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NFPA 72 National Fire Alarm and Signaling Code 2010 Edition

17.14.5 Manual fire alarm boxes shall be installed so that they are conspicuous, unobstructed, and accessible.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure a pull station was unobstructed and accessible.

The deficiencies had the potential to delay or prevent the activation of the pull station and fire alarm system.

Finding:

On 12/12/18 at 1:15 p.m. and 3:15 p.m. at the main hospital first floor, the evaluator observed the manual fire alarm box (pull station) across from the surgery information desk was obstructed by a Christmas tree placed in front of the pull station.

During an interview at the same time as the 3:15 p.m. observation the Manager of Plant Maintenance stated the Christmas tree would be moved.

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

5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following:
(1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5
(2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6

5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage, and corrosion.

5.4.1.5 The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For protected facilities having under 300 sprinklers-no fewer than 6 sprinklers
(2) For protected facilities having 300 to 1000 sprinklers - no fewer than 12 sprinklers
(3) For protected facilities having over 1000 sprinklers - no fewer than 24 sprinklers

5.4.1.6* A special sprinkler wrench shall be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

5.4.1.6.1 One sprinkler wrench shall be provided for each type of sprinkler installed.

13.3.1* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

13.7.1 Fire department connections shall be inspected quarterly to verify the following:
(1) The fire department connections are visible and accessible.
(2) Couplings or swivels are not damaged and rotate smoothly.
(3) Plugs or caps are in place and undamaged.
(4) Gaskets are in place and in good condition.
(5) Identification signs are in place.
(6) The check valve is not leaking.
(7) The automatic drain valve is in place and operating properly.
(8) The fire department connection clapper(s) is in place and operating properly.

The Standard was not met as evidenced by:

Based on document review and observation the facility failed to ensure deficiencies found during an inspection of the automatic sprinkler system were corrected.

The deficiency had the potential for the sprinkler system to not work as designed, to not have spare sprinklers readily available to replace activated sprinkler heads to place the system back in a condition to protect that building, and to not identify a control valve and connection.

Finding:

On 12/12/18 at 8 a.m., at the Outpatient Services Mammography in Hacienda Heights, review by the evaluator of the automatic sprinkler system inspection, testing, and maintenance report dated 10/1/18, revealed the report had 12 listed deficiencies. Although the 12 deficiencies were at locations of the building that were outside the suite that housed the outpatient mammography service, 3 of 12 of the deficiencies were in common areas that had the potential of affecting the suite.

These deficiencies included the following:

PIV (post indicator valve) and FDC (fire department connection) need custom sign.
Spare head box needs two 1/2 inch TY3531 155 degrees SR concealer heads with TY3531 head wrench.
1st floor South riser replace leaking 4" pipe in 3 different areas.

Review of an e-mail communication provided by the facility dated 11/26/18 indicates the facility agreeing with a vendor to a date of 12/22/18 for repair of the 12 deficiencies.

At 9 a.m., the evaluator observed a 5 inch by 12 inch sign with 1 inch lettering at the PIV that read "FDC services 1850 Azusa Ave", no sign at the PIV, 2 wrenches and different types of spare sprinklers in the spare sprinkler box, and water leak staining at the 1st floor stairwell riser.

Based on observation and interview the hospital failed to ensure a corridor door held closed.

Doors protecting corridor openings play an integral role in interrupting the spread of smoke. The deficiency had the potential to permit the spread of smoke.

Findings:

Main Hospital (2 North)

On 12/14/18 at 9:19 a.m., at the main hospital emergency department, the evaluator observed the corridor door of room 26 failed to hold closed.

During an interview at the same time as the observation the Manager of Plant Maintenance acknowledged the door failed to hold closed.

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

5.2.4.1.1 Waste and linen chutes shall terminate or discharge directly into a room having a minimum fire resistance rating not less than that specified for the chute.

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

This Standard was not met as evidenced by:

Based on observation and interview the facility failed to ensure a chute discharge door was unobstructed from closing.

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

Findings:

On 12/14/18 at 9:55 a.m., the evaluator observed the linen chute room at the 4 story Shannon Tower lower level floor on the main hospital campus. The evaluator further observed the linen chute's discharge door was obstructed from closing by a bin over filled with bags of linen directly under the open chute door and into the chute.

During an interview at the same time as the observation environmental services staff acknowledged the obstruction of the linen chute's discharge door and stated that the chute served the Shannon Tower.

NFPA 99 Health Care Facilities Code 2012 Edition

11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

This Code was not met as evidenced by:

Based on observation and interview the facility failed to ensure empty and full cylinders were segregated, and empty cylinders were marked.

The deficiency had the potential for a nurse to pick up an empty oxygen cylinder in an emergency.

Findings:

On 12/12/18 at 2 p.m., in the Outpatient Services Cardiac Testing on the main hospital campus, the evaluator observed 4 oxygen cylinders stored together in an oxygen cylinder rack without signage identifying which cylinders were empty and which were full.

During an interview at the same time as the observation the Lead Cardiology Registered Nurse stated that one of the cylinders was full and three were empty.