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Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This affected 1 of 21 smoke compartments.

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the facility walls and ceilings were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

1. At 9:30 a.m., in Room 5E845, there were three approximately 3/4 inch penetrations in the center of the left corner wall.

2. At 2:33 p.m., in the corridor wall across from Room 1E034 on the 1st floor there were 3 penetrations approximately ? inch round each in the wall next to the equipment tracker.

3. At 2:47 p.m., in Room 1E087, there was an approximately 1/2 inch penetration in the center of the right wall.

Based on observation, the facility failed to maintain the integrity of the corridor walls to resist the passage of smoke as evidenced by a penetration in one corridor wall. This finding could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 21 smoke compartments.

Findings:

Sharp Chula Vista Medical Center at 751 Medical Center Court


During the facility tour with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the corridor walls were observed.

November 2, 2010:

At 10:30 a.m., in the corridor by the smoke barrier wall next to Room 3W041, there was an approximately 2 inch square penetration, on the left surrounding the magnetic hold open device.

Based on observation and interview, the facility failed to maintain the corridor doors, as evidenced by corridor doors that were obstructed from closing, corridor doors that failed to positive latch upon closure and, by one door with scotch tape over the latching mechanism. This could result in the failure to confine the fire in the room and result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff. This affected 4 of 21 smoke compartments.

Findings:

During a tour of the facility with Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the facilities corridor doors were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

1. At 9:45 a.m., Room 4E645, on the 4th floor, had a door that failed to positive latch.

2. At 9:48 a.m., in Room 4N Staff Lounge, the latching mechanism for the corridor door was covered with tape preventing the door from latching.

3. At 10:05 a.m., the self-closing door to Room 4W040, failed to close and positive latch.

2. At 2:40 p.m., the door to the Rehab was held open by a door wedge that prevented it from closing.

3. At 2:45 p.m., the door to Room 1E087, was blocked open with a wedge under the door.

On November 3, 2010:

4. At 10:20 a.m., the self-closing door to Room 5W556, failed to fully close and positive latch.


Outpatient Services - Rehab (PT, OT & SPEECH) at 752 Medical Center Court, Ste. 303A:

On November 2, 2010:

5. At 8:41 a.m., Room 338 had two Hydroculator machines preventing the door from closing.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction for the smoke barrier walls in 5 of 21 smoke compartments as evidenced by unsealed penetrations in the smoke barrier walls. This could result in the transfer of fire and smoke from one smoke compartment to another and increase the risk of injury to patients, visitors and staff in the event of a fire.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with facility the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the smoke barrier walls were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

1. At 10:15 a.m., in the smoke barrier wall located by Room 472, there were three approximately 1 and 1/2 inch square unsealed penetrations in the left bottom of the wall above the dropped ceiling.

2. At 10:20 a.m., in the smoke barrier wall located by Room 453, there was an approximately 18 inch by 12 inch unsealed cut-out in the center top of the wall above the dropped ceiling.

3. At 1:30 p.m., in the smoke barrier wall located by Room 2E269, there was an approximately 24 inch by 1/2 inch unsealed penetration on the left side of the wall along the cable tray above the dropped ceiling.

Based on observation, the facility failed to maintain their smoke barrier double doors in 6 of 21 smoke compartments as evidenced by smoke barrier doors that failed to fully close and positive latch upon closure. This finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During fire alarm testing with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the smoke barrier doors were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 3, 2010:

1. At 10:22 a.m., the smoke barrier double door 1-7 by the entrance to 5 West TCU, the leaf door leaf failed to fully close and positive latch when released from the magnetic lock.

2. At 1:20 p.m., the smoke barrier double door #2 by the entrance to Administration, the door leafs failed to fully close and positive latch when released from the magnetic locks.

3. At 1:30 p.m., the smoke barrier double door 03 by Radiation Treatment, the right door leaf failed to fully close and positive latch when released from the magnetic hold open device.

Based on observation, the facility failed to protect hazardous areas with self-closing doors. This was evidenced by a hazardous area with a door blocked from closing. This could potentially allow the spread of smoke and fire from hazardous areas to other areas, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 1 of 21 smoke compartments.

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the hazardous areas were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

At 11:30 a.m., in Medical Records, the door to Room 2L021 was blocked open with a chart file.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by Emerald Textile Carts approximately 2 feet of the exit doors. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This affected 1 of 3 smoke compartments.

Findings:

During the tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the exit access was observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

At 2:36 p.m., the exit doors by Room 1E034 on the 1st floor were blocked by 8 Emerald Textile Carts lined up and down the corridor ending approximately 2ft from the exit door. Each cart was approximately 5ft wide by 6ft tall.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the facility failure to display the correct time on the fire alarm control panels. This could result in the failure of the fire alarm system to operate effectively in the event of a fire and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During observation of the facility with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the fire alarm panels were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 12:55 p.m., the Fire Alarm Control Panel showed the time as 11:55 a.m. and the right time was of 12:55 p.m.

Outpatient Services - Surgery at 765 Medical Center Court

On November 3, 2010:

At 5:55 p.m., the Fire Alarm Control Panel showed the time as 16:12 p.m. and the right time was 5:55 p.m.

Based on record review, the facility failed to ensure smoke detectors were maintained, inspected and tested as evidenced by the facility's failure to provide sensitivity testing for their system based smoke detection devices. This could cause harm to patients and staff in the event of a fire. This affected 2 of 21 smoke compartments.

NFPA 72 - 7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years there after.

Findings:

During document review with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the facility failed to provide a record of sensitivity testing for the system based smoke detection devices.

Outpatient Services - Surgery at 765 Medical Center Court

November 1, 2010:

At 11:00 a.m., there was no record of sensitivity testing for the smoke detectors in the Out Patient Services Surgery Center building.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads that did not have escutcheon rings, sprinklers with escutcheon rings that were not flush to the ceiling, sprinklers that were not free of debris and Tampers in the stairwells that were not locked. These could result in the fire sprinkler system not functioning as designed in the event of a fire, the spread of fire throughout the facility and the increased risk of injury to the patients, visitors and staff. This affected 4 of 21 smoke compartments.

Findings:

On November 2, 2010 through November 4, 2010, the tamper alarms were tested and sprinkler system was observed with the Director of Facilities.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

1. At 9:00 a.m., in Room 5W527, the sprinkler head was missing the trim ring.

2. At 9:35 a.m., in the Restroom of Patient Room 520, there was a build-up of debris on 1 of 1 sprinkler heads.

3. At 9:38 a.m., in Room 5E851 on the 5th floor there was a sprinkler missing the escutcheon ring.

4. At 9:40 a.m., in the Restroom of Patient Room 524, there was a build-up of debris on 1 of 1 sprinkler heads.

5. At 10:00 a.m., in 4N Room 6, there was a build-up of debris on 1 of 1 sprinkler heads.

6. At 1:26 p.m., in Room 2E268 on the 2nd floor there was a sprinkler missing the cap cover.

7. At 2:15 p.m., in the corridor by the elevator under repair on the 1st floor there was a sprinkler missing the escutcheon ring.

8. At 2:30 p.m., in the Kitchen Dish Room, there 2 of 6 sprinklers with escutcheon rings that had a 1 inch gap from the ceiling.

9. At 2:35 p.m., in the Pharmacy Storage, there 1 of 2 sprinklers missing an escutcheon ring.

10. At 2:38 p.m., in Room 1E090 on the 1st floor there was a sprinkler missing the escutcheon ring.

November 3, 2010:

11. At 10:30 a.m., the Tampers alarms in the stairwells on the 1st, 3rd and 5th floors were tested and the locks on the Tamper valve wheels were missing in every stairwell. When interviewed on November 3, 2010, the Vendor Representative conducting the testing stated that they had been at the facility the week before testing and had forgotten to lock all the Tampers in the stairwells.

Based on observation, the facility failed to ensure that their portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by fire extinguishers that were impeded from access. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire. This affected 5 of 21 smoke compartments.

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.

Findings:

During the facility tour with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the fire extinguishers were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

1. At 8:55 a.m., the fire extinguisher located in the 5W corridor by Room 5W527, had no handle on the case making it difficult to open.

2. At 2:50 p.m., in the Boiler Room, 1 of 2 fire extinguishers was sitting on the floor.

Outpatient Services - Rehab (PT, OT & Speech) at 752 Medical Center Court, Ste. 303A

November 3, 2010

3. At 8:45 a.m., in the Outpatient Office, 1 of 2 fire extinguishers was impeded by a water purifier.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 3, 2010

4. At 12:35 p.m., in Delivery Room I, the fire extinguisher was blocked by a cart and equipment.

5. At 12:40 p.m., in Delivery Room II, the fire extinguisher was blocked by a cart and equipment.

6. At 1:10 p.m., in the OR Hallway, fire extinguisher 125 was impeded by equipment.

7. At 1:15 p.m., in OR 7, the fire extinguisher was blocked by a cart and equipment.

Based on document review and interview, the facility failed to provide records verifying the testing and inspection for 195 of 332 fire/smoke dampers. This could result in faster spread of fire and smoke through smoke compartments in the event of a fire.

NFPA 90A, 5.4.5.4.1 requires fire dampers be tested in accordance with UL 555 "Standard for Safety Fire Dampers."

NFPA 90A, 5.4.7 requires at least every 4 years the following maintenance be performed:
(1) Fusible links (where applicable) shall be removed.
(2) All dampers shall be operated to verify that they close fully.
(3) The latch, if provided, shall be checked.
(4) Moving parts shall be lubricated as necessary.

Findings:

During document review with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the facility's fire/smoke damper maintenance records were reviewed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 1, 2010:

At 10:30 a.m., the facility records were reviewed and there was no documentation provided to verify the testing and inspection for 195 of 332 fire/smoke dampers. When interviewed on November 1, 2010 at 10:30 a.m., the Director of Facilities Engineering stated that the dampers located in 1 hour rated fire walls were not required to be inspected if the building was fully sprinklered. The fire/smoke dampers that were not tested were in the 1 hour wall.

Based on document review, interview and observation, the facility failed to upgrade their kitchen suppression system. This was evidenced by failing to install a standard UL300 rated system. This could result in the suppression system not functioning properly and delay in the notification to patients, staff and local emergency services in the event of a fire. This affected 21 of 21 smoke compartments.

NFPA 96
10-2.3 Automatic fire-extinguishing systems shall comply with standard UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with the requirements of the listing.

Findings:

During document review and a tour of the facility with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the kitchen fire suppression system was observed and maintenance documents were reviewed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 2:20 p.m., the kitchen fire suppression system was observed in the kitchen and had a red tag dated 5/20/10 indicating that it had failed to pass inspection. When interviewed on November 2, 2010 at 2:20 p.m., the Director of Facilities Engineering stated that they had already submitted the paperwork to the Office of Statewide Planning and Development (OSHPD) and were planning on upgrading their system within the next couple of months.

Based on observation, the facility failed to ensure that the oxygen cylinders were properly secured. This was evidenced by unsecured oxygen tank. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 1 of 5 smoke compartments.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.1.1
Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the facility was observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 11:28 a.m., Room 7 on the 2nd floor had 1 E-tank laying on the floor unsecured.

Based on document review, the facility failed to ensure that generator 4 at the (OP) Outpatient Surgery Services was inspected weekly as evidenced by no weekly inspection records in a twelve month continuous period. This creates the potential for loss of power which could cause harm to patients and staff in the event of an emergency. This affected 3 of 3 smoke compartments.

NFPA 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.

(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During facility document review with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the generator maintenance records were reviewed.

OP Services Surgery Center at 765 Medical Center Court

November 1, 2010:

At 10:00 a.m., the records indicated that no weekly generator inspections were conducted in a twelve month continuous period.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by electrical appliances plugged into multi-plug power strips and not directly into electrical outlets. This could result in an increased risk of electrical fire and potential injury to patients, visitors and staff in the event of a fire. This affected 2 of 21 smoke compartments.

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

NFPA 70 Section 400-8 1999 Ed. 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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the electrical system was observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 10:25 a.m., Room 3W039 on the 3rd floor had a refrigerator plugged into a multi-plug surge protection strip.

November 3, 2010

At 12:45 p.m., in the OR Break Room, there was a refrigerator plugged into a multi-outlet adapter and not directly into the wall.

Based on observation, the facility failed to ensure the Alcohol Based Hand Dispensers were installed away from ignition sources in 2 of 21 smoke compartments as evidenced by Alcohol Based Hand Dispensers mounted adjacent to electrical outlets. This could result in a fire and increase the risk of injury to patients, visitors and staff.

Findings:
During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the ABHR dispensers were observed.
Sharp Chula Vista Medical Center at 751 Medical Center Court:

1. At 9:48 a.m., in Room 4E645 there was a ABHR dispenser mounted approximately 1 ? inches from an electrical light switch.
2. At 3:20 p.m., in the Pulmonary Office, the Alcohol Based Hand Dispenser was mounted over the light switch.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This affected 1 of 21 smoke compartments.

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the facility walls and ceilings were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

1. At 9:30 a.m., in Room 5E845, there were three approximately 3/4 inch penetrations in the center of the left corner wall.

2. At 2:33 p.m., in the corridor wall across from Room 1E034 on the 1st floor there were 3 penetrations approximately ? inch round each in the wall next to the equipment tracker.

3. At 2:47 p.m., in Room 1E087, there was an approximately 1/2 inch penetration in the center of the right wall.

Based on observation, the facility failed to maintain the integrity of the corridor walls to resist the passage of smoke as evidenced by a penetration in one corridor wall. This finding could result in the spread of smoke and fire and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 21 smoke compartments.

Findings:

Sharp Chula Vista Medical Center at 751 Medical Center Court


During the facility tour with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the corridor walls were observed.

November 2, 2010:

At 10:30 a.m., in the corridor by the smoke barrier wall next to Room 3W041, there was an approximately 2 inch square penetration, on the left surrounding the magnetic hold open device.

Based on observation and interview, the facility failed to maintain the corridor doors, as evidenced by corridor doors that were obstructed from closing, corridor doors that failed to positive latch upon closure and, by one door with scotch tape over the latching mechanism. This could result in the failure to confine the fire in the room and result in the spread of smoke and fire throughout the facility and increase the risk of injury to patients, visitors and staff. This affected 4 of 21 smoke compartments.

Findings:

During a tour of the facility with Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the facilities corridor doors were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

1. At 9:45 a.m., Room 4E645, on the 4th floor, had a door that failed to positive latch.

2. At 9:48 a.m., in Room 4N Staff Lounge, the latching mechanism for the corridor door was covered with tape preventing the door from latching.

3. At 10:05 a.m., the self-closing door to Room 4W040, failed to close and positive latch.

2. At 2:40 p.m., the door to the Rehab was held open by a door wedge that prevented it from closing.

3. At 2:45 p.m., the door to Room 1E087, was blocked open with a wedge under the door.

On November 3, 2010:

4. At 10:20 a.m., the self-closing door to Room 5W556, failed to fully close and positive latch.


Outpatient Services - Rehab (PT, OT & SPEECH) at 752 Medical Center Court, Ste. 303A:

On November 2, 2010:

5. At 8:41 a.m., Room 338 had two Hydroculator machines preventing the door from closing.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction for the smoke barrier walls in 5 of 21 smoke compartments as evidenced by unsealed penetrations in the smoke barrier walls. This could result in the transfer of fire and smoke from one smoke compartment to another and increase the risk of injury to patients, visitors and staff in the event of a fire.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed of the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During the facility tour with facility the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the smoke barrier walls were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

1. At 10:15 a.m., in the smoke barrier wall located by Room 472, there were three approximately 1 and 1/2 inch square unsealed penetrations in the left bottom of the wall above the dropped ceiling.

2. At 10:20 a.m., in the smoke barrier wall located by Room 453, there was an approximately 18 inch by 12 inch unsealed cut-out in the center top of the wall above the dropped ceiling.

3. At 1:30 p.m., in the smoke barrier wall located by Room 2E269, there was an approximately 24 inch by 1/2 inch unsealed penetration on the left side of the wall along the cable tray above the dropped ceiling.

Based on observation, the facility failed to maintain their smoke barrier double doors in 6 of 21 smoke compartments as evidenced by smoke barrier doors that failed to fully close and positive latch upon closure. This finding could result in the spread of smoke and fire from one smoke compartment to the adjacent smoke compartment and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During fire alarm testing with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the smoke barrier doors were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 3, 2010:

1. At 10:22 a.m., the smoke barrier double door 1-7 by the entrance to 5 West TCU, the leaf door leaf failed to fully close and positive latch when released from the magnetic lock.

2. At 1:20 p.m., the smoke barrier double door #2 by the entrance to Administration, the door leafs failed to fully close and positive latch when released from the magnetic locks.

3. At 1:30 p.m., the smoke barrier double door 03 by Radiation Treatment, the right door leaf failed to fully close and positive latch when released from the magnetic hold open device.

Based on observation, the facility failed to protect hazardous areas with self-closing doors. This was evidenced by a hazardous area with a door blocked from closing. This could potentially allow the spread of smoke and fire from hazardous areas to other areas, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 1 of 21 smoke compartments.

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the hazardous areas were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

At 11:30 a.m., in Medical Records, the door to Room 2L021 was blocked open with a chart file.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by Emerald Textile Carts approximately 2 feet of the exit doors. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This affected 1 of 3 smoke compartments.

Findings:

During the tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the exit access was observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court:

November 2, 2010:

At 2:36 p.m., the exit doors by Room 1E034 on the 1st floor were blocked by 8 Emerald Textile Carts lined up and down the corridor ending approximately 2ft from the exit door. Each cart was approximately 5ft wide by 6ft tall.

Based on observation, the facility failed to maintain the fire alarm system as evidenced by the facility failure to display the correct time on the fire alarm control panels. This could result in the failure of the fire alarm system to operate effectively in the event of a fire and increase the risk of injury to patients, visitors and staff due to smoke and fire.

Findings:

During observation of the facility with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the fire alarm panels were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 12:55 p.m., the Fire Alarm Control Panel showed the time as 11:55 a.m. and the right time was of 12:55 p.m.

Outpatient Services - Surgery at 765 Medical Center Court

On November 3, 2010:

At 5:55 p.m., the Fire Alarm Control Panel showed the time as 16:12 p.m. and the right time was 5:55 p.m.

Based on record review, the facility failed to ensure smoke detectors were maintained, inspected and tested as evidenced by the facility's failure to provide sensitivity testing for their system based smoke detection devices. This could cause harm to patients and staff in the event of a fire. This affected 2 of 21 smoke compartments.

NFPA 72 - 7.2.2 Fire alarm systems and other systems and equipment that are associated with fire alarm systems and accessory equipment shall be tested according to Table 7-2.2 13. Initiating Devices (g) Smoke Detectors
The detectors shall be tested in place to ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer shall be permitted as acceptable test methods. Other methods approved by the manufacturer that ensure smoke entry into the sensing chamber shall be permitted.
Additionally any of the following tests shall be performed to ensure that each smoke detector is within its listed and marked sensitivity range:
(a)Calibrated test method
(b) Manufacturer's calibrated sensitivity test instrument
(c)Listed control equipment arranged for the purpose
(d) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit when its sensitivity is outside its listed sensitivity range
(e) Other calibrated sensitivity test method approved by the authority having jurisdiction.
Smoke sensitivity testing is required the first year of installation of the smoke detector, the third year and every five years there after.

Findings:

During document review with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the facility failed to provide a record of sensitivity testing for the system based smoke detection devices.

Outpatient Services - Surgery at 765 Medical Center Court

November 1, 2010:

At 11:00 a.m., there was no record of sensitivity testing for the smoke detectors in the Out Patient Services Surgery Center building.

Based on observation, the facility failed to maintain their automatic sprinkler system. This was evidenced by sprinkler heads that did not have escutcheon rings, sprinklers with escutcheon rings that were not flush to the ceiling, sprinklers that were not free of debris and Tampers in the stairwells that were not locked. These could result in the fire sprinkler system not functioning as designed in the event of a fire, the spread of fire throughout the facility and the increased risk of injury to the patients, visitors and staff. This affected 4 of 21 smoke compartments.

Findings:

On November 2, 2010 through November 4, 2010, the tamper alarms were tested and sprinkler system was observed with the Director of Facilities.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

1. At 9:00 a.m., in Room 5W527, the sprinkler head was missing the trim ring.

2. At 9:35 a.m., in the Restroom of Patient Room 520, there was a build-up of debris on 1 of 1 sprinkler heads.

3. At 9:38 a.m., in Room 5E851 on the 5th floor there was a sprinkler missing the escutcheon ring.

4. At 9:40 a.m., in the Restroom of Patient Room 524, there was a build-up of debris on 1 of 1 sprinkler heads.

5. At 10:00 a.m., in 4N Room 6, there was a build-up of debris on 1 of 1 sprinkler heads.

6. At 1:26 p.m., in Room 2E268 on the 2nd floor there was a sprinkler missing the cap cover.

7. At 2:15 p.m., in the corridor by the elevator under repair on the 1st floor there was a sprinkler missing the escutcheon ring.

8. At 2:30 p.m., in the Kitchen Dish Room, there 2 of 6 sprinklers with escutcheon rings that had a 1 inch gap from the ceiling.

9. At 2:35 p.m., in the Pharmacy Storage, there 1 of 2 sprinklers missing an escutcheon ring.

10. At 2:38 p.m., in Room 1E090 on the 1st floor there was a sprinkler missing the escutcheon ring.

November 3, 2010:

11. At 10:30 a.m., the Tampers alarms in the stairwells on the 1st, 3rd and 5th floors were tested and the locks on the Tamper valve wheels were missing in every stairwell. When interviewed on November 3, 2010, the Vendor Representative conducting the testing stated that they had been at the facility the week before testing and had forgotten to lock all the Tampers in the stairwells.

Based on observation, the facility failed to ensure that their portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by fire extinguishers that were impeded from access. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire. This affected 5 of 21 smoke compartments.

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.

Findings:

During the facility tour with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the fire extinguishers were observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

1. At 8:55 a.m., the fire extinguisher located in the 5W corridor by Room 5W527, had no handle on the case making it difficult to open.

2. At 2:50 p.m., in the Boiler Room, 1 of 2 fire extinguishers was sitting on the floor.

Outpatient Services - Rehab (PT, OT & Speech) at 752 Medical Center Court, Ste. 303A

November 3, 2010

3. At 8:45 a.m., in the Outpatient Office, 1 of 2 fire extinguishers was impeded by a water purifier.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 3, 2010

4. At 12:35 p.m., in Delivery Room I, the fire extinguisher was blocked by a cart and equipment.

5. At 12:40 p.m., in Delivery Room II, the fire extinguisher was blocked by a cart and equipment.

6. At 1:10 p.m., in the OR Hallway, fire extinguisher 125 was impeded by equipment.

7. At 1:15 p.m., in OR 7, the fire extinguisher was blocked by a cart and equipment.

Based on document review and interview, the facility failed to provide records verifying the testing and inspection for 195 of 332 fire/smoke dampers. This could result in faster spread of fire and smoke through smoke compartments in the event of a fire.

NFPA 90A, 5.4.5.4.1 requires fire dampers be tested in accordance with UL 555 "Standard for Safety Fire Dampers."

NFPA 90A, 5.4.7 requires at least every 4 years the following maintenance be performed:
(1) Fusible links (where applicable) shall be removed.
(2) All dampers shall be operated to verify that they close fully.
(3) The latch, if provided, shall be checked.
(4) Moving parts shall be lubricated as necessary.

Findings:

During document review with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the facility's fire/smoke damper maintenance records were reviewed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 1, 2010:

At 10:30 a.m., the facility records were reviewed and there was no documentation provided to verify the testing and inspection for 195 of 332 fire/smoke dampers. When interviewed on November 1, 2010 at 10:30 a.m., the Director of Facilities Engineering stated that the dampers located in 1 hour rated fire walls were not required to be inspected if the building was fully sprinklered. The fire/smoke dampers that were not tested were in the 1 hour wall.

Based on document review, interview and observation, the facility failed to upgrade their kitchen suppression system. This was evidenced by failing to install a standard UL300 rated system. This could result in the suppression system not functioning properly and delay in the notification to patients, staff and local emergency services in the event of a fire. This affected 21 of 21 smoke compartments.

NFPA 96
10-2.3 Automatic fire-extinguishing systems shall comply with standard UL 300, Standard for Fire Testing of Fire Extinguishing Systems for Protection of Restaurant Cooking Areas, or other equivalent standards and shall be installed in accordance with the requirements of the listing.

Findings:

During document review and a tour of the facility with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the kitchen fire suppression system was observed and maintenance documents were reviewed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 2:20 p.m., the kitchen fire suppression system was observed in the kitchen and had a red tag dated 5/20/10 indicating that it had failed to pass inspection. When interviewed on November 2, 2010 at 2:20 p.m., the Director of Facilities Engineering stated that they had already submitted the paperwork to the Office of Statewide Planning and Development (OSHPD) and were planning on upgrading their system within the next couple of months.

Based on observation, the facility failed to ensure that the oxygen cylinders were properly secured. This was evidenced by unsecured oxygen tank. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner. This affected 1 of 5 smoke compartments.

NFPA 99 Health Care Facilities, 1999 Edition
4-3.1.1.1
Cylinder and Container Management. Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the facility was observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 11:28 a.m., Room 7 on the 2nd floor had 1 E-tank laying on the floor unsecured.

Based on document review, the facility failed to ensure that generator 4 at the (OP) Outpatient Surgery Services was inspected weekly as evidenced by no weekly inspection records in a twelve month continuous period. This creates the potential for loss of power which could cause harm to patients and staff in the event of an emergency. This affected 3 of 3 smoke compartments.

NFPA 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.

(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.
2. Test Conditions. The scheduled test under load conditions shall include a complete simulated cold start and appropriate automatic and manual transfer of all essential electrical system loads.
3. Test Personnel. The scheduled tests shall be conducted by competent personnel. The tests are needed to keep the machines ready to function and, in addition, serve to detect causes of malfunction and to train personnel in operating procedures.

NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During facility document review with the Director of Facilities Engineering on November 1, 2010 through November 4, 2010, the generator maintenance records were reviewed.

OP Services Surgery Center at 765 Medical Center Court

November 1, 2010:

At 10:00 a.m., the records indicated that no weekly generator inspections were conducted in a twelve month continuous period.

Based on observation, the facility failed to maintain electrical safety. This was evidenced by electrical appliances plugged into multi-plug power strips and not directly into electrical outlets. This could result in an increased risk of electrical fire and potential injury to patients, visitors and staff in the event of a fire. This affected 2 of 21 smoke compartments.

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

NFPA 70 Section 400-8 1999 Ed. 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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During a tour of the facility with the Director of Facilities Engineering on November 2, 2010 through November 4, 2010, the electrical system was observed.

Sharp Chula Vista Medical Center at 751 Medical Center Court

November 2, 2010:

At 10:25 a.m., Room 3W039 on the 3rd floor had a refrigerator plugged into a multi-plug surge protection strip.

November 3, 2010

At 12:45 p.m., in the OR Break Room, there was a refrigerator plugged into a multi-outlet adapter and not directly into the wall.