HospitalInspections.org

NFPA 101 Life Safety Code 2012 edition

7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

This Code was not met as evidenced by:

Based on observation and interview the facility staff failed to ensure that an exit was marked by an approved sign.

The deficiency had the potential to delay or prevent the rapid egress of patients, staff and visitors in the event of an emergency evacuation.

Finding:

Out Patient Chino Hills Diagnostic X-ray

During the LSC code survey on 5/9/18 at 10:10 a.m., the evaluator noted that there was no exit sign at one of three exit doors of Suite 150C. Two exit doors at the front of the suite had illuminated exit signage, but the suite's back exit that opened to an exit corridor did not have exit signage.

During an interview at the same time as the observation the Vice President of Support Services stated that it may be that there was no exit signage because of the small square footage of the occupancy.

Standard: NFPA 101, Sect. 19.3.2.1 states that any hazardous areas shall have smoke-resisting doors that are self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 Square ft. (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

This requirement is not met as evidenced by:

Based on observation and interview, the facility failed to ensure that storage areas greater than 50 square feet that were filled with combustible materials had a corridor door that was self-closing and positively latching. In the event of a fire, containment of smoke and fire would not be achieved with non-latching self-closing doors in a hazardous use area.

Findings:

On 5/8/18 at 3:50 p.m., during the Life Safety Code inspection of the facility in the presence of the administrative licensed nurse and the safety director, the corridor door to the supply storage room located at the Main Hospital Emergency Room (ER-3) was not equipped with a "Self-Closing Device."
The supply storage room measured 240 square feet and contained combustible items such as boxes of bandages, splint, casting materials, disposable cups that were stored on shelves.

In an interview during the observation on the same date, the director of environmental safety acknowledged the findings and stated that the self-closing device will be installed.

Based on observation and interview, the facility failed to maintain a Class A, B or C flame spread rating finish in the main hospital's wall and ceiling by having unsealed penetrations through the basement, first and second floors, and walls and ceiling thereby, compromising the fire rating and containment of smoke and/or fire by the fire rated surfaces.

Findings:

During the Life Safety Code (LSC) tours in the presence of the director of environmental safety between 5/8/18 and 5/9/18, the surveyor observed the following penetrations:

1. Sterile Processing Area, Main Hospital Basement

(a). A linear penetration measuring 3-inch in diameter was noted around the base of the sprinkler head that extended through the corridor ceiling in front of mechanical room (EB17-H).

(b). A 10-inch linear penetration was observed in the ceiling around a broken AC (air conditioner) vent cover located inside the infusion pump repair room (EB17-A).

2. Laboratory Unit, Main Hospital First Floor

The evaluator observed an 11 by 11-inch penetration in ceiling above Biohazard Cabinet located inside the laboratory biohazard cabinet room.

During an interview on 5/9/18, at 2:20 p.m., the director of environmental safety acknowledged the findings and stated that the penetrations would be sealed.

NFPA 13 Installations of Sprinkler Systems, 1999 Edition

5-5.6 Clearance to Storage
The clearance between the deflector and the top of storage shall be 18 inches (457 mm) or greater.

Based on observation and interview, the facility failed to maintain 18 inch clearance between the sprinkler head deflector and the top of the stored items inside the "Hospital Gift Shop". In the event of a fire, a clear and unobstructed water discharge from the sprinkler head deflector to the top of the stored items where 18 inches of clearance is maintained will ensure that water from the sprinkler head will disperse and reach the protected hazard.

Findings:

During the Life Safety Code survey on 5/8/18 at 2:00 p. m., the evaluator, in the presence of the environmental safety director observed various assorted patch-dolls that were stored beyond 18 inches clearance between the sprinkler head deflector and top of the gift shop shelves at the main hospital front lobby.

During the observation on the same date the safety director acknowledged the findings and stated that the facility will provide the require 18 inch clearance.

NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition

5.4.1.8* Sprinklers shall not be altered in any respect or have any type of ornamentation, paint, or coatings applied after shipment from the place of manufacture.

This Standard was not met as evidenced by:

Based on observation and interview the facility failed to maintain escutcheons in place at two pendent sprinklers.

Unaltered sprinklers maintained per their listings help ensure sprinklers will perform as designed during a fire emergency.

Findings:

Out Patient Claremont

1. During the LSC code survey on 5/9/18 at 11:20 a.m., the evaluator noted
a sprinkler escutcheon seperated at the ceiling sprinkler head in Suite 170, .

2. During the LSC code survey on 5/9/18 at 11:55 a.m., the evaluator noted
a loose escutcheon at the clean linen closet ceiling sprinkler.

During an interview at the same time as the observations the Vice President of Support Services acknowledged that the escutcheons were out of place.

Based on observation and interview the facility staff failed to ensure that corridor doors were able to be held in the closed position.

The deficiency had a potential to create a condition conducive to the potential transfer of smoke, heat, gases, and fire during a fire emergency.

Findings:

Medical Center Pomona

1. During the LSC survey on 5/8/18 at 2:50 p.m., the evaluator noted that the 3rd floor corridor door to room 339 could not be held in the closed position.

During an interview at the same time as the observation, the Director of Facilities stated that the door did not hold in the closed position because the door had a loose strike plate.

2. At 3:10 p.m., the evaluator noted that the 3rd floor corridor door to room 361 could not also be held in the closed position.

Based on observation and interview the evaluator noted that there were holes and a penetration at smoke barrier walls.

The deficiency had the potential to facilitate the passage of smoke, heat and fire during a fire emergency.

Findings:

Out Patient Oncology Pomona

1. Durning the LSC survey on 5/9/18 at 1:45 p.m., the evaluator noted a ½-inch diameter hole, a 2-inch by 4-inch hole, and a 1-inch by 2-inch hole at one side of smoke barrier wall located above the drop down ceiling of the cross corridor door at the north corridor.

2. On 5/9/18 at 1:45 p.m., the evaluator noted a ½-inch diameter penetration through a smoke barrier wall located above the drop down ceiling of the cross corridor door at the south corridor.

During an interview at the same times as the observations the Vice President of Support Services acknowledged the holes and penetration at the smoke barrier walls and stated they would be repaired.

NFPA 70 National Electrical Code 2011 Edition

110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a workmanlike manner.

110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably grounded.

406.5 Receptacle Mounting. Receptacles shall be mounted in boxes or assemblies designed for the purpose, and such boxes or assemblies shall be securely fastened in place unless otherwise permitted elsewhere in Code.

This Code was not met as evidenced by:

Based on observation and interview, the facility staff failed to ensure

Based on observation and interview, the facility failed to ensure that electrical wiring and equipment were in accordance with NFPA 70 as evidenced by a loose electrical receptacle. The facility also failed to ensure that the facility's main electrical panel rooms were not used for storage.

The deficiencies had the potential to obstruct easy access to electrical panels essential for prompt response to electrical emergency and without fear/risk of electrical shock and fire hazard.

Findings:

Out Patient Oncology Pomona

1. During the LSC survey on 5/9/18 at 1:45 p.m., the evaluator noted that there was storage of a mobile step ladder with a plywood base in the main electrical panel room.

During an interview at the same time as the observation the Vice President of Support Services stated that the ladder would be removed from the electrical panel room.

Out Patient Claremont

2. During the LSC survey on 5/9/18 at 11:55 a.m., the evaluator noted a loose electrical receptacle in Suite 270 near the corridor by room 7.

Out Patient Pavilion (OPP) Pomona

3. On 5/10/18 at 9 a.m., the evaluator noted that the storage of ceiling tiles in the main electrical panel room.

NFPA 82 Standard on Incinerators and Waste and Linen Handling Systems
and Equipment 2009 Edition

10.2.1 Chute loading and discharge doors shall be maintained clear and unobstructed at all times.

This Standard was not met as evidenced by:

Based on observation and interview the facility staff failed to ensure
the soiled linen chute was unobstructed from closing.

In the event of a fire, the conditions that existed in the soiled linen chute discharge room had the potential for preventing the chute's discharge door from closing thereby, creating a chimney effect, a condition conducive to the spread of fire and smoke vertically to the floors above.

Finding:

Medical Center Pomona

During LSC observation on 5/10/18 at 9:35 a.m., the evaluator noted that in the bin in the E-building basement trash chute discharge room was overfilled with trash bin creating a condition that could obstruct the chutes door from closing in the event of a fire.

During an interview at the same time as the observation the Environmental Services Facilities Manager stated that the removal of the trash from the bottom of the trash chutes is a continuous process.

Draperies, Curtains, and Loosely Hanging Fabrics
Draperies, curtains including cubicle curtains and loosely hanging fabric or films shall be in accordance with 10.3.1. Excluding curtains and draperies: at showers and baths; on windows in patient sleeping room located in sprinklered compartments; and in non-patient sleeping rooms in sprinklered compartments where individual drapery or curtain panels do not exceed 48 square feet or total area does not exceed 20 percent of the wall.
18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1

Based on observation and interview, the facility failed to ensure that the privacy curtain in the Main Hospital Women's Center was flame resistant in accordance with 10.3.1. Flame resistant curtains, window shades, drapes and valances are essential in preventing a fire from spreading.

Finding:

During the Life Safety Code tours on 5/8/18 in the presence of the safety director, the evaluator observed a privacy curtain inside the Lactation room (<--which area of the room and what was the dimension?) located at the main Hospital Women's Center. There were no evidence (tags, labels, invoice or receipt) showing that the privacy curtain materials was flame resistant.

In an interview on the same date, the assigned facility staff members that were present at the time of observation were unable to provide proof showing that the privacy curtain were flame resistant.