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Based on observation, record review, and interview, the facility failed to maintain their fire alarm system. This was evidenced by the repeated failure of fire alarm notification devices, by the failure to transmit the correct type of fire alarm signal to the monitoring station, and by the frequent placement of the fire alarm system in test mode that resulted in the failure to dispatch the fire department during a Code Red event. This was also evidenced by incorrectly addressed smoke detectors that caused personnel to respond to the wrong location during a Code Red event. This affected the entire Culver City Campus and the Van Nuys Building. This could result in a delay in fire department dispatch, a delay in response during a fire, and the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
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.

9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

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.

9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
Exception No. 1: Areas not subject to occupancy by persons who are hearing impaired shall not be required to comply with the provisions for visible signals.
Exception No. 2: Visible-only signals shall be provided where specifically permitted in health care occupancies in accordance with the provisions of Chapters 18 and 19.
Exception No. 3: Existing alarm systems shall not be required to comply with the provision for visible signals.
Exception No. 4: Visible signals shall not be required in lodging or rooming houses in accordance with the provisions of Chapter 26.

NFPA 72, National Fire Alarm Code, 1999 Edition.
Definitions
1-4 Central Station. A supervising station that is listed for central station service.
Proprietary Supervising Station. A location to which alarm or supervisory signaling devices on proprietary fire alarm systems are connected and where personnel are in attendance at all times to supervise operation and investigate signals.
Proprietary Supervising Station Fire Alarm System. An installation of fire alarm systems that serves contiguous and noncontiguous properties, under one ownership, from a proprietary supervising station located at the protected property, at which trained, competent personnel are in constant attendance. This includes the proprietary supervising station; power supplies; signal-initiating devices; initiating device circuits; signal notification appliances; equipment for the automatic, permanent visual recording of signals; and equipment for initiating the operation of emergency building control services.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

5-2.5.1 The central station shall have sufficient personnel, but not less than two persons, on duty at the central station at all times to ensure disposition of signals in accordance with the requirements of 5-2.6.1.

5-2.5.2 Operation and supervision shall be the primary functions of the operators, and no other interest or activity shall take precedence over the protective service.

5-2.6.1.5.2 Any test signal not received by the central station shall be investigated immediately and action shall be taken to reestablish system integrity.

5-3.2.1 Proprietary supervising stations shall be operated by trained, competent personnel in constant attendance who are responsible to the owner of the protected property. The requirements of 5-3.5.3 shall apply.

5-3.3.1 The proprietary supervising station shall be located in a fire-resistive, detached building or in a cutoff room and shall not be exposed to the hazardous parts of the premises that are protected.

5-3.4.1 Signal-receiving equipment in a proprietary supervising station shall comply with 5-3.4.

5-3.4.2 Provision shall be made to designate the building in which a signal originates. The floor, section, or other subdivision of the building shall be designated at the proprietary supervising station or at the building that is protected.
Exception: Where the area, height, or special conditions of occupancy make detailed designation unessential as approved by the authority having jurisdiction. This detailed designation shall use indicating appliances accepted by the authority having jurisdiction.

5-3.5.1 At least two operators shall be on duty at all times. One of the two operators shall be permitted to be a runner.
Exception: If the means for transmitting alarms to the fire department is automatic, at least one operator shall be on duty at all times.

5-3.5.3 The primary duties of the operator(s) shall be to monitor signals, operate the system, and take such action as shall be required by the authority having jurisdiction. The operator(s) shall not be assigned any additional duties that would take precedence over the primary duties.

5-3.6.6.1 Alarms. Upon receipt of a fire alarm signal, the proprietary supervising station operator shall initiate action to perform the following:
(1) Immediately notify the fire department, the plant fire brigade, and such other parties as the authority having jurisdiction requires.
(2) Promptly dispatch a runner to the alarm location (travel time shall not exceed 1 hour).
(3) Restore the system as soon as possible after disposition of the cause of the alarm signal.

Findings:

During tour of facility with staff from 4/4/16 to 4/8/16, the fire alarm systems were tested and observed. The Pavilion and the Tower building, located across the street from the Pavilion, shared the same fire alarm system.

Van Nuys:

1. From 12:00 p.m., to 12:30 p.m., on 4/6/16, fire alarm testing was conducted and this included initiating devices such as pull stations, smoke detectors, and waterflow switches. At 4:17 p.m., the monitoring report from the testing was provided. The monitoring report showed that the remote monitoring station only received Zone 2 fire trouble signals for all types of initiation devices tested.

During a telephone interview at 4:18 p.m., a representative from the monitoring company stated that they would not dispatch the fire department upon receipt of a Zone 2 trouble signal.

During a telephone interview at 4:47 p.m., another representative from the monitoring company stated that the last Zone 1 fire alarm signal received from the facility was on 12/30/15. He stated that only fire trouble signals were received on 1/23/16. The annual testing of the fire alarm system was conducted on 1/23/16 and documents showed that all initiation devices were tested on that day.

During an interview at 5:00 p.m., the Director of Facilities Services (DFS2) stated that a fire watch would be implemented immediately until the fire alarm panel was fixed.

Records showed that a fire alarm vendor fixed the panel on 4/7/16. The vendor reported that there was a loose wire for Zone 1 in the panel that caused all the signals to be reported as Zone 2.

Pavilion:

2. At 10:28 a.m., on 4/4/16, the fire alarms sounded and a Code Red was paged overhead. PBX paged "Code Red Sixth Floor" three times. At 10:33 a.m., the Head of Security (HS1) reset the fire alarm system at the notification panel in the lobby.

During an interview at 10:33 a.m., HS1 stated that security staff have investigated and saw no signs of fire. He stated that the panel indicated that the smoke detector was activated in the hallway outside the EVS (environmental services) closet on the sixth floor.

At 10:35 a.m., there were two security staff holding fire extinguishers in Wing A of the sixth floor. They stated that the smoke detector inside Room 605, which was adjacent to an EVS closet, was blinking red. They gave an "all clear" after inspecting that room.

At 10:50 a.m., Plant Operations Lead Staff (PO1) removed the detector in Room 605 and an addressable trouble signal on the panel read "Pav 6th Smoke Patient Room 605."

During an interview at 10:51 a.m., PO1 and HS1 were unsure if Room 605 was the origin of the fire alarm activation/Code Red and if security staff responded to the wrong location.

At 2:37 p.m., a print out from the panel indicated that, "Pav 6th Smoke Patient Room 605" caused a "Common Trbl Act" (a local trouble signal) at 10:24 a.m. and that, "Pav 6th Smoke Hall Outside EVS" caused an "Alarm Active" at 10:28 a.m.

During an interview at 2:38 p.m., the Fire Alarm Technician (F.A. Tech2) stated that the source of the fire alarm activation was not Room 605. He said that he and the other technicians were still trying to locate the smoke detector that was addressed incorrectly as "outside EVS."

During an interview at 4:05 p.m., F.A. Tech2 stated that the smoke detector that caused the Code Red was actually in a Wing C linen closet, not in the Wing A corridor outside the EVS closet.

Facility staff responded to the wrong location during the Code Red incident due to a smoke detector that was not addressed correctly on the panel.


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Culver City Campus:

3. Per record review and interviews, it was observed that the fire alarm system was frequently placed on test during the past month. When the system is on test, fire alarm signals received by the remote monitoring station would not result in dispatch of the fire department. During the Code Red on 4/4/16 (Finding 2 above), the fire department was not dispatched.

During an interview at 10:33 a.m., on 4/4/16, HS1 stated that the system was on test and PBX would call the fire department upon investigation by the facility and security staff.

At 4:05 p.m., on 4/6/16, this surveyor was unable to conduct an interview with the PBX operator. There was only one PBX operator at the time and he was busy with phone calls. The fire alarm annunciator in PBX was across the room from the operator. PBX did not meet the NFPA 72 requirements of a listed central station or proprietary supervising station.

During an interview at 1:57 p.m., on 4/5/16, the Los Angeles Fire Prevention Specialist (LAFPS) from Culver City Fire stated that the Fire Department should have been dispatched during the Code Red incident yesterday (Finding 2 above) and the Code Red incident in December (See K48 from the December 2015 Life Safety Code Survey). He stated the last time the fire department was notified of a fire alarm at the facility was on 3/11/16. He stated that the fire department was not notified of the alarms in the building yesterday. He requested to review a month of the monitoring reports from the offsite monitoring stations.

During an interview at 5:01 p.m., on 4/6/16, Plant Operations Lead Staff (PO1) stated that the facility placed the fire alarm system in test mode daily, for both the Tower and Pavilion, although construction was only conducted in the Pavilion Penthouse.

During an interview at 8:49 a.m., on 4/7/16, the LAFPS stated the facility cannot place the fire alarm system on test daily without informing the local AHJ that the system is out of service. He stated he was unaware of any construction work that would require that the entire fire alarm system be put on test daily for both Tower and Pavilion Buildings.

During an interview at 8:50 a.m., on 4/7/16, the Los Angeles Fire Inspector (LAFI) from the local Fire Department stated the facility cannot be on test so often without notifying the local AHJ. He stated that the facility must notify the AHJ when the fire alarm system is on test for construction work.

During an interview at 11:44 a.m., on 4/7/16, the Office of Statewide Health Planning and Development (OSHPD) Fire Life Safety Officer (FLSO) stated the facility should get approval from the FLSO for putting the system on test during any construction.

During an interview at 12:30 p.m., on 4/7/16, the Director of Facilities Services (DFS1) stated that PBX was carrying out instructions from the previous Facilities Director to put the system on test from 5 a.m. to 5 p.m. daily whether the fire alarm system was being worked on or not.

During an interview at 2:48 p.m., on 4/7/16, F.A. Tech1 stated the fire alarm system has the capability to place only certain zones on test, such as specific construction areas or while working on a portion of the fire alarm system.

During an interview at 9:50 a.m., on 4/8/16, F.A. Tech1 stated he was unaware that the facility had placed the fire alarm system on test when he and his staff were not working on the system. F.A. Tech1 provided his staff's work schedule for the month of March 2016. He confirmed that they were not in the building during the Code Red incident on 4/4/16.

At 10 a.m., on 4/13/16, comparison of the facility's fire alarm monitoring reports and the fire alarm vendor's work schedule showed days that the fire system was placed on test while no work was conducted on the system. The monitoring report indicated that the facility placed the entire fire alarm system on test from 5:00 a.m., to 5:00 p.m. for most days, including Saturdays and Sundays, without notifying the local AHJ. The fire alarm system was placed on test late into the evening on other days: on 3/14/16, the system was placed on test from 7:28 p.m., until 11:30 p.m. and on 3/22/16, from 6:16 p.m., until 11:59 p.m.

The monitoring report indicated the system was placed on test on 3/11/16 from 5:00 a.m., to 5:00 p.m., for selective zones only. A fire alarm was activated in an area that was not on test and the fire department was dispatched. Interview with LAFPS above confirmed that this was the last time they received fire alarm signal from the facility.

Per the monitoring report and the fire alarm vendor's schedule for March 2016, the facility had their entire fire alarm system on test from 5:00 a.m., to 5:00 p.m. for 14 days (including Saturdays and Sundays) while there was no fire alarm vendor in the building. The system was on test on 3/9/16 while there was no fire alarm vendor working on the fire alarm panel. The report indicated the panel exhibited a supervisory signal. The signal was not sent to the local fire department.

Tower
First Floor:

4. At 3:53 p.m., on 4/6/16, the pull station on the first floor in the Emergency Department was tested. The fire alarm chimes failed to activate an audible alarm and no fire alarms could be heard throughout the building.

At 3:54 p.m., on 4/6/16, the pull station by the exit door of the Emergency Department was tested. The fire alarm chimes failed to activate an audible alarm and no fire alarms could be heard throughout the building.

During an interview at 3:55 p.m., F.A. Tech1 stated he would go and investigate the problem.

At 5:52 p.m., the notification devices at the Tower were still not repaired.

During an interview at 9:01 a.m., on 4/7/16, F.A. Tech1 stated he finished working on the fire alarm system yesterday at approximately 8:30 p.m., and all the chimes on all the floors of the Tower should be working now.

Tower
Basement:

At 10:29 a.m., a pull station was tested and the fire alarm chime box failed. No alarms could be heard in the basement.

This deficiency was cited during the September 2015 and December 2015 Life Safety Code surveys under K52. During the survey on 9/22/15, the fire alarm chimes on the first floor and fourth floor of the Tower failed during testing of the fire alarm system. During the survey on 12/16/15, the fire alarm chimes failed on the seventh floor of the Tower while fire alarm testing. Documentation from the Inspector of Record (IOR) showed that, during testing on 1/22/16, the audible fire alarms failed on the first floor, third floor, basement, and fifth floor of the Tower. The items were documented as having been corrected on 1/27/16. The recurring failure of the fire alarm chimes had not been corrected.

Based on record review, the facility failed to ensure that fire watch rounds were conducted in accordance with the instructions from the authority having jurisdiction (AHJ). This affected the penthouse of the Pavilion and could result in a delay in extinguishing a fire in the mechanical room.

Findings:

During record review with staff from 4/4/16 to 4/8/16, the fire watch logs were provided.

Pavilion
Penthouse:

1. At 11:02 a.m., on 4/4/16, there was scaffolding blocking the spray pattern of the sprinkler heads in the mechanical room. The scaffolding was erected as part of an HVAC (heating, ventilating, and air-conditioning) restoration project after a fire in the penthouse destroyed an air handler on 1/29/15. The facility was instructed by the local fire marshal to conduct fire watch rounds in the mechanical room due to the obstructed sprinkler heads.

At 11:21 a.m., the fire watch instructions on the Fire Watch Log Sheet read in bold and capital letters that "A PATROL IS TO BE CONDUCTED EVERY 30 MINUTES."

The logs from March and April 2016 showed that fire watch patrols were missed during the following dates and times:

a. There was one patrol missing between 2:30 p.m. to 3:30 p.m. on 4/3/16.
b. There was one patrol missing at 11:30 p.m. on 4/2/16.
c. There were two patrols missing between 10:00 p.m. and 11:30 p.m. on 3/31/16.
d. There was one patrol missing between 9:30 a.m. and 10:30 a.m. on 3/30/16.
e. There was one patrol missing at 11:00 p.m. on 3/25/16.
f. There was one patrol missing at 4:00 p.m. on 3/24/16.
g. There was one patrol missing at 1:00 p.m. on 3/23/16.
h. There was one patrol missing at 3:00 p.m. on 3/22/16.
i. There were three patrols missing between 1:30 p.m. and 3:30 p.m. on 3/21/16.