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Based on observation, the facility failed to maintain the building construction in 1 of 2 smoke compartments as evidenced by an unsealed penetration within the facility which had the potential to allow the spread of smoke during a fire and could result in harm to residents, staff and visitors.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 2 of 2 compartments and could result in potential harm to Residents, staff and visitors.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the building construction was observed.

North Building, First Floor on 6/4/12:
1. At 2:20 p.m., there was an approximately 2 inch circular penetration in the Old Cashier Office.
2. At 2:30 p.m., there were five approximately 1 inch circular penetrations in the upper front wall by the door in the IDF1.1 Office.

Based on observation, the facility failed to maintain the integrity of the corridor doors to provide an effective smoke barrier in the event of a fire as evidenced by doors to patient rooms that failed to latch and by failing to keep impediments from obstructing the closing of doors. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition.
15-2.3.3 Blocking or wedging of doors in the open position shall be prohibited.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the corridor doors were observed.

West Building, Second Floor on 6/4/12:
1. At 2:58 p.m., the door failed to latch when closed to Patient room 233.

2. At 3:01 p.m., the door failed to latch when closed to Patient room 234.

3. At 3:08 p.m., the corridor door strike plate was broken resulting in the doors failure to close for Patient room 240.

4. At 3:12 p.m., the corridor door strike plate was broken resulting in the doors failure to close for Patient room 243.

North Building, First Floor on 6/6/12:
5. At 1:57 p.m., the corridor door failed to latch when closed to CT Room 1.















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North Building, Fifth Floor on 6/4/12:
6. At 10:35 a.m., the bathroom door failed to latch shut when closed to Patient room 576.
7. At 10:40 a.m., the door failed to latch shut when closed to Patient room 572.

North Building, Third Floor on 6/4/12:
8. At 11:45 a.m., the door failed to latch shut due to chair propped to Patient room 377-2.
9. At 11:57 a.m., the door failed to latch shut when closed due to equipment in the corridor plugged into electrical outlet inside Patient room 360-2.

North Building, Second Floor on 6/4/12:
10. At 1:35 p.m., the door failed to latch shut when closed to Patient room 286.
11. At 1:40 p.m., the door failed to latch shut when closed to Patient room 273.

North Building, First Floor on 6/6/12:
12. At 1:57 p.m., the corridor to CT Room 1 failed to latch shut when closed.

Original Building, Third Floor on 6/4/12:
13. At 3:50 p.m., the door failed to latch shut when closed to RIE Room 2.

Original Building, Second Floor on 6/4/12:
14. At 4:10 p.m., the door failed to latch shut when closed to Room 205-1.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls to prevent the passage of smoke as evidenced by penetrations in the smoke barrier walls. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the smoke barrier walls were observed.
North Building, Fourth Floor on 6/4/12:
1. At 11:22 a.m., there was an approximately 1/2 inch penetration surrounding an orange cable in the center of the smoke barrier wall above the drop down ceiling at the entrance to Side 3.
North Building, Third Floor on 6/4/12:
2. At 11:40 a.m., there was an approximately 1/2 inch penetration below the upper pipe in the left center of the smoke barrier wall above the drop down ceiling by the 3 North Nurse Station 1.
Original Building, Third Floor on 6/4/12:
3. At 3:45 p.m., there was an approximately 1/2 inch penetration in the center of the smoke barrier wall above the drop down ceiling by Stair 8.
Original Building, Second Floor on 6/4/12:
4. At 4:00 p.m., there were two approximately 1 inch penetrations surrounding two pipes in the left center of the smoke barrier wall above the drop down ceiling by Room 204-2.

Based on observation, the facility failed to maintain the fire rated smoke barriers doors on magnetic devices to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by the failure of smoke barrier doors failing to latch upon closure. This could result in the potential spread of fire and smoke in the event of a fire, from one compartment to another causing harm to patients in the effected smoke compartments.

NFPA 101, Life Safety Code 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During the testing of the Fire Alarm System with Staff on June 5, 2012, through June 7, 2012, the smoke barrier doors and doors on hold open devices were observed.

North Building, Second Floor on 6/5/12:
1. At 3:13 p.m., the smoke barrier door located next to the Nurse Station and Patient Room 282, released from its magnetic device, but failed to latch shut during the testing of the Fire Alarm System.




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North Building, Second Floor on 6/5/12:
2. At 3:15 p.m., the smoke barrier door left leaf failed to fully close and latch shut to the Unit Entrance.

North Building, First Floor on 6/6/12:
3. At 1:45 p.m., the two rear smoke barrier doors failed to latch shut to the X-Ray Room next to GI 3 and Chemistry Supplies.

North Building, Basement Floor on 6/6/12:
4. At 2:00 p.m., 1 of 2 smoke barrier doors failed to fully close and latch shut at the Entrance to the Equipment Depo.


West Building, Second Floor on 6/6/12:
5. At 3:25 p.m., the two entrance double smoke barrier doors left leafs failed to latch shut between 2 Main and 2 West.

Based on observation, the facility failed to maintain its fire rated smoke barriers doors on magnetic devices to latch upon activation of the fire alarm system and to resist the passage of smoke as evidenced by smoke barrier doors that failed to latch upon closure upon release of its magnetic device. This failure could result in the transfer of fire and or smoke in the event of a fire from one smoke compartment to another, resulting in potential harm to patients in the affected smoke compartments.

Findings:

During the testing of the fire alarm system with Staff on June 5, 2012, through June 7, 2012, the fire rated smoke barrier doors were observed.

Southwest Building, Third Floor on 6/5/12:
1. At 2:15 p.m., the smoke barrier door left leaf failed to latch shut by Room SW322.

Southwest Building, First Floor on 6/5/12:
2. At 2:25 p.m., the smoke barrier door left leaf failed to latch shut by Room SW90.

Based on observation, the facility failed to maintain the integrity of the fire rated doors and enclosure to provide an effective smoke barrier in the event of a fire as evidenced by failing to keep impediments from obstructing the closing of doors and failing to seal penetrations in the fire rated walls. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the hazardous areas were observed.

Southwest Tower, First Floor on 6/4/12:
1. At 11:22 a.m., there was card board stuck in the strike plate impeding the door from latching upon self-closure in the Trash and Linen room 172

Outpatient Services, Center for Rehabilitation and Wellness Center (CRW) on 6/7/12:
2. At 9:24 a.m., there was an unsealed penetration around the sprinkler escutcheon ring in the Elevator Equipment room 1145.
3. At 9:27 a.m.., there were two unsealed conduits in the left side of the wall behind the water heater in Equipment room 1122-A.

Based on observation the facility failed to maintain the Gift Shop as evidenced by the failure to maintain an 18 inch storage clearance from the ceiling. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

During a tour of the facility with Staff on June 4, 2012 through June 7, 2012, the Gift Shop was observed.

Original Building, First Floor on 6/6/12:
1. At 1:55 p.m., the shelves were stocked to the ceiling with stuffed animals and various items in the Gift Shop.

Based on observation and interview, the facility failed to provide an accessible egress, as evidenced by egress doors with two locks requiring a double action in order to open the doors. This failure could result in the delay of evacuation in the event of an emergency causing potential harm to residents in affected smoke compartments.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in.(122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the exit doors were observed.

St Jude Plaza Surgery Center on 6/7/12:
1. At 9:30 a.m., the entrance doors to the seven operating rooms and the six doors to the the Patient Recovery Area of the building were equipped with two locks requiring a double action if the doors were locked. The door could be locked on one side and required a key for the other side. The Administrator stated that the doors were never locked. The Administrator and Maintenance could open the doors with a key.

Based on observation and interview, the facility failed to ensure its Fire Alarm devices provide an effective warning in the event of a fire or other emergency as evidenced by a Inspectors Test Valve that was incorrectly labeled at the Main Fire Alarm Control Panel. This could delay notification to staff and emergency personnel in the event of a fire, and could result in potential harm to patients in the affected smoke compartments.

Findings:

During the testing of the Fire Alarm System with Staff on June 5, 2012, through June 7, 2012, the fire alarm devices were tested and observed.

Southwest Tower, First Floor on 6/5/12:
1. At 2:15 p.m., the Inspectors Test Valve (water flow) located on the First floor Stairwell #11, reported to the Fire Alarm Control Panel as Fifth Floor water flow. This was acknowledged and confirmed by the Fire Alarm Engineer that was conducting the test.

Based on observation, the facility failed to ensure audible devices in the facility provide an effective warning in the event of a fire or other emergency and failed to keep impediments from obstructing fire alarm devices from full instant use in the event of an emergency as evidenced by failure of audible devices and a manual pull station that was blocked by equipment. This could delay staff notification in the event of a fire, and could result in potential harm to patients in the affected smoke compartments.

Findings:

During the testing of the Fire Alarm System with Staff on June 5, 2012, through June 7, 2012, the fire alarm devices were observed.

North Building, Fifth Floor on 6/5/12:
1. At 2:50 p.m., a computer on wheels (cow's) was plugged into a receptacle and left unattended in front of a manual pull station, impeding the access to the manual pull station located across from Patient room 577.

North Building, Third Floor on 6/5/12:
2. At 3:00 p.m., during fire alarm testing the chime located across from Patient room 379 failed to activate an audible alarm.

North Building, First Floor on 6/6/12:
3. At 1:30 p.m., during fire alarm testing the chime located next to the Microbiology Managers office failed to activate an audible alarm.

North Building, Basement on 6/6/12
4. At 2:30 p.m., during fire alarm testing the chime located in the corridor next to Pharmacy failed to activate an audible alarm.
5. At 2:46 p.m., during fire alarm testing 1 of 1 chimes failed to activate an audible alarm in the Kitchen area. This failure was acknowledged by staff and the Fire Alarm Engineer that was conducting the test.



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North Building, First Floor on 6/4/12:
6. At 2:35 p.m., the manual pull station was blocked from access by a copy machine in the Microbiology Lab.

North Building, Fifth Floor on 6/5/12:
7. At 2:50 p.m., 1 of 4 fire alarms 5N3/1 failed to sound an alarm located across from Room 555.

North Building, Third Floor on 6/5/12:
8. At 3:05 p.m., the fire alarm N4/1 failed to sound an alarm.

North Building, Basement Floor on 6/6/12:
9. At 2:20 p.m., the alarm clicked but failed to activate and the overhead speaker could not be heard in the Surgery corridor in the the North Building.

West Building, Basement Floor on 6/6/12:
10. At 2:30 p.m., the fire alarm made a clicking sound but failed to activate in the Surgery corridor in the West Building.
11. At 3:20 p.m., the fire alarm/strobe failed to flash in MRI over the emergency plan.

Based on document review and interview, the facility failed to maintain the integrity of the smoke detection devices according to the manufactures recommendations as evidenced by incomplete sensitivity testing by a certified vendor and failing to provide documentation of a maintenance and battery replacement program for 6 of 6 battery powered smoke detectors. This failure could result in the smoke detection devices not functioning as designed in the event of a fire resulting in potential harm to patients and staff in the affected smoke compartments.

NFPA 72, National Fire Alarm Code 1999 Edition
NFPA 72 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. after the second required calibration test, if sensitivity tests indicated that the detector has remained within its listed and marked sensitivity range (or 4% obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance show any increase over the previous year, calibration tests shall be performed.


NFPA 101, Life Safety Code 2000, Edition
4.6.12 Maintenances and Testing.
4.6.12.1 Whenever or wherever any device, equipment, sytem, 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.

Findings:

During record review and interview with staff on June 4, 2012 through June 7, 2012, documents were reviewed and staff interviewed.

Outpatient Services at 1901 Sunnycrest Drive, Fullerton on 6/6/12:
1. At 11:10 a.m., during document review and interview, the facility failed to provide documentation for the testing of 6 smoke detectors in the facility according to the manufactures specifications. During interview, Maintenance Staff stated they did not have documentation for the maintenance and testing of the battery powered smoke detectors. The Facility is non-sprinklered.




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2. At 10:30 a.m. on June 5, 2012, the sensitivity test provided by a certified vendor showed that 48 smoke detector devices were not tested. Interview with staff stated that areas were not accessible at the time of vendor testing and had not been retested. The areas were marked as follows: No access to device. DSD 3M7-5,6,8,9,10,11,12 2N8-6,8,9,12,17,18,19,20 3N8-6,7,8,9,14,16 4W7-7. SD 4N1-15 4N8-1,3,4,5,6,7,8,17,23,24,33,47 5N8-1,2,12,13 5N8-5 could not remove detector from base. DHS 1W1-17 door holder smoke detector 214 no access at time. DSD 1W3-9,10,11 unable to locate device. SD 2W1-19 DSD 2W3-14 to small of an access to device. 4W7-1 no access-above sensitive equipment or patient.

Based on observation, the facility failed to ensure portable Fire Extinguishers are accessible and not obstructed as evidenced by a Fire extinguisher that were blocked from view and access. This has the potential for inaccessibility to the fire extinguisher in the event of a fire resulting in potential harm to Patients in the affected smoke compartments.

NFPA 10, Standard for Portable Fire Extinguishers 1998 Edition
1-6 General Requirements.
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.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility with Staff on June 4, 2012, through June 7, 2012, the Fire Extinguishers were observed.

North Building, First Floor on 6/6/12:
1. At 3:00 p.m., the Fire Extinguisher was obstructed from access and view by a Clean Linen Cart that was left unattended in front of the Fire Extinguisher in the MRI Suite. There was no sign above the Extinguisher indicating a Fire Extinguisher was in the location.


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West Building, Basement Floor on 6/6/12:
2. At 2:30 p.m., the fire hose was blocked from access by a cart in the West Building Operating Room corridor next to the fire alarm.

3. At 3:15 p.m., 1 of 2 portable fire extinguishers was obstructed from view by a soiled linen cart in MRI.

Based on observation, the facility failed to maintain the smoking areas as evidenced by the failure to provide self-closing containers for the disposal of the cigarettes. This failure has the potential for an outside fire.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the smoking area was observed.

1. At 9:40 a.m. on June 5, 2012, the ashtrays provided contained 3 open containers with approximately 60 cigarette butts in each container in the smoking area adjacent to the Original Building.

Based on observation and interview, the facility failed to maintain their means of egress free from obstructions and or impediments as evidenced by a door that was impeded. This failure could result in the delayed evacuation of patients in the affected area and had the potential for the spread of fire or smoke in the event of a fire affecting patients in the affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the means of egress were observed.
Southwest Building, Basement Floor on 6/5/12:
1. At 2:35 p.m., the right leaf was blocked from access by a gurney at the exit double door by Room SWB158.

Based on observation and interview, the facility failed to maintain their means of egress free from obstructions and or impediments as evidenced by doors that were blocked or failed to close. This failure could result in the delayed evacuation and has the potential for the spread of fire or smoke in the event of a fire affecting patients in the affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the means of egress were observed.
Original Building, Fourth Floor on 6/4/12:
1. At 3:20 p.m., the emergency exit door failed to fully close and latch to Stair 7.

North Building, Fifth Floor on 6/5/12:
2. At 2:45 p.m., the left leaf to the double door by Room 584, was blocked from access by a bed.

Based on observation, the facility failed to maintain the compressed gas cylinders in the Gas Cylinder Bulk Storage Area as evidenced by tanks secured with one chain and not individually secured. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

NFPA 99 (1999 Edition) 8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the facility compressed gas cylinder storage areas were observed.

Gas Cylinder Bulk Storage Area behind Main Hospital on 6/6/12:
1. At 10:45 a.m., there were 2 JE nitrous oxide cylinders secured with one chain, 2 H helium cylinders secured with one chain, 1 H helium cylinder and 1 H nitrogen cylinder loosely secured.

Based on document review, and interview, the facility failed to ensure the emergency generator is inspected weekly, as evidenced by the failure to provide documentation for the weekly visual inspections of the emergency generator. This failure could result in generator failure in the event of an emergency and affected Patients at two Outpatient Facilities.

Findings:

During document review and interview with Staff on June 4, 2012, through June 7, 2012, the generator log was reviewed.

Outpatient Services, 1835 Sunnycrest Drive, Fullerton on 6/6/12:
1. At 10:22 p.m., facility staff provided documentation for bi-weekly 30 minutes load test for the emergency generator. During interview, Staff stated they only document the bi-weekly load test and stated he did not document weekly visual inspections of the emergency generator. In addition Staff stated the emergency generator also provides emergency back up power for the Endoscopy Outpatient facility located at 1839 Sunnycrest Drive, Fullerton.

:

Based on observation, the facility failed to maintain its electrical equipment and appliances, in accordance with NFPA 70 National Electrical Code, as evidenced by failing to prevent electrical appliances from being plugged into a multi-plug power strip, and not directly into an electrical outlet, by failing to prevent the use of unapproved flexible extension cords and by the unauthorized use of electrical equipment such as flexible extension cords and power strips plugged into power strips (daisy chain). This failure could increase the risk of an electrical fire and or shock and could result in potential harm to patients in the affected smoke compartments.

NFPA 70, National Electrical Code 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the facility electrical wiring and equipment was observed.

North Building, Basement on 6/4/12:
1. At 1:48 p.m., there was a microwave and a refrigerator plugged into a multi-plug power strip and not directly into a electrical outlet in the Central Supply Storage area.
2. At 2:05 p.m., there was a white extension cord plugged into an other white extension cord that was plugged into a multi-plug power strip in the Outpatient Pharmacy.

Outpatient Services (Pre-op) at 1835 Sunnycrest Dr. Fullerton on 6/6/12:
3. At 9:26 a.m., there were four different desk that had multi-plug power strips plugged into another multi-plug power strip in the Patient Admitting Office (PAS). This was acknowledged by Staff during the survey.



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North Building, Fifth Floor on 6/4/12:
4. At 10:50 a.m., there was a refrigerator plugged into a surge protector and not directly into the wall in the Employee Lounge.

North Building, Fourth Floor on 6/4/12:
5. At 11:15 a.m., there was a recycling bin blocking access to the Electrical Panel NS-3 on the Fourth Floor.

North Building, First Floor on 6/4/12:
6. At 2:33 p.m., there was a biohazard cart blocking access to the Electrical Panel by the emergency exit in the Chemistry Lab.
7. At 2:40 p.m., there was a 6 plug adapter box plugged into a two receptacle outlet in the Lab Office.
8. At 2:45 p.m., there was a 6 plug multi-outlet adapter plugged into in a 4 plug adapter box in GI 3.

Original Building, Fourth Floor on 6/4/12:
9. At 3:10 p.m., there was a refrigerator plugged into an extension cord attached to the wall in the Pexis Room.

Based on observation the facility failed to maintain its electrical equipment and appliances, in accordance with NFPA 70 National Electrical Code, as evidenced by failing to prevent the use of a multi-outlet adapter. This could result in a electrical fire or shock resulting in potential harm to patients and staff in the affected smoke compartments.
Findings:
During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the electrical equipment and appliances were observed.

St Jude Plaza Surgery Center on 6/7/12:
1. At 10:00 a.m., there was a multi-outlet adapter attached to the wall in the Staff Lounge 4103.

Based on observation, the facility failed to maintain the building construction in 1 of 2 smoke compartments as evidenced by an unsealed penetration within the facility which had the potential to allow the spread of smoke during a fire and could result in harm to residents, staff and visitors.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by failing to repair and seal penetrations in the facility to prevent the spread of fire and smoke. This failure affected 2 of 2 compartments and could result in potential harm to Residents, staff and visitors.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the building construction was observed.

North Building, First Floor on 6/4/12:
1. At 2:20 p.m., there was an approximately 2 inch circular penetration in the Old Cashier Office.
2. At 2:30 p.m., there were five approximately 1 inch circular penetrations in the upper front wall by the door in the IDF1.1 Office.

Based on observation, the facility failed to maintain the integrity of the corridor doors to provide an effective smoke barrier in the event of a fire as evidenced by doors to patient rooms that failed to latch and by failing to keep impediments from obstructing the closing of doors. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 Edition.
15-2.3.3 Blocking or wedging of doors in the open position shall be prohibited.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the corridor doors were observed.

West Building, Second Floor on 6/4/12:
1. At 2:58 p.m., the door failed to latch when closed to Patient room 233.

2. At 3:01 p.m., the door failed to latch when closed to Patient room 234.

3. At 3:08 p.m., the corridor door strike plate was broken resulting in the doors failure to close for Patient room 240.

4. At 3:12 p.m., the corridor door strike plate was broken resulting in the doors failure to close for Patient room 243.

North Building, First Floor on 6/6/12:
5. At 1:57 p.m., the corridor door failed to latch when closed to CT Room 1.















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North Building, Fifth Floor on 6/4/12:
6. At 10:35 a.m., the bathroom door failed to latch shut when closed to Patient room 576.
7. At 10:40 a.m., the door failed to latch shut when closed to Patient room 572.

North Building, Third Floor on 6/4/12:
8. At 11:45 a.m., the door failed to latch shut due to chair propped to Patient room 377-2.
9. At 11:57 a.m., the door failed to latch shut when closed due to equipment in the corridor plugged into electrical outlet inside Patient room 360-2.

North Building, Second Floor on 6/4/12:
10. At 1:35 p.m., the door failed to latch shut when closed to Patient room 286.
11. At 1:40 p.m., the door failed to latch shut when closed to Patient room 273.

North Building, First Floor on 6/6/12:
12. At 1:57 p.m., the corridor to CT Room 1 failed to latch shut when closed.

Original Building, Third Floor on 6/4/12:
13. At 3:50 p.m., the door failed to latch shut when closed to RIE Room 2.

Original Building, Second Floor on 6/4/12:
14. At 4:10 p.m., the door failed to latch shut when closed to Room 205-1.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls to prevent the passage of smoke as evidenced by penetrations in the smoke barrier walls. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the smoke barrier walls were observed.
North Building, Fourth Floor on 6/4/12:
1. At 11:22 a.m., there was an approximately 1/2 inch penetration surrounding an orange cable in the center of the smoke barrier wall above the drop down ceiling at the entrance to Side 3.
North Building, Third Floor on 6/4/12:
2. At 11:40 a.m., there was an approximately 1/2 inch penetration below the upper pipe in the left center of the smoke barrier wall above the drop down ceiling by the 3 North Nurse Station 1.
Original Building, Third Floor on 6/4/12:
3. At 3:45 p.m., there was an approximately 1/2 inch penetration in the center of the smoke barrier wall above the drop down ceiling by Stair 8.
Original Building, Second Floor on 6/4/12:
4. At 4:00 p.m., there were two approximately 1 inch penetrations surrounding two pipes in the left center of the smoke barrier wall above the drop down ceiling by Room 204-2.

Based on observation, the facility failed to maintain the fire rated smoke barriers doors on magnetic devices to latch and resist the passage of smoke upon activation of the fire alarm system. This was evidenced by the failure of smoke barrier doors failing to latch upon closure. This could result in the potential spread of fire and smoke in the event of a fire, from one compartment to another causing harm to patients in the effected smoke compartments.

NFPA 101, Life Safety Code 2000 Edition
19.2.2.2.6* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility.

Findings:

During the testing of the Fire Alarm System with Staff on June 5, 2012, through June 7, 2012, the smoke barrier doors and doors on hold open devices were observed.

North Building, Second Floor on 6/5/12:
1. At 3:13 p.m., the smoke barrier door located next to the Nurse Station and Patient Room 282, released from its magnetic device, but failed to latch shut during the testing of the Fire Alarm System.




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North Building, Second Floor on 6/5/12:
2. At 3:15 p.m., the smoke barrier door left leaf failed to fully close and latch shut to the Unit Entrance.

North Building, First Floor on 6/6/12:
3. At 1:45 p.m., the two rear smoke barrier doors failed to latch shut to the X-Ray Room next to GI 3 and Chemistry Supplies.

North Building, Basement Floor on 6/6/12:
4. At 2:00 p.m., 1 of 2 smoke barrier doors failed to fully close and latch shut at the Entrance to the Equipment Depo.


West Building, Second Floor on 6/6/12:
5. At 3:25 p.m., the two entrance double smoke barrier doors left leafs failed to latch shut between 2 Main and 2 West.

Based on observation, the facility failed to maintain its fire rated smoke barriers doors on magnetic devices to latch upon activation of the fire alarm system and to resist the passage of smoke as evidenced by smoke barrier doors that failed to latch upon closure upon release of its magnetic device. This failure could result in the transfer of fire and or smoke in the event of a fire from one smoke compartment to another, resulting in potential harm to patients in the affected smoke compartments.

Findings:

During the testing of the fire alarm system with Staff on June 5, 2012, through June 7, 2012, the fire rated smoke barrier doors were observed.

Southwest Building, Third Floor on 6/5/12:
1. At 2:15 p.m., the smoke barrier door left leaf failed to latch shut by Room SW322.

Southwest Building, First Floor on 6/5/12:
2. At 2:25 p.m., the smoke barrier door left leaf failed to latch shut by Room SW90.

Based on observation, the facility failed to maintain the integrity of the fire rated doors and enclosure to provide an effective smoke barrier in the event of a fire as evidenced by failing to keep impediments from obstructing the closing of doors and failing to seal penetrations in the fire rated walls. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the hazardous areas were observed.

Southwest Tower, First Floor on 6/4/12:
1. At 11:22 a.m., there was card board stuck in the strike plate impeding the door from latching upon self-closure in the Trash and Linen room 172

Outpatient Services, Center for Rehabilitation and Wellness Center (CRW) on 6/7/12:
2. At 9:24 a.m., there was an unsealed penetration around the sprinkler escutcheon ring in the Elevator Equipment room 1145.
3. At 9:27 a.m.., there were two unsealed conduits in the left side of the wall behind the water heater in Equipment room 1122-A.

Based on observation the facility failed to maintain the Gift Shop as evidenced by the failure to maintain an 18 inch storage clearance from the ceiling. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

During a tour of the facility with Staff on June 4, 2012 through June 7, 2012, the Gift Shop was observed.

Original Building, First Floor on 6/6/12:
1. At 1:55 p.m., the shelves were stocked to the ceiling with stuffed animals and various items in the Gift Shop.

Based on observation and interview, the facility failed to provide an accessible egress, as evidenced by egress doors with two locks requiring a double action in order to open the doors. This failure could result in the delay of evacuation in the event of an emergency causing potential harm to residents in affected smoke compartments.
7.2.1.5.4* A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 in. (86 cm), and not more than 48 in.(122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the exit doors were observed.

St Jude Plaza Surgery Center on 6/7/12:
1. At 9:30 a.m., the entrance doors to the seven operating rooms and the six doors to the the Patient Recovery Area of the building were equipped with two locks requiring a double action if the doors were locked. The door could be locked on one side and required a key for the other side. The Administrator stated that the doors were never locked. The Administrator and Maintenance could open the doors with a key.

Based on observation and interview, the facility failed to ensure its Fire Alarm devices provide an effective warning in the event of a fire or other emergency as evidenced by a Inspectors Test Valve that was incorrectly labeled at the Main Fire Alarm Control Panel. This could delay notification to staff and emergency personnel in the event of a fire, and could result in potential harm to patients in the affected smoke compartments.

Findings:

During the testing of the Fire Alarm System with Staff on June 5, 2012, through June 7, 2012, the fire alarm devices were tested and observed.

Southwest Tower, First Floor on 6/5/12:
1. At 2:15 p.m., the Inspectors Test Valve (water flow) located on the First floor Stairwell #11, reported to the Fire Alarm Control Panel as Fifth Floor water flow. This was acknowledged and confirmed by the Fire Alarm Engineer that was conducting the test.

Based on observation, the facility failed to ensure audible devices in the facility provide an effective warning in the event of a fire or other emergency and failed to keep impediments from obstructing fire alarm devices from full instant use in the event of an emergency as evidenced by failure of audible devices and a manual pull station that was blocked by equipment. This could delay staff notification in the event of a fire, and could result in potential harm to patients in the affected smoke compartments.

Findings:

During the testing of the Fire Alarm System with Staff on June 5, 2012, through June 7, 2012, the fire alarm devices were observed.

North Building, Fifth Floor on 6/5/12:
1. At 2:50 p.m., a computer on wheels (cow's) was plugged into a receptacle and left unattended in front of a manual pull station, impeding the access to the manual pull station located across from Patient room 577.

North Building, Third Floor on 6/5/12:
2. At 3:00 p.m., during fire alarm testing the chime located across from Patient room 379 failed to activate an audible alarm.

North Building, First Floor on 6/6/12:
3. At 1:30 p.m., during fire alarm testing the chime located next to the Microbiology Managers office failed to activate an audible alarm.

North Building, Basement on 6/6/12
4. At 2:30 p.m., during fire alarm testing the chime located in the corridor next to Pharmacy failed to activate an audible alarm.
5. At 2:46 p.m., during fire alarm testing 1 of 1 chimes failed to activate an audible alarm in the Kitchen area. This failure was acknowledged by staff and the Fire Alarm Engineer that was conducting the test.



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North Building, First Floor on 6/4/12:
6. At 2:35 p.m., the manual pull station was blocked from access by a copy machine in the Microbiology Lab.

North Building, Fifth Floor on 6/5/12:
7. At 2:50 p.m., 1 of 4 fire alarms 5N3/1 failed to sound an alarm located across from Room 555.

North Building, Third Floor on 6/5/12:
8. At 3:05 p.m., the fire alarm N4/1 failed to sound an alarm.

North Building, Basement Floor on 6/6/12:
9. At 2:20 p.m., the alarm clicked but failed to activate and the overhead speaker could not be heard in the Surgery corridor in the the North Building.

West Building, Basement Floor on 6/6/12:
10. At 2:30 p.m., the fire alarm made a clicking sound but failed to activate in the Surgery corridor in the West Building.
11. At 3:20 p.m., the fire alarm/strobe failed to flash in MRI over the emergency plan.

Based on document review and interview, the facility failed to maintain the integrity of the smoke detection devices according to the manufactures recommendations as evidenced by incomplete sensitivity testing by a certified vendor and failing to provide documentation of a maintenance and battery replacement program for 6 of 6 battery powered smoke detectors. This failure could result in the smoke detection devices not functioning as designed in the event of a fire resulting in potential harm to patients and staff in the affected smoke compartments.

NFPA 72, National Fire Alarm Code 1999 Edition
NFPA 72 7-3.2.1 Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. after the second required calibration test, if sensitivity tests indicated that the detector has remained within its listed and marked sensitivity range (or 4% obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance show any increase over the previous year, calibration tests shall be performed.


NFPA 101, Life Safety Code 2000, Edition
4.6.12 Maintenances and Testing.
4.6.12.1 Whenever or wherever any device, equipment, sytem, 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.

Findings:

During record review and interview with staff on June 4, 2012 through June 7, 2012, documents were reviewed and staff interviewed.

Outpatient Services at 1901 Sunnycrest Drive, Fullerton on 6/6/12:
1. At 11:10 a.m., during document review and interview, the facility failed to provide documentation for the testing of 6 smoke detectors in the facility according to the manufactures specifications. During interview, Maintenance Staff stated they did not have documentation for the maintenance and testing of the battery powered smoke detectors. The Facility is non-sprinklered.




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2. At 10:30 a.m. on June 5, 2012, the sensitivity test provided by a certified vendor showed that 48 smoke detector devices were not tested. Interview with staff stated that areas were not accessible at the time of vendor testing and had not been retested. The areas were marked as follows: No access to device. DSD 3M7-5,6,8,9,10,11,12 2N8-6,8,9,12,17,18,19,20 3N8-6,7,8,9,14,16 4W7-7. SD 4N1-15 4N8-1,3,4,5,6,7,8,17,23,24,33,47 5N8-1,2,12,13 5N8-5 could not remove detector from base. DHS 1W1-17 door holder smoke detector 214 no access at time. DSD 1W3-9,10,11 unable to locate device. SD 2W1-19 DSD 2W3-14 to small of an access to device. 4W7-1 no access-above sensitive equipment or patient.

Based on observation, the facility failed to ensure portable Fire Extinguishers are accessible and not obstructed as evidenced by a Fire extinguisher that were blocked from view and access. This has the potential for inaccessibility to the fire extinguisher in the event of a fire resulting in potential harm to Patients in the affected smoke compartments.

NFPA 10, Standard for Portable Fire Extinguishers 1998 Edition
1-6 General Requirements.
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.
1-6.6 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility with Staff on June 4, 2012, through June 7, 2012, the Fire Extinguishers were observed.

North Building, First Floor on 6/6/12:
1. At 3:00 p.m., the Fire Extinguisher was obstructed from access and view by a Clean Linen Cart that was left unattended in front of the Fire Extinguisher in the MRI Suite. There was no sign above the Extinguisher indicating a Fire Extinguisher was in the location.


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West Building, Basement Floor on 6/6/12:
2. At 2:30 p.m., the fire hose was blocked from access by a cart in the West Building Operating Room corridor next to the fire alarm.

3. At 3:15 p.m., 1 of 2 portable fire extinguishers was obstructed from view by a soiled linen cart in MRI.

Based on observation, the facility failed to maintain the smoking areas as evidenced by the failure to provide self-closing containers for the disposal of the cigarettes. This failure has the potential for an outside fire.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the smoking area was observed.

1. At 9:40 a.m. on June 5, 2012, the ashtrays provided contained 3 open containers with approximately 60 cigarette butts in each container in the smoking area adjacent to the Original Building.

Based on observation and interview, the facility failed to maintain their means of egress free from obstructions and or impediments as evidenced by a door that was impeded. This failure could result in the delayed evacuation of patients in the affected area and had the potential for the spread of fire or smoke in the event of a fire affecting patients in the affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the means of egress were observed.
Southwest Building, Basement Floor on 6/5/12:
1. At 2:35 p.m., the right leaf was blocked from access by a gurney at the exit double door by Room SWB158.

Based on observation and interview, the facility failed to maintain their means of egress free from obstructions and or impediments as evidenced by doors that were blocked or failed to close. This failure could result in the delayed evacuation and has the potential for the spread of fire or smoke in the event of a fire affecting patients in the affected smoke compartments.

Findings:

During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the means of egress were observed.
Original Building, Fourth Floor on 6/4/12:
1. At 3:20 p.m., the emergency exit door failed to fully close and latch to Stair 7.

North Building, Fifth Floor on 6/5/12:
2. At 2:45 p.m., the left leaf to the double door by Room 584, was blocked from access by a bed.

Based on observation, the facility failed to maintain the compressed gas cylinders in the Gas Cylinder Bulk Storage Area as evidenced by tanks secured with one chain and not individually secured. This failure could result in the spread of fire and smoke in the event of a fire causing potential harm to patients in affected smoke compartments.

NFPA 99 (1999 Edition) 8-3.1.11.2 (h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.

NFPA 99 (1999 edition), 4-3.5.2.1(b) 27 Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the facility compressed gas cylinder storage areas were observed.

Gas Cylinder Bulk Storage Area behind Main Hospital on 6/6/12:
1. At 10:45 a.m., there were 2 JE nitrous oxide cylinders secured with one chain, 2 H helium cylinders secured with one chain, 1 H helium cylinder and 1 H nitrogen cylinder loosely secured.

Based on document review, and interview, the facility failed to ensure the emergency generator is inspected weekly, as evidenced by the failure to provide documentation for the weekly visual inspections of the emergency generator. This failure could result in generator failure in the event of an emergency and affected Patients at two Outpatient Facilities.

Findings:

During document review and interview with Staff on June 4, 2012, through June 7, 2012, the generator log was reviewed.

Outpatient Services, 1835 Sunnycrest Drive, Fullerton on 6/6/12:
1. At 10:22 p.m., facility staff provided documentation for bi-weekly 30 minutes load test for the emergency generator. During interview, Staff stated they only document the bi-weekly load test and stated he did not document weekly visual inspections of the emergency generator. In addition Staff stated the emergency generator also provides emergency back up power for the Endoscopy Outpatient facility located at 1839 Sunnycrest Drive, Fullerton.

:

Based on observation, the facility failed to maintain its electrical equipment and appliances, in accordance with NFPA 70 National Electrical Code, as evidenced by failing to prevent electrical appliances from being plugged into a multi-plug power strip, and not directly into an electrical outlet, by failing to prevent the use of unapproved flexible extension cords and by the unauthorized use of electrical equipment such as flexible extension cords and power strips plugged into power strips (daisy chain). This failure could increase the risk of an electrical fire and or shock and could result in potential harm to patients in the affected smoke compartments.

NFPA 70, National Electrical Code 1999 Edition
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Findings:

During a tour of the facility with staff on June 4, 2012 through June 7, 2012, the facility electrical wiring and equipment was observed.

North Building, Basement on 6/4/12:
1. At 1:48 p.m., there was a microwave and a refrigerator plugged into a multi-plug power strip and not directly into a electrical outlet in the Central Supply Storage area.
2. At 2:05 p.m., there was a white extension cord plugged into an other white extension cord that was plugged into a multi-plug power strip in the Outpatient Pharmacy.

Outpatient Services (Pre-op) at 1835 Sunnycrest Dr. Fullerton on 6/6/12:
3. At 9:26 a.m., there were four different desk that had multi-plug power strips plugged into another multi-plug power strip in the Patient Admitting Office (PAS). This was acknowledged by Staff during the survey.



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North Building, Fifth Floor on 6/4/12:
4. At 10:50 a.m., there was a refrigerator plugged into a surge protector and not directly into the wall in the Employee Lounge.

North Building, Fourth Floor on 6/4/12:
5. At 11:15 a.m., there was a recycling bin blocking access to the Electrical Panel NS-3 on the Fourth Floor.

North Building, First Floor on 6/4/12:
6. At 2:33 p.m., there was a biohazard cart blocking access to the Electrical Panel by the emergency exit in the Chemistry Lab.
7. At 2:40 p.m., there was a 6 plug adapter box plugged into a two receptacle outlet in the Lab Office.
8. At 2:45 p.m., there was a 6 plug multi-outlet adapter plugged into in a 4 plug adapter box in GI 3.

Original Building, Fourth Floor on 6/4/12:
9. At 3:10 p.m., there was a refrigerator plugged into an extension cord attached to the wall in the Pexis Room.

Based on observation the facility failed to maintain its electrical equipment and appliances, in accordance with NFPA 70 National Electrical Code, as evidenced by failing to prevent the use of a multi-outlet adapter. This could result in a electrical fire or shock resulting in potential harm to patients and staff in the affected smoke compartments.
Findings:
During a tour of the facility with staff on June 4, 2012, through June 7, 2012, the electrical equipment and appliances were observed.

St Jude Plaza Surgery Center on 6/7/12:
1. At 10:00 a.m., there was a multi-outlet adapter attached to the wall in the Staff Lounge 4103.