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Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed the following corridor doors would not close when tested as the installed door closing device were disconnected or impeded.

1. Third floor, triage door number 3127, door closing device disconnected
2. Second floor, Lab door number E 2464 will not close tight and positively latch, as a bolt has been screwed into the door frame
3. Second floor, Cath Lab, room one and two, door closing devices removed
4. First floor, D 1193 and 1193 A, R/F# two, door closing devices removed
5. First floor, D 1209, X-Ray # three, door closing device removed
6. First floor, E 1312 B, in patient Admitting, door with a closing device impeded by a table and door wedge
7. First floor, E 1361 A door with closing device impeded by a trash can

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM..

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 requires that hazardous areas be
separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed the Anesthesia Workroom door E 2444, the door rated at sixty minutes with a door closing device had been tied open with wire, and would not close and positively latch.

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM

The tied open door could allow heat and smoke to spread into the exit corridor which could cause harm to residents.

Based on observation and testing the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1, Section 18.2.1 states that exit components shall be in accordance with Chapter 7. Section 7.2.1.6.1(c) " An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15lbf nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.

Findings Include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed and tested Door G 3008, North to South, the door did not have an audible signal.

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM.

Failure of the exit door to operate during an emergency could harm residents, staff and other occupants.

Based on observation, interview and review of " Code Red-Fire Response Procedure " , it was determined the facilities failed to implement their written plan for the protection of all patients in time of a fire or emergency.
NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.1.1 reveals: "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 a fire, for their evacuation to areas of refuge, and from the 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. "
Findings include:
On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager discussed the review of the written emergency " Code Red-Fire Response Procedure " policy manual.
A review of facilities documentation and photos from April 16, 2013 at 10:02 AM revealed a Fire Alarm with smoke was transmitted from the Angio equipment room because the Siemens control cabinet transformer burnt up. The circuit breaker tripped, the first security officer (I.C.) on scene announced all clear one minute later at 10:03 AM. And canceled the Fire Department response. The security officer statement included, there was no active fire, very light smoke and odor, consistent with an electrical problem, and he saw no need with his training of having the Fire Department respond. At 10:17 Plant Operations restored the fire panel to normal condition and PBX announced All Clear overhead.
Facility policy " Code Red-Fire Response Procedure " , Page 4 of 5 # 7. Indicates " Consult with Fire Department Incident Commander for further actions. " Recovery: # 5 " insure all evidence is secure from fire scene working with Fire Department " . These two actions did not happen as Fire Response was canceled.
NFPA 101 2000 edition, 18.7.2.1* 2 Transmission of alarm to the fire department and #5 Evacuation of Immediate area.
A Patient was undergoing a procedure at the time of the incident and not evacuated from the immediate area. The Security Officer stated during interview there was visible smoke in the corridor. Oxygen was present during the procedure where a high voltage fire occurred in the equipment room. With smoke and, heat, toxic gases would be present.
During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM.

In time of an emergency, an emergency policy manual must be readily available for the staff. Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observation the facility failed to provide a medical gas cylinder storage room free of combustible materials, and the facility failed to secure oxygen bottles.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", Chapter 8, Section 8-3.1.11 "Storage Requirements, Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic, feet. " (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...." Chapter 4, Section 4-3.5.2.1 (b) "Special Precautions - Oxygen Cylinders and Manifolds". (27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings Include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed the following oxygen storage areas;

1. Forth floor, Rehab services, 1 E-02 bottle stored by combustibles and electrical
2. Forth floor, A wing equipment room, 1-E 02 bottle outside of, and next to an approved oxygen cabinet, stored by electrical and combustibles
3. Third floor, G 3112 storage room, 3 E 02 bottles stored
4. Second floor, OR-2 1 E 02 bottle unsecured laying on the floor
5. CYSTO corridor, 1 O2 bottle laying on a bed unsecured

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients and staff. Failing to secure compressed gas cylinders could cause harm to the residents/patients.

Based on observation the facility failed to maintain corridor doors to resist the passage of heat/smoke.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.3.6.3.1, 18.3.6.3.2, 18.3.6.3.3. Section 18.3.6.3.1 "Doors protecting corridor openings shall be constructed to resist the passage of smoke. Clearance between the bottom of the door and the floor covering not exceeding 1 in. shall be permitted for corridor doors." Section 18.3.6.3.2 "Doors shall be provided with positive latching hardware. Roller latches shall be prohibited." Section 18.3.6.3.3 "Hold -open devices that release when the door is pushed or pulled shall be permitted."

Findings Include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed the following corridor doors would not close when tested as the installed door closing device were disconnected or impeded.

1. Third floor, triage door number 3127, door closing device disconnected
2. Second floor, Lab door number E 2464 will not close tight and positively latch, as a bolt has been screwed into the door frame
3. Second floor, Cath Lab, room one and two, door closing devices removed
4. First floor, D 1193 and 1193 A, R/F# two, door closing devices removed
5. First floor, D 1209, X-Ray # three, door closing device removed
6. First floor, E 1312 B, in patient Admitting, door with a closing device impeded by a table and door wedge
7. First floor, E 1361 A door with closing device impeded by a trash can

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM..

In time of a fire failing to protect patients from heat and smoke could cause harm to the patients.

Based on observation the facility did not maintain the integrity, smoke resistance, of doors in hazardous areas.

NFPA 101, Life Safety Code, 2000, Chapter 18, Section 18.3.2.1 requires that hazardous areas be
separated and/or protected by one hour rated construction and automatic sprinklers. If protected by automatic sprinklers the walls and doors must be able to resist the passage of smoke. NFPA 80 "Fire Doors and Fire Windows" Chapter 2, Section 2-3.1.7 "The clearance between the edge of the door on the pull side and the frame, and the meeting edges of doors swinging in pairs on the pull side shall be 1/8 in. +/- 1/16 in for steel doors and shall not exceed 1/8 in. for wood doors.

Findings include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed the Anesthesia Workroom door E 2444, the door rated at sixty minutes with a door closing device had been tied open with wire, and would not close and positively latch.

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM

The tied open door could allow heat and smoke to spread into the exit corridor which could cause harm to residents.

Based on observation and testing the facility did not keep exits readily accessible at all times.

NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.2.1, Section 18.2.1 states that exit components shall be in accordance with Chapter 7. Section 7.2.1.6.1(c) " An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15lbf nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.

Findings Include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed and tested Door G 3008, North to South, the door did not have an audible signal.

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM.

Failure of the exit door to operate during an emergency could harm residents, staff and other occupants.

Based on observation, interview and review of " Code Red-Fire Response Procedure " , it was determined the facilities failed to implement their written plan for the protection of all patients in time of a fire or emergency.
NFPA 101 Life Safety Code, 2000, Chapter 18, Section 18.7.1.1 reveals: "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 a fire, for their evacuation to areas of refuge, and from the 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. "
Findings include:
On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager discussed the review of the written emergency " Code Red-Fire Response Procedure " policy manual.
A review of facilities documentation and photos from April 16, 2013 at 10:02 AM revealed a Fire Alarm with smoke was transmitted from the Angio equipment room because the Siemens control cabinet transformer burnt up. The circuit breaker tripped, the first security officer (I.C.) on scene announced all clear one minute later at 10:03 AM. And canceled the Fire Department response. The security officer statement included, there was no active fire, very light smoke and odor, consistent with an electrical problem, and he saw no need with his training of having the Fire Department respond. At 10:17 Plant Operations restored the fire panel to normal condition and PBX announced All Clear overhead.
Facility policy " Code Red-Fire Response Procedure " , Page 4 of 5 # 7. Indicates " Consult with Fire Department Incident Commander for further actions. " Recovery: # 5 " insure all evidence is secure from fire scene working with Fire Department " . These two actions did not happen as Fire Response was canceled.
NFPA 101 2000 edition, 18.7.2.1* 2 Transmission of alarm to the fire department and #5 Evacuation of Immediate area.
A Patient was undergoing a procedure at the time of the incident and not evacuated from the immediate area. The Security Officer stated during interview there was visible smoke in the corridor. Oxygen was present during the procedure where a high voltage fire occurred in the equipment room. With smoke and, heat, toxic gases would be present.
During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM.

In time of an emergency, an emergency policy manual must be readily available for the staff. Patients will be harmed if the Staff is not trained or is unable to locate the emergency evacuation policy manual.

Based on observation the facility failed to provide a medical gas cylinder storage room free of combustible materials, and the facility failed to secure oxygen bottles.

NFPA 101 Life Safety Code 2000, Chapter 18, Section 18.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99 Standard for Health Care Facilities" NFPA 99, "Health Care Facilities", Chapter 8, Section 8-3.1.11 "Storage Requirements, Section 8-3.1.11.2 "Storage of nonflammable gases less than 3000 cubic, feet. " (a) "Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. (c) "Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by: (c) (2) A minimum distance of 5 ft. if the entire storage location is protected by an automatic sprinkler system...." Chapter 4, Section 4-3.5.2.1 (b) "Special Precautions - Oxygen Cylinders and Manifolds". (27) "Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart."

Findings Include:

On May 21, 2013, the surveyor, accompanied by the Manager of Plant Operations and the EOC Program Manager observed the following oxygen storage areas;

1. Forth floor, Rehab services, 1 E-02 bottle stored by combustibles and electrical
2. Forth floor, A wing equipment room, 1-E 02 bottle outside of, and next to an approved oxygen cabinet, stored by electrical and combustibles
3. Third floor, G 3112 storage room, 3 E 02 bottles stored
4. Second floor, OR-2 1 E 02 bottle unsecured laying on the floor
5. CYSTO corridor, 1 O2 bottle laying on a bed unsecured

During the exit conference on May 22, 2013, the above findings were again acknowledged by the Vice President of Operations, ECO Program Manager, Manager of Plant Operations, Safety Risk Analyst QM, Dignity Health Director Pt. safety and Accrediting, Director of QM.

Leaking oxygen will penetrate combustible material and create an extreme fire hazard, which will cause harm to the patients and staff. Failing to secure compressed gas cylinders could cause harm to the residents/patients.