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Based on observation, the facility failed to maintain the battery-powered emergency lights. This was evidenced by an emergency light that failed to illuminate when tested. This could result in a loss of visibility in the event of a power failure. This affected one of six smoke compartments on the Second Floor of Patient Tower 1.

NFPA 99, 2012 Edition
6.3.2.2.11 Battery-Powered Lighting Units.
6.3.2.2.11.1 One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.

6.3.2.2.11.2 The lighting level of each unit shall be sufficient to terminate procedures intended to be performed within the operating room.

6.3.2.2.11.3 The sensor for units shall be wired to the branch circuit(s) serving general lighting within the room.

6.3.2.2.11.4 Units shall be capable of providing lighting for 1 1/2 hours.

NFPA 70, 2011 Edition
Battery-Powered Lighting Units. Individual unit equipment for backup illumination consisting of the following:
(1) Rechargeable battery
(2) Battery-charging means
(3) Provisions for one or more lamps mounted on the equipment, or with terminals for remote lamps, or both
(4) Relaying device arranged to energize the lamps automatically upon failure of the supply to the unit equipment

517.63 Grounded Power Systems in Anesthetizing Locations.
(A) Battery-Powered Lighting Units. One or more battery-powered lighting units shall be provided and shall be permitted to be wired to the critical lighting circuit in the area and connected ahead of any local switches.

Findings:

During a tour of the facility with staff on 5/10/17, the battery-powered emergency lights were observed.

5/10/17

1. At 2:46 p.m., the battery-powered emergency light inside Operating Room 1 failed to illuminate when tested. Three attempts were made.

Life Safety Officer 1 and Facilities Maintenance Staff 1 acknowledged and confirmed this finding.

Based on document review and interview, the facility failed to provide a complete Fire Watch Policy. This was evidenced by the absence of language specifying notification to the California Department of Public Health (CDPH) in the event of a fire alarm system disruption in service. This could result in CDPH's inability to exercise oversight in the event of a fire alarm system shut down. This affected the Main Hospital and all offsite locations.

NFPA 101, 2012 Edition
9.6.1.6* Where a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated, or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service.

Findings:

During document review with staff on 5/9/17, the Fire Watch Policy was requested and reviewed.

1. At 3:31 p.m., the Fire Watch Policy did not indicate that CDPH would be notified in the event of a disruption of fire alarm system services. Life Safety Officer 1 acknowledged and confirmed this finding.

Based on observation and interview, the facility failed to maintain the automatic fire sprinkler system. This was evidenced by the presence of foreign material on two sprinklers. This could result in a delayed response of the automatic fire sprinkler system, in the event of a fire, and affected one of five smoke compartments on the First Floor and one of six smoke compartments on the Second Floor of Patient Tower 1.

NFPA 25, Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2010 Edition
Chapter 5 Sprinkler Systems
5.2 Inspection.
5.2.1 Sprinklers.
5.2.1.1 Sprinklers shall be inspected from the floor level annually.

5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer

Findings:

During a tour of the facility with staff on 5/11/17, the automatic fire sprinkler system was observed.

1. At 1:03 p.m., the sprinkler in the EVS Closet, near the Nurses Station on 2 Central, was observed with paint between the deflector spokes.

2. At 1:36 p.m., the sprinkler inside the Emergency Department Staff Locker Room was loaded with dirt and debris.

Facilities Maintenance Staff 1 acknowledged and confirmed these findings.

Based on document review and interview, the facility failed to provide a complete Fire Watch Policy. This was evidenced by the absence of language specifying notification to the California Department of Public Health (CDPH) in the event of an automatic fire sprinkler system disruption in service. This could result in CDPH's inability to exercise oversight in the event of an automatic fire sprinkler system shut down. This affected the Main Hospital and all offsite locations.

NFPA 101, 2012 Edition
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, 2011 Edition
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

Findings:

During document review with staff on 5/9/17, the Fire Watch Policy was requested and reviewed.

1. At 3:31 p.m., the Fire Watch Policy did not indicate that CDPH would be notified in the event of a disruption of automatic fire sprinkler system services. Life Safety Officer 1 acknowledged and confirmed this finding.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by unsecured fire extinguishers and by one fire extinguisher that was not equipped with a location designating sign. This could result in a fire extinguisher being knocked over and damaged or a delay in locating the nearest fire extinguisher in the event of a fire. This affected Patient Tower 1, Patient Tower 2, and Lobby Area of the Cancer Center.

NFPA 101, Life Safety Code, 2012 Edition
9.7.4 Manual Extinguishing Equipment.
9.7.4.1* Where required by the provisions of another section of this Code, portable fire extinguishers shall be selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
6.1.3 Placement.
6.1.3.1 Fire extinguishers shall be conspicuously located where they are readily accessible and immediately available in the event of fire.

6.1.3.2 Fire extinguishers shall be located along normal paths of travel, including exits from areas.

6.1.3.3 Visual Obstructions.
6.1.3.3.1 Fire extinguishers shall not be obstructed or obscured from view.

6.1.3.3.2 In large rooms and in certain locations where visual obstructions cannot be completely avoided, means shall be provided to indicate the extinguisher location.

6.1.3.4* Portable fire extinguishers other than wheeled extinguishers shall be installed using any of the following means:
(1) Securely on a hanger intended for the extinguisher
(2) In the bracket supplied by the extinguisher manufacturer
(3) In a listed bracket approved for such purpose
(4) In cabinets or wall recesses

6.1.3.6 Fire extinguishers installed under conditions where they are subject to dislodgement shall be installed in manufacturer's strap-type brackets specifically designed for this problem.

6.1.3.7 Fire extinguishers installed under conditions where they are subject to physical damage (e.g., from impact, vibration, the environment) shall be protected against damage.

Findings:

During a tour of the facility with the Life Safety Officer 1 and Facilities Maintenance Manager on 5/10/17 and 5/11/17, the fire extinguishers were observed.

Rideout Memorial Hospital - Patient Tower 2

1. On 5/10/17, at 3:35 p.m., there were three portable fire extinguishers free-standing and unsecured on the floor of the Security Office. The office was located near the Emergency Room on the First Floor. The Life Safety Officer confirmed the findings.

Rideout Memorial Hospital - Patient Tower 1

2. On 5/11/17, at 1:29 p.m., there was a portable fire extinguisher free-standing and unsecured on a table in the Old Switchboard Room. The room was located near the Emergency Department on the First Floor.

Cancer Center

3. At 2:11 p.m., a portable fire extinguisher was observed inside the Main Entrance Conference Room. There was no sign designating its location inside the room, and another portable fire extinguisher was not observed within 25 feet from the Main Entrance Conference Room.

Based on observation and interview, the facility failed to maintain corridor doors to resist the passage of smoke and/or fire. This was evidenced by doors that were obstructed from closing and by doors that failed to latch. This affected the Rideout Memorial Hospital - West Wing, Cancer Care Center and Patient Tower 1. This could result in the faster spread of smoke and fire, in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition
19.3.6.3* Corridor Doors.
19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke and shall be constructed of materials such as the following:
(1) 13?4 in. (44 mm) thick, solid-bonded core wood
(2) Material that resists fire for a minimum of 20 minutes

19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply:
(1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door.
(2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7.

19.3.6.3.10* Doors shall not be held open by devices other than those that release when the door is pushed or pulled.

7.2.1.8 Self-Closing Devices.
7.2.1.8.1* A door leaf 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, unless otherwise permitted by 7.2.1.8.3.

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

Findings:

During a tour of the facility with Life Safety Officer 1 and Facilities Maintenance Manager on 5/11/17, the corridor doors were observed.

West Wing

1. At 10:34 a.m., the door to Room 312, located on third floor, was equipped with a self-closing device. The door failed to latch when fully opened and allowed to close. When interviewed, Life Safety Officer 1 confirmed the finding and stated the latching mechanism was not functioning.

Cancer Center

2. At 2:19 p.m., the door to the Physician of the Year Office failed to latch. The door was tested four times and failed. The finding was confirmed by Life Safety Officer 1.

3. At 2:21 p.m., the door to the Doctor's Office, near the Physician of the Year Office, was obstructed from closing by the door frame.


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Patient Tower 1

4. At 1:04 p.m., the door to the EVS Closet, located near the Nurses Station on 2 Central, was obstructed from closing. The door was obstructed from closing by the placement of the janitorial cleaning cart.

Based on observation and interview, the facility failed to maintain the electrical equipment. This was evidenced by two panels that were obstructed and by faceplates that were missing, cracked, or not secured. This affected Rideout Memorial Hospital - Patient Tower 1, Patient Tower 2, West Wing. This could result in delayed access of the panels in the event of an electrical emergency or an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2012 Edition
19.5 Building Services.
19.5.1 Utilities.
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service.

NFPA 70, National Electrical Code, 2011 edition
110.26 Spaces About Electrical Equipment. Access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.
(2) Width of Working Space. The width of the working space in front of the electrical equipment shall be the width of the equipment or 762 mm (30 in.), whichever is greater.
In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.

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

Findings:

During a tour of the facility with Life Safety Officer 1 and Facilities Maintenance Manager on 5/10/17 and 5/11/17, the facility electrical equipment was observed.

Patient Tower 2
5/10/17

1. At 9:38 a.m., the medical gas monitor panel and fire sub-panel were obstructed by a Pediatric Crash cart. Facilities Maintenance Manager confirmed the findings.

Patient Tower 1
5/11/17

2. At 9:41 a.m., there was a cracked red outlet faceplate behind a refrigerator/blanket warmer machine, in the Nutrition Room at the Nurse Station on the fourth floor.

3. At 12:43 p.m., a telephone outlet faceplate was not flush with the wall, in the HVAC Office located on the second floor.

West Wing
5/11/17

4. At 1:08 p.m., there was a missing telephone outlet faceplate in the Storage Room located on the second floor.


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5. At 12:54 p.m., the electrical outlets in Room 226 were observed. The faceplate on an outlet on the wall across from the bed was not secured against the wall. This exposed a 3 inch by 1/8 inch gap along the top, and a 5 inch by 1/8 inch gap along the left side.

Based on observation and interview, the facility failed to maintain their electrical wiring. This was evidenced by the use of power strips as substitutes for fixed wiring. This affected Rideout Memorial Hospital - Patient Tower 2 and West Wing. This could result in the ignition of an electrical fire.

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

NFPA 70, National Electrical Code, 2011 Edition
400.8 Uses Not Permitted. Unless specifically permitted
in 400.7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368.56(B)
(5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings
(6) Where installed in raceways, except as otherwise permitted in this Code
(7) Where subject to physical damage

Findings

During a tour of the facility with Life Safety Officer 1 and Facilities Maintenance Manager on 5/11/17, the electrical wiring and equipment was observed.

Patient Tower 2

1. At 9:18 a.m., medical equipment, at the Nurses Station in Cardio Vascular Intensive Care Unit, was connected to a power strip. The power strip did not meet UL 1363A or UL 60601-1 requirements. The medical equipment included two IV pump towers.


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West Wing

2. At 10:31 a.m., a microwave oven was plugged into a suspended power strip, in the Break Room for 3 West.