desk with office supplies and a storage box with paper in the egress corridor, by the piped-in oxygen gas shut-off valve.

5. At 8:50 a.m., on 12/18/15, there was an industrial-sized laundry receptacle stored in the egress corridor near Housekeeping.

Based on observation and interview, the facility failed to ensure that highly flammable decorations were not used. This was evidenced by the presence of two live cut Christmas trees. This could result in the faster spread of smoke and fire due to the dry vegetation. This affected one of four smoke compartments in the Van Nuys building and one of six floors in the Pavilion.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.4 Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant.
Exception: Combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the lobby area was observed.

Pavilion
First Floor:

1. At 4:36 p.m., on 12/14/15, there was an approximately 8 foot tall live cut Christmas tree in the lobby near the security desk. The tree was cut at the roots and dry.

During an interview at 4:37 p.m., the Director of Facilities Services (DFS1) stated that the tree was flame resistant and the facility had documentation from the local fire marshal to show this.

There was a folded red tag that was stapled at the bottom of the tree but was not legible. DFS1 stated that this was the certificate from the fire marshal about the tree's flame resistance and he had a copy he could provide.

A copy of the flame resistance certificate was not provided.


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Van Nuys:

2. At 8:55 a.m., on 12/16/15, there was an approximately 6 foot tall live cut Christmas tree in the front lobby/waiting room. The tree was cut at the roots and dry.

Based on observation and interview, the facility failed to maintain the storage of their soiled linen and trash receptacles. This was evidenced by a trash collection room door that failed to latch. This affected the basement of the Pavilion and could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the soiled linen and trash collection rooms were observed.

Pavilion
Basement:

1. At 3:40 p.m., on 12/15/15, the self-closing door to the trash chute room failed to latch. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview at 3:41 p.m., Plant Operations Lead Staff (PO1) stated that the latch hardware required adjustment.

Based on observation, the facility failed to maintain their medical gas cylinder storage. This was evidenced by four medical gas cylinders that were not individually secured. This affected the basement of the Pavilion and could result in the increased risk of injury, in the event a cylinder is knocked over.

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
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
4-3.1.1.1 Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the medical gas cylinders were observed.

Pavilion
Basement:

1. At 3:47 p.m., on 12/14/15, there were four nitrous oxide H-cylinders that were chained together, and not individually secured, in the nitrous oxide piped-in medical gas room.

Based on observation and interview, the facility failed to maintain their piped-in medical gas systems. This was evidenced by the absence of an emergency oxygen supply connection. This affected the patients in the Pavilion and could result in the delay in emergency response and the increased risk of hazardous conditions.

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
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-3.1.1.8 General Requirements for Gas Central Supply Systems. Piped oxygen and medical air shall not be piped to or used for, any purpose except for use in patient care applications.
(h)Emergency Oxygen Supply Connection. Where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system an inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled "EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET." This connection shall be installed downstream of the shutoff valve on the main supply line (see 4-3.1.2.3(b)) and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the piped-in medical gas system was observed.

Pavilion:

1. At 9:05 a.m., on 12/15/15, the cryogenic system was not equipped with an emergency oxygen supply connection (oxygen autofill port). This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview, the Director of Facilities Services (DFS2) stated that the facility was in the process of obtaining approval for a project to add an autofill port.

Based on record review and interview, the facility failed to maintain the relative humidity levels in the anesthetizing locations. This was evidenced by records of the humidity levels falling below 35% during procedures in operating rooms (ORs) and by ORs that were not equipped with a means to mechanically increase humidity levels. This was also evidenced by the adoption of policies to lower the humidity in ORs below 35% without providing documentation of a categorical waiver in accordance with Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 13-25-LSC. This affected all the ORs in the Pavilion and all the ORs in the Hollywood Building. This could result in the increased risk of a fire and the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 5 Environmental Systems
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.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures.

Findings:

During document review with staff from 12/14/15 to 12/18/15, the humidity logs were reviewed.

Pavilion and Hollywood:
1. At 10:33 a.m., on 12/15/15, the "Operating Procedure Rooms Temperature and Humidity Monitoring" Policy (#SUR.048) stated that the facility would follow the Association of periOperative Registered Nurses (AORN) standard recommended humidity range of 30 to 60%.

The policy stated that it was applicable to the Culver City Campus and Hollywood Campus.

At 12:37 p.m., on 12/14/15, the Pavilion "OR Temperature and Humidity Monitoring Sheet" logs were reviewed. The top portion of the log indicated that the desired humidity range was 20 to 60%.

At 2:33 p.m., on 12/14/15, the Director of Facilities Services (DFS1) stated that the facility did not elect to use any categorical waivers. The facility did not provide documentation of a categorical waiver per Centers for Medicare & Medicaid Services Survey & Certification Letter S&C: 13-25-LSC, dated 4/19/13 to lower relative humidity in the anesthetizing locations to 20%.

Pavilion
Basement:
2. At 2:34 p.m., on 12/14/15, the humidity monitoring sheets indicated that humidity levels in the ORs fell below 35% immediately preceding procedures during the following dates and times:

a. On 12/7/15 at 7:00 a.m., the humidity was recorded as 23.9% before a procedure in OR 2.

b. On 12/7/15 at 12:00 p.m., the humidity was recorded as 29% before a procedure in OR 2.

c. On 12/7/15 at 6:00 a.m., the humidity was recorded as 28% before a procedure in OR 3.

d. On 12/7/15 at 6:00 a.m., the humidity was recorded as 24% before a procedure in OR 4.

e. On 12/7/15 at 7:00 a.m., the humidity was recorded as 25.5% before a procedure in OR 5.

Hollywood
Basement:
3. At 4:30 p.m., on 12/16/15, there were no humidity controls observed in ORs 1, 2, and 3. Humidity logs showed that humidity levels fell below 35% in the ORs (see Deficiency 4).

During an interview at 5:20 p.m., on 12/17/15, the Director of Facilities Services (DFS2) stated that the ORs were not equipped with an air handling system that could mechanically raise the humidity levels. He stated that humidity in the ORs depends on the outside humidity levels.

4. At 4:56 p.m., on 12/17/15, records indicated that humidity levels in the OR fell below 35% immediately preceding procedures during the following dates and times:

a. On 11/17/15 at 6:00 p.m., the humidity was recorded as 10% before a procedure in OR 1.

b. On 11/17/15 at 7:00 p.m., the humidity was recorded as 12% before a procedure in OR 1.

c. On 11/17/15 at 6:00 a.m., the humidity was recorded as 10% before a procedure in OR 3

d. On 11/17/15 at 6:00 p.m., the humidity was recorded as 18% before a procedure in OR 3.

e. On 11/20/15 at 12:00 p.m., the humidity was recorded as 24% before a procedure in OR 3.

f. On 11/23/15 at 7:30 a.m., the humidity was recorded as 10% before a procedure in OR 1.

g. On 12/1/15 at 6:00 a.m., the humidity was recorded as 18.5% before a procedure in OR 3.

h. On 12/2/15 at 6:00 a.m., the humidity was recorded as 16.9% before a procedure in OR 1

i. On 12/2/15 at 10:30 a.m., the humidity was recorded as 22% before a procedure in OR 1.

j. On 12/3/15 at 7:30 a.m., the humidity was recorded as 15% before a procedure in OR 3.

k. On 12/3/15 at 10:30 a.m., the humidity was recorded as 13.8% before a procedure in OR 3.

"Operating Procedure Rooms Temperature and Humidity Monitoring" Policy (#SUR.048) stated that the facility will follow the Association of periOperative Registered Nurses (AORN) standard recommended humidity range of 30 to 60%.

Section 1.7 of the policy stated, "if temperature and humidity cannot be controlled within specified levels, all scheduled procedures for that specific room will be canceled."

During an interview at 5:35 p.m., two surgical staff confirmed that cases were not canceled because of the low humidity readings.

Based on observation, the facility failed to maintain their oxygen storage areas. This was evidenced by the absence of precautionary signage in one oxygen storage area. This affected one of six floors in the Pavilion and could result in the failure to take the proper precautions required for an oxygen storage room.

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
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(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.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(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.

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

Findings:

During facility tour with staff from 12/14/15 to 12/18/15, the facility was observed.

Pavilion Building
Fourth Floor:

1. At 9:57 a.m., on 12/17/15, there were oxygen cylinders stored in the rehabilitation gym. The door to the rehabilitation gym was not labeled with a precautionary sign.

The above finding was acknowledged by Director of Emergency Services.

Based on observation, record review, and interview, the facility failed to maintain their emergency generators. This was evidenced by generators that were not monitored by remote alarm annunciators, by a generator enclosure that was not equipped with battery-powered emergency lights, and by one generator with an inoperable block heater. This affected three of three buildings at the Culver City Campus and the Van Nuys Building. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 70 , National Electrical Code, 1999 Edition
700-12 The annunciator shall indicate alarm condition of the emergency or auxiliary power source as follows:
(a)Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b)Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

3-5.5.2 (d) Battery powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2 (d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6.1 A remote,, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During tour of facility with staff from 12/14/15 to 12/18/15, the generators and generator components were observed.

Culver City Campus:

1. At 4:21 p.m., on 12/14/15, there were no remote alarm annunciators for three of three generators at Culver City. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

During an interview at 4:22 p.m., Plant Operations Lead Staff (PO1) confirmed that the generators did not have remote alarm annunciators.

2. At 1:04 p.m., on 12/15/15, records indicated that a load bank test was conducted for the North Ramp generator on 12/11/15. Per the Emergency Generator Test Run Log, the North Ramp generator is a 400 kW (kilowatt) diesel generator that supplies emergency power to the surgical basement in Pavilion. The vendor noted in his findings that the block heater was not working and needed to be replaced. There were no records of repairing the block heater.

Van Nuys:

3. At 10:34 a.m., on 12/16/15, there was no battery-powered emergency lighting in the generator room.

4. At 11:19 a.m., on 12/16/15, there was a low fuel sensor alarm for the generator's main diesel tank at the Unit 2 nurses station but no remote alarm annunciator. The Director of Facilities Services (DFS2) confirmed this finding. This finding was previously cited during a Life Safety Code Survey conducted in September 2015.

Based on observation, record review, and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of a compromised power strip, by an electrical box with a broken cover, and by the rewiring of electrical circuits without approval from the authority having jurisdiction. This affected one of four smoke compartments in the Van Nuys Building and two of two stairwells in the Hollywood Building. These deficient practices could result in the increased risk of an electrical fire and an increased risk of malfunction of essential electrical equipment. This could result in the increased risk of harm to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

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

NFPA 70, National Electrical Code, 1999 Edition.
Section 90-4 Enforcement. This Code is intended to be suitable for mandatory application by governmental bodies that exercise legal jurisdiction over electrical installations and for use by insurance inspectors. The authority having jurisdiction for enforcement of the Code will have the responsibility for making interpretations of the rules for deciding on the approval of equipment and materials, and for granting the special permission contemplated in a number of the rules. The authority having jurisdiction may waive specific requirements in this Code or permit alternate methods where it is assured that equivalent objectives can be achieved by establishing and maintaining effective safety. This Code may require new products, constructions, or materials that may not yet be available at the time the Code is adopted. In such event, the authority having jurisdiction may permit the use of the products, constructions, or materials that comply with the most recent previous edition of this Code adopted by the jurisdiction.

90-7 Examination of Equipment for Safety. For specific items of equipment and materials referred to in this Code, examinations for safety made under standard conditions will provide a basis for approval where the record is made generally available through promulgation by organization properly equipped and qualified for experimental testing, inspections of the run of goods at factories, and service-value determination through field inspections. This avoids the necessity for repetition of examinations by different examiners, frequently with inadequate facilities for such work, and the confusion that would result from conflicting reports as to the suitability of devices and materials examined for a given purpose.
It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations or damage, if the equipment has been listed by a qualified electrical testing laboratory that is recognized as having the facilities described above and that require suitability for installation in accordance with this Code.

110-3. Examination, Identification, Installation, and Use of Equipment.
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
(b) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures, into which persons enter for installation and maintenance.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

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

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

400-8 Uses Not Permitted
Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a facility tour with staff from 12/14/15 to 12/18/15, the electrical wiring was observed.

Pavilion
First Floor:

1. At 9:53 a.m., on 12/15/15, there was a 4 inch by 4 inch electrical box with a broken cover in the Green Room. The wiring in the electrical box was exposed.

Van Nuys:

2. At 10:05 a.m., on 12/16/15, the medication dispenser in the Unit 2 Medication Room was plugged into a six-plug power strip. The insulation on the power strip cord was ripped and wiring was exposed.

Hollywood
East and West Stairwells:

3. At 10:38 a.m., on 12/17/15, records indicated that a contractor rewired the stairwell light circuits on 10/23/15 so that they are serviced by the generator.

During an interview at 10:39 a.m., the Director of Facilities (DFS2) stated that, after the last Life Safety Code Survey, it was discovered that the stairwell lights are not hooked up to the generator and the stairwells were dark during a power outage. He stated that this contractor was hired to amend that issue. He said that the rewiring of the lighting and emergency circuits was not approved by the Office of Statewide Health Planning and Development.

Based on observation, document review, and interview, the facility failed to maintain their elevators. This was evidenced by the failure to ensure conveyance permits are current for the elevators. This was also evidenced by the failure to provide maintenance records for two elevators and the failure to provide repair records for the Phase II fire fighter service of one elevator. This affected the elevators in the Pavilion and the Tower. This could result in the increased risk of malfunction of the elevators and possible harm to patients, visitors, and staff.

NFPA 101 Life Safety Code, 2000 Edition
19.5.3 Elevators, Escalators, and Conveyors. Elevators, escalators, and conveyors shall comply with the provisions of Section 9.4.
9.4.6 Elevator Testing. Elevators shall be subject to routine and periodic inspections and test as specified in ASME/ANSI A17.1, Safety Code for Elevators and Escalators. All elevators equipped with fire fighter service in accordance with 9.4.4 and 9.4.5 shall be subject to a monthly operation with a written record of the findings made and kept on the premises as required by ASME/ANSI A17.1, Safety Code for Elevators and Escalators

Findings:

During record review with staff from 12/14/15 to 12/18/15, the elevator inspection records were reviewed.

Culver City Campus:

1. At 12:20 p.m., on 12/17/15, records indicated that the facility failed to ensure elevator conveyance permits were current since 9/2014. Reports sent to the facility from the State of California Department of Industrial Relations Division of Occupational Safety and Health (CDIRDOSH) were reviewed:

a. The facility received a notice, dated 2/1/15, of an overdue payment for a 12/23/14 inspection of Elevator Conveyance Permit #050929. The notice had a compliance date of 2/16/15.

b. The facility received a notice, dated 10/7/14, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #050930.

c. The facility received a notice, dated 10/7/14, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #065766.

d. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/15 inspection of Elevator Conveyance Permit #050902.

e. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #051351.

e. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #036094.

f. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 Inspection of Elevator Conveyance Permit #036088.

g. The facility received a final notice, dated 7/12/15, of an overdue payment for a 9/30/14 inspection of Elevator Conveyance Permit #050901.

Documents indicated that payments were made by the facility for Elevator Conveyance Permits 036088, 05090, 036094, 051351, and 050902 on 7/23/15, after receiving final notices of shutdown from CDIRDOSH.

At 9:04 a.m., on 12/18/15, Elevator Conveyance Permit #036088 had an expiration date of 9/30/14.

During an interview at 9:05 a.m., the Director of Facilities Services (DFS1) stated that the final notices were paid and the facility was waiting for CDIRDOSH to send in current permit.

During a telephone interview at 3:45 p.m., on 12/22/15, staff at CDIRDOSH stated that the facility is current for 2014 conveyance permits but not for 2015. She stated this was due to the delinquency in compliance and payment for the 9/2014 inspection.

2. At 12/18/15, at 10:00 a.m., the facility failed to provide documents to show maintenance inspections were conducted for Elevators 050930 and 051351.

3. At 12/18/15, at 10:15 a.m., a vendor indicated in December 2014 and 1/25/15 that the Phase II fire fighter service for Elevator 065766 did not function. There were no records of repairing the deficiency noted by the vendor.