HospitalInspections.org

Based on observation, the facility failed to maintain their fire doors to operate without interference and to prevent the passage of smoke or fire. This was evidenced by fire doors equipped with self-closing/automatic-closing mechanisms that failed to close when tested and that were impeded from closing. This could result in the spread of smoke and fire, increasing the risk of injury to patients. This failure affected 1 of 10 floors in the McLeod Tower at the Palomar Health Downtown Campus and 1 of 11 floors in the Palomar Medical Center.

NFPA 101 - Life Safety Code, 2012 Edition
19.2.2.2.7* 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.
7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic-closing, provided that all of the following criteria are met:
(1) Upon release of the hold-open mechanism, the leaf becomes self-closing.
(2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self-closing, or the leaf can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing.

Findings:

During a tour of the facility with the Hospital Engineering Staff from 8/14/2017 to 8/17/2017, the fire doors equipped with self-closing/automatic-closing mechanisms were observed.

McLeod Tower at Palomar Health Downtown Campus, 8/16/2017:
1. At 1:37 p.m., the center core fire door #DH5:4, located by the Nurse Station on the 5th Floor, failed to close after activating the fire alarm system. The door remained open and was observed to not have adequate clearance between the bottom of the door and the floor. The door was also impeded from closing by a medical records transport cart that was placed along the door closing pathway. The Hospital Staff FACS-3, FACS-4, and FACS-8 were present when the deficiency was identified.



Palomar Medical Center, 8/15/2017:
2. At 9:13 a.m., on the 5th floor, the self closing door to Room # 05-748 was tested. The door was fully opened and released. When the door closed, the door failed to positively latch.

The above findings were acknowledged during the exit conference on 8/17/17 by FACS-1 and the Hospital's Facilities Staff.

Based on document review, observation and staff interview, the facility failed to maintain the width of exit access corridors. This was evidenced by patient beds placed in the egress corridor. This could result in the delayed evacuation of patients in the event of an emergency. This failure affected 1 of 11 floors in the Palomar Medical Center.

NFPA 101 - Life Safety Code, 2012 Edition
19.2.3.4* Any required aisle, corridor, or ramp shall be not less than 48 in. (1220 mm) in clear width where serving as means of egress from patient sleeping rooms, unless otherwise permitted by one of the following:
(1) Aisles, corridors, and ramps in adjunct areas not intended for the housing, treatment, or use of inpatients shall be not less than 44 in. (1120 mm) in clear and unobstructed width.
(2)*Where corridor width is at least 6 ft (1830 mm), noncontinuous projections not more than 6 in. (150 mm) from the corridor wall, above the handrail height, shall be permitted.
(3) Exit access within a room or suite of rooms complying with the requirements of 19.2.5 shall be permitted.
(4) Projections into the required width shall be permitted for wheeled equipment, provided that all of the following conditions are met:
(a) The wheeled equipment does not reduce the clear unobstructed corridor width to less than 60 in.(1525 mm).
(b) The health care occupancy fire safety plan and training program address the relocation of the wheeled equipment during a fire or similar emergency.
(c)*The wheeled equipment is limited to the following:
i. Equipment in use and carts in use
ii. Medical emergency equipment not in use
iii. Patient lift and transport equipment
(5)*Where the corridor width is at least 8 ft (2440 mm), projections into the required width shall be permitted for fixed furniture, provided that all of the following conditions are met:
(a) The fixed furniture is securely attached to the floor or to the wall.
(b) The fixed furniture does not reduce the clear unobstructed corridor width to less than 6 ft (1830 mm), except as permitted by 19.2.3.4(2).
(c) The fixed furniture is located only on one side of the corridor.
(d) The fixed furniture is grouped such that each grouping does not exceed an area of 50 ft2 (4.6 m2).
(e) The fixed furniture groupings addressed in 19.2.3.4(5)(d) are separated from each other by a distance of at least 10 ft (3050 mm).
(f)*The fixed furniture is located so as to not obstruct access to building service and fire protection equipment.
(g) Corridors throughout the smoke compartment are protected by an electrically supervised automatic smoke detection system in accordance with 19.3.4, or the fixed furniture spaces are arranged and located to allow direct supervision by the facility staff from a nurses' station or similar space.
(h) The smoke compartment is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.8.
19.2.3.5 The aisle, corridor, or ramp shall be arranged to avoid any obstructions to the convenient removal of nonambulatory persons carried on stretchers or on mattresses serving as stretchers.

Findings:

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the facility exit passageways were observed.

Palomar Medical Center, 8/16/2017:
At 9:16 a.m., on the 1st floor in the Emergency Department POD A, two emergency bed stations were set up along the egress corridor. The corridor measured 8 feet wide. The two beds and a privacy screen minimized the corridor passage way to approximately 4.5 feet wide. During an interview, staff stated the beds were used as overflow treatment areas for ambulatory patients. The two stations are utilized on a regular basis.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation and staff interview, the facility failed to maintain the fire alarm system. This was evidenced by an ear-piercing sound emitted from fire alarm notification devices and by a strobe light that failed to illuminate when tested. This could result in injury to occupants and could result in the failure to notify occupants of a fire emergency. This failure affected 2 of 2 floors at the Palomar Outpatient Services Building and 1 of 4 floors in the Adams Wing at the Palomar Health Downtown Campus.

NFPA 101 - Life Safety Code, 2012 Edition
9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72 - National Fire Alarm and Signaling Code, 2010 Edition
18.4.1.2* The total sound pressure level produced by combining the ambient sound pressure level with all audible notification appliances operating shall not exceed 110 dBA at the minimum hearing distance.
18.4.1.3* Sound from normal or permanent sources, having a duration greater than 60 seconds, shall be included when
measuring maximum ambient sound level. Sound from temporary or abnormal sources shall not be required to be included when measuring maximum ambient sound level.

Findings:

During a tour of the facility with the Hospital Engineering Staff from 8/14/2017 to 8/17/2017, the fire alarm system was tested and observed.

Palomar Outpatient Services, 8/16/2017
1. At 11:12 a.m., during testing of the fire alarm system, staff and patients complained the alarm was extremely loud. Several patients and staff members exited the building when the testing of the fire alarm commenced due to the extreme loudness of the notification devices. Staff confirmed the fire alarm system was very loud, especially in Suite 109.

Adams Wing at Palomar Health Downtown Campus, 8/16/2017
2. At 2:36 p.m., on the 2nd floor, the chime/strobe combo outside of the Kitchen Wash Area, failed to illuminate during testing of the fire alarm system. The chime functioned as designed, the strobe did not.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 101, 2012 Edition. This was evidenced by failing to complete monthly visual inspections of components to the wet pipe sprinkler system, by cover plates to recessed type sprinklers that were missing, and by valves that did not display signs to indicate the areas it controls. This could affect the operation of the sprinkler system causing delay in extinguishing a fire resulting in injury to patients. This affected all Palomar Health Campuses containing automatic wet pipe sprinkler system.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.
9.7.5 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.
9.7.8 Record Keeping. Testing and maintenance records required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, shall be maintained at an approved, secured location.

NFPA 25 - Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition
5.2.4.1* Gauges on wet pipe sprinkler systems shall be inspected monthly to ensure that they are in good condition and that normal water supply pressure is being maintained.
13.3.1* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.
13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.
13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.
13.3.2.2* The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2)*Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification
13.4.1 Inspection of Alarm Valves. Alarm valves shall be inspected as described in 13.4.1.1 and 13.4.1.2.
13.4.1.1* Alarm valves and system riser check valves shall be externally inspected monthly and shall verify the following:
(1) The gauges indicate normal supply water pressure is being maintained.
(2) The valve is free of physical damage.
(3) All valves are in the appropriate open or closed position.
(4) The retarding chamber or alarm drains are not leaking.
Table E.1 Examples of Classifications of Needed Corrections and Repairs
*Item: Sprinklers; Finding: Leaking, heavily corroded, painted operating element or bulb or deflector or cover plate, heavily loaded, foreign materials attached to or suspended from, improper orientation, glass bulbs that have lost fluid; Reference: 5.2.1.1.1.
*Item: Escutcheons; Finding: Missing, painted, or rusted; Reference: 5.2.1.1.4.
*Item: Control valve; Finding: Not sealed, locked, or supervised, not accessible, no appropriate wrench if required, and no identification; Reference: 13.3.2.2

Findings:

During document review with the Facility Manager on 8/14/17, the sprinkler system's testing and inspection records were reviewed.

1. At 11:45 a.m., the testing and inspection records provided for the wet pipe sprinkler system, failed to include the monthly visual inspections of the alarm valves, gauges, and control valves. The Facility Manager was interviewed and he stated that he did not document the monthly visual inspections of the sprinkler system's alarm valves, gauges, and control valves they were doing daily.


During a tour of the facility with the Hospital Staff from 8/14/2017 through 8/17/2017, the sprinkler system was observed.

Palomar Medical Center, 8/14/2017:
2. At 11:54 a.m., two recessed type sprinklers, located in Room 354A by the MRI and CT Rooms, were missing their cover plates. The Hospital Staff FACS-2 was present when the deficiency was identified.

McLeod Tower at Palomar Health Downtown Campus, 8/16/2017:
3. At 2:34 p.m., the valves, located on the 2nd Floor in the stairwell landing by Elevators 1 and 2, failed to have a sign that identified the area/s of the building it controlled. During an interview with Hospital Staff FACS-8, he was unable to readily identify the sprinkler test valves for the McLeod Tower. The Hospital Staff FACS-3, FACS-4, and FACS-8 were present when the deficiency was identified.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation, the facility failed to maintain their fire extinguishers. This was evidenced by a fire extinguisher that was mounted above the maximum allowed height. This had the potential to delay the removal of the fire extinguishers from their mounts and cause delay in extinguishing a fire. This failure affected 1 of 4 floors in the Adams Wing at the Palomar Health Downtown Campus.

NFPA 101 - Life Safety Code, 2012 Edition.
19.3.5.12 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 selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10 - Standard for Portable Fire Extinguishers, 2010 Edition.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

Findings:

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the fire extinguishers were observed.

Adams Wing at Palomar Health Downtown Campus:
At 11:27 a.m., there was an ABC-type fire extinguisher in the kitchen, located on the 2nd Floor, that was mounted above 60-inches. The fire extinguisher was located by the Men's restroom and it measured approximately 70-inches from the floor to the handle. The fire extinguisher was labeled to have a gross weight that was less than 40-pounds. The Hospital Staff FACS-3 and FACS-4 were present when the deficiency was identified.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by doors that failed to positively latch and be maintained closed when applying force on the doors. This could result in the rapid spread of smoke and fire throughout the facility, resulting in injury to patients. This failure affected 1 of 10 floors in the McLeod Tower at the Palomar Health Downtown Campus and 1 of 11 floors in the Palomar Medical Center.

NFPA 101 - Life Safety Code, 2012 Edition
19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.
A.19.3.6.3.10 Doors should not be blocked open by furniture, door stops, chocks, tie-backs, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action to close. Examples of hold-open devices that release when the door is pushed or pulled are friction catches or magnetic catches.

Findings:

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the corridor doors were observed.

McLeod Tower at Palomar Health Downtown Campus, 8/16/2017:
1. At 3:29 p.m., the corridor door to the Patient Room 220, located in the Behavioral Health Unit that was on the 2nd Floor, failed latch and remain closed when applying a five pound force. The Hospital Staff FACS-3 and FACS-8 were present when the deficiency was identified.

2. At 3:30 p.m., the corridor door to the Patient Room 221, located in the Behavioral Health Unit that is on the 2nd Floor, failed latch and remain closed when applying a five pound force. The Hospital Staff FACS-3 and FACS-8 were present when the deficiency was identified.


Palomar Medical Center, 8/15/2017:
3. At 9:40 a.m., on the 6th floor, the corridor door to Resident Room 674 (#06-754) failed to positively latch when closed. The door was tested three times. Staff confirmed the door failed to latch.

4. At 9:54 a.m., on the 6th floor, the corridor door to Resident Room 622 (#06-552) failed to positively latch when closed. The door was tested three times. Staff confirmed the door failed to latch.

5. At 10:02 a.m., on the 6th floor, the corridor door to Resident Room 610 (#06-576) failed to positively latch when closed. The door was tested three times. Staff confirmed the door failed to latch.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation and staff interview, the facility failed to maintain the fire doors. This was evidenced by two doors that remained fully open during testing of the fire alarm system. This could result in the passage of smoke in the event of a fire. This failure affected 1 of 11 floors in the Palomar Medical Center.

NFPA 101 Life Safety Code, 2012 Edition
19.3.7.6 Openings in smoke barriers shall be protected using one of the following methods:
(1) Fire-rated glazing
(2) Wired glass panels in steel frames
(3) Doors, such as 1 3/4 in. (44 mm) thick, solid-bonded wood-core doors
(4) Construction that resists fire for a minimum of 20 minutes.
19.3.7.8* Doors in smoke barriers shall comply with 8.5.4 and all of the following:
(1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7.
(2) Latching hardware shall not be required
(3) The doors shall not be required to swing in the direction of egress travel.
8.5.4 Opening Protectives.
8.5.4.1* Doors in smoke barriers shall close the opening, leaving only the minimum clearance necessary for proper operation, and shall be without louvers or grilles. The clearance under the bottom of a new door shall be a maximum of 3/4 in. (19 mm).
8.5.4.2 Where required by Chapters 11 through 43, doors in smoke barriers that are required to be smoke leakage-rated shall comply with the requirements of 8.2.2.4.
8.5.4.3 Latching hardware shall be required on doors in smoke barriers, unless specifically exempted by Chapters 11 through 43.
8.5.4.4* Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1.
8.5.4.5 Fire window assemblies shall comply with 8.3.3.

Findings

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the facility fire doors were observed.

Palomar Medical Center, 8/16/2017:
At 9:20 a.m., on the 1st floor in the Emergency Department POD B, Fire Doors # 01-300 were observed. When the fire alarm system was activated, the two fire doors remained fully open. The doors failed to release and close. Staff confirmed the doors failed to release from the control mechanism.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation and staff interview, the facility failed to maintain electrical safety. This was evidenced by junction boxes that were not completely covered. This could result in the spread of an electrical fire. This failure affected 1 of 10 floors in the McLeod Tower and 1 of 6 floors in the West Tower at the Palomar Health Downtown Campus.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 Edition
406.6 Receptacle Faceplates (Cover Plates). Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface. Receptacle faceplates mounted inside a box having a recess-mounted receptacle shall effectively close the opening and seat against the mounting surface.

Findings:

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the facility wall outlets were observed.

McLeod Tower at Palomar Health Downtown Campus, 8/16/17:
1. At 3:33 p.m., on the 5th floor in Resident Room 509, the cover plate for the junction box above the resident bed was broken. The junction box contents were exposed.

West Tower at Palomar Health Downtown Campus, 8/17/17:
2. At 9:02 a.m., on the 3rd floor in the Old Medical Records Department, the cover plate for the wall outlet was hanging off the wall. The contents of the junction box were exposed.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation, the facility failed to maintain the electrical safety as evidenced by the non compliant use of extension cords and surge protectors. This could result in an electrical fire. This failure affected 1 of 1 floors at the Palomar Outpatient Behavioral Health Services and 1 of 6 floors in the West Tower at the Palomar Health Downtown Campus.

NFPA 101, Life Safety Code, 2012 edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.
9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 edition
400.8 Uses Not Permitted. Unless specifically permitted in 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 to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage
590.3 Time Constraints.
(A) During the Period of Construction. Temporary electric power and lighting installations shall be permitted during the period of construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities.
(B) 90 Days. Temporary electric power and lighting installations shall be permitted for a period not to exceed 90 days for holiday decorative lighting and similar purposes.
(D) Removal. Temporary wiring shall be removed immediately upon completion of construction or purpose for which the wiring was installed.

Findings

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the facility electrical equipment was observed.

Palomar Outpatient Behavioral Health Services, 8/16/2017:
1. At 12:47 p.m., in the Interview Room, computer equipment was plugged into a surge protected power strip. The power strip was plugged into an extension instead of directly into a wall outlet.

2. At 12:49 p.m., in the Program Nurse Office, a surge protected power strip under the desk was plugged into a surge protected power strip instead of directly into the wall outlet.

West Tower at Palomar Health Downtown Campus, 8/17/2017:
3. At 9 a.m., on the 3rd floor in the Administration Office, under the Receptionist Desk, computer equipment was plugged into a surge protected power strip. The power strip was plugged into another power strip instead of directly into a wall outlet.

4. At 9:06 a.m., on the 3rd floor in the ED break room, a microwave was plugged into a power strip instead of directly into the wall outlet.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation, the facility failed to properly store their portable oxygen cylinders. This was evidenced by oxygen cylinders that were not properly secured. This could cause harm to patients or staff in the event that the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 2 of 11 floors in the Palomar Medical Center.

NFPA 99 - Health Care Facilities, 2012 Edition
11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures: (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During a tour of the facility with the Hospital Staff from 8/14/2017 to 8/17/2017, the oxygen cylinders storage areas were observed.

Palomar Medical Center, 8/15/2017:
1. At 10:51 a.m., the oxygen cylinder, located in Equipment Room 08-620A on the 8th Floor, was found standing upright and unsecured. The oxygen cylinder was an E-size, containing approximately 24 cubic feet of volume. The Hospital Staff FACS-2 was present when the deficiency was identified.


Palomar Medical Center, 8/15/2017:
2. At 9:23 a.m., on the 6th floor, in the Equipment Room (#06-620A), an E-sized oxygen tank was found unsecured. The tank was observed free standing next to a storage rack.

3. At 9:58 a.m., on the 6th floor, in the Equipment Room 3 (#06-576), an E-sized oxygen tank was found unsecured. The tank was observed free standing next to a storage rack.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.

Based on observation, the facility failed to display all required signage. This was evidenced by failing to have signage at the bulk oxygen systems that includes the minimum wording "OXYGEN - NO SMOKING - NO OPEN FLAMES." This had the potential for causing fire and result in injury to patients. This failure affected the bulk oxygen system at the Palomar Health Downtown Campus.

NFPA 99 - Health Care Facilities, 2012 Edition
5.1.3.5.12.1 Bulk cryogenic liquid storage systems shall be in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code.

NFPA 55 - Compressed Gases and Cryogenic Fluids Code, 2010 Edition
4.10.3 No Smoking Signs. Signs prohibiting smoking shall be provided for an entire site or building, or in the following locations:
(1) In rooms or areas where hazardous materials are stored or dispensed or used in open systems in amounts requiring a permit in accordance with Section 4.1
(2) Within 25 ft (7.6 m) of outdoor storage, dispensing, or open-use areas
(3) In areas containing flammable gases
9.4.4 Signage. The bulk oxygen storage location shall be permanently placarded to read as follows:
OXYGEN - NO SMOKING - NO OPEN FLAMES

Findings:

During a tour of the facility with the Hospital Staff FACS-3 and FACS-8 on 8/17/2017, the area containing the bulk oxygen system was observed.

Palomar Health Downtown Campus:
At 8:57 a.m., the area surrounding the outdoor enclosure to the bulk oxygen system, failed to display signage that included "OXYGEN - NO SMOKING - NO OPEN FLAMES" and that was visible from all entry points to the system. The bulk oxygen system included a 6,000 gallon storage tank that was at 220 inches of water column and a 500 gallon storage tank that was at 40 inches of water column. The Hospital Staff FACS-3 and FACS-8 were present when the deficiency was identified.

The above findings were acknowledged during the exit conference on 8/17/2017 by FACS-1 and the Hospital's Facilities Staff.