HospitalInspections.org

Based on observation and record review, the facility failed to maintain the integrity of the building construction. This was evidenced by the use of combustible construction barriers in areas where the building integrity was damaged due to leaks. This affected one of six floors and the basement of the Pavilion. This finding could result in the faster spread of smoke and fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, 2000 Edition
19.1.1.4.6 Construction, Repair, and Improvement Operations. (See 4.6.10.)

4.6.10 Construction, Repair, and Improvement Operations.
4.6.10.1* Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

4.6.10.2* In buildings under construction, adequate escape facilities shall be maintained at all times for the use of construction workers. Escape facilities shall consist of doors, walkways, stairs, ramps, fire escapes, ladders, or other approved means or devices arranged in accordance with the general principles of the Code insofar as they can reasonably be applied to buildings under construction.

4.6.10.3 Flammable or explosive substances or equipment for repairs or alterations shall be permitted in a building while the building is occupied if the condition of use and safeguards provided do not create any additional danger or impediment to egress beyond the normally permissible conditions in the building.

Findings:

During the facility tour with Facilities Staff 1 and Facilities Staff 2 from 9/21/15 to 9/25/15, the building walls were observed.

9/22/15
Pavilion
Basement:

1. At 8:15 a.m., on 9/22/15, there was a non-rated plastic construction barrier in the corridor outside of the fire alarm panel control room.
A Construction Advisory Report from the Office of Statewide Health Planning and Development (OSHPD) was provided on 9/23/15. The OSHPD Compliance Officer stated that the construction barrier was installed without a permit.

Third Floor:

2. At 3:40 p.m., on 9/23/15, there were missing tiles in the ceiling of the corridor by Room 333. There was a plastic tarp partially covering the area with the missing tiles. The plastic tarp had water stains.

Based on observation and interview, the facility failed to maintain their doors. This was evidenced by corridors doors that were obstructed from closing. This affected two of three buildings at the Culver City campus. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients due to smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During facility tour with staff from 9/21/15 to 9/25/15, the corridor doors were observed.

Tower
First Floor:

1. At 9:45 a.m., on 9/22/15, the door to the S4 treatment room in the Emergency Department was obstructed from closing by a plastic door wedge.

Pavilion
Sixth Floor:

2. At 11:02 a.m., on 9/25/15, the door to Room 651 was obstructed from closing by a rolled up towel positioned by the door leaf.

3. At 11:03 a.m., on 9/25/15, the door to Room 622 was obstructed from closing by a rolled up towel positioned by the door leaf.

Basement:

4. At 1:08 p.m., on 9/25/15, the corridor door to the kitchen was obstructed from closing by a wooden door wedge.


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Pavilion
Third Floor:

5. At 11:14 a.m., on 9/25/15, the door to Room 332 in the Intensive Care Unit (ICU) was equipped with a self-closing device. The door was propped open and obstructed from closing by a chair.

During an interview at 11:15 a.m., Facilities Staff 2 stated that the ICU room doors were equipped with self-closing devices and they sometimes had to prop the doors open for the patients.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by smoke barrier doors that failed to close and latch. This affected two of three buildings at the Culver City campus. This could result in the spread of smoke from one smoke compartment to another and the increased risk of injury to patients, visitors, and staff in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers' installation instructions and shall be adjusted to function as described in the listing.

Findings:

During a facility tour with Facilities Staff 1 and Facilities Staff 2 from 9/21/15 to 9/25/15, the smoke barrier doors was observed.

Tower
First Floor:

1. At 2:41 p.m., on 9/22/15, the smoke barrier double doors by the Paramedic Lounge were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between the door leaves.

Pavilion
Sixth Floor:

2. At 2:40 p.m., on 9/23/15, the smoke barrier double doors by Room 651 were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.

Fifth Floor:

3. At 3:11 p.m., on 9/23/15, the smoke barrier double doors by Room 522 were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.

Basement:

4. At 9:47 a.m., on 9/24/15, the smoke barrier double doors at the tunnel entrance were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.

5. At 9:48 a.m., on 9/24/15, the smoke barrier double doors by the autoclave room were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.


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Pavilion
Fifth Floor:

6. At 3:11 p.m., on 9/23/15, the smoke barrier double doors by Room 509 were held open with electronic automatic-closing devices. One leaf closed less than 1 inch upon activation of the fire alarm system and remained almost completely open.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by emergency lights that failed when tested and by no records of testing the battery-powered emergency lights. This affected two of three buildings at the Culver City campus and two of six floors at the Hollywood Building. This could result in a delayed evacuation due to limited visibility, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the emergency lights were observed and maintenance logs were requested.

Tower and Pavilion:

1. At 11:45 a.m., on 9/24/15, no records of monthly and annual tests and inspections of the emergency battery-powered lights were provided. There was no documentation that indicated the emergency battery-powered lights were tested monthly for 30 seconds and annually for 90 minutes.

2. At 11:46 a.m., on 9/24/15, Facilities Staff 2 was asked if the exit stairwells were equipped with emergency lighting. The presence of emergency lighting in the exit stairwells at the Pavilion and Tower Buildings could not be confirmed.

During an interview at 11:46 a.m., Facilities Staff 2 stated that he did not know if the stairwells were equipped with emergency lighting and was unsure if the stairwell emergency lights were inspected during the monthly generator load tests.

The facility failed to provide documentation showing that emergency lights in stairwells were tested and maintained.

Tower
Basement:

3. At 3:41 p.m., on 9/24/15, in the automatic transfer switch room, the battery-powered emergency lights failed when tested by Facilities Staff 2.


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Hollywood
Fourth Floor:

4. At 2:44 p.m., on 9/25/15, the battery-powered emergency lighting unit, across from the nurses station, failed to illuminate when tested.

5. At 2:51 p.m., on 9/25/15, the ballast light fixture in Stairwell 1 was equipped with battery-operated emergency power. The light failed to illuminate when tested.

Third Floor:

6. At 2:58 p.m., on 9/25/15, the battery-powered emergency lighting unit, across from the nurses station, failed to illuminate when tested.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by one exit sign with battery-operated emergency illumination that failed to illuminate when tested and by no records of annually testing of exit signs with battery-operated emergency illumination. This affected four of four smoke compartments at the Van Nuys Building. This could result in a delayed evacuation, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
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.

7.10.4 Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the exit signs were observed and maintenance records were requested.

Van Nuys:

1. At 9:28 a.m., on 9/22/15, the exit sign in the administration area was equipped with battery-operated emergency illumination. The exit sign failed to illuminate when tested by Facilities Staff 1.

2. At 2:52 p.m., on 9/22/15, there were no records of 90-minute annual testing of the exit signs with battery-operated emergency illumination.

At 10:43 a.m., on 9/23/15, Facilities Staff 3 provided documentation of annually voltage testing of the batteries in the exit signs.

During an interview at 10:55 a.m., Facilities Staff 6 confirmed that the exit signs were not tested for 90 minutes annually.

Based on observation and interview, the facility failed to ensure that their fire alarm system was in reliable operating condition. This was evidenced by a disabled fire alarm sub-panel in the continuously monitored public box exchange (PBX) office. This affected three of three buildings at the Culver City campus and could result in a delayed notification of, and response to, a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition.
4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

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.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.1.3 System Design. Fire alarm system plans and specifications shall be developed in accordance with this code by persons who are experienced in the proper design, application, installation, and testing of fire alarm systems. The system designer shall be identified on the system design documents. Evidence of qualifications shall be provided when requested by the authority having jurisdiction.

1-5.5.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

Findings:

During a facility tour with Facilities Staff 2 from 9/21/15 to 9/25/15, the PBX room was observed.

Pavilion
Basement:

1. At 4:10 p.m., on 9/22/15, the fire alarm sub-panel in PBX was disconnected from the main fire alarm control panels.

During an interview at 4:10 p.m., Facilities Staff 2 stated that he disconnected the fire alarm panel in the PBX office because the continuous trouble alarms were a bother to the PBX staff and he stated that the fire alarm panel in PBX was not a necessary fire alarm panel.

During an interview at 1:50 p.m., on 9/23/15, PBX Operator 1 stated that the fire alarm panel in PBX was disconnected approximately 2 weeks ago and was told by the facility that security staff would notify them of any alarms and troubles.

During an interview at 1:26 p.m., on 9/23/15, Security Staff 1 stated that if the fire alarm system activated, he would notify engineering.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in reliable operating condition. This was evidenced by the failure of audible fire alarm notification devices, pull stations that were not readily accessible, fire alarm panel batteries that were not dated, and by ongoing trouble signals on the fire alarm panel. This affected three of three buildings at the Culver City campus. This could result in a malfunctioning fire alarm system and a delayed notification of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.5.1 Voltage, Temperature, and Humidity Variation. Equipment shall be designed so that it is capable of performing its intended functions under the following conditions:
(1) At 85 percent and at 110 percent of the nameplate primary (main) and secondary (standby) input voltage(s)
(2) At ambient temperatures of 32°F (0°C) and 120°F (49°C)
(3) At a relative humidity of 85 percent and an ambient temperature of 86°F (30°C)

1-5.5.2.4 Equipment shall be installed in locations where conditions do not exceed the voltage, temperature, and humidity limits specified in 1-5.5.1.
Exception: Equipment specifically listed for use in locations where conditions can exceed the upper and lower limits specified in 1-5.5.1.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

2-1.3.3 Initiating devices shall be installed in all areas where required by other NFPA codes and standards or the authority having jurisdiction. Each installed initiating device shall be accessible for periodic maintenance and testing.

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the fire alarm system was tested and system components were observed.

Pavilion
Basement:

1. At 8:59 a.m., on 9/22/15, the sealed-lead acid batteries in the Pavilion 1 and Pavilion 2 fire alarm control panels (FACPs) were not labeled with installation dates. The sealed-lead acid batteries in the emergency voice/alarm power supply box was not labeled with installation dates. Information about the dates of installation of the batteries was requested but not provided.

Tower and Single Story Building
First Floor:

2. At 2:45 p.m., on 9/22/15, the Inspector's Test Valve (ITV), located between the hallways of the Tower Building and Single Story Building, was activated. The fire alarm strobes were activated but the audible notification devices failed to emit an audible alarm.

Tower
First Floor:

3. At 3:30 p.m., on 9/22/15, there was a staff work station (desk and chair) positioned directly in-front of the fire alarm panel in the FACP room by the Emergency Department.

Fourth Floor:

4. At 3:02 p.m., on 9/22/15, a smoke detector was activated and the audible notification devices on the 4th floor failed to emit an audible alarm.

Pavilion
Sixth Floor:

5. At 2:42 p.m., on 9/23/15, five of six staff working in the southeast psychiatric locked unit were unable to activate a manual fire alarm pull box. Five of six staff were not equipped with a key to activate the key-operated manual fire alarm pull boxes.

6. At 2:43 p.m., on 9/23/15, three of three staff working in the southwest psychiatric locked unit were not equipped with a key to activate the key-operated manual fire alarm pull boxes.


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Pavilion
Basement:

7. At 11:41 a.m., on 9/21/15, the Pavilion 1 and the Pavilion 2 FACPs exhibited four trouble signals each.

During an interview at 11:42 a.m., Facilities Staff 2 stated that the panels had been in trouble for approximately two weeks.

During an interview at 10:15 a.m., on 9/23/15, Administrative Staff 2 stated that the failure of audible alarms during fire alarm testing on 9/22/15, and the continuous troubles exhibited in the FACPs, were caused by the dampness and humidity in the building due to the leaks in pipes. (Leaks in the steam pipe in the FACP Room is cited in K067)

Based on record review, the facility failed to maintain their smoke detectors. This was evidenced by no record of repairs or replacement for smoke detectors that failed sensitivity testing. This affected the mechanical roof, the basement, and one of six floors in the Hollywood Building. This could result in the increased risk of smoke detector failure and a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

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.


Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the smoke detectors were tested and maintenance records were requested.

Hollywood:

1. At 5:51 p.m., on 9/24/15, records indicated that smoke detector sensitivity testing was conducted on 3/27/14. The report stated that three smoke detectors failed sensitivity testing. The smoke detector in the elevator machine room on the roof, the smoke detector in the sixth floor stairwell, and the smoke detector in the west elevator lobby in the basement failed sensitivity testing. There were no records of repairing or replacing the failed detectors.

Based on observation, record review, and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to provide records for three of four quarterly inspections, the failure to maintain fire department connections (FDCs), by sprinkler heads that were corroded, by sprinkler heads that were missing escutcheon rings, by sprinkler pipes subjected to external loads, and by one waterflow valve that failed to activate the fire alarm system. This affected three of three buildings at the Culver City campus and four of four smoke compartments in the Van Nuys Building. This could result in the increased risk of an automatic sprinkler system failure and a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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 the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:During a tour of the facility with Facilities Staff 1 and Facilities Staff 2 from 9/21/15 to 9/25/15, the automatic sprinkler system was observed and maintenance records were requested.

Pavilion:

1. At 2:26 p.m., on 9/22/15, the shrubs and foliage blocked access to the FDCs near the exterior front stairs.

2. At 9:30 a.m., on 9/24/15, four of four FDCs by the south Pavilion stairwell were not equipped with caps.

3. At 9:32 a.m., on 9/24/15, four of eight sprinkler heads, under the front entrance overhang, showed signs of corrosion and one of eight sprinkler heads was missing an escutcheon ring.

Pavilion and Tower:

4. At 8:40 a.m., on 9/24/15, the facility failed to provide records of three of four quarterly inspections for the buildings at the Culver City campus.

During an interview at 8:40 a.m., Facilities Staff 1 acknowledged that the documentation was not provided.

Tower:

5. At 11:40 a.m., on 9/25/15, the FDCs on the west exterior wall showed signs of corrosion and were unable to rotate freely.


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Pavilion
Basement:

6. At 12:03 p.m., on 9/21/15, there were two pest strips attached to the sprinkler pipe in the trash chute room.

Van Nuys:

7. At 1:36 p.m., on 9/22/15, water was flowed through the Inspector's Test Valve (ITV) for more than 2 minutes. The fire alarm system failed to activate within 90 seconds. At 1:40 p.m., the ITV was tested again for 2 minutes 8 seconds and the fire alarm system failed to activate for a second time.

Based on observation and interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. This was evidenced by a patient care corridor where travel distance to a fire extinguisher was more than 75 feet away. This was also evidenced by no fire extinguisher provided at a designated smoking area. This affected one of four smoke compartments and one of two designated smoking areas at the Van Nuys Building. This could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 10, Standard 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.

2-1* General Requirements. The selection of fire extinguishers for a given situation shall be determined by the character of the fires anticipated, the construction and occupancy of the individual property, the vehicle or hazard to be protected, ambient-temperature conditions, and other factors (see Table A-2-1). The number, size, placement, and limitations of use of fire extinguishers required shall meet the requirements of Chapter 3.

2-2.1 Fire extinguishers shall be selected for the class(es) of hazards to be protected in accordance with the following subdivisions. (For specific hazards, see Section 2-3.)

3-1.2 Fire extinguishers shall be provided for the protection of both the building structure and the occupancy hazards contained therein.

3-1.2.2* Occupancy hazard protection shall be provided by fire extinguishers suitable for such Class A, B, C, D, or K fire potentials as might be present.

3-2.4 The protection requirements shall be permitted to be fulfilled with fire extinguishers of higher rating, provided the travel distance to such larger fire extinguishers does not exceed 75 ft (22.7 m).

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the fire extinguishers were observed.

Van Nuys:

1. At 9:17 a.m., on 9/22/15, there were no fire extinguishers from the locked cross-corridor door at the far end of Unit 2 to the Unit 2 Nurses Station.

During an interview at 9:18 a.m., Facilities Staff 3 and Facilities Staff 6 stated that the distance from the door to the nurse station was approximately 110 feet and confirmed that there was no fire extinguisher down that corridor.

2. At 9:28 a.m., on 9/22/15, there was no fire extinguisher in the Unit 1 smoking area. Facilities Staff 3 confirmed that there was no extinguisher.

Based on observation, the facility failed to maintain their smoking areas. This was evidenced by a broken safety type ashtray and by a designated smoking area located in close proximity to electrical transformers. This affected two of three buildings at the Culver City campus and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.


Findings:

During the tour of the facility with Facilities Staff 4 from 9/21/15 to 9/25/15, the smoking areas were observed.

Pavilion:

1. At 11:20 a.m., on 9/25/15, there was a broken safety-type ashtray in the east designated smoking area. Smoke from a lit cigarette was observed in the base of the broken ashtray.

Tower:

2. At 11:29 a.m., on 9/25/15, the designated smoking area, located by the valet parking lot, was less than 5 feet from the public electrical circuit panels, electrical poles, and transformers. The smoking area was enclosed with a fence covered in a green colored combustible material. The fire rating and specifications of the material was not provided.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) system. This was evidenced by the use of portable air conditioners (ACs) that were exhausted into the ceiling, by the use of temporary chillers without approval from the authority having jurisdiction (AHJ), by a leaking steam pipe, and by the alteration of a temporary HVAC unit without approval. This was also evidenced by an air handler with a leaking condenser. This affected three of three buildings at the Culver City campus, the basements in the Hollywood Building, and four of four smoke compartment in the Van Nuys building. These deficient practices could result in changes in the airflow and air exchange and could compromise the fire rating of the ceilings where the portable ACs were exhausted.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

8.2.3.2.4.1 Openings in fire barriers for air-handling duct work or air movement shall be protected in accordance with 9.2.1.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.
2-1.4 Electrical Wiring and equipment shall be installed in accordance with NFPA 70, National Electrical Code.
2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.
2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.
2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.
2-3.1.3 All air duct materials shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the air duct.
2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.
2-3.11.1 Egress Corridors. Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.
Exception No. 1: Toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridors.
Exception No. 2: Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Fire Windows, air transfer caused by pressure differentials shall be permitted.
Exception No. 3: Use of egress corridors as part of an engineered smoke-control system.
Exception No. 4: In detention and correctional occupancies with corridor separations of open construction (e.g. grating doors or grating partitions).
2-3.12 Smoke Control. Where a smoke-control or exhaust system is required, in shall conform to the requirements of the building code of the authority having jurisdiction.
3-1.4 Other Spaces Housing Air-Handling Units. Other spaces housing air-handling units shall meet the requirements of the building code the authority having jurisdiction
3-3.1.2 Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
3-3.3 Floor- or Roof- Ceiling Assemblies having a fire Resistance Rating. Where air ducts and openings for air ducts are used in a floor- or roof-ceiling assembly that is required to have fire resistance rating, all the materials and the construction of the assembly, including the air duct materials and the size and protection of the openings, shall conform with the design of the fire-resistive assembly, as tested in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. (Where dampers are required, see 3-4.4.)

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the HVAC systems were observed.

Culver City:

1. At 11:22 a.m., on 9/21/15, there was a portable AC in the Pavilion conference room with an exhaust pipe that penetrated the ceiling and exhausted hot air into the attic.

During an interview at 11:23 a.m., Facilities Staff 2 stated that the hospital was using portable ACs throughout including at all nurses stations in the Pavilion, two in the clinical lab, four in the Emergency Department in the Tower, and several other locations. He stated that the units were either exhausted directly into the attic or into return air ducts but was unsure about the specifics of each unit. He stated that the units were rented approximately one month ago because of the heat wave.

On 9/23/15, at 5:30 p.m., Facilities Staff 1 provided records of a rental agreement for 12 portable ACs that had been rented since 8/31/15 and four that were rented since 9/10/15.

During the survey, portable ACs were observed on the first floor, third floor, fourth floor, fifth floor, and sixth floor of the Pavilion. Portable ACs were observed in Emergency Department in the Tower. The units were exhausted into the attic or return air ducts without oversight from the AHJ. There were no records that indicated the facility had performed routine maintenance on the portable ACs in accordance with manufacturer's specifications.

On 9/25/15, the facility installed a temporary chiller in the penthouse of the Pavilion. At 11:05 a.m., the temporary chiller was turned on but then failed.

During an interview at 1:45 p.m., Facilities Staff 2 stated that temporary chiller had "tripped" but was now turned on again. Facilities Staff 1 stated that the vendor had to "babysit" the unit until it was fully operational.

At 2:01 p.m., Vendor 2, who installed the temporary chiller, stated that the chiller had to be turned off earlier in the morning to clear the pipes and when it was turned on again at 11 a.m., the unit tripped because they tried to reduce the temperature too quickly.

In an email to Facilities Staff 1, dated 9/24/15 at 5:02 p.m., the Office of Statewide Health Planning and Development (OSHPD) Regional Compliance Officer granted permission for the emergency repair of the HVAC system and the installation of the temporary chiller. The email stated that the authorization was valid for 30 days and, as a condition of the authorization, the facility was instructed to arrange for plan review and obtain a permit.

2. During an interview at 11:23 a.m., on 9/23/15, Facilities Staff 2 stated that the facility was using a temporary HVAC unit after a fire in the HVAC system in January 2015. The temporary HVAC unit was approved by OSHPD in March 2015.

An OSHPD Compliance Officer (CO) was onsite on 9/23/15. A Construction Advisory Report from the CO's visit was provided. The report indicated the approved temporary HVAC unit had been worked on by the facility without authorization and the facility had removed the outside air ducting. The CO confirmed the widespread presence of portable ACs in the report and stated that the facility was not getting enough cool air.

3. At 11:43 a.m., on 9/21/15, there was water leaking from the ceiling in the basement of the Pavilion. Leaking water was observed in the fire alarm control panel (FACP) room, the mechanical room, the sump pump room, and the hallway behind the surgical recovery area. In the FACP Room, approximately half the ceiling tiles were missing and at least two ceiling tiles had black mold and water stains.

During an interview at 11:44 a.m., Facilities Staff 2 stated that there were leaks in the steam pipes.

In the Construction Advisory Report from OSHPD, dated 9/23/15, the CO confirmed the steam pipe leaks in the basement of the Pavilion. The CO also stated that unauthorized repairs, like the installation of new piping, were conducted on the pipes.

Van Nuys:

4. At 10:00 a.m., on 9/22/15, there was a portable AC in the dried food storage room. The unit was surrounded by boxes blocking the air inlet and outlet.

The manufacturer's specifications for the unit stated "do not use this appliance for special purposes such as cooling pets, food, or precision machinery." The specifications also stated "Do Not block inlet or outlet of air flow" and stated "clean filter every two weeks." There were no records of cleaning the air filter.

5. At 10:16 a.m., on 9/22/15, there was a temporary chiller on a wheeled portable flat bed in the west parking lot.

During an interview at 10:17 a.m., Facilities Staff 3 stated that the temporary chiller was rented and hooked up three weeks ago. He stated that the chiller was installed without approval from OSHPD.

An invoice from the HVAC vendor, provided on 9/24/15, indicated that the temporary chiller was installed on 7/17/15 after the vendor got an emergency call from the facility for no cooling. The invoice was for the rental of the 20-ton chiller and the rental of the portable 5-ton unit in the kitchen.

Hollywood:
Basement:

6. At 4:33 p.m., on 9/22/15, the autoclave room next to OR 3 was 90°F.
During an interview at 4:36 p.m., Facilities Staff 3 stated that the exhaust fan appeared to be non-operational.

At 8:29 a.m., on 9/23/15, the temperature in the autoclave room was 89°F. During an interview at 8:30 a.m., Facilities Staff 3 stated that the supply air duct in the room was working but the air return was not.

Mechanical Basement:

7. At 9:05 a.m., on 9/23/15, the air handler in the basement was leaking from beneath the unit. There was a large puddle of water spreading towards the main electrical switch.

During an interview at 9:06 a.m., Facilities Staff 3 stated that the condenser hose was clogged causing the condensing tray to overflow.

Based on observation and interview, the facility failed to provide adequate ventilation for their boiler rooms. This was evidenced by one boiler room without an operable exhaust fan. This affected one of six floors in the Hollywood Building and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.2 Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Exception No. 1: Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient sleeping areas, provided that such heaters are located high enough to be out of the reach of persons using the area and are equipped with the safety features required by 19.5.2.2.
Exception No. 2: Fireplaces shall be permitted and used only in areas other than patient sleeping areas, provided that such areas are separated from patient sleeping spaces by construction having not less than a 1-hour fire resistance rating and that such fireplaces comply with the provisions of 9.2.2. In addition, the fireplace shall be equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650°F (343°C) and constructed of heat-tempered glass or other approved material. If, in the opinion of the authority having jurisdiction, special hazards are present, a lock on the enclosure and other safety precautions shall be permitted to be required.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the boiler rooms were observed.

Hollywood
Sixth Floor:

1. At 1:40 p.m., on 9/24/15, the temperature in the boiler room was over 90°F. The exhaust fan located at the window was not turned on.

During an interview at 1:41 p.m., Facilities Staff 7 stated that when the exhaust fan is turned on, the pilot light for the domestic hot water line turns off from the airflow so the exhaust fan is not used.

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by no filters in one kitchen hood, by incomplete documentation of fire suppression system inspections, by one kitchen hood with a filter that was not tight-fitting, and by grease-laden deposits on the kitchen hood and suppression system equipment. This affected one of three buildings at the Culver City campus and one of six floors at the Hollywood Building. This could result in the increased risk of a kitchen grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

8-2 Inspection. 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.

8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper orientation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
Exception:Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzle.

8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

10.6.6 A signed and dated log of maintenance as performed in accordance with 10-6.4 and 10.6.5 shall be available on the premises for use by the authority having jurisdiction.

Findings:

During a tour of the facility with Facility Staff 1 from 9/21/15 to 9/25/15, the commercial cooking equipment was observed.

Pavilion
First Floor:

1. At 10:26 a.m., on 9/24/15, the kitchen hood above the stove was not equipped with grease filters.

During an interview at 10:27 a.m., Dietary Staff 1 stated the the filters were removed approximately 3 months ago and the facility had ordered custom built filters.

2. At 4:50 p.m., on 9/24/15, the facility provided invoices for two semi-annual inspection reports of the fire suppression system in the kitchen hood. The facility failed to provide and maintain the actual inspection reports that would indicate what components were inspected and the results of the inspection. The facility also failed to provide information about the most recent hydrostatic test on the wet chemical fire suppression system.


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Hollywood
First Floor:

3. At 9:38 a.m., on 9/23/15, one of four filters in the kitchen hood was not installed in the designed orientation, revealing an approximately 4 inch gap and exposing the interior hood. Facilities Staff 3 confirmed that the filter was not put on correctly and adjusted it to fit.

4. At 9:46 a.m., on 9/23/15, Facilities Staff 3 removed the hood filters. The entire kitchen hood, including the exhaust duct and fusible links, was covered in thick grease-laden deposits.

Based on observation and interview, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by items blocking the egress paths and corridors. This affected two of three buildings at the Culver City campus and the Van Nuys building. This could result in a delayed evacuation of the facility in the event of an emergency and the increased risk of injury to the patients and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.6.1 General. Walking surfaces in the means of egress shall comply with 7.1.6.2 through 7.1.6.4.
Exception: Existing walking surfaces shall be permitted where approved by the authority having jurisdiction.

7.1.6.4 Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the means of egress were observed.

Pavilion
Basement:

1. At 11:45 a.m., on 9/21/15, there was an approximately 1 inch deep puddle of water in the hallway directly outside the emergency exit door behind the surgical recovery room. The puddle was spread along the entire width of the hallway, that was marked with emergency exit signs, and was approximately 10 feet long. The water caused the egress pathway to be slippery and unsafe.

During an interview at 11:46 a.m., Facilities Staff 2 stated that the puddle was caused from condensation on the boiler lines. He stated that the boiler was shut down for repairs from 3 a.m. to 8 a.m. that morning and when it was turned on, the condensation caused the large puddle of water. He confirmed that the hallway was an emergency egress path.

During a telephone conference with Facilities Staff 2 at 11:40 a.m., on 9/22/15, he stated that the excess water was caused by a blocked condenser drain.

2. At 11:47 a.m., on 9/21/15, there were two surgical beds and two surgical microscopes in the emergency exit hallway behind the surgical recovery room. The equipment obstructed the egress corridor.

During an interview at 12:06 p.m., Surgical Services Staff 1 stated that surgical equipment was always kept in the back of the recovery room, and in the hallway behind the recovery room, until it was sterilized for use during surgery.

3. At 12:03 p.m., on 9/21/15, there were three bariatric wheelchairs in the corridor outside the surgery department, across from Central Supply. The wheelchairs were observed again at 12:55 p.m. and there were two gurneys along the same corridor wall.

4. At 1:02 p.m., on 9/21/15, the tunnel connecting the basement of the Pavilion to the Tower was observed. One side of the ramp in the tunnel was used for the storage of 11 beds. One side of the corridor by the patient elevator was used for the storage of seven beds. The ramp and corridor were labeled as emergency exits.

During an interview at 1:05 p.m., Surgical Services Staff 1 and Facilities Staff 2 stated that the tunnel was used to transfer patients from the surgery department to the Tower. Facilities Staff 2 stated that the hospital did not have space to store extra beds so they were kept in the tunnel.

Van Nuys:

5. At 8:53 p.m., on 9/22/15, the exit door from the Unit 2 dining room was obstructed from opening. Van Nuys Nursing Staff 1 had to remove a patio chair that was placed directly in front of the door in order to open it.

Pavilion
Fifth Floor:

6. At 3:48 p.m., on 9/23/15, there were four workstations on wheels (WOWs) parked in the corridor by Room 533. The WOWs were connected to data cables in the corridor and one WOW was connected to a cable that went through the corridor wall into Room 536. There were also two carts in the corridor.

Pavilion
Third Floor:

7. At 3:43 p.m., on 9/23/15, there was a 2 1/2 foot wide portable air conditioner (AC) in the hallway outside Room 309.


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Pavilion
Basement:

8. At 8:15 a.m., on 9/22/15, there was barrier, made from a non-rated combustible material, taped across the entire width of the egress corridor outside the fire alarm panel control room.

9. At 8:30 a.m., on 9/22/15, there were wet blankets and water puddles on the floor in the egress corridor near the fire alarm panel room and the surgical recovery unit.

Tower Building
First Floor:

10. At 9:48 a.m., on 9/22/15, there were two portable ACs, with exhaust ducts extended into the ceiling, in the means of egress of the Emergency Department.

11. At 2:39 p.m., on 9/22/15, there were three unattended gurneys in the means of egress of the Emergency Department. One of the three gurneys was positioned by the emergency exit doors.

12. At 3:30 p.m., on 9/22/15, there was a portable AC in the Emergency Department waiting room that obstructed access to the means of egress.

Fourth Floor:

13. At 3:06 p.m., on 9/22/15, a garbage bin, approximately 6 feet in height, and a copy machine were in the egress corridor near the nurse station.

Sixth Floor:

14. At 3:19 p.m., on 9/22/15, the facility used the elevator lobby as a patients pre-admission waiting room. There were chairs in the egress corridor in front of the elevators.

Pavilion
Sixth Floor:

15. At 2:45 p.m., on 9/23/15, there was a telephone mounted on the wall, in a wooden cabinet, by Room 617. The wooden cabinet protruded approximately 12 inches from the wall and into the egress corridor. A vendor walked into the wooden cabinet and stumbled. The cabinet obstructed egress and protruded more than six inches into the corridor.

Second Floor:

16. At 9:10 a.m., on 9/24/15, there were three unattended WOWs in the egress corridor between Rooms 231 and 232. The WOWs were plugged into the electrical wall outlets and were hooked up to data cables in the corridor.

17. At 9:11 a.m., on 9/24/15, a portable filtration unit was in the egress hallway by Room 229.

18. At 9:15 a.m., on 9/24/15, there was an industrial fan in the egress corridor by Room 235.

First Floor:

19. At 9:40 a.m., on 9/24/15, a portable AC blocked access to the right exit door in the laboratory.

Sixth Floor:

20. At 11:10 a.m., on 9/25/15, there were four unattended WOWs plugged in the electrical wall outlets and hooked up to data cables in the north east egress corridor. There were linen carts in the same corridor that blocked egress.

Based on observation, the facility failed to maintain the storage of their soiled linen and trash receptacles. This was evidenced by linen and trash room doors that were not maintained. This was also evidenced by the storage of soiled linen receptacles, with capacities greater than 32-gallons, outside of rooms protected as hazardous areas. This affected the basement of the Pavilion and the basement of the Hollywood Building. This could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the soiled linen and trash receptacles were observed.

Pavilion
Basement:

1. At 12:00 p.m., on 9/21/15, the latching hardware on the door to the soiled linen chute room was taped down and the door failed to latch. The room contained more than 10 large bags of soiled linen.

2. At 12:02 p.m., on 9/21/15, the strike plate on the door frame of the trash chute room was damaged and missing a screw. The door failed to latch when tested. The room contained a 125-gallon trash receptacle full of trash bags and an additional two trash bags that obstructed the chute hatch from closing.

3. At 12:52 p.m., on 9/21/15, the self-closing door to the biohazard waste room in the surgical department failed to latch.

Hollywood
Basement:

4. At 4:30 p.m., on 9/22/15, there were two 55-gallon soiled linen bins and one approximately 32-gallon biohazard waste receptacle in the elevator lobby of the surgical department. The three receptacles were observed again at 8:31 a.m., on 9/23/15.

Based on observation and interview, the facility failed to maintain their oxygen cylinder storage areas. This was evidenced by the storage of combustibles in close proximity to the oxygen cylinders, by electrical switches that were installed less than 5 feet from the floor, and by the absence of precautionary signage. This affected one of three buildings at the Culver City campus. This could result in the increased risk of hazardous conditions and the increased risk of harm to patients.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers-Level 1.
(b) Special Precautions-Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During tour of facility with staff from 9/21/15 to 9/25/15, oxygen storage rooms were observed.

Pavilion
Basement:

1. At 9:01 a.m., on 9/22/15, the oxygen storage area in the post-anesthesia care unit (PACU) was observed. The electrical wall outlet was less than 3 feet from the floor and oxygen cylinders were stored next to the outlet. There were combustible supplies in carts stored next to the oxygen cylinders. The room was not equipped with the precautionary signage required for oxygen storage rooms. Facilities Staff 2 confirmed the findings.


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Pavilion
Basement:

2. At 12:40 p.m., on 9/21/15, the room labeled "Tank Room" in the surgical department was observed. There was a cardboard box of supplies and a plastic tarp placed on top of several oxygen E-cylinders. The room was not provided with the required No Smoking sign. The light switch in the room, next to the oxygen cylinder rack, was installed less than 4 feet from the floor.

During an interview at 12:41 p.m., Surgical Services Staff 1 stated that the supplies were not supposed to be stored in the Tank Room.

Based on observation, record review, and interview, the facility failed to maintain their piped-in medical gas systems. This was evidenced by the absence of emergency shut-off zone valves for the piped-in vacuum systems in anesthetizing locations, by obstructed emergency shut-off valves, and by alarm panels that were not functioning. This was also evidenced by the absence of an emergency oxygen supply connection. This affected three of three buildings at the Culver City campus and three of three anesthetizing locations at Hollywood. This could result in a malfunctioning piped-in medical gas system or a delayed response to an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-2 Nature of Hazards.
4-2.2 Vacuum Systems. There are potential fire and explosion hazards associated with medical gas central piping systems and medical-surgical vacuum systems. The various components are usually not independent isolated components, but are parts of a larger system dedicated to total patient care and safety.
Many of these components are covered by existing standards to minimize the fire, explosive, and patient safety hazard. With the increased use of vacuum systems, the potential for mistaken interconnection with oxidizing gases, for ingestion of flammable anesthetic gases, and for under capacity requiring extended overheated operation all present potential hazards or compound other hazardous conditions that should be properly addressed. While the potential for these problems exists, the former Subcommittee on Vacuum Systems and Equipment was unaware of the actual occurrence of any significant fire-related hazards with vacuum systems.
There are also potential hazards to patients in the unplanned shutdown or failure of the systems secondary to a fire and/or the inability of the system to provide adequate levels of performance under normal or emergency situations. There is also the potential for mistaken interconnection with pressurized nonflammable medical gas systems described in Sections 4-3 through 4-6.

4-3.1.2 Distribution-Level 1 (Manifold, Piping, Valving/Controls, Outlets/Terminals, Alarms).
4-3.1.2.2 Gas Warning Systems.
(a) General.
4. Where multiple panels are intended to indicate the same condition(s):
b. Both master alarms required by 4-3.1.2.2(b)2 shall be connected by dedicated wiring directly to the sensor(s) or switch(es).
8. All wiring from switch or sensors shall be protected as required by Section 517-30(c)(3) of NFPA 70, National Electrical Code, for emergency system circuits.
(b) Master Alarms
1. A master alarm system shall be provided to monitor operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems.
2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location).

4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

4-3.2 Piped Vacuum Systems (Source and Distribution) -- Level 1.
4-3.2.2.6 Vacuum System Shutoff Valves.
(g) Zone Valve. A shutoff valve shall be located immediately outside of each vital life-support, critical care, or anesthetizing location in each vacuum line, and located as to be readily accessible in an emergency or for maintenance of the terminals or piping within the individual zone served.

4-3.1.1.8 General Requirements for Gas Central Supply Systems. Piped oxygen and medical air shall not be piped to or used for, any purpose except for use in patient care applications.
(h)Emergency Oxygen Supply Connection. Where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system an inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled "EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET." This connection shall be installed downstream of the shutoff valve on the main supply line (see 4-3.1.2.3(b)) and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the piped-in medical gas systems were observed.

Pavilion
Basement:

1. At 12:30 p.m., on 9/21/15, Operating Rooms (ORs) 1, 2, 3, 4, 5, 6, 7, and 8 were all equipped with piped-in oxygen, nitrous oxide, and vacuum systems. All ORs, except OR 7, were not provided with emergency shut-off valves for their piped-in vacuum systems. Facilities Staff 2 confirmed that there were no vacuum system shut-off valves outside ORs 1, 2, 3, 4, 5, 6, and 8.

During an interview at 10:47 a.m., on 9/25/15, Facilities Staff 2 stated that he did not know where the main line shut-off valve for the piped-in vacuum system was located.

Hollywood
Basement:

2. At 4:05 p.m., on 9/22/15, ORs 1, 2, and 3 were equipped with piped-in oxygen, nitrous oxide, and vacuum systems. All three ORs did not have emergency shut-off valves for their piped-in vacuum system. The main-line vacuum shut-off valve was in the mechanical basement, accessible only to facilities and engineering staff.

3. At 4:13 p.m., on 9/22/15, the emergency shut-off valve assembly outside OR 2, for the oxygen and nitrous oxide piped-in gas systems, had a cover that was broken and taped to the wall instead of fitted on the box.

4. At 4:15 p.m., on 9/22/15, access to the emergency shut-off valve for the piped-in oxygen system in the recovery room was blocked by a cart. Facilities Staff 3 removed the cart but the shut-off valve was observed to be blocked again by the same cart at 4:36 p.m. The shut-off valve was blocked again by the same cart at 8:34 a.m. on 9/23/15.

5. At 9:30 a.m., on 9/24/15, records indicated that an inspection of the piped-in medical gas systems was conducted by a vendor on 4/27/15. The documentation indicated that the nitrous oxide area alarms in the surgery department and PBX failed because it had "no electrical wiring." On 6/17/15, when the vendor came back for corrective actions, the document noted that the nitrous panels were labeled as "not in service" by the technician.

At 10:12 a.m., on 9/24/15, the nitrous oxide alarms in the medical gas warning panel outside OR 3 was labeled "not in service" and none of the LED lights were illuminated.

At 10:18 a.m., on 9/24/15, the nitrous oxide alarm panel in PBX was also labeled "not in service" and none of the LED lights were illuminated.

During an interview at 3:23 p.m., Facilities Staff 3 stated that the power supply for the alarm panel was rated at 12 Amps and the power output was 15 Amps causing the motherboard for the panel to burn out.


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Pavilion and Tower:

6. At 4:02 p.m., on 9/22/15, the facility was not equipped with an emergency oxygen supply connection (oxygen autofill port).

During an interview at 4:02 p.m., Facilities Staff 2 confirmed that the facility was not equipped with an emergency oxygen supply connection. He stated that the facility was in the process of obtaining approval for the construction of the emergency oxygen supply and emergency shut-off valve for the cryogenic oxygen supply.

Based on observation and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by operating rooms (ORs) that were not equipped with a means of controlling relative humidity (RH) during surgery and by the failure to implement corrective actions when RH levels were out of range. This affected eight of eight ORs in the Pavilion and could result in the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures

Findings:

During a facility tour with Facilities Staff 2 and Surgical Services Staff 2 on 9/21/15, the ORs were observed.

Pavilion
Basement:

1. At 12:50 p.m., on 9/21/15, the humidity in OR 6 was 67 percent. Staff were in the OR prepping for a case.

During an interview at 12:51 p.m., Surgical Services Staff 1 stated that it was the facility policy to maintain the humidity between 30 percent and 60 percent. She stated that if the humidity did not decrease in OR 6, they would relocate the procedure to another room or cancel the case.

During an interview at 12:52 p.m., Facilities Staff 1 stated that the RH levels cannot be controlled mechanically by the air handlers in the ORs. They can only try to adjust the RH levels by setting the chillers to their lowest cooling point.

Surveyors from the California Department of Public Health (CDPH) observed a case in OR 6 later in the day (9/22/15) at 3:25 p.m. when humidity had reached 70 percent.

During a telephone conference with Facilities Staff 2 at 11:20 a.m., on 9/22/15, Facilities Staff 2 again confirmed that the humidity in the ORs could not be controlled by the mechanical ventilation system.

Based on record review and interview, the facility failed to ensure that fire drills were conducted quarterly for laboratory personnel. This was evidenced by the failure to provide documentation for quarterly drills conducted by laboratory staff and by laboratory staff that were unfamiliar with the location of the fire alarm manual pull stations. This affected one of six floors of the Pavilion. This could result in a delayed staff response to a laboratory fire.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 12 Hospital Requirements
12-3.7.2 Laboratories. Equipment shall conform to the nonpatient electrical equipment requirements in Chapter 7.

12-4.2 Laboratories. Laboratories in hospitals shall comply with the requirements of Chapter 10 as applicable and the requirements of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, as applicable.

10-2.1.4.3 Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually.

Findings:

During record review with staff from 9/21/15 to 9/25/15, the fire drills records were reviewed.

Pavilion
First Floor:

1. During an interview at 10:55 a.m., on 9/24/15, Laboratory Staff 1 stated that laboratory staff participate in an annual safety drill.

During an interview at 10:59 a.m., two laboratory staff were unfamiliar with the location of the fire alarm manual pull stations in the laboratory.

At 4:15 p.m., the facility failed to provide documents of laboratory fire drills and failed to provide documentation of laboratory staff participating in the main hospital's quarterly fire drills.

Based on record review, the facility failed to maintain their laboratory and pharmacy fume hoods. This was evidenced by no records of a current annual certification and by no records of current calibration tests for components of the fume hood system that were due for calibration. This affected two of three buildings at the Culver City campus. This could cause hoods to a malfunction and increase the risk of hazardous conditions.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 12 Hospital Requirements
12-3.7.2 Laboratories. Equipment shall conform to the nonpatient electrical equipment requirements in Chapter 7.

12-4.2 Laboratories. Laboratories in hospitals shall comply with the requirements of Chapter 10 as applicable and the requirements of NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, as applicable.

10-3.5 Fume Hoods. Fume hoods shall conform to 5-4.3 and 5-6.2.

5-4.3.4 Fume hood ventilating controls shall be so arranged that shutting off the ventilation of one fume hood will not reduce the exhaust capacity or create an imbalance between exhaust and supply for any other hood connected to the same system.
The operation of these controls shall be tested annually by a qualified person who shall certify the result of the test.

NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals, 1996 Edition
6-13.1 When installed or modified and at least annually thereafter, laboratory hoods, laboratory hood exhaust systems, and laboratory special exhaust systems shall be inspected and tested. The following inspections and tests, as applicable, shall be made:
(a) Visual inspection of the physical condition of the hood interior, sash, and ductwork (see 5-5.2 );
(b) Flow monitor;
(c) Low airflow and loss-of-airflow alarms at each alarm location;
(d) Face velocity;
(e) Verification of inward airflow over the entire hood face; and
(f) Changes in work area conditions that might affect hood performance.

Findings:

During record review with staff from 9/21/15 to 9/25/15, the fume hood maintenance records were reviewed.

Tower and Pavilion:

1. At 5:10 p.m., on 9/24/15, the annual fume hood certification record for the microbiology lab, dated 9/12/14, indicated that the UV and fluorescent lights were not working and had to be replaced. The facility failed to provide documentation that indicated repairs were made.

2. At 5:11 p.m., on 9/24/15, the annual fume hood certification for the pathology lab was dated 9/12/14. The facility failed to provide documentation of a 2015 annual fume hood certification.

3. At 5:12 p.m., on 9/24/15, the fume hood certification records indicated that several fume hood components were due for recalibration in January 2015, February 2015, June 2015, and July 2015. No records for the recalibration of the components were provided.

4. At 11:15 a.m., on 9/25/15, the facility failed to provide records of the annual certification of the pharmacy fume hood.

Based on observation and interview, the facility failed to maintain their emergency generators. This was evidenced by a generator enclosure that was not equipped with battery-powered emergency lights, by a fuel tank gauge that was inoperable, and by the failure to ensure that facility generators were monitored by remote alarm annunciators. This affected three of three buildings at the Culver City Campus and affected the Van Nuys Building. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 70 , National Electrical Code, Section 700-12).
The annunciator shall indicate alarm condition of the emergency or auxiliary power source as follows:
(a)Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b)Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

3-5.5.2 (d) Battery powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2 (d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6.1 A remote,, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During tour of facility with staff from 9/21/15 to 9/25/15, the generator room was observed.

Tower
Basement:

1. At 3:34 p.m., on 9/22/15, the generator room was not equipped with battery-powered emergency lights.

2. At 4:03 p.m., on 9/22/15, there were no remote alarm annunciators for three of three generators at Culver City.

During an interview at 4:03 p.m., Administrative Staff 3 confirmed that the facility was not equipped with remote alarm annunciators for three of three generators.


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Van Nuys Building
Basement:

3. At 10:40 a.m., on 9/22/15, the diesel day tank connected to the generator had a gauge that showed the fuel level as empty. The tank was approximately 100 percent full upon inspection. Facilities Staff 6 pushed the test button on the day tank and the gauge on the tank did not move.

During an interview at 10:41 a.m., Facilities Staff 6 stated that when the test button is pushed, the gauge should have read the accurate level of diesel fuel.

During an interview at 2:20 p.m., Facilities Staff 3 stated that the gauge would work if the generator was running. Facilities Staff 6 ran the generator and the gauge was still stuck on empty.

4. At 10:45 a.m., on 9/22/15, there was no remote alarm annunciator for the diesel generator at Van Nuys.

During an interview at 10:46 a.m., Facilities Staff 6 confirmed that there was no remote alarm annunciator for this generator.

Based on observation and interview, the facility failed to maintain the integrity of their electrical wiring. This was evidenced by modifications to an electrical panel to power portable air cooling units, by the use of power strips and extension cords, by the failure to safeguard a defective electrical outlet, and by an obstructed electrical panel. These deficient practices affected two of three buildings at the Culver City campus, one of four smoke compartments at the Van Nuys Building, and the Hollywood Building. This could cause an electrical fire and potential harm to residents and staff in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
Section 90-4 Enforcement. This Code is intended to be suitable for mandatory application by governmental bodies that exercise legal jurisdiction over electrical installations and for use by insurance inspectors. The authority having jurisdiction for enforcement of the Code will have the responsibility for making interpretations of the rules for deciding on the approval of equipment and materials, and for granting the special permission contemplated in a number of the rules. The authority having jurisdiction may waive specific requirements in this Code or permit alternate methods where it is assured that equivalent objectives can be achieved by establishing and maintaining effective safety. This Code may require new products, constructions, or materials that may not yet be available at the time the Code is adopted. In such event, the authority having jurisdiction may permit the use of the products, constructions, or materials that comply with the most recent previous edition of this Code adopted by the jurisdiction.

90-7 Examination of Equipment for Safety. For specific items of equipment and materials referred to in this Code, examinations for safety made under standard conditions will provide a basis for approval where the record is made generally available through promulgation by organization properly equipped and qualified for experimental testing, inspections of the run of goods at factories, and service-value determination through field inspections. This avoids the necessity for repetition of examinations by different examiners, frequently with inadequate facilities for such work, and the confusion that would result from conflicting reports as to the suitability of devices and materials examined for a given purpose.
It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations or damage, if the equipment has been listed by a qualified electrical testing laboratory that is recognized as having the facilities described above and that require suitability for installation in accordance with this Code.

110-3. Examination, Identification, Installation, and Use of Equipment.
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
(b) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures, into which persons enter for installation and maintenance.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with staff from 9/21/15 to 9/25/15, the electrical wiring was observed.

Tower
First Floor:

1. At 10:01 a.m., on 9/22/15, the electrical outlet on the wall above Bed S1 in the Emergency Department had a loose faceplate.

Basement:

2. At 3:30 p.m., on 9/22/15, Electrical Panel BEA was painted shut and was obstructed from opening.

Pavilion
Basement:

3. At 4:05 p.m., on 9/22/15, a refrigerator, a microwave oven, and a coffee pot were plugged into a multi-plug power-strip in the public box exchange office.

Sixth Floor:

4. At 2:38 p.m., on 9/23/15, the portable air conditioning unit, located in the egress corridor near the nurse station, was plugged into an extension cord.

Second Floor:

5, At 9:05 p.m., on 9/24/15, there was white tape placed over the faceplate of the red emergency electrical outlet by Room 208.

First Floor:

6. At 9:45 a.m., on 9/24/15, the portable air conditioner in the laboratory was plugged into a multi-plug power strip.


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Pavilion
Basement:

7. At 12:24 p.m., on 9/21/15, there was a cautery unit plugged into a four-plug extension in Operating Room (OR) 1. The unit was marked with a "hospital grade only" sticker near its electrical adaptor. The extension cord did not have hospital grade plugs.

During an interview at 12:25 p.m., Facilities Staff 2 confirmed that the plugs were not hospital grade.

8. At 12:36 p.m., on 9/21/15, there was a four-plug outlet hanging from the ceiling by a cable, near the surgical table in OR 4. The outlet was labeled as "defective" by a biomed technician in 2009. The outlet was only labeled on one side and the plugs were still accessible for use.

Van Nuys:

9. At 10:01 a.m., on 9/22/15, the portable AC in the dry kitchen storage room was plugged into an extension cord.

Under the Electrical Safety section of the unit manufacturer's manual, it stated "Do not use extension cords."

10. At 10:04 a.m., on 9/22/15, a large cable was wired from behind Electrical Panel KS to power the temporary cooling unit on the main floor of the kitchen.

During an interview at 10:04 a.m., Facilities Staff 3 stated that it had been this way for approximately three months and that the electrical wiring was not approved by the authority having jurisdiction.

Hollywood
Basement:

11. At 4:25 p.m., on 9/22/15, the surgical table in OR 1 was plugged into a multi-plug power strip.

First Floor:

12. At 9:32 a.m., on 9/23/15, the electrical connection for the portable cooling unit in the kitchen could not be observed. A large cable ran into the same exhaust unit as the faulty swamp cooler.

During an interview at 9:34 a.m., Facilities Staff 3 stated that the temporary cooling unit was wired into the swamp cooler disconnect and will remain that way until the swamp cooler was repaired.

Mechanical Roof:

13. At 1:26 p.m., on 9/24/15, there were two 4 by 4 electrical boxes in the ceiling connected via conduit to the smoke detector in the elevator machine room. The electrical boxes had no covers and the electrical relays were protruding more than 1 inch out of the boxes.

Based on observation and record review, the facility failed to maintain the integrity of the building construction. This was evidenced by the use of combustible construction barriers in areas where the building integrity was damaged due to leaks. This affected one of six floors and the basement of the Pavilion. This finding could result in the faster spread of smoke and fire and the increased risk of injury to patients, staff, and visitors.

NFPA 101, 2000 Edition
19.1.1.4.6 Construction, Repair, and Improvement Operations. (See 4.6.10.)

4.6.10 Construction, Repair, and Improvement Operations.
4.6.10.1* Buildings or portions of buildings shall be permitted to be occupied during construction, repair, alterations, or additions only where required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the authority having jurisdiction are in place.

4.6.10.2* In buildings under construction, adequate escape facilities shall be maintained at all times for the use of construction workers. Escape facilities shall consist of doors, walkways, stairs, ramps, fire escapes, ladders, or other approved means or devices arranged in accordance with the general principles of the Code insofar as they can reasonably be applied to buildings under construction.

4.6.10.3 Flammable or explosive substances or equipment for repairs or alterations shall be permitted in a building while the building is occupied if the condition of use and safeguards provided do not create any additional danger or impediment to egress beyond the normally permissible conditions in the building.

Findings:

During the facility tour with Facilities Staff 1 and Facilities Staff 2 from 9/21/15 to 9/25/15, the building walls were observed.

9/22/15
Pavilion
Basement:

1. At 8:15 a.m., on 9/22/15, there was a non-rated plastic construction barrier in the corridor outside of the fire alarm panel control room.
A Construction Advisory Report from the Office of Statewide Health Planning and Development (OSHPD) was provided on 9/23/15. The OSHPD Compliance Officer stated that the construction barrier was installed without a permit.

Third Floor:

2. At 3:40 p.m., on 9/23/15, there were missing tiles in the ceiling of the corridor by Room 333. There was a plastic tarp partially covering the area with the missing tiles. The plastic tarp had water stains.

Based on observation and interview, the facility failed to maintain their doors. This was evidenced by corridors doors that were obstructed from closing. This affected two of three buildings at the Culver City campus. This could result in the spread of smoke and fire throughout the facility and the increased risk of injury to the patients due to smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

7.2.1.8.1 A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During facility tour with staff from 9/21/15 to 9/25/15, the corridor doors were observed.

Tower
First Floor:

1. At 9:45 a.m., on 9/22/15, the door to the S4 treatment room in the Emergency Department was obstructed from closing by a plastic door wedge.

Pavilion
Sixth Floor:

2. At 11:02 a.m., on 9/25/15, the door to Room 651 was obstructed from closing by a rolled up towel positioned by the door leaf.

3. At 11:03 a.m., on 9/25/15, the door to Room 622 was obstructed from closing by a rolled up towel positioned by the door leaf.

Basement:

4. At 1:08 p.m., on 9/25/15, the corridor door to the kitchen was obstructed from closing by a wooden door wedge.


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Pavilion
Third Floor:

5. At 11:14 a.m., on 9/25/15, the door to Room 332 in the Intensive Care Unit (ICU) was equipped with a self-closing device. The door was propped open and obstructed from closing by a chair.

During an interview at 11:15 a.m., Facilities Staff 2 stated that the ICU room doors were equipped with self-closing devices and they sometimes had to prop the doors open for the patients.

Based on observation, the facility failed to maintain their smoke barrier doors. This was evidenced by smoke barrier doors that failed to close and latch. This affected two of three buildings at the Culver City campus. This could result in the spread of smoke from one smoke compartment to another and the increased risk of injury to patients, visitors, and staff in the event of a fire.

NFPA 101, Life Safety Code 2000 Edition
4.61.2 Any requirement that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.7.6 Doors in smoke barriers shall comply with 8.3.4 and shall be self-closing or automatic-closing in accordance with 19.2.2.2.6. Such doors in smoke barriers shall not be required to swing with egress travel. Positive latching hardware shall not be required.

8.2.3.2.1 Door assemblies in fire barriers shall be of an approved type with the appropriate fire protection rating for the location in which they are installed and shall comply with the following.
(a) Fire doors shall be installed in accordance with NFPA 80, Standard for Fire Doors and Fire Windows. Fire doors shall be of a design that has been tested to meet the conditions of acceptance of NFPA 252, Standard Methods of Fire Tests of Door Assemblies.
Exception: The requirement of 8.2.3.2.1(a) shall not apply where otherwise specified by 8.2.3.2.3.1.
(b) Fire doors shall be self-closing or automatic-closing in accordance with 7.2.1.8 and, where used within the means of egress, shall comply with the provisions of 7.2.1.

NFPA 80, Standard for Fire Doors and Fire Windows, 1999 edition.
2-5.2 Manufacturers' Instructions. All components shall be installed in accordance with the manufacturers' installation instructions and shall be adjusted to function as described in the listing.

Findings:

During a facility tour with Facilities Staff 1 and Facilities Staff 2 from 9/21/15 to 9/25/15, the smoke barrier doors was observed.

Tower
First Floor:

1. At 2:41 p.m., on 9/22/15, the smoke barrier double doors by the Paramedic Lounge were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between the door leaves.

Pavilion
Sixth Floor:

2. At 2:40 p.m., on 9/23/15, the smoke barrier double doors by Room 651 were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.

Fifth Floor:

3. At 3:11 p.m., on 9/23/15, the smoke barrier double doors by Room 522 were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.

Basement:

4. At 9:47 a.m., on 9/24/15, the smoke barrier double doors at the tunnel entrance were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.

5. At 9:48 a.m., on 9/24/15, the smoke barrier double doors by the autoclave room were held open with electronic automatic-closing devices. The doors failed to close and latch upon activation of the fire alarm system, leaving a gap between door leaves.


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Pavilion
Fifth Floor:

6. At 3:11 p.m., on 9/23/15, the smoke barrier double doors by Room 509 were held open with electronic automatic-closing devices. One leaf closed less than 1 inch upon activation of the fire alarm system and remained almost completely open.

Based on observation, record review, and interview, the facility failed to maintain their battery-powered emergency lights. This was evidenced by emergency lights that failed when tested and by no records of testing the battery-powered emergency lights. This affected two of three buildings at the Culver City campus and two of six floors at the Hollywood Building. This could result in a delayed evacuation due to limited visibility, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.9.1 Emergency lighting shall be provided in accordance with Section 7.9.

19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices

7.9.1.1 Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 42
(2) Underground and windowless structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed egress locks
(5) The stair shaft and vestibule of smokeproof enclosures, which shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment and used for the stair shaft and vestibule emergency lighting power supply For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, ramps, aisles, walkways, and escalators leading to a public way.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the emergency lights were observed and maintenance logs were requested.

Tower and Pavilion:

1. At 11:45 a.m., on 9/24/15, no records of monthly and annual tests and inspections of the emergency battery-powered lights were provided. There was no documentation that indicated the emergency battery-powered lights were tested monthly for 30 seconds and annually for 90 minutes.

2. At 11:46 a.m., on 9/24/15, Facilities Staff 2 was asked if the exit stairwells were equipped with emergency lighting. The presence of emergency lighting in the exit stairwells at the Pavilion and Tower Buildings could not be confirmed.

During an interview at 11:46 a.m., Facilities Staff 2 stated that he did not know if the stairwells were equipped with emergency lighting and was unsure if the stairwell emergency lights were inspected during the monthly generator load tests.

The facility failed to provide documentation showing that emergency lights in stairwells were tested and maintained.

Tower
Basement:

3. At 3:41 p.m., on 9/24/15, in the automatic transfer switch room, the battery-powered emergency lights failed when tested by Facilities Staff 2.


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Hollywood
Fourth Floor:

4. At 2:44 p.m., on 9/25/15, the battery-powered emergency lighting unit, across from the nurses station, failed to illuminate when tested.

5. At 2:51 p.m., on 9/25/15, the ballast light fixture in Stairwell 1 was equipped with battery-operated emergency power. The light failed to illuminate when tested.

Third Floor:

6. At 2:58 p.m., on 9/25/15, the battery-powered emergency lighting unit, across from the nurses station, failed to illuminate when tested.

Based on observation, record review, and interview, the facility failed to maintain their exit signs. This was evidenced by one exit sign with battery-operated emergency illumination that failed to illuminate when tested and by no records of annually testing of exit signs with battery-operated emergency illumination. This affected four of four smoke compartments at the Van Nuys Building. This could result in a delayed evacuation, in the event of an emergency.

NFPA 101, Life Safety Code, 2000 Edition.
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.

7.10.4 Power Source. Where emergency lighting facilities are required by the applicable provisions of Chapters 11 through 42 for individual occupancies, the signs, other than approved self-luminous signs, shall be illuminated by the emergency lighting facilities. The level of illumination of the signs shall be in accordance with 7.10.6.3 or 7.10.7 for the required emergency lighting duration as specified in 7.9.2.1. However, the level of illumination shall be permitted to decline to 60 percent at the end of the emergency lighting duration.

7.10.5.1 General. Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

7.10.5.2 Continuous Illumination. Every sign required to be illuminated by 7.10.6.3 and 7.10.7 shall be continuously illuminated as required under the provisions of Section 7.8.
Exception: Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

7.10.9.2 Testing. Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and test shall be kept by the owner for inspection by the authority having jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency lighting equipment that automatically performs a test for not less than 30 seconds and diagnostic routine not less than once every 30 days and indicates failures by a status indicator shall be exempt from the 30 day functional test, provided that a visual inspection is performed at 30-day intervals.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the exit signs were observed and maintenance records were requested.

Van Nuys:

1. At 9:28 a.m., on 9/22/15, the exit sign in the administration area was equipped with battery-operated emergency illumination. The exit sign failed to illuminate when tested by Facilities Staff 1.

2. At 2:52 p.m., on 9/22/15, there were no records of 90-minute annual testing of the exit signs with battery-operated emergency illumination.

At 10:43 a.m., on 9/23/15, Facilities Staff 3 provided documentation of annually voltage testing of the batteries in the exit signs.

During an interview at 10:55 a.m., Facilities Staff 6 confirmed that the exit signs were not tested for 90 minutes annually.

Based on observation and interview, the facility failed to ensure that their fire alarm system was in reliable operating condition. This was evidenced by a disabled fire alarm sub-panel in the continuously monitored public box exchange (PBX) office. This affected three of three buildings at the Culver City campus and could result in a delayed notification of, and response to, a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition.
4.1.1 Fire and Similar Emergency. The goal of this Code is to provide an environment for the occupants that is reasonably safe from fire and similar emergencies by the following means:
(1) Protection of occupants not intimate with the initial fire development
(2) Improvement of the survivability of occupants intimate with the initial fire development.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

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.

9.6.1.5 All systems and components shall be approved for the purpose for which they are installed.

9.6.1.6 Fire alarm system installation wiring or other transmission paths shall be monitored for integrity in accordance with 9.6.1.4.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.1.3 System Design. Fire alarm system plans and specifications shall be developed in accordance with this code by persons who are experienced in the proper design, application, installation, and testing of fire alarm systems. The system designer shall be identified on the system design documents. Evidence of qualifications shall be provided when requested by the authority having jurisdiction.

1-5.5.2.1 All systems shall be installed in accordance with the specifications and standards approved by the authority having jurisdiction.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

1-6.1.1 The authority having jurisdiction shall be notified prior to installation or alteration of equipment or wiring. At its request, complete information regarding the system or system alterations, including specifications, wiring diagrams, battery calculation, and floor plans shall be submitted for approval.

Findings:

During a facility tour with Facilities Staff 2 from 9/21/15 to 9/25/15, the PBX room was observed.

Pavilion
Basement:

1. At 4:10 p.m., on 9/22/15, the fire alarm sub-panel in PBX was disconnected from the main fire alarm control panels.

During an interview at 4:10 p.m., Facilities Staff 2 stated that he disconnected the fire alarm panel in the PBX office because the continuous trouble alarms were a bother to the PBX staff and he stated that the fire alarm panel in PBX was not a necessary fire alarm panel.

During an interview at 1:50 p.m., on 9/23/15, PBX Operator 1 stated that the fire alarm panel in PBX was disconnected approximately 2 weeks ago and was told by the facility that security staff would notify them of any alarms and troubles.

During an interview at 1:26 p.m., on 9/23/15, Security Staff 1 stated that if the fire alarm system activated, he would notify engineering.

Based on observation and interview, the facility failed to ensure that the fire alarm system was maintained in reliable operating condition. This was evidenced by the failure of audible fire alarm notification devices, pull stations that were not readily accessible, fire alarm panel batteries that were not dated, and by ongoing trouble signals on the fire alarm panel. This affected three of three buildings at the Culver City campus. This could result in a malfunctioning fire alarm system and a delayed notification of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
4.2.3 Systems Effectiveness. Systems utilized to achieve the goals of Section 4.1 shall be effective in mitigating the hazard or condition for which they are being used, shall be reliable, shall be maintained to the level at which they were designed to operate, and shall remain operational.

4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-5.5.1 Voltage, Temperature, and Humidity Variation. Equipment shall be designed so that it is capable of performing its intended functions under the following conditions:
(1) At 85 percent and at 110 percent of the nameplate primary (main) and secondary (standby) input voltage(s)
(2) At ambient temperatures of 32°F (0°C) and 120°F (49°C)
(3) At a relative humidity of 85 percent and an ambient temperature of 86°F (30°C)

1-5.5.2.4 Equipment shall be installed in locations where conditions do not exceed the voltage, temperature, and humidity limits specified in 1-5.5.1.
Exception: Equipment specifically listed for use in locations where conditions can exceed the upper and lower limits specified in 1-5.5.1.

1-5.7.1.1 The primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation. All required annunciation means shall be readily accessible to responding personnel and shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation.

2-1.3.3 Initiating devices shall be installed in all areas where required by other NFPA codes and standards or the authority having jurisdiction. Each installed initiating device shall be accessible for periodic maintenance and testing.

2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the fire alarm system was tested and system components were observed.

Pavilion
Basement:

1. At 8:59 a.m., on 9/22/15, the sealed-lead acid batteries in the Pavilion 1 and Pavilion 2 fire alarm control panels (FACPs) were not labeled with installation dates. The sealed-lead acid batteries in the emergency voice/alarm power supply box was not labeled with installation dates. Information about the dates of installation of the batteries was requested but not provided.

Tower and Single Story Building
First Floor:

2. At 2:45 p.m., on 9/22/15, the Inspector's Test Valve (ITV), located between the hallways of the Tower Building and Single Story Building, was activated. The fire alarm strobes were activated but the audible notification devices failed to emit an audible alarm.

Tower
First Floor:

3. At 3:30 p.m., on 9/22/15, there was a staff work station (desk and chair) positioned directly in-front of the fire alarm panel in the FACP room by the Emergency Department.

Fourth Floor:

4. At 3:02 p.m., on 9/22/15, a smoke detector was activated and the audible notification devices on the 4th floor failed to emit an audible alarm.

Pavilion
Sixth Floor:

5. At 2:42 p.m., on 9/23/15, five of six staff working in the southeast psychiatric locked unit were unable to activate a manual fire alarm pull box. Five of six staff were not equipped with a key to activate the key-operated manual fire alarm pull boxes.

6. At 2:43 p.m., on 9/23/15, three of three staff working in the southwest psychiatric locked unit were not equipped with a key to activate the key-operated manual fire alarm pull boxes.


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Pavilion
Basement:

7. At 11:41 a.m., on 9/21/15, the Pavilion 1 and the Pavilion 2 FACPs exhibited four trouble signals each.

During an interview at 11:42 a.m., Facilities Staff 2 stated that the panels had been in trouble for approximately two weeks.

During an interview at 10:15 a.m., on 9/23/15, Administrative Staff 2 stated that the failure of audible alarms during fire alarm testing on 9/22/15, and the continuous troubles exhibited in the FACPs, were caused by the dampness and humidity in the building due to the leaks in pipes. (Leaks in the steam pipe in the FACP Room is cited in K067)

Based on record review, the facility failed to maintain their smoke detectors. This was evidenced by no record of repairs or replacement for smoke detectors that failed sensitivity testing. This affected the mechanical roof, the basement, and one of six floors in the Hollywood Building. This could result in the increased risk of smoke detector failure and a delay in notification, in the event of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.5.1 Detection systems, where required, shall be in accordance with Section 9.6.

9.6.1.3 The provisions of Section 9.6 cover the basic functions of a complete fire alarm system, including fire detection, alarm, and communications. These systems are primarily intended to provide the indication and warning of abnormal conditions, the summoning of appropriate aid, and the control of occupancy facilities to enhance protection of life.

9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm Code.

NFPA 72, National Fire Alarm Code, 1999 Edition.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

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.


Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the smoke detectors were tested and maintenance records were requested.

Hollywood:

1. At 5:51 p.m., on 9/24/15, records indicated that smoke detector sensitivity testing was conducted on 3/27/14. The report stated that three smoke detectors failed sensitivity testing. The smoke detector in the elevator machine room on the roof, the smoke detector in the sixth floor stairwell, and the smoke detector in the west elevator lobby in the basement failed sensitivity testing. There were no records of repairing or replacing the failed detectors.

Based on observation, record review, and interview, the facility failed to maintain the automatic sprinkler system. This was evidenced by the failure to provide records for three of four quarterly inspections, the failure to maintain fire department connections (FDCs), by sprinkler heads that were corroded, by sprinkler heads that were missing escutcheon rings, by sprinkler pipes subjected to external loads, and by one waterflow valve that failed to activate the fire alarm system. This affected three of three buildings at the Culver City campus and four of four smoke compartments in the Van Nuys Building. This could result in the increased risk of an automatic sprinkler system failure and a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition
19.3.5.1 Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.
Exception: In Type I and Type II construction, where approved by the authority having jurisdiction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as nonsprinklered.

9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition.
1-8 Records. Records of inspections, tests, and maintenance of the system and its components shall be made available to the authority having jurisdiction upon request. Typical records include, but are not limited to, valve inspections; flow, drain, and pump tests; and trip tests of dry pipe, deluge, and preaction valves.

1-8.1 Records shall indicate the procedure performed (e.g., inspection, test, or maintenance), the organization that performed the work, the results, and the date.

1-8.2 Records shall be maintained by the owner. Original records shall be retained for the life of the system. Subsequent records shall be retained for a period of one year after the next inspection, test, or maintenance required by the standard.

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 the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation.

2-2.2 Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. Pipe and fittings shall be in good condition and free of mechanical damage, leakage, corrosion, and misalignment. Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.
Exception No. 1:Pipe and fittings installed in concealed spaces such as above suspended ceilings shall not require inspection.
Exception No. 2: Pipe installed in areas that are inaccessible for safety considerations due to process operations shall be inspected during each scheduled shutdown.

2-2.6 Alarm Devices. Alarm devices shall be inspected quarterly to verify that they are free of physical damage.

2-3.3 Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.

9-2.7 Waterflow Alarm. All waterflow alarms shall be tested quarterly in accordance with the manufacturer's instructions.

9-5.1.1 All valves shall be inspected quarterly. The inspection shall verify that the valves are in the following condition:
(a) In the open position
(b) Not leaking
(c) Maintaining downstream pressures in accordance with the design criteria
(d) In good condition, with handwheels installed and unbroken

9-7 Fire Department Connections.
9-7.1 Fire department connections shall be inspected quarterly. The inspection shall verify the following:
(a) The fire department connections are visible and accessible.
(b) Couplings or swivels are not damaged and rotate smoothly.
(c) Plugs or caps are in place and undamaged.
(d) Gaskets are in place and in good condition.
(e) Identification signs are in place.
(f) The check valve is not leaking.
(g) The automatic drain valve is in place and operating properly.

Findings:During a tour of the facility with Facilities Staff 1 and Facilities Staff 2 from 9/21/15 to 9/25/15, the automatic sprinkler system was observed and maintenance records were requested.

Pavilion:

1. At 2:26 p.m., on 9/22/15, the shrubs and foliage blocked access to the FDCs near the exterior front stairs.

2. At 9:30 a.m., on 9/24/15, four of four FDCs by the south Pavilion stairwell were not equipped with caps.

3. At 9:32 a.m., on 9/24/15, four of eight sprinkler heads, under the front entrance overhang, showed signs of corrosion and one of eight sprinkler heads was missing an escutcheon ring.

Pavilion and Tower:

4. At 8:40 a.m., on 9/24/15, the facility failed to provide records of three of four quarterly inspections for the buildings at the Culver City campus.

During an interview at 8:40 a.m., Facilities Staff 1 acknowledged that the documentation was not provided.

Tower:

5. At 11:40 a.m., on 9/25/15, the FDCs on the west exterior wall showed signs of corrosion and were unable to rotate freely.


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Pavilion
Basement:

6. At 12:03 p.m., on 9/21/15, there were two pest strips attached to the sprinkler pipe in the trash chute room.

Van Nuys:

7. At 1:36 p.m., on 9/22/15, water was flowed through the Inspector's Test Valve (ITV) for more than 2 minutes. The fire alarm system failed to activate within 90 seconds. At 1:40 p.m., the ITV was tested again for 2 minutes 8 seconds and the fire alarm system failed to activate for a second time.

Based on observation and interview, the facility failed to provide portable fire extinguishers in accordance with NFPA 10. This was evidenced by a patient care corridor where travel distance to a fire extinguisher was more than 75 feet away. This was also evidenced by no fire extinguisher provided at a designated smoking area. This affected one of four smoke compartments and one of two designated smoking areas at the Van Nuys Building. This could result in a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.5.6 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

9.7.4.1 Where required by the provisions of another section of this Code, portable fire extinguishers shall be installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

NFPA 10, Standard 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.

2-1* General Requirements. The selection of fire extinguishers for a given situation shall be determined by the character of the fires anticipated, the construction and occupancy of the individual property, the vehicle or hazard to be protected, ambient-temperature conditions, and other factors (see Table A-2-1). The number, size, placement, and limitations of use of fire extinguishers required shall meet the requirements of Chapter 3.

2-2.1 Fire extinguishers shall be selected for the class(es) of hazards to be protected in accordance with the following subdivisions. (For specific hazards, see Section 2-3.)

3-1.2 Fire extinguishers shall be provided for the protection of both the building structure and the occupancy hazards contained therein.

3-1.2.2* Occupancy hazard protection shall be provided by fire extinguishers suitable for such Class A, B, C, D, or K fire potentials as might be present.

3-2.4 The protection requirements shall be permitted to be fulfilled with fire extinguishers of higher rating, provided the travel distance to such larger fire extinguishers does not exceed 75 ft (22.7 m).

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the fire extinguishers were observed.

Van Nuys:

1. At 9:17 a.m., on 9/22/15, there were no fire extinguishers from the locked cross-corridor door at the far end of Unit 2 to the Unit 2 Nurses Station.

During an interview at 9:18 a.m., Facilities Staff 3 and Facilities Staff 6 stated that the distance from the door to the nurse station was approximately 110 feet and confirmed that there was no fire extinguisher down that corridor.

2. At 9:28 a.m., on 9/22/15, there was no fire extinguisher in the Unit 1 smoking area. Facilities Staff 3 confirmed that there was no extinguisher.

Based on observation, the facility failed to maintain their smoking areas. This was evidenced by a broken safety type ashtray and by a designated smoking area located in close proximity to electrical transformers. This affected two of three buildings at the Culver City campus and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
Exception: In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(2) Smoking by patients classified as not responsible shall be prohibited.
Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision.
(3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.


Findings:

During the tour of the facility with Facilities Staff 4 from 9/21/15 to 9/25/15, the smoking areas were observed.

Pavilion:

1. At 11:20 a.m., on 9/25/15, there was a broken safety-type ashtray in the east designated smoking area. Smoke from a lit cigarette was observed in the base of the broken ashtray.

Tower:

2. At 11:29 a.m., on 9/25/15, the designated smoking area, located by the valet parking lot, was less than 5 feet from the public electrical circuit panels, electrical poles, and transformers. The smoking area was enclosed with a fence covered in a green colored combustible material. The fire rating and specifications of the material was not provided.

Based on observation, record review, and interview, the facility failed to maintain their heating, ventilating, and air conditioning (HVAC) system. This was evidenced by the use of portable air conditioners (ACs) that were exhausted into the ceiling, by the use of temporary chillers without approval from the authority having jurisdiction (AHJ), by a leaking steam pipe, and by the alteration of a temporary HVAC unit without approval. This was also evidenced by an air handler with a leaking condenser. This affected three of three buildings at the Culver City campus, the basements in the Hollywood Building, and four of four smoke compartment in the Van Nuys building. These deficient practices could result in changes in the airflow and air exchange and could compromise the fire rating of the ceilings where the portable ACs were exhausted.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer's specifications.
Exception: As modified in 19.5.2.2.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

8.2.3.2.4.1 Openings in fire barriers for air-handling duct work or air movement shall be protected in accordance with 9.2.1.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition.
2-1.2 Equipment shall be selected and installed based on its proper application with respect to the manufacturer's installation instructions and listing as applicable.
2-1.3 Equipment shall be guarded for personnel protection and against the intake of foreign matter into the system.
2-1.4 Electrical Wiring and equipment shall be installed in accordance with NFPA 70, National Electrical Code.
2-2.4.1 Installation. Heating and cooling equipment shall be installed in accordance with the applicable NFPA standards and the manufacturer's instructions. The equipment shall be approved for the specific installation.
2-2.4.3 Mechanical Cooling. Mechanical refrigeration used with air duct systems shall be installed in accordance with recognized safety practices. Installations conforming to ANSI/ASHRAE 15, Safety Code for Mechanical Refrigeration, shall be considered in compliance with these requirements.
2-3.1.2 Air ducts shall be permitted to be rigid or flexible and shall be constructed of materials that are reinforced and sealed to satisfy the requirements for the use of the air duct system, such as the supply air system, the return or exhaust air system, and the variable volume/pressure air system.
2-3.1.3 All air duct materials shall be suitable for continuous exposure to the temperature and humidity conditions of the environmental air in the air duct.
2-3.7 Air Inlets -- Return or Exhaust or Return and Exhaust
2-3.7.1 General. Air shall not be recirculated from any space in which flammable vapors, flyings, or dust is present in quantities and concentrations that would introduce a hazardous condition into the return air system.
2-3.11.1 Egress Corridors. Egress corridors in health care, detention and correctional, and residential occupancies shall not be used as a portion of a supply, return, or exhaust air system serving adjoining areas. An air transfer opening(s) shall not be permitted in walls or in doors separating egress corridors from adjoining areas.
Exception No. 1: Toilet rooms, bathrooms, shower rooms, sink closets, and similar auxiliary spaces opening directly onto the egress corridors.
Exception No. 2: Where door clearances do not exceed those specified for fire doors in NFPA 80, Standard for Fire Doors and Fire Windows, air transfer caused by pressure differentials shall be permitted.
Exception No. 3: Use of egress corridors as part of an engineered smoke-control system.
Exception No. 4: In detention and correctional occupancies with corridor separations of open construction (e.g. grating doors or grating partitions).
2-3.12 Smoke Control. Where a smoke-control or exhaust system is required, in shall conform to the requirements of the building code of the authority having jurisdiction.
3-1.4 Other Spaces Housing Air-Handling Units. Other spaces housing air-handling units shall meet the requirements of the building code the authority having jurisdiction
3-3.1.2 Approved fire dampers shall be provided in all air transfer openings in partitions that are required to have a fire resistance rating and in which other openings are required to be protected.
3-3.3 Floor- or Roof- Ceiling Assemblies having a fire Resistance Rating. Where air ducts and openings for air ducts are used in a floor- or roof-ceiling assembly that is required to have fire resistance rating, all the materials and the construction of the assembly, including the air duct materials and the size and protection of the openings, shall conform with the design of the fire-resistive assembly, as tested in accordance with NFPA 251, Standard Methods of Tests of Fire Endurance of Building Construction and Materials. (Where dampers are required, see 3-4.4.)

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the HVAC systems were observed.

Culver City:

1. At 11:22 a.m., on 9/21/15, there was a portable AC in the Pavilion conference room with an exhaust pipe that penetrated the ceiling and exhausted hot air into the attic.

During an interview at 11:23 a.m., Facilities Staff 2 stated that the hospital was using portable ACs throughout including at all nurses stations in the Pavilion, two in the clinical lab, four in the Emergency Department in the Tower, and several other locations. He stated that the units were either exhausted directly into the attic or into return air ducts but was unsure about the specifics of each unit. He stated that the units were rented approximately one month ago because of the heat wave.

On 9/23/15, at 5:30 p.m., Facilities Staff 1 provided records of a rental agreement for 12 portable ACs that had been rented since 8/31/15 and four that were rented since 9/10/15.

During the survey, portable ACs were observed on the first floor, third floor, fourth floor, fifth floor, and sixth floor of the Pavilion. Portable ACs were observed in Emergency Department in the Tower. The units were exhausted into the attic or return air ducts without oversight from the AHJ. There were no records that indicated the facility had performed routine maintenance on the portable ACs in accordance with manufacturer's specifications.

On 9/25/15, the facility installed a temporary chiller in the penthouse of the Pavilion. At 11:05 a.m., the temporary chiller was turned on but then failed.

During an interview at 1:45 p.m., Facilities Staff 2 stated that temporary chiller had "tripped" but was now turned on again. Facilities Staff 1 stated that the vendor had to "babysit" the unit until it was fully operational.

At 2:01 p.m., Vendor 2, who installed the temporary chiller, stated that the chiller had to be turned off earlier in the morning to clear the pipes and when it was turned on again at 11 a.m., the unit tripped because they tried to reduce the temperature too quickly.

In an email to Facilities Staff 1, dated 9/24/15 at 5:02 p.m., the Office of Statewide Health Planning and Development (OSHPD) Regional Compliance Officer granted permission for the emergency repair of the HVAC system and the installation of the temporary chiller. The email stated that the authorization was valid for 30 days and, as a condition of the authorization, the facility was instructed to arrange for plan review and obtain a permit.

2. During an interview at 11:23 a.m., on 9/23/15, Facilities Staff 2 stated that the facility was using a temporary HVAC unit after a fire in the HVAC system in January 2015. The temporary HVAC unit was approved by OSHPD in March 2015.

An OSHPD Compliance Officer (CO) was onsite on 9/23/15. A Construction Advisory Report from the CO's visit was provided. The report indicated the approved temporary HVAC unit had been worked on by the facility without authorization and the facility had removed the outside air ducting. The CO confirmed the widespread presence of portable ACs in the report and stated that the facility was not getting enough cool air.

3. At 11:43 a.m., on 9/21/15, there was water leaking from the ceiling in the basement of the Pavilion. Leaking water was observed in the fire alarm control panel (FACP) room, the mechanical room, the sump pump room, and the hallway behind the surgical recovery area. In the FACP Room, approximately half the ceiling tiles were missing and at least two ceiling tiles had black mold and water stains.

During an interview at 11:44 a.m., Facilities Staff 2 stated that there were leaks in the steam pipes.

In the Construction Advisory Report from OSHPD, dated 9/23/15, the CO confirmed the steam pipe leaks in the basement of the Pavilion. The CO also stated that unauthorized repairs, like the installation of new piping, were conducted on the pipes.

Van Nuys:

4. At 10:00 a.m., on 9/22/15, there was a portable AC in the dried food storage room. The unit was surrounded by boxes blocking the air inlet and outlet.

The manufacturer's specifications for the unit stated "do not use this appliance for special purposes such as cooling pets, food, or precision machinery." The specifications also stated "Do Not block inlet or outlet of air flow" and stated "clean filter every two weeks." There were no records of cleaning the air filter.

5. At 10:16 a.m., on 9/22/15, there was a temporary chiller on a wheeled portable flat bed in the west parking lot.

During an interview at 10:17 a.m., Facilities Staff 3 stated that the temporary chiller was rented and hooked up three weeks ago. He stated that the chiller was installed without approval from OSHPD.

An invoice from the HVAC vendor, provided on 9/24/15, indicated that the temporary chiller was installed on 7/17/15 after the vendor got an emergency call from the facility for no cooling. The invoice was for the rental of the 20-ton chiller and the rental of the portable 5-ton unit in the kitchen.

Hollywood:
Basement:

6. At 4:33 p.m., on 9/22/15, the autoclave room next to OR 3 was 90°F.
During an interview at 4:36 p.m., Facilities Staff 3 stated that the exhaust fan appeared to be non-operational.

At 8:29 a.m., on 9/23/15, the temperature in the autoclave room was 89°F. During an interview at 8:30 a.m., Facilities Staff 3 stated that the supply air duct in the room was working but the air return was not.

Mechanical Basement:

7. At 9:05 a.m., on 9/23/15, the air handler in the basement was leaking from beneath the unit. There was a large puddle of water spreading towards the main electrical switch.

During an interview at 9:06 a.m., Facilities Staff 3 stated that the condenser hose was clogged causing the condensing tray to overflow.

Based on observation and interview, the facility failed to provide adequate ventilation for their boiler rooms. This was evidenced by one boiler room without an operable exhaust fan. This affected one of six floors in the Hollywood Building and could result in the increased risk of a fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.2.2 Any heating device other than a central heating plant shall be designed and installed so that combustible material will not be ignited by the device or its appurtenances. If fuel-fired, such heating devices shall be chimney connected or vent connected, shall take air for combustion directly from the outside, and shall be designed and installed to provide for complete separation of the combustion system from the atmosphere of the occupied area. Any heating device shall have safety features to immediately stop the flow of fuel and shut down the equipment in case of either excessive temperature or ignition failure.
Exception No. 1: Approved, suspended unit heaters shall be permitted in locations other than means of egress and patient sleeping areas, provided that such heaters are located high enough to be out of the reach of persons using the area and are equipped with the safety features required by 19.5.2.2.
Exception No. 2: Fireplaces shall be permitted and used only in areas other than patient sleeping areas, provided that such areas are separated from patient sleeping spaces by construction having not less than a 1-hour fire resistance rating and that such fireplaces comply with the provisions of 9.2.2. In addition, the fireplace shall be equipped with a fireplace enclosure guaranteed against breakage up to a temperature of 650°F (343°C) and constructed of heat-tempered glass or other approved material. If, in the opinion of the authority having jurisdiction, special hazards are present, a lock on the enclosure and other safety precautions shall be permitted to be required.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the boiler rooms were observed.

Hollywood
Sixth Floor:

1. At 1:40 p.m., on 9/24/15, the temperature in the boiler room was over 90°F. The exhaust fan located at the window was not turned on.

During an interview at 1:41 p.m., Facilities Staff 7 stated that when the exhaust fan is turned on, the pilot light for the domestic hot water line turns off from the airflow so the exhaust fan is not used.

Based on observation, record review, and interview, the facility failed to maintain their commercial cooking equipment. This was evidenced by no filters in one kitchen hood, by incomplete documentation of fire suppression system inspections, by one kitchen hood with a filter that was not tight-fitting, and by grease-laden deposits on the kitchen hood and suppression system equipment. This affected one of three buildings at the Culver City campus and one of six floors at the Hollywood Building. This could result in the increased risk of a kitchen grease fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.6 Cooking Facilities. Cooking facilities shall be protected in accordance with 9.2.3.
Exception: Where domestic cooking equipment is used for food-warming or limited cooking, protection or segregation of food preparation facilities shall not be required.

9.2.3 Commercial Cooking Equipment. Commercial cooking equipment shall be in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, 1998 Edition.
3-2.3 Grease filters shall be listed and constructed of steel or listed equivalent material and shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions. Filters shall be tightfitting and firmly held in place.

8-2 Inspection. 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.

8-2.2 Fusible links (including fusible links on fire-actuated damper assemblies) and automatic sprinkler heads shall be replaced at least annually, or more frequently if necessary, to ensure proper orientation of the system. Other detection devices shall be serviced or replaced in accordance with the manufacturer's recommendations.
Exception:Where automatic bulb-type sprinklers or spray nozzles are used and annual examination shows no buildup of grease or other material on the sprinkler or spray nozzle.

8.3.1 Hoods, Grease removal devices, fans, ducts, and other appurtenances shall be cleaned to bare metal at frequent intervals prior to surfaces becoming heavily contaminated with grease or oily sludge. After the exhaust system is cleaned to bare metal, it shall not be coated with power or there substance. The entire exhaust system shall be inspected by a properly trained, qualified, and certified company or person(s) acceptable to the authority having jurisdiction in accordance with Table 8-3.1

10.6.6 A signed and dated log of maintenance as performed in accordance with 10-6.4 and 10.6.5 shall be available on the premises for use by the authority having jurisdiction.

Findings:

During a tour of the facility with Facility Staff 1 from 9/21/15 to 9/25/15, the commercial cooking equipment was observed.

Pavilion
First Floor:

1. At 10:26 a.m., on 9/24/15, the kitchen hood above the stove was not equipped with grease filters.

During an interview at 10:27 a.m., Dietary Staff 1 stated the the filters were removed approximately 3 months ago and the facility had ordered custom built filters.

2. At 4:50 p.m., on 9/24/15, the facility provided invoices for two semi-annual inspection reports of the fire suppression system in the kitchen hood. The facility failed to provide and maintain the actual inspection reports that would indicate what components were inspected and the results of the inspection. The facility also failed to provide information about the most recent hydrostatic test on the wet chemical fire suppression system.


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Hollywood
First Floor:

3. At 9:38 a.m., on 9/23/15, one of four filters in the kitchen hood was not installed in the designed orientation, revealing an approximately 4 inch gap and exposing the interior hood. Facilities Staff 3 confirmed that the filter was not put on correctly and adjusted it to fit.

4. At 9:46 a.m., on 9/23/15, Facilities Staff 3 removed the hood filters. The entire kitchen hood, including the exhaust duct and fusible links, was covered in thick grease-laden deposits.

Based on observation and interview, the facility failed to ensure that means of egress were free from obstructions. This was evidenced by items blocking the egress paths and corridors. This affected two of three buildings at the Culver City campus and the Van Nuys building. This could result in a delayed evacuation of the facility in the event of an emergency and the increased risk of injury to the patients and staff.

NFPA 101, Life Safety Code, 2000 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7.
Exception: As modified by 19.2.2 through 19.2.11.

7.1.6.1 General. Walking surfaces in the means of egress shall comply with 7.1.6.2 through 7.1.6.4.
Exception: Existing walking surfaces shall be permitted where approved by the authority having jurisdiction.

7.1.6.4 Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel.

7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

7.1.10.2.1 No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the means of egress were observed.

Pavilion
Basement:

1. At 11:45 a.m., on 9/21/15, there was an approximately 1 inch deep puddle of water in the hallway directly outside the emergency exit door behind the surgical recovery room. The puddle was spread along the entire width of the hallway, that was marked with emergency exit signs, and was approximately 10 feet long. The water caused the egress pathway to be slippery and unsafe.

During an interview at 11:46 a.m., Facilities Staff 2 stated that the puddle was caused from condensation on the boiler lines. He stated that the boiler was shut down for repairs from 3 a.m. to 8 a.m. that morning and when it was turned on, the condensation caused the large puddle of water. He confirmed that the hallway was an emergency egress path.

During a telephone conference with Facilities Staff 2 at 11:40 a.m., on 9/22/15, he stated that the excess water was caused by a blocked condenser drain.

2. At 11:47 a.m., on 9/21/15, there were two surgical beds and two surgical microscopes in the emergency exit hallway behind the surgical recovery room. The equipment obstructed the egress corridor.

During an interview at 12:06 p.m., Surgical Services Staff 1 stated that surgical equipment was always kept in the back of the recovery room, and in the hallway behind the recovery room, until it was sterilized for use during surgery.

3. At 12:03 p.m., on 9/21/15, there were three bariatric wheelchairs in the corridor outside the surgery department, across from Central Supply. The wheelchairs were observed again at 12:55 p.m. and there were two gurneys along the same corridor wall.

4. At 1:02 p.m., on 9/21/15, the tunnel connecting the basement of the Pavilion to the Tower was observed. One side of the ramp in the tunnel was used for the storage of 11 beds. One side of the corridor by the patient elevator was used for the storage of seven beds. The ramp and corridor were labeled as emergency exits.

During an interview at 1:05 p.m., Surgical Services Staff 1 and Facilities Staff 2 stated that the tunnel was used to transfer patients from the surgery department to the Tower. Facilities Staff 2 stated that the hospital did not have space to store extra beds so they were kept in the tunnel.

Van Nuys:

5. At 8:53 p.m., on 9/22/15, the exit door from the Unit 2 dining room was obstructed from opening. Van Nuys Nursing Staff 1 had to remove a patio chair that was placed directly in front of the door in order to open it.

Pavilion
Fifth Floor:

6. At 3:48 p.m., on 9/23/15, there were four workstations on wheels (WOWs) parked in the corridor by Room 533. The WOWs were connected to data cables in the corridor and one WOW was connected to a cable that went through the corridor wall into Room 536. There were also two carts in the corridor.

Pavilion
Third Floor:

7. At 3:43 p.m., on 9/23/15, there was a 2 1/2 foot wide portable air conditioner (AC) in the hallway outside Room 309.


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Pavilion
Basement:

8. At 8:15 a.m., on 9/22/15, there was barrier, made from a non-rated combustible material, taped across the entire width of the egress corridor outside the fire alarm panel control room.

9. At 8:30 a.m., on 9/22/15, there were wet blankets and water puddles on the floor in the egress corridor near the fire alarm panel room and the surgical recovery unit.

Tower Building
First Floor:

10. At 9:48 a.m., on 9/22/15, there were two portable ACs, with exhaust ducts extended into the ceiling, in the means of egress of the Emergency Department.

11. At 2:39 p.m., on 9/22/15, there were three unattended gurneys in the means of egress of the Emergency Department. One of the three gurneys was positioned by the emergency exit doors.

12. At 3:30 p.m., on 9/22/15, there was a portable AC in the Emergency Department waiting room that obstructed access to the means of egress.

Fourth Floor:

13. At 3:06 p.m., on 9/22/15, a garbage bin, approximately 6 feet in height, and a copy machine were in the egress corridor near the nurse station.

Sixth Floor:

14. At 3:19 p.m., on 9/22/15, the facility used the elevator lobby as a patients pre-admission waiting room. There were chairs in the egress corridor in front of the elevators.

Pavilion
Sixth Floor:

15. At 2:45 p.m., on 9/23/15, there was a telephone mounted on the wall, in a wooden cabinet, by Room 617. The wooden cabinet protruded approximately 12 inches from the wall and into the egress corridor. A vendor walked into the wooden cabinet and stumbled. The cabinet obstructed egress and protruded more than six inches into the corridor.

Second Floor:

16. At 9:10 a.m., on 9/24/15, there were three unattended WOWs in the egress corridor between Rooms 231 and 232. The WOWs were plugged into the electrical wall outlets and were hooked up to data cables in the corridor.

17. At 9:11 a.m., on 9/24/15, a portable filtration unit was in the egress hallway by Room 229.

18. At 9:15 a.m., on 9/24/15, there was an industrial fan in the egress corridor by Room 235.

First Floor:

19. At 9:40 a.m., on 9/24/15, a portable AC blocked access to the right exit door in the laboratory.

Sixth Floor:

20. At 11:10 a.m., on 9/25/15, there were four unattended WOWs plugged in the electrical wall outlets and hooked up to data cables in the north east egress corridor. There were linen carts in the same corridor that blocked egress.

Based on observation, the facility failed to maintain the storage of their soiled linen and trash receptacles. This was evidenced by linen and trash room doors that were not maintained. This was also evidenced by the storage of soiled linen receptacles, with capacities greater than 32-gallons, outside of rooms protected as hazardous areas. This affected the basement of the Pavilion and the basement of the Hollywood Building. This could result in the faster spread of smoke and fire.

NFPA 101, Life Safety Code, 2000 Edition.
19.7.5.5 Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not exceed 0.5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2 (5.9-m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.
Exception: Container size and density shall not be limited in hazardous areas.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the soiled linen and trash receptacles were observed.

Pavilion
Basement:

1. At 12:00 p.m., on 9/21/15, the latching hardware on the door to the soiled linen chute room was taped down and the door failed to latch. The room contained more than 10 large bags of soiled linen.

2. At 12:02 p.m., on 9/21/15, the strike plate on the door frame of the trash chute room was damaged and missing a screw. The door failed to latch when tested. The room contained a 125-gallon trash receptacle full of trash bags and an additional two trash bags that obstructed the chute hatch from closing.

3. At 12:52 p.m., on 9/21/15, the self-closing door to the biohazard waste room in the surgical department failed to latch.

Hollywood
Basement:

4. At 4:30 p.m., on 9/22/15, there were two 55-gallon soiled linen bins and one approximately 32-gallon biohazard waste receptacle in the elevator lobby of the surgical department. The three receptacles were observed again at 8:31 a.m., on 9/23/15.

Based on observation and interview, the facility failed to maintain their oxygen cylinder storage areas. This was evidenced by the storage of combustibles in close proximity to the oxygen cylinders, by electrical switches that were installed less than 5 feet from the floor, and by the absence of precautionary signage. This affected one of three buildings at the Culver City campus. This could result in the increased risk of hazardous conditions and the increased risk of harm to patients.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.
12-3.8.1 Patient. Equipment shall conform to the patient equipment requirements in Chapter 8, "Gas Equipment."
12-3.8.2 Nonpatient. Equipment shall conform to the non-patient equipment requirements in Chapter 8, "Gas Equipment."

Chapter 8 Gas Equipment
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
(a) Nonflammable Gases (Any Quantity; In-Storage, Connected, or Both)
11. Construction and Arrangement of Supply System Locations.
d. Ordinary electrical wall fixtures in supply rooms shall be installed in fixed locations not less than 5 ft (1.5 m) above the floor to avoid physical damage.

4-3.5.2.1 Gases in Cylinders and Liquefied Gases in Containers-Level 1.
(b) Special Precautions-Oxygen Cylinders and Manifolds. Great care shall be exercised in handling oxygen to prevent contact of oxygen under pressure with oils, greases, organic lubricants, rubber, or other materials of an organic nature. The following regulations, based on those of the CGA Pamphlet G-4, Oxygen, shall be observed:
27. Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.

Findings:

During tour of facility with staff from 9/21/15 to 9/25/15, oxygen storage rooms were observed.

Pavilion
Basement:

1. At 9:01 a.m., on 9/22/15, the oxygen storage area in the post-anesthesia care unit (PACU) was observed. The electrical wall outlet was less than 3 feet from the floor and oxygen cylinders were stored next to the outlet. There were combustible supplies in carts stored next to the oxygen cylinders. The room was not equipped with the precautionary signage required for oxygen storage rooms. Facilities Staff 2 confirmed the findings.


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Pavilion
Basement:

2. At 12:40 p.m., on 9/21/15, the room labeled "Tank Room" in the surgical department was observed. There was a cardboard box of supplies and a plastic tarp placed on top of several oxygen E-cylinders. The room was not provided with the required No Smoking sign. The light switch in the room, next to the oxygen cylinder rack, was installed less than 4 feet from the floor.

During an interview at 12:41 p.m., Surgical Services Staff 1 stated that the supplies were not supposed to be stored in the Tank Room.

Based on observation, record review, and interview, the facility failed to maintain their piped-in medical gas systems. This was evidenced by the absence of emergency shut-off zone valves for the piped-in vacuum systems in anesthetizing locations, by obstructed emergency shut-off valves, and by alarm panels that were not functioning. This was also evidenced by the absence of an emergency oxygen supply connection. This affected three of three buildings at the Culver City campus and three of three anesthetizing locations at Hollywood. This could result in a malfunctioning piped-in medical gas system or a delayed response to an emergency.

NFPA 101, Life Safety Code, 2000 Edition
19.3.2.4 Medical Gas.
Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
1-2 Application
Chapters 12 through 18 specify the conditions under which the requirements of Chapters 3 through 11 shall apply in Chapters 12 through 18.

Chapter 12 Hospital Requirements
12-1 Scope. This chapter addresses safety requirements of hospitals.
12-3.4.1 If installed, patient gas systems shall conform to Level 1 gas systems of Chapter 4.

12-3.4.3 If installed, patient vacuum systems shall conform to the safe use of electric appliances. to Level 1 vacuum systems of Chapter 4.

4-2 Nature of Hazards.
4-2.2 Vacuum Systems. There are potential fire and explosion hazards associated with medical gas central piping systems and medical-surgical vacuum systems. The various components are usually not independent isolated components, but are parts of a larger system dedicated to total patient care and safety.
Many of these components are covered by existing standards to minimize the fire, explosive, and patient safety hazard. With the increased use of vacuum systems, the potential for mistaken interconnection with oxidizing gases, for ingestion of flammable anesthetic gases, and for under capacity requiring extended overheated operation all present potential hazards or compound other hazardous conditions that should be properly addressed. While the potential for these problems exists, the former Subcommittee on Vacuum Systems and Equipment was unaware of the actual occurrence of any significant fire-related hazards with vacuum systems.
There are also potential hazards to patients in the unplanned shutdown or failure of the systems secondary to a fire and/or the inability of the system to provide adequate levels of performance under normal or emergency situations. There is also the potential for mistaken interconnection with pressurized nonflammable medical gas systems described in Sections 4-3 through 4-6.

4-3.1.2 Distribution-Level 1 (Manifold, Piping, Valving/Controls, Outlets/Terminals, Alarms).
4-3.1.2.2 Gas Warning Systems.
(a) General.
4. Where multiple panels are intended to indicate the same condition(s):
b. Both master alarms required by 4-3.1.2.2(b)2 shall be connected by dedicated wiring directly to the sensor(s) or switch(es).
8. All wiring from switch or sensors shall be protected as required by Section 517-30(c)(3) of NFPA 70, National Electrical Code, for emergency system circuits.
(b) Master Alarms
1. A master alarm system shall be provided to monitor operation and condition of the source of supply, the reserve (if any), and the pressure of the main lines of all medical gas piping systems.
2. The master alarm system shall consist of two or more alarm panels located in two separate locations. One panel shall be located in the principal working area of the individual responsible for the maintenance of the medical gas piping systems and one or more panels shall be located to assure continuous surveillance during the working hours of the facility (e.g., the telephone switchboard, security office, or other continuously staffed location).

4-3.1.2.3 Gas Shutoff Valves. Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.
All gas-delivery columns, hose reels, ceiling tracks, control panels, pendants, booms, alarm panels, or other special installations shall be located downstream of this valve.
(n) A shutoff valve shall be located outside each anesthetizing location in each medical gas line, so located as to be readily accessible at all times for use in an emergency. These valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others. Valves shall be of an approved type, mounted on a pedestal or otherwise properly safeguarded against physical damage, and marked in accordance with 4-3.5.4.2.

4-3.2 Piped Vacuum Systems (Source and Distribution) -- Level 1.
4-3.2.2.6 Vacuum System Shutoff Valves.
(g) Zone Valve. A shutoff valve shall be located immediately outside of each vital life-support, critical care, or anesthetizing location in each vacuum line, and located as to be readily accessible in an emergency or for maintenance of the terminals or piping within the individual zone served.

4-3.1.1.8 General Requirements for Gas Central Supply Systems. Piped oxygen and medical air shall not be piped to or used for, any purpose except for use in patient care applications.
(h)Emergency Oxygen Supply Connection. Where the cryogenic oxygen supply is located outside of the building served, there shall be incorporated in the piping system an inlet for connecting a temporary auxiliary source of supply for emergency or maintenance situations. The inlet shall be located on the exterior of the building served and shall be physically protected to prevent tampering and unauthorized access. It shall be labeled "EMERGENCY LOW PRESSURE GASEOUS OXYGEN INLET." This connection shall be installed downstream of the shutoff valve on the main supply line (see 4-3.1.2.3(b)) and be suitably controlled with the necessary valves to allow emergency supply of oxygen and isolation of the piping to the normal source of supply. It shall have one check valve in the main line between the main line shutoff valve and the tee'd connection and one check valve between the tee'd connection and the emergency supply shutoff valve.

Findings:

During a facility tour with staff from 9/21/15 to 9/25/15, the piped-in medical gas systems were observed.

Pavilion
Basement:

1. At 12:30 p.m., on 9/21/15, Operating Rooms (ORs) 1, 2, 3, 4, 5, 6, 7, and 8 were all equipped with piped-in oxygen, nitrous oxide, and vacuum systems. All ORs, except OR 7, were not provided with emergency shut-off valves for their piped-in vacuum systems. Facilities Staff 2 confirmed that there were no vacuum system shut-off valves outside ORs 1, 2, 3, 4, 5, 6, and 8.

During an interview at 10:47 a.m., on 9/25/15, Facilities Staff 2 stated that he did not know where the main line shut-off valve for the piped-in vacuum system was located.

Hollywood
Basement:

2. At 4:05 p.m., on 9/22/15, ORs 1, 2, and 3 were equipped with piped-in oxygen, nitrous oxide, and vacuum systems. All three ORs did not have emergency shut-off valves for their piped-in vacuum system. The main-line vacuum shut-off valve was in the mechanical basement, accessible only to facilities and engineering staff.

3. At 4:13 p.m., on 9/22/15, the emergency shut-off valve assembly outside OR 2, for the oxygen and nitrous oxide piped-in gas systems, had a cover that was broken and taped to the wall instead of fitted on the box.

4. At 4:15 p.m., on 9/22/15, access to the emergency shut-off valve for the piped-in oxygen system in the recovery room was blocked by a cart. Facilities Staff 3 removed the cart but the shut-off valve was observed to be blocked again by the same cart at 4:36 p.m. The shut-off valve was blocked again by the same cart at 8:34 a.m. on 9/23/15.

5. At 9:30 a.m., on 9/24/15, records indicated that an inspection of the piped-in medical gas systems was conducted by a vendor on 4/27/15. The documentation indicated that the nitrous oxide area alarms in the surgery department and PBX failed because it had "no electrical wiring." On 6/17/15, when the vendor came back for corrective actions, the document noted that the nitrous panels were labeled as "not in service" by the technician.

At 10:12 a.m., on 9/24/15, the nitrous oxide alarms in the medical gas warning panel outside OR 3 was labeled "not in service" and none of the LED lights were illuminated.

At 10:18 a.m., on 9/24/15, the nitrous oxide alarm panel in PBX was also labeled "not in service" and none of the LED lights were illuminated.

During an interview at 3:23 p.m., Facilities Staff 3 stated that the power supply for the alarm panel was rated at 12 Amps and the power output was 15 Amps causing the motherboard for the panel to burn out.


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Pavilion and Tower:

6. At 4:02 p.m., on 9/22/15, the facility was not equipped with an emergency oxygen supply connection (oxygen autofill port).

During an interview at 4:02 p.m., Facilities Staff 2 confirmed that the facility was not equipped with an emergency oxygen supply connection. He stated that the facility was in the process of obtaining approval for the construction of the emergency oxygen supply and emergency shut-off valve for the cryogenic oxygen supply.

Based on observation and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by operating rooms (ORs) that were not equipped with a means of controlling relative humidity (RH) during surgery and by the failure to implement corrective actions when RH levels were out of range. This affected eight of eight ORs in the Pavilion and could result in the increased risk of injury to patients.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.2.3 Anesthetizing locations shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 5 Environmental Systems
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

5-6.1 Anesthetizing Locations.
5-6.1.1 Ventilating and humidifying equipment for anesthetizing locations shall be kept in operable condition and be continually operating during surgical procedures

Findings:

During a facility tour with Facilities Staff 2 and Surgical Services Staff 2 on 9/21/15, the ORs were observed.

Pavilion
Basement:

1. At 12:50 p.m., on 9/21/15, the humidity in OR 6 was 67 percent. Staff were in the OR prepping for a case.

During an interview at 12:51 p.m., Surgical Services Staff 1 stated that it was the facility policy to maintain the humidity between 30 percent and 60 percent. She stated that if the humidity did not decrease in OR 6, they would relocate the procedure to another room or cancel the case.

During an interview at 12:52 p.m., Facilities Staff 1 stated that the RH levels cannot be controlled mechanically by the air handlers in the ORs. They can only try to adjust the RH levels by setting the chillers to their lowest cooling point.

Surveyors from the California Department of Public Health (CDPH) observed a case in OR 6 later in the day (9/22/15) at 3:25 p.m. when humidity had reached 70 percent.

During a telephone conference with Facilities Staff 2 at 11:20 a.m., on 9/22/15, Facilities Staff 2 again confirmed that the humidity in the ORs could not be controlled by the mechanical ventilation system.

Based on observation and interview, the facility failed to maintain their emergency generators. This was evidenced by a generator enclosure that was not equipped with battery-powered emergency lights, by a fuel tank gauge that was inoperable, and by the failure to ensure that facility generators were monitored by remote alarm annunciators. This affected three of three buildings at the Culver City Campus and affected the Van Nuys Building. This could result in a delay in staff notification and response to troubles with the generator and the increased risk of injury to the patients.

NFPA 101, Life Safety Code, 2000 Edition.
7.9.2.3 Emergency generators providing power to emergency lighting systems shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. Stored electrical energy systems, where required in this Code, shall be installed and tested in accordance with NFPA 111, Standard on Stored Electrical Energy Emergency and Standby Power Systems.

9.1.3 Emergency Generators. Emergency generators, where required for compliance with this Code, shall be tested and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power System.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.1.1.4 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service.
(a) Type I and Type II essential electrical system power (107C) or the engine water-jacket temperature at not less than sources shall be classified as Type 10, Class X, Level 1 generator sets per NFPA 110, Standard for Emergency and Standby Power Systems.

3-4.1.1.15 A remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. (See NFPA 70, National Electrical Code, Section 700-12)
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:
(a) Individual visual signals shall indicate:
1. When the emergency power source is operating to supply power to load
2. When the battery charger is malfunctioning.
(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Over crank (failed to start)
6. Overspeed
Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually.

NFPA 70 , National Electrical Code, Section 700-12).
The annunciator shall indicate alarm condition of the emergency or auxiliary power source as follows:
(a)Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load
2. When the battery charger is malfunctioning
(b)Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply
5. Overcrank (failed to start)
6. Overspeed

3-5.5.2 (d) Battery powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2 (d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).

3-5.6.1 A remote,, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2(d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 edition.
3-5.5.2 An automatic control and safety panel shall be a part of the EPS and shall contain the following equipment or possess the following characteristics, or both:
(a) Cranking control equipment to provide the complete cranking cycle described in 3-5.4.2 and Table 3-5.4.2.
(b) A panel-mounted control switch(es) marked " run-off-automatic " to perform the following functions:
1. Run: Manually initiate, start, and run prime mover
2. Off: Stop prime mover or reset safeties, or both
3. Automatic: Allow prime mover to start by closing a remote contact and stop by opening the remote contact
(c) Controls to shut down and lock out the prime mover under the following conditions: failing to start after specified cranking time, overspeed, low lubricating-oil pressure, high engine temperature, or operation of remote manual stop station. An automatic engine shutdown device for high lubricating-oil temperature shall not be required. (See 3-5.5.6.)
(d) Battery-powered individual alarm indication to annunciate visually at the control panel the occurrence of any of the conditions in Table 3-5.5.2(d); additional contacts or circuits for a common audible alarm that signals locally and remotely when any of the itemized conditions occurs. A lamp test switch(es) shall be provided to test the operation of all alarm lamps listed in Table 3-5.5.2(d).
(e) Controls to shut down the prime mover upon removal of the initiating signal or manual emergency shutdown.
(f) The ac instruments listed in 3-5.9.7. Where the control panel is mounted on the energy converter, it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability.

3-5.6 Remote Controls and Alarms
3-5.6.1 A remote, common audible alarm powered by the storage battery shall be provided as specified in 3-5.5.2 (d). This remote alarm shall be located outside of the EPS service room at a work site readily observable by personnel.

3-5.6.2 An alarm-silencing means shall be provided, and the panel shall include repetitive alarm circuitry so that, after the audible alarm is silenced, it is reactivated after clearing the fault condition and must be restored to its normal position to be silenced.
Exception: In lieu of the requirement of 3-5.6.2, a manual alarm-silencing means shall be permitted that silences the audible alarm after the occurrence of the alarm condition, provided such means do not inhibit any subsequent alarms from sounding the audible alarm again without further manual action.

5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.

Findings:

During tour of facility with staff from 9/21/15 to 9/25/15, the generator room was observed.

Tower
Basement:

1. At 3:34 p.m., on 9/22/15, the generator room was not equipped with battery-powered emergency lights.

2. At 4:03 p.m., on 9/22/15, there were no remote alarm annunciators for three of three generators at Culver City.

During an interview at 4:03 p.m., Administrative Staff 3 confirmed that the facility was not equipped with remote alarm annunciators for three of three generators.


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Van Nuys Building
Basement:

3. At 10:40 a.m., on 9/22/15, the diesel day tank connected to the generator had a gauge that showed the fuel level as empty. The tank was approximately 100 percent full upon inspection. Facilities Staff 6 pushed the test button on the day tank and the gauge on the tank did not move.

During an interview at 10:41 a.m., Facilities Staff 6 stated that when the test button is pushed, the gauge should have read the accurate level of diesel fuel.

During an interview at 2:20 p.m., Facilities Staff 3 stated that the gauge would work if the generator was running. Facilities Staff 6 ran the generator and the gauge was still stuck on empty.

4. At 10:45 a.m., on 9/22/15, there was no remote alarm annunciator for the diesel generator at Van Nuys.

During an interview at 10:46 a.m., Facilities Staff 6 confirmed that there was no remote alarm annunciator for this generator.

Based on observation and interview, the facility failed to maintain the integrity of their electrical wiring. This was evidenced by modifications to an electrical panel to power portable air cooling units, by the use of power strips and extension cords, by the failure to safeguard a defective electrical outlet, and by an obstructed electrical panel. These deficient practices affected two of three buildings at the Culver City campus, one of four smoke compartments at the Van Nuys Building, and the Hollywood Building. This could cause an electrical fire and potential harm to residents and staff in the event of a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition.
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.

9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 70, National Electrical Code, 1999 Edition.
Section 90-4 Enforcement. This Code is intended to be suitable for mandatory application by governmental bodies that exercise legal jurisdiction over electrical installations and for use by insurance inspectors. The authority having jurisdiction for enforcement of the Code will have the responsibility for making interpretations of the rules for deciding on the approval of equipment and materials, and for granting the special permission contemplated in a number of the rules. The authority having jurisdiction may waive specific requirements in this Code or permit alternate methods where it is assured that equivalent objectives can be achieved by establishing and maintaining effective safety. This Code may require new products, constructions, or materials that may not yet be available at the time the Code is adopted. In such event, the authority having jurisdiction may permit the use of the products, constructions, or materials that comply with the most recent previous edition of this Code adopted by the jurisdiction.

90-7 Examination of Equipment for Safety. For specific items of equipment and materials referred to in this Code, examinations for safety made under standard conditions will provide a basis for approval where the record is made generally available through promulgation by organization properly equipped and qualified for experimental testing, inspections of the run of goods at factories, and service-value determination through field inspections. This avoids the necessity for repetition of examinations by different examiners, frequently with inadequate facilities for such work, and the confusion that would result from conflicting reports as to the suitability of devices and materials examined for a given purpose.
It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations or damage, if the equipment has been listed by a qualified electrical testing laboratory that is recognized as having the facilities described above and that require suitability for installation in accordance with this Code.

110-3. Examination, Identification, Installation, and Use of Equipment.
(a) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code
FPN: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other equipment, the adequacy of the protection thus provided
(3) Wire-bending and connection space
(4) Electrical insulation
(5) Heating effects under normal conditions of use and also under abnormal conditions likely to arise in service
(6) Arcing effects
(7) Classification by type, size, voltage, current capacity, and specific use
(8) Other factors that contribute to the practical safeguarding of persons using or likely to come in contact with the equipment
(b) Installation and Use. Listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling.

110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner.
(a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
(b) Subsurface Enclosures. Conductors shall be racked to provide ready and safe access in underground and subsurface enclosures, into which persons enter for installation and maintenance.
(c) Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces, shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; or deteriorated by corrosion, chemical action, or overheating.

240-4 Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b).
(a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.

370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

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
Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8.
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

During a tour of the facility with staff from 9/21/15 to 9/25/15, the electrical wiring was observed.

Tower
First Floor:

1. At 10:01 a.m., on 9/22/15, the electrical outlet on the wall above Bed S1 in the Emergency Department had a loose faceplate.

Basement:

2. At 3:30 p.m., on 9/22/15, Electrical Panel BEA was painted shut and was obstructed from opening.

Pavilion
Basement:

3. At 4:05 p.m., on 9/22/15, a refrigerator, a microwave oven, and a coffee pot were plugged into a multi-plug power-strip in the public box exchange office.

Sixth Floor:

4. At 2:38 p.m., on 9/23/15, the portable air conditioning unit, located in the egress corridor near the nurse station, was plugged into an extension cord.

Second Floor:

5, At 9:05 p.m., on 9/24/15, there was white tape placed over the faceplate of the red emergency electrical outlet by Room 208.

First Floor:

6. At 9:45 a.m., on 9/24/15, the portable air conditioner in the laboratory was plugged into a multi-plug power strip.


29665

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Pavilion
Basement:

7. At 12:24 p.m., on 9/21/15, there was a cautery unit plugged into a four-plug extension in Operating Room (OR) 1. The unit was marked with a "hospital grade only" sticker near its electrical adaptor. The extension cord did not have hospital grade plugs.

During an interview at 12:25 p.m., Facilities Staff 2 confirmed that the plugs were not hospital grade.

8. At 12:36 p.m., on 9/21/15, there was a four-plug outlet hanging from the ceiling by a cable, near the surgical table in OR 4. The outlet was labeled as "defective" by a biomed technician in 2009. The outlet was only labeled on one side and the plugs were still accessible for use.

Van Nuys:

9. At 10:01 a.m., on 9/22/15, the portable AC in the dry kitchen storage room was plugged into an extension cord.

Under the Electrical Safety section of the unit manufacturer's manual, it stated "Do not use extension cords."

10. At 10:04 a.m., on 9/22/15, a large cable was wired from behind Electrical Panel KS to power the temporary cooling unit on the main floor of the kitchen.

During an interview at 10:04 a.m., Facilities Staff 3 stated that it had been this way for approximately three months and that the electrical wiring was not approved by the authority having jurisdiction.

Hollywood
Basement:

11. At 4:25 p.m., on 9/22/15, the surgical table in OR 1 was plugged into a multi-plug power strip.

First Floor:

12. At 9:32 a.m., on 9/23/15, the electrical connection for the portable cooling unit in the kitchen could not be observed. A large cable ran into the same exhaust unit as the faulty swamp cooler.

During an interview at 9:34 a.m., Facilities Staff 3 stated that the temporary cooling unit was wired into the swamp cooler disconnect and will remain that way until the swamp cooler was repaired.

Mechanical Roof:

13. At 1:26 p.m., on 9/24/15, there were two 4 by 4 electrical boxes in the ceiling connected via conduit to the smoke detector in the elevator machine room. The electrical boxes had no covers and the electrical relays were protruding more than 1 inch out of the boxes.