HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of the fire barrier wall. This was evidenced by missing sheet rock (fire resistant Gypsum board) in one area. This could result in the spread of a fire and possible harm to residents and staff. This affected the 1st Floor of Hospital Building-B.

Findings:

During a tour of the facility with Engineering Staff 1, on January 25, 2012, the fire walls were observed in Hospital Building-B, 1st Floor:

At 11:20 a.m., there was an approximately 3 inch area of sheet rock missing from the 1st layer of sheet rock on the left side of the fire barrier wall, by Room 110, in Labor and Delivery. There was an approximately 3 inch area of sheet rock missing from the first layer on the right side of the wall.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This could result in the spread of smoke or fire to other locations in the hospital. This affected the Main Hospital Building-A (1st, 3rd, & 4th Floors), Behavioral Health Building (C & D Floors), Hospital Building-B (Basement Level), Outpatient Imaging Services-3 (Suite 212), and Outpatient Clinics (3rd Floor).

Findings:

During a tour of the facility with the Hospital Staff, from January 23, 2012 through January 27, 2012, the building construction was observed.

Behavioral Health Building, San Diego,
C Floor:
1. On January 23, 2012, at 10:50 a.m., there were 3 approximately 1/4 inch round penetrations, in the wall above the oxygen tank storage, in the "Breeze Way Doctor Dictation Room."

D Floor:
2. On January 23, 2012, at 11:39 a.m., there were 4 approximately 1/4 inch round penetrations, in the wall above the file cabinet, in Room D-22.

Main Hospital Building-A, 1st Floor:
3. On January 23, 2012, at 3:36 p.m., there were 5 approximately 1/2 inch round penetrations, in the wall in Room 1-100.

Hospital Building-B, Basement Level:
4. On January 25, 2012, at 9:30 a.m., there was a hook hanging from the sheet rock wall, behind the oxygen cart, in the Clean Utility Room LL-1146. This created an approximately 1 inch x 1 inch penetration.

Outpatient Imaging Services-3, Suite 212:
5. On January 25, 2012, at 2:50 p.m., there were two approximately 1/2 inch round penetrations behind the water cooler.


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Main Hospital Building-A,
4th Floor:
6. On January 23, 2012, at 3:08 p.m., there was a piece of white paper covering the opening of a missing junction box and cover plate in the wall of Room 427. The missing junction box created an approximately 3 inch x 3 inch penetration in the wall.

7. On January 23, 2012, at 3:09 p.m., the data cable cover plate was loose from the wall in Room 427. There was an approximately 1/8 inch penetration around the loose data cable cover plate.

3rd Floor:
8. On January 24, 2012, at 8:23 a.m., there was approximately 1/8 inch circular penetration around the smoke detector, in the Gift Shop, on the 3rd floor.

Outpatient Imaging Services-3, Suite 212:
9. On January 25, 2012, at 2:13 p.m., there was a quarter size penetration around a white cable in the waiting room of Suite 212.


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Outpatient Clinics at 4020 5th Avenue, 3rd Floor:
10. On January 24, 2012, at 11:50 a.m., there was an approximately 1/2 inch x 2 inch penetration, on the wall adjacent to the door, in the Pixies Room, located on the 3rd Floor of the Primary Care Clinic.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridors doors that were obstructed from closing and by door that failed to latch. This could result in the spread of smoke and fire throughout the facility and increased the risk of injury to the patients. This affected the Main Hospital Building-A, 6 of 11 floors, (1st, 2nd, 6th, 7th, 8th, and 11th Floors), Hospital Building-B (2nd & 3rd Floors), Outpatient Imaging Services-3 (Suite 212), Behavioral Health Building (C & D Floors), and Outpatient Rehabilitation Services-1 (Suite 300).

Findings:

During a tour of the facility with the Hospital Staff from January 23, 2012 through January 27, 2012, the corridor doors were observed.

Main Hospital Building-A,
11th Floor:
1. On January 23, 2012, at 10:25 a.m., the corridor door to Room 1108 failed to latch when closed.

2. On January 23, 2012, at 10:39 a.m., the corridor door to Negative Pressure Room 1121 failed to latch when closed.

8th Floor:
3. On January 23, 2012, at 11:37 a.m., the corridor door to Negative Pressure Room 824 failed to latch when closed.

7th Floor:
4. On January 23, 2012, at 1:14 p.m., the corridor door to Negative Pressure Room 712 failed to latch when closed. The door was held open by a wooden door wedge positioned under the door.

6th Floor:
5. On January 23, 2012, at 1:57 p.m., the corridor door to Room 604 failed to latch when closed. The door strike plate was broken.

Hospital Building-B, Chula Vista, 3rd Floor:
6. On January 25, 2012, at 9:16 a.m., the corridor door to Room 326 was held open by a trash can. The door closed if the trash can was removed.

Outpatient Imaging Services-3, Suite 212:
7. On January 25, 2012, at 2:14 p.m., the corridor door to the inside waiting Room of Suite 212 was held open by 3 joined chairs.


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Behavioral Health Building, C Floor:
8. On January 23, 2012, at 10:53 a.m. the door to Room C-50, the patient kitchen, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to latch.

Behavioral Health Building, D Floor:
9. On January 23, 2012, at 11 a.m., the door to Room D-3 failed to positive latch upon closure.

Main Hospital Building-A,
1st Floor:
10. On January 23, 2012, at 3:36 p.m., Door 28-01-1045, in the Emergency Department, failed to positive latch upon closure.

2nd Floor:
11. On January 24, 2012, at 9:37 a.m., the door to the EVS Closet,in CICU, was wedged open and obstructed from closing.

Outpatient Rehabilitation Services-1 - Physical and Occupational Therapy, 4th Floor, Suite 300:
12. On January 24, 2012, at 11:20 a.m., the door to the Staff Lounge was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

13. On January 24, 2012, at 11:25 a.m., the door to "Scripps Mercy Respiratory Pulmonary Function Laboratory" was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

Hospital Building-B, 2nd Floor:
14. On January 25, 2012, at 10:25 a.m., the door to Room 203 failed to latch.

15. On January 25, 2012, at 10:30 a.m., the door to Room 02-1106 was equipped with an automatic closing device connected to the fire alarm system. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

Based on observation, the facility failed to ensure fire doors are only held open with devices that release upon activation of the fire alarm system. This was evidenced by failing doors to stairwells equipped with kick type hardware to keep the doors open. This could result in the spread of fire and smoke, in the event of a fire, and potential harm to staff and visitors. This affected 2 of 3 floors at the Outpatient Rehabilitation Services-2, (1st and 2nd Floors).

Findings:

During a tour of the facility with hospital staff, from January 23, 2012 through January 27, 2012, the stairwell doors were observed.

On January 25, 2012, at 2:33 p.m., the doors to the 1st and 2nd floors in Stairwell #1 had kick down type door stops. The door stops obstructed the doors from automatically closing upon activation of the fire alarm system.

Based on observation, the facility failed to ensure exit signs mark the way to an exit. This was evidenced by an exit sign positioned over a non-exit door and by no exit sign installed on or by a door designated as an exit. This could cause confusion and delay in evacuation during a fire or other emergency. This could increase the risk of harm to patients, visitors and staff. This affected 2 of 11 buildings, the Main Hospital Building-A (2nd Floor) and Outpatient Imaging Services-3 (2nd Floor).

Findings:

During a tour of the facility with hospital staff from January 23, 2012 through January 27, 2012, the exit signs were observed.

Main Hospital Building-A, 2nd Floor:
On January 24, 2012, at 9:05 a.m., there was an exit sign in the egress corridor, on the wall over the mechanical door, in the 2nd Floor Cath lab. The mechanical door is not an exit.


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Outpatient Imaging Services-3, 2nd Floor:
On January 25, 2012, at 2:13 p.m., there were no exit signs, outside of Suite 212, for 2 of 2 pathways to reach exits. The first pathway did not have a readily apparent exit when the smoke barrier doors were closed outside of Suite 212. There was no exit sign placed over or near the smoke barrier doors. The second pathway did not have directional signs that lead to the stairwell exit. The exit pathway was not readily apparent.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by penetrations in smoke barrier walls and missing areas of sheet rock. This could result in the spread of smoke and fire to other smoke compartments. This affected 2 of 12 floors in the Main Hospital Building-A (1st & 2nd Floors).

Findings:

During a tour of the facility with hospital staff on January 23, 2012 and January 24, 2012, the smoke barrier walls were observed.

Main Hospital Building-A, 2nd Floor:
1. On January 24, 2012, at 9:24 a.m., the smoke barrier wall by the exercise lab, in the 2nd Floor Cardiac Recovery Unit, was observed. There was an approximately 4 feet piece of sheet rock missing from the top of the wall.

2. On January 24, 2012, at 9:57 a.m., the smoke barrier wall by smoke barrier door number FD02806A on the 2nd floor was observed. There was an approximately 2 feet piece of sheet rock missing from the wall.

3. On January 24, 2012, at 10:08 a.m., there was an approximately 3 inch circular penetration in the smoke barrier wall by door FD02823B on the 2nd floor.


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Main Hospital Building-A, 1st Floor:
4. On January 23, 2012, at 3:23 p.m., there was a 1-inch unsealed penetration around a pipe in the smoke barrier wall and a 2-inch round penetration in the left smoke barrier wall above fire doors 1-273A.

Based on observation, the facility failed to maintain their smoke barrier doors to prevent the passage of smoke. This was evidenced by doors that failed to positive latch. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 3 of 12 floors and the basement in the Main Hospital Building-A (1st, 5th, & 9th Floors), 2 of 4 floors and the basement in Hospital Building-B (1st & 3rd Floors), and Outpatient Imaging Services-3 (2nd Floor).

Findings:

During the facility tour with the Hospital Staff on January 23, 2012 through January 27, 2012, the smoke barrier doors were observed.

Main Hospital Building-A, 1st Floor:
1. On January 24, 2012, at 3:50 p.m., 1 of 2 smoke barrier, cross-corridor doors, FD01806B, failed to close and positive latch. The doors were located on the 1st Floor in the Emergency Department.

Outpatient Imaging Services-3 2nd Floor:
2. On January 26, 2012, at 7:31 a.m., 1 of 2 smoke barrier, cross-corridor doors, located on the 2nd Floor outside of Suite 212, failed to close and positive latch.

Hospital Building-B, (1st Floor):
3. On January 26, 2012, at 9:28 a.m., 1 of 2 smoke barrier, cross-corridor doors, located on the 1st Floor in the Mother Baby Unit by Sleep Room 1, failed to close and positive latch.

Hospital Building-B, (Basement Level):
4. On January 26, 2012, at 9:51 a.m., 1 of 2 smoke barrier, cross-corridor doors, FDLL2015B, located on the Basement Level by Elevator #3, failed to close and positive latch.

5. On January 26, 2012, at 9:58 a.m., 2 of 2 smoke barrier, cross-corridor doors, FDLL2025B, located on the Basement Level by the Pathology Laboratory, failed to close and positive latch.


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Main Hospital Building-A, San Diego 9th Floor:
6. On January 24, 2012, at 2:49 p.m., the smoke barrier doors by Room 921 failed to latch.

5th Floor:
7. On January 24, 2012, 3:06 p.m., the smoke barrier doors by door FD0581A F failed to close and latch. The gap between the two leaves of the door was approximately ? inch.


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Lower Level:
8. On January 24, 2012, at 4:12 p.m., the smoke barrier door L52 failed to positive latch on the left side after activation of the fire alarm system.

Hospital Building-B, 3rd Floor:
9. On January 26, 2012, at 9:06 a.m., the smoke barrier doors by Room 313 failed to latch on the right side after activation of the fire alarm system.

Basement Level:
10. On January 26, 212, at 10:10 a.m., the smoke barrier doors, FD2023 that lead to ICU, failed to latch on the right side after activation of the fire alarm system.

11. On January 26, 2012, at 10:20 a.m., the smoke barrier doors, by the Nursing Station in ICU, failed to latch on the right side after activation of the fire alarm system.

Based on observation, the facility failed to protect hazardous areas. This was evidenced by a door to the dirty/soiled utility room that was not equipped with a self-closing device. This could potentially increase the spread of fire and smoke to other areas of the facility. This affected Outpatient Imaging Services-3 (Suite 103).

Findings:

During tour of facility with Engineer Staff 1, hazardous areas were observed.

Outpatient Imaging Services-3, Suite 103:
On January 25, 2012, at 2 p.m., the dirty/soiled utility room in Suite 103 was not equipped with a self-closing device.

Based on observation, the facility failed to maintain signage of hazardous materials in accordance with NFPA 99. This was evidenced by laboratories containing significant quantities of flammable liquids with no signage posted on entry doors. This could result in personnel entering room to be unaware of the hazardous content and potentially cause injury or death in the event of a fire or other emergency. This affected 1 of 12 floors at the Main Hospital Building-A, 2nd Floor.

NFPA 99, Health Care Facilities, 1999 Edition
10-8.2.1 All doors leading to laboratories in health-related facilities shall be marked with signage indicating the fire hazards of materials when significant quantities, as defined below, are intended to be used within the area. For signage "significant quantities" in an area shall include any of the following:
(a) Hazardous materials in glass containers that are 1 gal (4.4 L) in size or larger
(b) Compressed gases or cryogenic liquids in containers that are greater than 5 in. (12.7 cm) in diameter and 15 in. (48 cm) in length
(c) Dry hazardous chemicals in containers in excess of 5 lb (2.2.7 kg)
(d) Aggregate quantities of hazardous materials exceeding 200 lb (91 kg), or flammable liquids exceeding 10 gal (44.4 L)
10-8.2.2 All doors leading to laboratories, laboratory work areas, and laboratory storage areas, shall be identified with signs to warn emergency response personnel of unusual or severe hazards that are not directly related to the fire hazards of contents.
10-8.2.3 It shall be the responsibility of the laboratory safety officer to ensure periodically that the signage properly indicates the nature of the materials being used within the identified space.
10-8.2.4 It shall be the duty of the senior person responsible for activities in respective laboratory areas to inform the laboratory safety officer of changes in protocol and procedures that involve variations in the fire and associated hazards of materials used in individual spaces.


Findings:

During a tour of the facility with the Hospital Staff on January 23, 2012 through January 27, 2012, , 2012, the laboratories were observed.

Main Hospital Building-A, 2nd Floor:
1. On January 24, 2012 at 9:31 a.m., the Laboratory was observed to contain flammable liquids, such as Methanol (Flammability Rating: 3) and Gram's Rapid Decolorizer (Flammability Rating: 4), in glass containers that were 1 gallon or larger. The following doors leading into the laboratory room did not have signage posted that identified the hazardous materials: FD02822A and FD02201.

2. On January 24, 2012 at 9:50 a.m., Room 2-225 was observed to contain flammable liquids, such as Xylene (Flammability Rating: 3) and Isopropanol (Flammability Rating: 3), in glass containers that were 1 gallon or larger. The door leading into Room 2-225 did not have signage posted that identified the hazardous materials in the room.

Based on observation and interview, the facility failed to maintain the fire resistance rating in one stairway access corridor. This was evidenced by an unsealed penetration in the corridor wall leading to one stairway. This could result in the spread of smoke and fire, in the event of a fire. This affected 1 of 12 floors in the Main Hospital Building-A (2nd Floor).

Findings:

During a tour of the facility with the Hospital Staff, on January 24, 2012, the exit stairway construction was observed.

Main Hospital Building-A, 2nd Floor:
On January 24, 2012, at 10:01 a.m., there was an approximately 2 inch x 2 inch penetration in the corridor wall above the exit to stairwell door 2-104.

When the Administrative Director 1 was interviewed at 10:01 a.m., he stated that the corridor was painted about 2 weeks ago and that they had forgotten to put the exit sign back over the door.

Based on observation, the facility failed to maintain the stairways in accordance with 7.2. This was evidenced by stairwells that were blocked by equipment. This had the potential to delay evacuation in the event of a fire. This affected 1 of 3 floors at Outpatient Rehabilitation Services-1 (4th Floor).

NFPA 101?, Life Safety Code?, 2000 Edition
7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Findings:

During a tour of the facility with the Hospital Staff, on January 24, 2012 , the stairway was observed in the Outpatient Rehabilitation Services Building, 4th Floor, Suite 300. At 11:15 a.m., there was a wooden sled and a dolly on the landing in the stairwell exiting from the 4th floor.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by medical equipment and supplies in the exit access corridors. This had the potential to delay evacuation and cause harm to patients and staff in the event of a fire. This affected 1 of 9 facility buildings, the basement level of Hospital Building-B.

Findings:

During a tour of the facility with Hospital Staff, on January 25, 2012 the corridors were observed at Hospital Building-B.

1. On January 25, 2012, at 8:55 a.m., there were 10 carts in the corridor in the back of Central Processing. The carts blocked part of the corridor that lead to the evacuation exit.

2. At 9:50 a.m., there were 2 wheelchairs, 2 gurneys, 3 imaging machines, a cart with boxes, and 2 patients beds, in the corridor between the Emergency Department and the ICU.

Based on observation and interview, the facility failed to maintain exit/directional signs, as evidenced by exit signs that were not fully illuminated. This could potentially delay evacuation in the event of a fire or other emergency. This affected 1 of 12 floors at the Main Hospital Building-A, 2nd Floor, and 1 of 5 floors at Outpatient Imaging Services-3 (Suite 102).


NFPA 101?, Life Safety Code?, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with the Hospital Staff from January 23, 2012 through January 27, 2012, exit signs and their illumination were observed.

Main Hospital Building-A, 2nd Floor:
1. On January 24, 2012 at 10:01 a.m., there was no exit sign over the door leading to stairwell 2-104.

During an interview on January 24, 2012, at 10:01 a.m., the Administrative Director 1 stated that the corridor was painted about 2 weeks ago and that they had forgotten to put the exit sign back over the door.

Outpatient Imaging Services-3, Suite 102:
2. On January 25, 2012 at 2:00 p.m., the exit sign leading outside of the suite failed to illuminate.

3. At 2:01 p.m., the exit sign leading to the stairwell failed to illuminate.

Based on record review and interview, the facility failed to maintain evacuation plans and instruct staff on life safety procedures and devices. This was evidenced by an outdated evacuation plan in 1 of 9 buildings. This had the potential to delay staff response to a fire, that could result in harm to patients, visitors, and staff. This affected Main Hospital Building-A.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

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

Findings:

During record review with Safety Officer-1, on January 24, 2012, the disaster manual was reviewed.

Main Hospital Building-A, San Diego:
At 8:20 a.m., the disaster plan titled "Evacuation & Discharge Guidelines During Emergencies" had an outdated evacuation plan. Pre-designated evacuation locations in 10, 11, and 12 were located in the Emergency Department's expansion area that was no longer an open area available for evacuation.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced no audible fire alarm in one area, by an inaccessible manual fire alarm pull box, and by a chime that failed to operate. This had the potential to delay notification in the event of a fire, increasing the risk of injury to patients, visitors and staff. This affected 2 of 9 buildings, the Main Hospital Building-A, 1st Floor and the Behavioral Health Building, E Floor.

9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with Hospital Staff, from January 23, 2012 through January 27, 2012, the fire alarm systems were tested and observed.

Behavioral Health Building, E Floor:
1. On January 23, 2012, at 11:58 a.m., the manual fire alarm pull box, in the storage area, was not visible and was blocked from access by a metal link fence and equipment.

Main Hospital Building-A, San Diego (1st Floor):
2. On January 24, 2012, at 3:50 p.m., the chime by door 1067 in the Emergency Department failed to activate during testing of the smoke detectors, manual pull stations and/or sprinkler system.


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Main Hospital Building-A, 1st Floor:
3. On January 24, 2012, at 3:51 p.m., the fire alarm system was activated on the 1st Floor in the Main Hospital Building-A. When tested, no alarm was heard in the "Blue Area" of the Emergency Department. Engineering Director-1 stated that the area was under construction.

Based on document review and observation, the facility failed to maintain their smoke detectors in reliable operating conditions in accordance with NFPA 72. This was evidenced by three smoke detectors that failed to activate, by no evidence of smoke detector sensitivity testing, and by a smoke detector that was covered with tape. This had the potential to delay smoke detection in the event of a fire, increasing the risk of injury to patients, visitors and staff. This affected 2 of 9 buildings, the Outpatient Imaging Services-3, Suite 212, and the Outpatient Rehabilitation Services-2, Suite 212.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
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 indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent 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 alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During fire alarm testing and record review, with Hospital Staff, on January 26, 2012 and January 27, 2012, the smoke detectors were tested, and the documents for sensitivity testing were requested.

Outpatient Imaging Services-3, Suite 212:
1. On January 26, 2012, at 7:19 a.m., one smoke detector failed to activate when tested with canned smoke. The detector was installed in the corridor by Ultrasound Room 3 in Suite 212 .

2. At 7:20 a.m., the smoke detector in the waiting room failed to activate when tested with canned smoke.

3. At 7:21 a.m., the smoke detector, installed in the corridor by Ultrasound Room 1, failed to activate when tested with canned smoke.

4. During an interview on January 27, 2012, at 11 a.m., the Administrative Director-2 stated that the facility at 480 4th Avenue was unable to provide evidence that the smoke detector sensitivity testing had been completed.


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Outpatient Rehabilitation Services-2 at 450 4th Avenue, Chula Vista, Suite 212:
5. On January 25, 2012, at 2:31 p.m., the smoke detector in the staff lounge was covered with tape.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by sprinkler heads that were covered in layers of dust or lint and by escutcheon rings that were not flush to the ceiling. The escutcheon ring is used to cover the penetration around the sprinkler head. This could potentially cause sprinkler system failure in the event of a fire. This affected 3 of 12 floors in the Main Hospital Building-A (Lower Level, 3rd & 6th Floors) and 1 of 4 floors in Hospital Building-B (1st Floor).

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 1998 Edition
2-2.1.1* Sprinklers shall be inspected from the floor level annually; Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with Hospital Staff, from January 23, 2012 through January 27, 2012, the sprinklers heads were observed.

Main Hospital Building-A, 6th Floor:
1. On January 23, 2012, at 1:52 p.m., three of four sprinkler heads were covered in dust and lint, in the Pharmacy Room on the 6th floor.

2. On January 23, 2012 at 2:01 p.m., two of two sprinkler heads in the Pantry Room were covered in dust and lint.

Main Hospital Building-A, 3rd Floor:
3. On January 24, 2012 at 3:23 p.m., two of two sprinkler heads in Operating Room 1 were covered in dust and lint.

Hospital Building-B, 1st Floor:
4. On January 25, 2012, at 9:20 a.m., 4 of 26 sprinkler heads in the kitchen were covered in dust and lint. There were 3 of 26 sprinkler escutcheon rings that were not flush to the ceiling.


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Main Hospital Building-A, Lower Level:
5. On January 23, 2012, at 2:40 p.m., 1 of 2 sprinklers were missing the escutcheon ring, in Room 32 of the Rehab area.

6. On January 23, 2012, at 2:45 p.m., 1 of 4 sprinklers was missing the escutcheon ring in the Mail Room.

Based on observation and interview, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguisher mounted above 5 feet from the floor and by extinguishers unsecured on the floor. This could cause a delay in reaching the fire extinguisher and a potential delay in extinguishing a fire, in the event of a fire. This affected 2 of 12 floors in the Main Hospital Building-A (1st & 3rd Floors), Imaging Services-2 (MRI mobile unit), and 1 of 4 floors in Hospital Building-B (Lower Level).

NFPA 10, Standards for Portable Fire Extinguishers, 1998 Edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions.
1-6.10 Fire extinguishers having a gross weight not exceeding 40lb (18.14kg) shall be installed so that the top of the fire extinguisher is not more than 5ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40lbs(18.14kg)(except wheeled types)shall be installed that the top of the fire extinguisher is not more than 3 ? ft.(1.07m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2cm).

Findings:

During a tour of the facility with Hospital Staff, from January 23, 2012 through January 27, 2012, fire extinguishers were observed.

Main Hospital Building-A, 3rd Floor:
1. On January 24, 2012, at 8:12 a.m., the fire extinguisher was stored on the floor in the Mechanical Room on the 3rd floor. The wall mounted bracket for the fire extinguisher was broken.

Imaging Services-2 (MRI):
2. On January 24, 2012, at 11:17 a.m., the fire extinguisher was stored on the floor of the MRI mobile unit.

Hospital Building-B, Lower Level:
3. On January 26, 2012, at 9:28 a.m., fire extinguisher 24 was installed on the wall in the surgery room, on the lower level. The extinguisher was approximately 57-inches above the floor.


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Main Hospital Building-A, 1st Floor:
4. On January 24, 2012, at 3:20 p.m., there were 2 fire extinguishers on the floor in the "Building Operation Center" room.

Based on observation, the facility failed to ensure smoking areas were in compliance with all regulations. This was evidenced by no self-closing, covered container for emptying ashtrays, available in the designated smoking area. This could increase the risk for fire, resulting in injury to patients, visitors, and staff. This affected Main Hospital Building-A.

Findings:

During a tour of the facility with Engineering Director-1 and Facilities Manager-1, the designated smoking areas were observed.

Main Hospital Building-A, San Diego:
On January 24, 2012, at 8:57 a.m., there was no metal self-closing container available at the designated smoking area on Lewis Street. The smoking area had open ashtrays.

Based on record review and interview, the facility failed to protect their cooking facility in accordance with NFPA 96. This was evidenced by no current certification for the kitchen suppression system which was not UL 300 compliant. This could result in an increased risk of fire, resulting in injury to patients, staff, and visitors. This affected 1 of 4 floors in Hospital Building B.


NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
7-2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

7-2.2* Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

Inspection of Fire-Extinguishing Systems.
8.2.1* An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

During document review with Hospital Staff, on January 25, 2012, the documentation for the kitchen fire suppression system was reviewed.

Hospital Building-B, 1st Floor:
At 10:20 a.m., the semi-annual kitchen automatic extinguishing systems report from Siemens', dated 11/16/2011, stated that the entire system did not pass service and certification.
These findings were noted on the report: the system does not comply with UL 300, the system does not operate from terminal link, nozzles are old and have improper coverage, the chemical tanks and 101-30/101-10 cartridges are overdue for hydro testing, the pull station is too high, and the tilt skillet extends outside of the hood's perimeter.

During an interview, Facilities Manager-1 stated that the facility had adopted Interim Life Safety Measures and had in-serviced staff since the suppression system was not certified during the semi-annual check on July 1, 2009.

The facility plans to upgrade the kitchen's UL 300 system and has a current permit (Project #SL112218) from the Office of Statewide Health Planning and Development (OSHPD), dated 8/15/2011.

Based on observation and interview, the facility failed to ensure portable space heating devices were prohibited. This was evidenced by the utilization of portable space heaters in multiple locations. This could increase the risk of fire, and cause harm or death to patients in the event of a fire. This affected 1 of 12 floors at the Main Hospital Building-A (Lower Level) and 3 of 3 floors at the Behavioral Health Building (C, D, & E Floors).

Findings:

During a tour of the facility with Hospital Staff, on January 23, 2012, portable space heaters were observed in two buildings.

Behavioral Health Building, C Floor:
1. On January 23, 2012 at 10:40 a.m., the "Supervisor Access Discharge" Office had a Holmes Heat Safe portable space heater under the desk. The heater was off. During an interview at 10:40 a.m., Inpatient Behavioral Health Staff 1 stated that she sees patients for discharge planning purposes.

Behavioral Health Building, D Floor:
2. On January 23, 2012 at 11:20 a.m., there was a portable space heater, Model # 792, 1500 Watts, in Room D-33. During an interview at 11:05 a.m., Safety Officer 1 stated that the space heater was hospital authorized Dayton Model# 3VU33, 120V, 1300/1500 W. Safety Officer 1 stated that patients are seen in the Therapist Office.

The Safety Officer provided the Space Heater, Guidelines effective 7-09 which state the following locations that portable space heating devices are prohibited in:
i. All patient care areas
ii. All laboratories
iii. All locations where combustible or flammable materials are stored
iv. Carpenter, wood shops or wood craft areas
v. Areas where there is moving machinery
vi. Wet locations
vii. In exits or walkways

On January 23, 2012, there were portable space heaters used to heat multiple patient care areas. The Therapist's offices are used for 20 minute one on one sessions between the therapist and the patient.

3. At 11:30 a.m., there was a portable space heater in Office D-32.

4. At 11:31 a.m., there was a portable space heater in Office D-31.

5. At 11:32 a.m., there was a portable space heater in Office D-29.

6. At 11:33 a.m., there was a portable space heater in Office D-79.

7. At 11:35 a.m., there was a portable space heater in Office D-25.

8. At 11:43 a.m., there was a portable space heater in Exam Room D-84B, sitting on the chair.

9. At 11:45 a.m., there was a portable space heater in Office D-80.

10. At 11:48 a.m., there was a portable space heater in the Program Manager Office D-10A.

11. At 11:49 a.m., there was a portable space heater in Office D-9C.

12. At 11:49 a.m., there was a portable space heater in Office D-9B.

13. At 11:49 a.m., there was a portable space heater in Office D-9A.

Behavioral Health Building, E Floor:
14. At 12:15 p.m., there was a portable space heater in the Group Therapy Room, on the floor between 2 chairs. There were patients sitting in the chairs.

Main Hospital Building-A, Lower Level:
15. At 2:00 p.m., in the Pediatric PT/OT Speech room there was a portable space heater on the table next to the Therapist. The space heater was on. When interviewed, the Primary Pediatric Occupational Therapist stated that they use the heater when they undress the babies and get them ready for therapy.

Based on observation and interview, the facility failed to maintain the path of egress free from obstructions. This was evidenced by furniture, equipment and wheelchairs stored in the corridor. This could create a delay in evacuation and potential harm to patients and staff in the event of a fire. This affected 3 of 12 floors at the Main Hospital Building-A (2nd, 5th, & 6th Floors) and and 1 of 4 floors at Hospital Building-B (3rd Floor).

Findings:

During the facility tour with Engineering Staff 1 and Administrative Staff 2, from January 23, 2012 through January 25, 2012, the corridors were observed.

Main Hospital Building-A,
6th Floor:
1. On January 23, 2012, at 1:55 p.m., three wheelchairs were stored in the corridor by the horizontal exit door, across from the elevators, on the 6th floor.
During an interview at 1:57 p.m., the nurse manager stated the corridor by the horizontal exit door is used for storing the wheelchairs.

5th Floor:
2. At 2:15 p.m., two wheelchairs were stored in the corridor by the horizontal exit door, across from the elevators, on the 5th floor.

2nd Floor:
3. On January 24, 2012, between 9:49 a.m. and 11:20 a.m., tables, portable carts, portable trays, chairs, a bed and a gurney were lined up in the corridor on the 2nd floor. The corridor ends at the trauma elevator and an exit door. There was a sign posted on the back wall, across from the elevator and above the gurney. The sign indicated "no storage of equipment."

Hospital Building-B, 3rd Floor:
4. On January 25, 2012, at 8:58 a.m., 4 wheelchairs, a patient weight scale, chairs, and a patient lift blocked the egress corridor by Room 315 and Room 316. The manager of the unit was interviewed. She stated the equipment and furniture are usually stored in the corridor by Room 315 and Room 316.

Based on observation, the facility failed to ensure no combustible room decorations were used, as evidenced by combustible decorations covering over 50 percent of the walls in one area. This could result in the rapid spread of fire in the event of a fire. This affected 1 of 3 floors in the Behavioral Health Building (D Floor).

Findings:

During a tour of the facility with Hospital Staff, on January 23, 2012, room decorations were observed.

Behavioral Health Building, D Floor:
At 11:31 a.m., there were tapestry/cloth wall hangings covering over 50 percent of the walls in the Room D-31 office. There was no label on the wall hangings indicating if they were fire resistant or flame retardant.

Based on observation and interview, the facility failed to ensure that the oxygen cylinders were not stored with combustible materials and that full cylinders remain separate from empty cylinders. This was evidenced by oxygen cylinders stored with combustible material and empty cylinders that were not separated from full cylinders. This could increase the spread of fire and could cause a delay in obtaining a full cylinder of oxygen in an emergency. This affected 3 of 12 floors in the Main Hospital Building-A (5th, 6th, & 7th Floors) and 1 of 4 floors in Hospital Building-B (2nd Floor).

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not
communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]. 1999 Edition

4-3.5.2.2 (b) (1) Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.

21-1.2.6 CGA Publications. Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.
Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.


Findings:

During a tour of the facility with Hospital Staff, on January 23, 2012 through January 27, 2012, the oxygen storage areas were observed.

Hospital Building-B, 2nd Floor:1. On January 25, 2012, at 10:40 a.m., there was 1 E oxygen cylinder stored with a dirty linen container and other combustible material in the Bio Hazard Room in the Nursing Station. During an interview at 10:40 a.m., Safety Officer 1 stated that the oxygen was not supposed to be stored in the Bio Hazard room.


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Main Hospital Building-A, 5th, 6th, & 7th Floors:
2. On January 23, 2012, at 2:45 p.m., oxygen crates were located on the 5th, 6th, & 7th floors by the nurses station. The crates contained both empty and full E-sized cylinders mixed together.

During an interview, the maintenance staff, who filled the oxygen crates on January 23, 2012, stated that the oxygen cylinders in the crates on the floors are checked approximately three times per day and empty cylinders are replaced with full ones.

During an interview on the 5th floor, at 2:55 p.m., nursing staff stated that staff check the gauge of the cylinder to know if the cylinder is empty or full before being used.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 99 and NFPA 70. This was evidenced by electrical appliances and patient equipment plugged into multi-outlet adapters and by access to the electrical panel blocked by equipment and furniture. This could increase the risk of an electrical fire and could delay access to the electrical panel. This affected 6 of 12 floors at the Main Hospital Building-A (1st, 2nd, 3rd, 8th, 10th, 11th Floors), 1 of 3 floors at the Behavioral Health Building (D Floor), 1 of 4 floors at Hospital Building-B, (Basement & 3rd Floor), and Imaging Services-2 (MRI Mobile Unit).

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas.
2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.
a. Receptacles for Patient Bed Location in General Care Areas. Each patient bed location shall be provided with a minimum of four receptacles.
b. Receptacles for Patient Bed Location in Critical Care Areas. Each patient bed location shall be provided with a minimum of six receptacles.
Exception No. 1: Receptacles shall not be required in bathrooms or toilet rooms.
Exception No. 2: Receptacles shall not be required in areas where medical requirements mandate otherwise; for example certain psychiatric, pediatric, or hydrotherapy areas.

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
(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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Section 305 -3(b) 90 Days Temporary electrical power and lighting in installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes.

Findings:

During a tour of the facility with the Hospital Staff on January 23, 2012 through January 27, 2012, the facility's electrical wiring and equipment were observed.

Behavioral Health Building, D Floor:
1. On January 23, 2012, at 11:46 a.m., there was a surge protector used to connect a refrigerator to the electrical outlet in the Med Room, D-76.

Main Hospital Building-A, 1st Floor:
2. On January 24, 2012, at 8:40 a.m., there was a surge protector connecting a refrigerator and a microwave to the electrical outlet, in the Security Room, 1-459.

3. On January 24, 2012, at 8:45 a.m., there was a surge protector connecting a refrigerator and a microwave to the wall outlet in the Patient Financial Services Office, by the water cooler.

4. On January 24, 2012, at 8:50 a.m., the electrical panel was blocked by a rack of blue prints in the Building Operations Center.

5. On January 24, 2012, at 9:10 a.m., there was a surge protector connecting a refrigerator and a microwave to the electrical outlet in the CBX Staff Only office.

Main Hospital Building-A, 2nd Floor:
6. On January 24, 2012, at 9:40 a.m., there was a surge protector used to connect a refrigerator to the electrical outlet in the Surgery Office of the Main OR.

7. On January 24, 2012, at 9:57 a.m., there was a surge protector used to provide power to a refrigerator in the ASC Employee Lounge room.

Hospital Building-B, Basement:
8. On January 25, 2012, at 9:00 a.m., there was a 6 plug adapter in a two plug outlet used to provide power for two crash carts in the corridor.

9. On January 25, 2012, at 9:51 a.m., there was a 4 plug adapter used to provide power to a microwave and coffee maker.


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Main Hospital Building-A, 11th Floor:
10. On January 23, 2012, at 10:08 a.m., in the storage room on the 11th floor, there were patient Doppler machines plugged into a multi-plug power strip.

Main Hospital Building-A, San Diego (10th Floor):
11. On January 23, 2012, at 11:16 a.m., in the 10th Floor Nurses' Station, there were two patient vital sign machines plugged into one multi-plug power strip.

Main Hospital Building-A, 8th Floor:
12. On January 23, 2012, at 11:47 a.m., in the Nourishment Room on the 8th floor, there were a table top blanket warmer and a patient Doppler machine plugged into a multi-plug power strip.

Main Hospital Building-A, 3rd Floor:
13. On January 23, 2012, at 3:59 p.m., in the employee lounge on the 3rd floor, there were a miniature refrigerator and toaster plugged into a multi-plug power strip instead of the electrical wall outlet.

Imaging Services-2 MRI by Main Hospital Building-A:
14. On January 24, 2012, at 11:10 a.m., there was a miniature refrigerator plugged into a multi-plug power strip.

Hospital Building-B, 3rd Floor:
15. On January 25, 2012 at 8:58 a.m., there were wheelchairs, patient weight scale, chairs and a patient lift blocking access to the Electrical Panel Closet by Room 315 and Room 316 on the 3rd floor.


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Main Hospital Building-A, 2nd Floor:
16. On January 24, 2012 at 9:45 a.m., the receptacle wall outlet in the Break Room 2-224, by the laboratory area, had a broken ground port.

Based on observation, the facility failed to ensure Alcohol Based Hand Rub (ABHR) dispensers were installed away from ignition sources. This was evidenced by an ABHR dispenser mounted on a wall over an ignition source. This could result in an increased risk of fire and the risk of injury to patients, visitors and staff in the event of a fire. This affected Main Hospital Building-A (3rd floor) and Outpatient Imaging Services-3 (Suite 212).

Findings:

During a tour of the facility with Engineer Staff 1 and Administrative Director 2, the ABHR dispensers were observed.

Main Hospital Building-A, 3rd floor:
1. On January 23, 2012, at 3:40 p.m., the ABHR dispenser was mounted directly above a light switch in the Medication Room on the 3rd floor in the labor and delivery unit.

Outpatient Imaging Services-3 at 480 4th Avenue, Suite 212:
2. On January 26, 2012, at 7:20 a.m., the ABHR dispenser was mounted directly above a light switch in Suite 212 reception area.

Based on observation, the facility failed to maintain the integrity of the fire barrier wall. This was evidenced by missing sheet rock (fire resistant Gypsum board) in one area. This could result in the spread of a fire and possible harm to residents and staff. This affected the 1st Floor of Hospital Building-B.

Findings:

During a tour of the facility with Engineering Staff 1, on January 25, 2012, the fire walls were observed in Hospital Building-B, 1st Floor:

At 11:20 a.m., there was an approximately 3 inch area of sheet rock missing from the 1st layer of sheet rock on the left side of the fire barrier wall, by Room 110, in Labor and Delivery. There was an approximately 3 inch area of sheet rock missing from the first layer on the right side of the wall.

Based on observation, the facility failed to maintain the integrity of the building construction, as evidenced by unsealed penetrations in the walls and ceilings. This could result in the spread of smoke or fire to other locations in the hospital. This affected the Main Hospital Building-A (1st, 3rd, & 4th Floors), Behavioral Health Building (C & D Floors), Hospital Building-B (Basement Level), Outpatient Imaging Services-3 (Suite 212), and Outpatient Clinics (3rd Floor).

Findings:

During a tour of the facility with the Hospital Staff, from January 23, 2012 through January 27, 2012, the building construction was observed.

Behavioral Health Building, San Diego,
C Floor:
1. On January 23, 2012, at 10:50 a.m., there were 3 approximately 1/4 inch round penetrations, in the wall above the oxygen tank storage, in the "Breeze Way Doctor Dictation Room."

D Floor:
2. On January 23, 2012, at 11:39 a.m., there were 4 approximately 1/4 inch round penetrations, in the wall above the file cabinet, in Room D-22.

Main Hospital Building-A, 1st Floor:
3. On January 23, 2012, at 3:36 p.m., there were 5 approximately 1/2 inch round penetrations, in the wall in Room 1-100.

Hospital Building-B, Basement Level:
4. On January 25, 2012, at 9:30 a.m., there was a hook hanging from the sheet rock wall, behind the oxygen cart, in the Clean Utility Room LL-1146. This created an approximately 1 inch x 1 inch penetration.

Outpatient Imaging Services-3, Suite 212:
5. On January 25, 2012, at 2:50 p.m., there were two approximately 1/2 inch round penetrations behind the water cooler.


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Main Hospital Building-A,
4th Floor:
6. On January 23, 2012, at 3:08 p.m., there was a piece of white paper covering the opening of a missing junction box and cover plate in the wall of Room 427. The missing junction box created an approximately 3 inch x 3 inch penetration in the wall.

7. On January 23, 2012, at 3:09 p.m., the data cable cover plate was loose from the wall in Room 427. There was an approximately 1/8 inch penetration around the loose data cable cover plate.

3rd Floor:
8. On January 24, 2012, at 8:23 a.m., there was approximately 1/8 inch circular penetration around the smoke detector, in the Gift Shop, on the 3rd floor.

Outpatient Imaging Services-3, Suite 212:
9. On January 25, 2012, at 2:13 p.m., there was a quarter size penetration around a white cable in the waiting room of Suite 212.


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Outpatient Clinics at 4020 5th Avenue, 3rd Floor:
10. On January 24, 2012, at 11:50 a.m., there was an approximately 1/2 inch x 2 inch penetration, on the wall adjacent to the door, in the Pixies Room, located on the 3rd Floor of the Primary Care Clinic.

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridors doors that were obstructed from closing and by door that failed to latch. This could result in the spread of smoke and fire throughout the facility and increased the risk of injury to the patients. This affected the Main Hospital Building-A, 6 of 11 floors, (1st, 2nd, 6th, 7th, 8th, and 11th Floors), Hospital Building-B (2nd & 3rd Floors), Outpatient Imaging Services-3 (Suite 212), Behavioral Health Building (C & D Floors), and Outpatient Rehabilitation Services-1 (Suite 300).

Findings:

During a tour of the facility with the Hospital Staff from January 23, 2012 through January 27, 2012, the corridor doors were observed.

Main Hospital Building-A,
11th Floor:
1. On January 23, 2012, at 10:25 a.m., the corridor door to Room 1108 failed to latch when closed.

2. On January 23, 2012, at 10:39 a.m., the corridor door to Negative Pressure Room 1121 failed to latch when closed.

8th Floor:
3. On January 23, 2012, at 11:37 a.m., the corridor door to Negative Pressure Room 824 failed to latch when closed.

7th Floor:
4. On January 23, 2012, at 1:14 p.m., the corridor door to Negative Pressure Room 712 failed to latch when closed. The door was held open by a wooden door wedge positioned under the door.

6th Floor:
5. On January 23, 2012, at 1:57 p.m., the corridor door to Room 604 failed to latch when closed. The door strike plate was broken.

Hospital Building-B, Chula Vista, 3rd Floor:
6. On January 25, 2012, at 9:16 a.m., the corridor door to Room 326 was held open by a trash can. The door closed if the trash can was removed.

Outpatient Imaging Services-3, Suite 212:
7. On January 25, 2012, at 2:14 p.m., the corridor door to the inside waiting Room of Suite 212 was held open by 3 joined chairs.


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Behavioral Health Building, C Floor:
8. On January 23, 2012, at 10:53 a.m. the door to Room C-50, the patient kitchen, was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to latch.

Behavioral Health Building, D Floor:
9. On January 23, 2012, at 11 a.m., the door to Room D-3 failed to positive latch upon closure.

Main Hospital Building-A,
1st Floor:
10. On January 23, 2012, at 3:36 p.m., Door 28-01-1045, in the Emergency Department, failed to positive latch upon closure.

2nd Floor:
11. On January 24, 2012, at 9:37 a.m., the door to the EVS Closet,in CICU, was wedged open and obstructed from closing.

Outpatient Rehabilitation Services-1 - Physical and Occupational Therapy, 4th Floor, Suite 300:
12. On January 24, 2012, at 11:20 a.m., the door to the Staff Lounge was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

13. On January 24, 2012, at 11:25 a.m., the door to "Scripps Mercy Respiratory Pulmonary Function Laboratory" was equipped with a self closing device. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

Hospital Building-B, 2nd Floor:
14. On January 25, 2012, at 10:25 a.m., the door to Room 203 failed to latch.

15. On January 25, 2012, at 10:30 a.m., the door to Room 02-1106 was equipped with an automatic closing device connected to the fire alarm system. The door was held open to the fullest extent and allowed to close. The door closed but failed to positive latch.

Based on observation, the facility failed to ensure fire doors are only held open with devices that release upon activation of the fire alarm system. This was evidenced by failing doors to stairwells equipped with kick type hardware to keep the doors open. This could result in the spread of fire and smoke, in the event of a fire, and potential harm to staff and visitors. This affected 2 of 3 floors at the Outpatient Rehabilitation Services-2, (1st and 2nd Floors).

Findings:

During a tour of the facility with hospital staff, from January 23, 2012 through January 27, 2012, the stairwell doors were observed.

On January 25, 2012, at 2:33 p.m., the doors to the 1st and 2nd floors in Stairwell #1 had kick down type door stops. The door stops obstructed the doors from automatically closing upon activation of the fire alarm system.

Based on observation, the facility failed to ensure exit signs mark the way to an exit. This was evidenced by an exit sign positioned over a non-exit door and by no exit sign installed on or by a door designated as an exit. This could cause confusion and delay in evacuation during a fire or other emergency. This could increase the risk of harm to patients, visitors and staff. This affected 2 of 11 buildings, the Main Hospital Building-A (2nd Floor) and Outpatient Imaging Services-3 (2nd Floor).

Findings:

During a tour of the facility with hospital staff from January 23, 2012 through January 27, 2012, the exit signs were observed.

Main Hospital Building-A, 2nd Floor:
On January 24, 2012, at 9:05 a.m., there was an exit sign in the egress corridor, on the wall over the mechanical door, in the 2nd Floor Cath lab. The mechanical door is not an exit.


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Outpatient Imaging Services-3, 2nd Floor:
On January 25, 2012, at 2:13 p.m., there were no exit signs, outside of Suite 212, for 2 of 2 pathways to reach exits. The first pathway did not have a readily apparent exit when the smoke barrier doors were closed outside of Suite 212. There was no exit sign placed over or near the smoke barrier doors. The second pathway did not have directional signs that lead to the stairwell exit. The exit pathway was not readily apparent.

Based on observation, the facility failed to maintain the integrity of the smoke barrier walls. This was evidenced by penetrations in smoke barrier walls and missing areas of sheet rock. This could result in the spread of smoke and fire to other smoke compartments. This affected 2 of 12 floors in the Main Hospital Building-A (1st & 2nd Floors).

Findings:

During a tour of the facility with hospital staff on January 23, 2012 and January 24, 2012, the smoke barrier walls were observed.

Main Hospital Building-A, 2nd Floor:
1. On January 24, 2012, at 9:24 a.m., the smoke barrier wall by the exercise lab, in the 2nd Floor Cardiac Recovery Unit, was observed. There was an approximately 4 feet piece of sheet rock missing from the top of the wall.

2. On January 24, 2012, at 9:57 a.m., the smoke barrier wall by smoke barrier door number FD02806A on the 2nd floor was observed. There was an approximately 2 feet piece of sheet rock missing from the wall.

3. On January 24, 2012, at 10:08 a.m., there was an approximately 3 inch circular penetration in the smoke barrier wall by door FD02823B on the 2nd floor.


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Main Hospital Building-A, 1st Floor:
4. On January 23, 2012, at 3:23 p.m., there was a 1-inch unsealed penetration around a pipe in the smoke barrier wall and a 2-inch round penetration in the left smoke barrier wall above fire doors 1-273A.

Based on observation, the facility failed to maintain their smoke barrier doors to prevent the passage of smoke. This was evidenced by doors that failed to positive latch. This could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 3 of 12 floors and the basement in the Main Hospital Building-A (1st, 5th, & 9th Floors), 2 of 4 floors and the basement in Hospital Building-B (1st & 3rd Floors), and Outpatient Imaging Services-3 (2nd Floor).

Findings:

During the facility tour with the Hospital Staff on January 23, 2012 through January 27, 2012, the smoke barrier doors were observed.

Main Hospital Building-A, 1st Floor:
1. On January 24, 2012, at 3:50 p.m., 1 of 2 smoke barrier, cross-corridor doors, FD01806B, failed to close and positive latch. The doors were located on the 1st Floor in the Emergency Department.

Outpatient Imaging Services-3 2nd Floor:
2. On January 26, 2012, at 7:31 a.m., 1 of 2 smoke barrier, cross-corridor doors, located on the 2nd Floor outside of Suite 212, failed to close and positive latch.

Hospital Building-B, (1st Floor):
3. On January 26, 2012, at 9:28 a.m., 1 of 2 smoke barrier, cross-corridor doors, located on the 1st Floor in the Mother Baby Unit by Sleep Room 1, failed to close and positive latch.

Hospital Building-B, (Basement Level):
4. On January 26, 2012, at 9:51 a.m., 1 of 2 smoke barrier, cross-corridor doors, FDLL2015B, located on the Basement Level by Elevator #3, failed to close and positive latch.

5. On January 26, 2012, at 9:58 a.m., 2 of 2 smoke barrier, cross-corridor doors, FDLL2025B, located on the Basement Level by the Pathology Laboratory, failed to close and positive latch.


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Main Hospital Building-A, San Diego 9th Floor:
6. On January 24, 2012, at 2:49 p.m., the smoke barrier doors by Room 921 failed to latch.

5th Floor:
7. On January 24, 2012, 3:06 p.m., the smoke barrier doors by door FD0581A F failed to close and latch. The gap between the two leaves of the door was approximately ? inch.


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Lower Level:
8. On January 24, 2012, at 4:12 p.m., the smoke barrier door L52 failed to positive latch on the left side after activation of the fire alarm system.

Hospital Building-B, 3rd Floor:
9. On January 26, 2012, at 9:06 a.m., the smoke barrier doors by Room 313 failed to latch on the right side after activation of the fire alarm system.

Basement Level:
10. On January 26, 212, at 10:10 a.m., the smoke barrier doors, FD2023 that lead to ICU, failed to latch on the right side after activation of the fire alarm system.

11. On January 26, 2012, at 10:20 a.m., the smoke barrier doors, by the Nursing Station in ICU, failed to latch on the right side after activation of the fire alarm system.

Based on observation, the facility failed to protect hazardous areas. This was evidenced by a door to the dirty/soiled utility room that was not equipped with a self-closing device. This could potentially increase the spread of fire and smoke to other areas of the facility. This affected Outpatient Imaging Services-3 (Suite 103).

Findings:

During tour of facility with Engineer Staff 1, hazardous areas were observed.

Outpatient Imaging Services-3, Suite 103:
On January 25, 2012, at 2 p.m., the dirty/soiled utility room in Suite 103 was not equipped with a self-closing device.

Based on observation, the facility failed to maintain signage of hazardous materials in accordance with NFPA 99. This was evidenced by laboratories containing significant quantities of flammable liquids with no signage posted on entry doors. This could result in personnel entering room to be unaware of the hazardous content and potentially cause injury or death in the event of a fire or other emergency. This affected 1 of 12 floors at the Main Hospital Building-A, 2nd Floor.

NFPA 99, Health Care Facilities, 1999 Edition
10-8.2.1 All doors leading to laboratories in health-related facilities shall be marked with signage indicating the fire hazards of materials when significant quantities, as defined below, are intended to be used within the area. For signage "significant quantities" in an area shall include any of the following:
(a) Hazardous materials in glass containers that are 1 gal (4.4 L) in size or larger
(b) Compressed gases or cryogenic liquids in containers that are greater than 5 in. (12.7 cm) in diameter and 15 in. (48 cm) in length
(c) Dry hazardous chemicals in containers in excess of 5 lb (2.2.7 kg)
(d) Aggregate quantities of hazardous materials exceeding 200 lb (91 kg), or flammable liquids exceeding 10 gal (44.4 L)
10-8.2.2 All doors leading to laboratories, laboratory work areas, and laboratory storage areas, shall be identified with signs to warn emergency response personnel of unusual or severe hazards that are not directly related to the fire hazards of contents.
10-8.2.3 It shall be the responsibility of the laboratory safety officer to ensure periodically that the signage properly indicates the nature of the materials being used within the identified space.
10-8.2.4 It shall be the duty of the senior person responsible for activities in respective laboratory areas to inform the laboratory safety officer of changes in protocol and procedures that involve variations in the fire and associated hazards of materials used in individual spaces.


Findings:

During a tour of the facility with the Hospital Staff on January 23, 2012 through January 27, 2012, , 2012, the laboratories were observed.

Main Hospital Building-A, 2nd Floor:
1. On January 24, 2012 at 9:31 a.m., the Laboratory was observed to contain flammable liquids, such as Methanol (Flammability Rating: 3) and Gram's Rapid Decolorizer (Flammability Rating: 4), in glass containers that were 1 gallon or larger. The following doors leading into the laboratory room did not have signage posted that identified the hazardous materials: FD02822A and FD02201.

2. On January 24, 2012 at 9:50 a.m., Room 2-225 was observed to contain flammable liquids, such as Xylene (Flammability Rating: 3) and Isopropanol (Flammability Rating: 3), in glass containers that were 1 gallon or larger. The door leading into Room 2-225 did not have signage posted that identified the hazardous materials in the room.

Based on observation and interview, the facility failed to maintain the fire resistance rating in one stairway access corridor. This was evidenced by an unsealed penetration in the corridor wall leading to one stairway. This could result in the spread of smoke and fire, in the event of a fire. This affected 1 of 12 floors in the Main Hospital Building-A (2nd Floor).

Findings:

During a tour of the facility with the Hospital Staff, on January 24, 2012, the exit stairway construction was observed.

Main Hospital Building-A, 2nd Floor:
On January 24, 2012, at 10:01 a.m., there was an approximately 2 inch x 2 inch penetration in the corridor wall above the exit to stairwell door 2-104.

When the Administrative Director 1 was interviewed at 10:01 a.m., he stated that the corridor was painted about 2 weeks ago and that they had forgotten to put the exit sign back over the door.

Based on observation, the facility failed to maintain the stairways in accordance with 7.2. This was evidenced by stairwells that were blocked by equipment. This had the potential to delay evacuation in the event of a fire. This affected 1 of 3 floors at Outpatient Rehabilitation Services-1 (4th Floor).

NFPA 101?, Life Safety Code?, 2000 Edition
7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress.
Exception: Enclosed, usable space shall be permitted under stairs, provided that the space is separated from the stair enclosure by the same fire resistance as the exit enclosure. Entrance to such enclosed usable space shall not be from within the stair enclosure. (See also 7.1.3.2.3.)

Findings:

During a tour of the facility with the Hospital Staff, on January 24, 2012 , the stairway was observed in the Outpatient Rehabilitation Services Building, 4th Floor, Suite 300. At 11:15 a.m., there was a wooden sled and a dolly on the landing in the stairwell exiting from the 4th floor.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by medical equipment and supplies in the exit access corridors. This had the potential to delay evacuation and cause harm to patients and staff in the event of a fire. This affected 1 of 9 facility buildings, the basement level of Hospital Building-B.

Findings:

During a tour of the facility with Hospital Staff, on January 25, 2012 the corridors were observed at Hospital Building-B.

1. On January 25, 2012, at 8:55 a.m., there were 10 carts in the corridor in the back of Central Processing. The carts blocked part of the corridor that lead to the evacuation exit.

2. At 9:50 a.m., there were 2 wheelchairs, 2 gurneys, 3 imaging machines, a cart with boxes, and 2 patients beds, in the corridor between the Emergency Department and the ICU.

Based on observation and interview, the facility failed to maintain exit/directional signs, as evidenced by exit signs that were not fully illuminated. This could potentially delay evacuation in the event of a fire or other emergency. This affected 1 of 12 floors at the Main Hospital Building-A, 2nd Floor, and 1 of 5 floors at Outpatient Imaging Services-3 (Suite 102).


NFPA 101?, Life Safety Code?, 2000 Edition
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Findings:

During a tour of the facility with the Hospital Staff from January 23, 2012 through January 27, 2012, exit signs and their illumination were observed.

Main Hospital Building-A, 2nd Floor:
1. On January 24, 2012 at 10:01 a.m., there was no exit sign over the door leading to stairwell 2-104.

During an interview on January 24, 2012, at 10:01 a.m., the Administrative Director 1 stated that the corridor was painted about 2 weeks ago and that they had forgotten to put the exit sign back over the door.

Outpatient Imaging Services-3, Suite 102:
2. On January 25, 2012 at 2:00 p.m., the exit sign leading outside of the suite failed to illuminate.

3. At 2:01 p.m., the exit sign leading to the stairwell failed to illuminate.

Based on record review and interview, the facility failed to maintain evacuation plans and instruct staff on life safety procedures and devices. This was evidenced by an outdated evacuation plan in 1 of 9 buildings. This had the potential to delay staff response to a fire, that could result in harm to patients, visitors, and staff. This affected Main Hospital Building-A.

NFPA 101, Life Safety Code, 2000 Edition
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.

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

Findings:

During record review with Safety Officer-1, on January 24, 2012, the disaster manual was reviewed.

Main Hospital Building-A, San Diego:
At 8:20 a.m., the disaster plan titled "Evacuation & Discharge Guidelines During Emergencies" had an outdated evacuation plan. Pre-designated evacuation locations in 10, 11, and 12 were located in the Emergency Department's expansion area that was no longer an open area available for evacuation.

Based on observation and interview, the facility failed to maintain their fire alarm system. This was evidenced no audible fire alarm in one area, by an inaccessible manual fire alarm pull box, and by a chime that failed to operate. This had the potential to delay notification in the event of a fire, increasing the risk of injury to patients, visitors and staff. This affected 2 of 9 buildings, the Main Hospital Building-A, 1st Floor and the Behavioral Health Building, E Floor.

9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.
9.6.3.7 The general evacuation alarm signal shall operate throughout the entire building.

NFPA 72, National Fire Alarm Code, 1999 Edition
2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a tour of the facility with Hospital Staff, from January 23, 2012 through January 27, 2012, the fire alarm systems were tested and observed.

Behavioral Health Building, E Floor:
1. On January 23, 2012, at 11:58 a.m., the manual fire alarm pull box, in the storage area, was not visible and was blocked from access by a metal link fence and equipment.

Main Hospital Building-A, San Diego (1st Floor):
2. On January 24, 2012, at 3:50 p.m., the chime by door 1067 in the Emergency Department failed to activate during testing of the smoke detectors, manual pull stations and/or sprinkler system.


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Main Hospital Building-A, 1st Floor:
3. On January 24, 2012, at 3:51 p.m., the fire alarm system was activated on the 1st Floor in the Main Hospital Building-A. When tested, no alarm was heard in the "Blue Area" of the Emergency Department. Engineering Director-1 stated that the area was under construction.

Based on document review and observation, the facility failed to maintain their smoke detectors in reliable operating conditions in accordance with NFPA 72. This was evidenced by three smoke detectors that failed to activate, by no evidence of smoke detector sensitivity testing, and by a smoke detector that was covered with tape. This had the potential to delay smoke detection in the event of a fire, increasing the risk of injury to patients, visitors and staff. This affected 2 of 9 buildings, the Outpatient Imaging Services-3, Suite 212, and the Outpatient Rehabilitation Services-2, Suite 212.

NFPA 101, Life Safety Code, 2000 Edition
9.6.1.4 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code, unless an existing installation, which shall be permitted to be continued in use, subject to the approval of the authority having jurisdiction.

NFPA 72, National Fire Alarm Code, 1999 Edition
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 indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent 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 alarms show any increase over the previous year, calibration tests shall be performed. To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer ' s calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: This requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Findings:

During fire alarm testing and record review, with Hospital Staff, on January 26, 2012 and January 27, 2012, the smoke detectors were tested, and the documents for sensitivity testing were requested.

Outpatient Imaging Services-3, Suite 212:
1. On January 26, 2012, at 7:19 a.m., one smoke detector failed to activate when tested with canned smoke. The detector was installed in the corridor by Ultrasound Room 3 in Suite 212 .

2. At 7:20 a.m., the smoke detector in the waiting room failed to activate when tested with canned smoke.

3. At 7:21 a.m., the smoke detector, installed in the corridor by Ultrasound Room 1, failed to activate when tested with canned smoke.

4. During an interview on January 27, 2012, at 11 a.m., the Administrative Director-2 stated that the facility at 480 4th Avenue was unable to provide evidence that the smoke detector sensitivity testing had been completed.


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Outpatient Rehabilitation Services-2 at 450 4th Avenue, Chula Vista, Suite 212:
5. On January 25, 2012, at 2:31 p.m., the smoke detector in the staff lounge was covered with tape.

Based on observation, the facility failed to maintain their automatic sprinkler system in accordance with NFPA 25. This was evidenced by sprinkler heads that were covered in layers of dust or lint and by escutcheon rings that were not flush to the ceiling. The escutcheon ring is used to cover the penetration around the sprinkler head. This could potentially cause sprinkler system failure in the event of a fire. This affected 3 of 12 floors in the Main Hospital Building-A (Lower Level, 3rd & 6th Floors) and 1 of 4 floors in Hospital Building-B (1st Floor).

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection System, 1998 Edition
2-2.1.1* Sprinklers shall be inspected from the floor level annually; Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.
Exception No. 1:* Sprinklers installed in concealed spaces such as suspended ceilings shall not require inspection.
Exception No. 2: Sprinklers installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

Findings:

During a tour of the facility with Hospital Staff, from January 23, 2012 through January 27, 2012, the sprinklers heads were observed.

Main Hospital Building-A, 6th Floor:
1. On January 23, 2012, at 1:52 p.m., three of four sprinkler heads were covered in dust and lint, in the Pharmacy Room on the 6th floor.

2. On January 23, 2012 at 2:01 p.m., two of two sprinkler heads in the Pantry Room were covered in dust and lint.

Main Hospital Building-A, 3rd Floor:
3. On January 24, 2012 at 3:23 p.m., two of two sprinkler heads in Operating Room 1 were covered in dust and lint.

Hospital Building-B, 1st Floor:
4. On January 25, 2012, at 9:20 a.m., 4 of 26 sprinkler heads in the kitchen were covered in dust and lint. There were 3 of 26 sprinkler escutcheon rings that were not flush to the ceiling.


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Main Hospital Building-A, Lower Level:
5. On January 23, 2012, at 2:40 p.m., 1 of 2 sprinklers were missing the escutcheon ring, in Room 32 of the Rehab area.

6. On January 23, 2012, at 2:45 p.m., 1 of 4 sprinklers was missing the escutcheon ring in the Mail Room.

Based on observation and interview, the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This was evidenced by fire extinguisher mounted above 5 feet from the floor and by extinguishers unsecured on the floor. This could cause a delay in reaching the fire extinguisher and a potential delay in extinguishing a fire, in the event of a fire. This affected 2 of 12 floors in the Main Hospital Building-A (1st & 3rd Floors), Imaging Services-2 (MRI mobile unit), and 1 of 4 floors in Hospital Building-B (Lower Level).

NFPA 10, Standards for Portable Fire Extinguishers, 1998 Edition
1-6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably they shall be located along normal paths of travel, including exits from areas.
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturer ' s instructions.
1-6.10 Fire extinguishers having a gross weight not exceeding 40lb (18.14kg) shall be installed so that the top of the fire extinguisher is not more than 5ft (1.53 m) above the floor. Fire extinguishers having a gross weight greater than 40lbs(18.14kg)(except wheeled types)shall be installed that the top of the fire extinguisher is not more than 3 ? ft.(1.07m)above the floor. In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2cm).

Findings:

During a tour of the facility with Hospital Staff, from January 23, 2012 through January 27, 2012, fire extinguishers were observed.

Main Hospital Building-A, 3rd Floor:
1. On January 24, 2012, at 8:12 a.m., the fire extinguisher was stored on the floor in the Mechanical Room on the 3rd floor. The wall mounted bracket for the fire extinguisher was broken.

Imaging Services-2 (MRI):
2. On January 24, 2012, at 11:17 a.m., the fire extinguisher was stored on the floor of the MRI mobile unit.

Hospital Building-B, Lower Level:
3. On January 26, 2012, at 9:28 a.m., fire extinguisher 24 was installed on the wall in the surgery room, on the lower level. The extinguisher was approximately 57-inches above the floor.


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Main Hospital Building-A, 1st Floor:
4. On January 24, 2012, at 3:20 p.m., there were 2 fire extinguishers on the floor in the "Building Operation Center" room.

Based on observation, the facility failed to ensure smoking areas were in compliance with all regulations. This was evidenced by no self-closing, covered container for emptying ashtrays, available in the designated smoking area. This could increase the risk for fire, resulting in injury to patients, visitors, and staff. This affected Main Hospital Building-A.

Findings:

During a tour of the facility with Engineering Director-1 and Facilities Manager-1, the designated smoking areas were observed.

Main Hospital Building-A, San Diego:
On January 24, 2012, at 8:57 a.m., there was no metal self-closing container available at the designated smoking area on Lewis Street. The smoking area had open ashtrays.

Based on record review and interview, the facility failed to protect their cooking facility in accordance with NFPA 96. This was evidenced by no current certification for the kitchen suppression system which was not UL 300 compliant. This could result in an increased risk of fire, resulting in injury to patients, staff, and visitors. This affected 1 of 4 floors in Hospital Building B.


NFPA 96, Standard for Ventilation Control and and Fire Protection of Commercial Cooking Equipment, 1998 Edition
7-2.1 Fire-extinguishing equipment shall include both automatic fire-extinguishing systems as primary protection and portable fire extinguishers as secondary backup.

7-2.2* Automatic fire-extinguishing systems shall comply with standard UL 300, Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with their listing.

Inspection of Fire-Extinguishing Systems.
8.2.1* An inspection and servicing of the fire-extinguishing system and listed exhaust hoods containing a constant or fire-actuated water system shall be made at least every 6 months by properly trained and qualified persons.

Findings:

During document review with Hospital Staff, on January 25, 2012, the documentation for the kitchen fire suppression system was reviewed.

Hospital Building-B, 1st Floor:
At 10:20 a.m., the semi-annual kitchen automatic extinguishing systems report from Siemens', dated 11/16/2011, stated that the entire system did not pass service and certification.
These findings were noted on the report: the system does not comply with UL 300, the system does not operate from terminal link, nozzles are old and have improper coverage, the chemical tanks and 101-30/101-10 cartridges are overdue for hydro testing, the pull station is too high, and the tilt skillet extends outside of the hood's perimeter.

During an interview, Facilities Manager-1 stated that the facility had adopted Interim Life Safety Measures and had in-serviced staff since the suppression system was not certified during the semi-annual check on July 1, 2009.

The facility plans to upgrade the kitchen's UL 300 system and has a current permit (Project #SL112218) from the Office of Statewide Health Planning and Development (OSHPD), dated 8/15/2011.

Based on observation and interview, the facility failed to ensure portable space heating devices were prohibited. This was evidenced by the utilization of portable space heaters in multiple locations. This could increase the risk of fire, and cause harm or death to patients in the event of a fire. This affected 1 of 12 floors at the Main Hospital Building-A (Lower Level) and 3 of 3 floors at the Behavioral Health Building (C, D, & E Floors).

Findings:

During a tour of the facility with Hospital Staff, on January 23, 2012, portable space heaters were observed in two buildings.

Behavioral Health Building, C Floor:
1. On January 23, 2012 at 10:40 a.m., the "Supervisor Access Discharge" Office had a Holmes Heat Safe portable space heater under the desk. The heater was off. During an interview at 10:40 a.m., Inpatient Behavioral Health Staff 1 stated that she sees patients for discharge planning purposes.

Behavioral Health Building, D Floor:
2. On January 23, 2012 at 11:20 a.m., there was a portable space heater, Model # 792, 1500 Watts, in Room D-33. During an interview at 11:05 a.m., Safety Officer 1 stated that the space heater was hospital authorized Dayton Model# 3VU33, 120V, 1300/1500 W. Safety Officer 1 stated that patients are seen in the Therapist Office.

The Safety Officer provided the Space Heater, Guidelines effective 7-09 which state the following locations that portable space heating devices are prohibited in:
i. All patient care areas
ii. All laboratories
iii. All locations where combustible or flammable materials are stored
iv. Carpenter, wood shops or wood craft areas
v. Areas where there is moving machinery
vi. Wet locations
vii. In exits or walkways

On January 23, 2012, there were portable space heaters used to heat multiple patient care areas. The Therapist's offices are used for 20 minute one on one sessions between the therapist and the patient.

3. At 11:30 a.m., there was a portable space heater in Office D-32.

4. At 11:31 a.m., there was a portable space heater in Office D-31.

5. At 11:32 a.m., there was a portable space heater in Office D-29.

6. At 11:33 a.m., there was a portable space heater in Office D-79.

7. At 11:35 a.m., there was a portable space heater in Office D-25.

8. At 11:43 a.m., there was a portable space heater in Exam Room D-84B, sitting on the chair.

9. At 11:45 a.m., there was a portable space heater in Office D-80.

10. At 11:48 a.m., there was a portable space heater in the Program Manager Office D-10A.

11. At 11:49 a.m., there was a portable space heater in Office D-9C.

12. At 11:49 a.m., there was a portable space heater in Office D-9B.

13. At 11:49 a.m., there was a portable space heater in Office D-9A.

Behavioral Health Building, E Floor:
14. At 12:15 p.m., there was a portable space heater in the Group Therapy Room, on the floor between 2 chairs. There were patients sitting in the chairs.

Main Hospital Building-A, Lower Level:
15. At 2:00 p.m., in the Pediatric PT/OT Speech room there was a portable space heater on the table next to the Therapist. The space heater was on. When interviewed, the Primary Pediatric Occupational Therapist stated that they use the heater when they undress the babies and get them ready for therapy.

Based on observation and interview, the facility failed to maintain the path of egress free from obstructions. This was evidenced by furniture, equipment and wheelchairs stored in the corridor. This could create a delay in evacuation and potential harm to patients and staff in the event of a fire. This affected 3 of 12 floors at the Main Hospital Building-A (2nd, 5th, & 6th Floors) and and 1 of 4 floors at Hospital Building-B (3rd Floor).

Findings:

During the facility tour with Engineering Staff 1 and Administrative Staff 2, from January 23, 2012 through January 25, 2012, the corridors were observed.

Main Hospital Building-A,
6th Floor:
1. On January 23, 2012, at 1:55 p.m., three wheelchairs were stored in the corridor by the horizontal exit door, across from the elevators, on the 6th floor.
During an interview at 1:57 p.m., the nurse manager stated the corridor by the horizontal exit door is used for storing the wheelchairs.

5th Floor:
2. At 2:15 p.m., two wheelchairs were stored in the corridor by the horizontal exit door, across from the elevators, on the 5th floor.

2nd Floor:
3. On January 24, 2012, between 9:49 a.m. and 11:20 a.m., tables, portable carts, portable trays, chairs, a bed and a gurney were lined up in the corridor on the 2nd floor. The corridor ends at the trauma elevator and an exit door. There was a sign posted on the back wall, across from the elevator and above the gurney. The sign indicated "no storage of equipment."

Hospital Building-B, 3rd Floor:
4. On January 25, 2012, at 8:58 a.m., 4 wheelchairs, a patient weight scale, chairs, and a patient lift blocked the egress corridor by Room 315 and Room 316. The manager of the unit was interviewed. She stated the equipment and furniture are usually stored in the corridor by Room 315 and Room 316.

Based on observation, the facility failed to ensure no combustible room decorations were used, as evidenced by combustible decorations covering over 50 percent of the walls in one area. This could result in the rapid spread of fire in the event of a fire. This affected 1 of 3 floors in the Behavioral Health Building (D Floor).

Findings:

During a tour of the facility with Hospital Staff, on January 23, 2012, room decorations were observed.

Behavioral Health Building, D Floor:
At 11:31 a.m., there were tapestry/cloth wall hangings covering over 50 percent of the walls in the Room D-31 office. There was no label on the wall hangings indicating if they were fire resistant or flame retardant.

Based on observation and interview, the facility failed to ensure that the oxygen cylinders were not stored with combustible materials and that full cylinders remain separate from empty cylinders. This was evidenced by oxygen cylinders stored with combustible material and empty cylinders that were not separated from full cylinders. This could increase the spread of fire and could cause a delay in obtaining a full cylinder of oxygen in an emergency. This affected 3 of 12 floors in the Main Hospital Building-A (5th, 6th, & 7th Floors) and 1 of 4 floors in Hospital Building-B (2nd Floor).

NFPA 99, Standard for Health Care Facilities, 1999 Edition
4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not
communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]. 1999 Edition

4-3.5.2.2 (b) (1) Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
(2) If stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed hurriedly.

21-1 Referenced Publications. The following documents or portions thereof are referenced within this standard and shall be considered part of the requirements of this document. The edition indicated for each reference is the current edition as of the date of the NFPA issuance of this document.

21-1.2.6 CGA Publications. Compressed Gas Association, Inc., 1725 Jefferson Davis Highway, Arlington, VA 22202.
Pamphlet G-4-1987, Oxygen. III. STORAGE OF COMPRESSED AND LIQUEFIED GAS, Storage Requirements. All gas cylinders: Shall be stored so that full cylinders remain separate from empty cylinders.


Findings:

During a tour of the facility with Hospital Staff, on January 23, 2012 through January 27, 2012, the oxygen storage areas were observed.

Hospital Building-B, 2nd Floor:1. On January 25, 2012, at 10:40 a.m., there was 1 E oxygen cylinder stored with a dirty linen container and other combustible material in the Bio Hazard Room in the Nursing Station. During an interview at 10:40 a.m., Safety Officer 1 stated that the oxygen was not supposed to be stored in the Bio Hazard room.


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Main Hospital Building-A, 5th, 6th, & 7th Floors:
2. On January 23, 2012, at 2:45 p.m., oxygen crates were located on the 5th, 6th, & 7th floors by the nurses station. The crates contained both empty and full E-sized cylinders mixed together.

During an interview, the maintenance staff, who filled the oxygen crates on January 23, 2012, stated that the oxygen cylinders in the crates on the floors are checked approximately three times per day and empty cylinders are replaced with full ones.

During an interview on the 5th floor, at 2:55 p.m., nursing staff stated that staff check the gauge of the cylinder to know if the cylinder is empty or full before being used.

Based on observation, the facility failed to maintain electrical safety in accordance with NFPA 99 and NFPA 70. This was evidenced by electrical appliances and patient equipment plugged into multi-outlet adapters and by access to the electrical panel blocked by equipment and furniture. This could increase the risk of an electrical fire and could delay access to the electrical panel. This affected 6 of 12 floors at the Main Hospital Building-A (1st, 2nd, 3rd, 8th, 10th, 11th Floors), 1 of 3 floors at the Behavioral Health Building (D Floor), 1 of 4 floors at Hospital Building-B, (Basement & 3rd Floor), and Imaging Services-2 (MRI Mobile Unit).

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.2 All Patient Care Areas.
2. Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters.
a. Receptacles for Patient Bed Location in General Care Areas. Each patient bed location shall be provided with a minimum of four receptacles.
b. Receptacles for Patient Bed Location in Critical Care Areas. Each patient bed location shall be provided with a minimum of six receptacles.
Exception No. 1: Receptacles shall not be required in bathrooms or toilet rooms.
Exception No. 2: Receptacles shall not be required in areas where medical requirements mandate otherwise; for example certain psychiatric, pediatric, or hydrotherapy areas.

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
(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
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Section 305 -3(b) 90 Days Temporary electrical power and lighting in installations shall be permitted for a period not to exceed 90 days for Christmas decorative lighting and similar purposes.

Findings:

During a tour of the facility with the Hospital Staff on January 23, 2012 through January 27, 2012, the facility's electrical wiring and equipment were observed.

Behavioral Health Building, D Floor:
1. On January 23, 2012, at 11:46 a.m., there was a surge protector used to connect a refrigerator to the electrical outlet in the Med Room, D-76.

Main Hospital Building-A, 1st Floor:
2. On January 24, 2012, at 8:40 a.m., there was a surge protector connecting a refrigerator and a microwave to the electrical outlet, in the Security Room, 1-459.

3. On January 24, 2012, at 8:45 a.m., there was a surge protector connecting a refrigerator and a microwave to the wall outlet in the Patient Financial Services Office, by the water cooler.

4. On January 24, 2012, at 8:50 a.m., the electrical panel was blocked by a rack of blue prints in the Building Operations Center.

5. On January 24, 2012, at 9:10 a.m., there was a surge protector connecting a refrigerator and a microwave to the electrical outlet in the CBX Staff Only office.

Main Hospital Building-A, 2nd Floor:
6. On January 24, 2012, at 9:40 a.m., there was a surge protector used to connect a refrigerator to the electrical outlet in the Surgery Office of the Main OR.

7. On January 24, 2012, at 9:57 a.m., there was a surge protector used to provide power to a refrigerator in the ASC Employee Lounge room.

Hospital Building-B, Basement:
8. On January 25, 2012, at 9:00 a.m., there was a 6 plug adapter in a two plug outlet used to provide power for two crash carts in the corridor.

9. On January 25, 2012, at 9:51 a.m., there was a 4 plug adapter used to provide power to a microwave and coffee maker.


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Main Hospital Building-A, 11th Floor:
10. On January 23, 2012, at 10:08 a.m., in the storage room on the 11th floor, there were patient Doppler machines plugged into a multi-plug power strip.

Main Hospital Building-A, San Diego (10th Floor):
11. On January 23, 2012, at 11:16 a.m., in the 10th Floor Nurses' Station, there were two patient vital sign machines plugged into one multi-plug power strip.

Main Hospital Building-A, 8th Floor:
12. On January 23, 2012, at 11:47 a.m., in the Nourishment Room on the 8th floor, there were a table top blanket warmer and a patient Doppler machine plugged into a multi-plug power strip.

Main Hospital Building-A, 3rd Floor:
13. On January 23, 2012, at 3:59 p.m., in the employee lounge on the 3rd floor, there were a miniature refrigerator and toaster plugged into a multi-plug power strip instead of the electrical wall outlet.

Imaging Services-2 MRI by Main Hospital Building-A:
14. On January 24, 2012, at 11:10 a.m., there was a miniature refrigerator plugged into a multi-plug power strip.

Hospital Building-B, 3rd Floor:
15. On January 25, 2012 at 8:58 a.m., there were wheelchairs, patient weight scale, chairs and a patient lift blocking access to the Electrical Panel Closet by Room 315 and Room 316 on the 3rd floor.


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Main Hospital Building-A, 2nd Floor:
16. On January 24, 2012 at 9:45 a.m., the receptacle wall outlet in the Break Room 2-224, by the laboratory area, had a broken ground port.