HospitalInspections.org

Based on observation, the facility failed to maintain their building construction. This was evidenced by penetrations in the ceilings of two offsite clinics. This affected two of eleven offsite buildings and could result in the faster spread of smoke and fire, in the event of a fire.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the walls and ceilings were observed.

Building 06 Fillmore CFH -

1. On 4/9/14, at 7:54 a.m., there was an approximately 4 inch by 2 inch penetration, around an electrical conduit, in the ceiling of the Business Office.

Building 11 Saviers CFH -

2. On 4/9/14, at 11:31 a.m., there was an approximately 3 inch round penetration in the ceiling above the monitor in the X-ray Room.

Based on observation, the facility failed to ensure that doors resist the passage of smoke. This was evidenced by doors that failed to close and latch. This could result in the failure to contain smoke or fire to a room, in the event of a fire. This affected patients, staff, and visitors in one of eight floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
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 a tour of the facility with staff from 4/7/14 to 4/10/14, the doors were observed.

Building 01 Main Hospital -

First Floor -

1. On 4/8/14, at 12:39 p.m., the door near X-ray Room 2 failed to close and latch.

2. On 4/8/14, at 3:00 p.m., the door to the Catheterization Laboratory Locker Room failed to close and latch.

Based on observation and interview, the facility failed to ensure that exits are marked by approved, readily visible signs. This was evidenced by self-luminous exit signs that had expired, by one exit door that was not marked with an exit sign, and by one directional arrow on an exit sign that was obstructed from view. This affected the MRI Unit at the main hospital and two of eleven offsite buildings. This could result in a delayed evacuation in the event of a fire or disaster emergency.

NFPA 101, Life Safety Code, 2000 Edition.
7.10.1.2 Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.1.4 Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the exit signs were observed.

Building 01 MRI Trailer at the Main Hospital -

1. On 4/8/14, at 10:14 a.m., three of three self-luminous exit signs in the MRI trailer were expired. The stickers at the bottom of each sign stated "Replace Before 6/2000." The exit signs were due to be replaced approximately 14 years ago.

Building 03 MAP -

2. On 4/8/14, at 3:06 p.m., the "Fire Plan" posted throughout the Urology Clinic indicated that the door from the staff lounge into the hallway is part of the emergency evacuation route. The door was not marked with an exit sign.

Building 11 Saviers CFH -

3. On 4/9/14, at 11:21 a.m., there was double-sided opaque white tape covering the directional indicator on the exit sign near the Family Practice Nurses Station. The exit sign was pointing towards the side door. During an interview at 11:22 a.m., the Clinic Manager confirmed that the directional sign pointed towards an exit door and should not have been covered.

Based on observation, record review, and interview, the facility failed to protect their hazardous areas. This was evidenced by the failure to ensure that doors protecting hazardous areas close and latch. This could result in the failure to contain smoke or fire to a room, in the event of a fire. This deficient practice affected patients, staff, and visitors in two of eight floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition Section
19.3.2.1 Any hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to the following:
(1) Boiler and fuel fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.

Findings:

During a tour of the facility with staff from 4/7/14 to 4/10/14, the hazardous areas were observed.

Building 01 Main Hospital -

Second Floor -

1. On 4/8/14, at 1:25 p.m., the 90-minute fire-rated corridor door to Materials Management failed to close and latch. The door was off the hinge and could not be closed.

First Floor -

2. On 4/10/14, at 10:46 a.m., the door to the storage room in the Cardiac Surgery suite failed to close and latch. There was an approximately 150-gallon trash receptacle in the room at the time of survey.

On 4/10/14, during an interview, Engineering Staff 1 stated that the deficient doors were damaged and required replacement. Engineering Staff 1 stated that the replacement doors have already been ordered. Engineering Staff 1 provided an invoice showing that the two doors have been ordered from a vendor on 3/19/14.

Based on observation and interview, the facility failed to maintain their exit pathways. This was evidenced by one exit corridor that was obstructed. This affected one of eleven offsite buildings and could result in a delay in evacuation, in the event of a fire or disaster emergency.

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.

7.1.10.1 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.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the exit pathways were observed.

Building 07 Santa Paula CFH -

1. On 4/9/14, at 9:10 a.m., there were four chairs in the exit corridor outside the psychiatric office. During an interview at 9:11 a.m., the clinic manager stated that they use a portion of the corridor as a waiting area for the psych office patients.

Based on observation, record review, and interview, the facility failed to maintain their emergency lighting. This was evidenced by one battery-powered emergency light that failed when tested and by the facility's failure to test their battery-powered emergency lights at one offsite clinic. This affected one of eleven offsite buildings and could result in limited visibility in the event of a power failure.

NFPA 101, Life Safety Code, 2000 Edition.
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 tests 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

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the emergency lighting was observed.

Building 04 Ashwood CFH -

1. On 4/8/14, at 1:57 p.m., one of two bulbs on the battery-powered emergency light fixture in Procedure Room 2 failed to illuminate when tested by Administrative Staff 1.

2. During an interview at 1:58 p.m., on 4/8/14, Administrative Staff 1 stated that he was unsure if the battery-powered emergency lights located throughout Ashwood CFH were tested. There were no records that indicated 30 second monthly testing and 90 minute annual testing had been completed on the emergency lights at Ashwood CFH.

Based on observation, the facility failed to ensure that all exit signs are continuously illuminated. This was evidenced by exit signs with failed illumination sources. This could result in a delay in evacuation, in the event of a fire or disaster emergency. This affected patients, staff and visitors in two of eight floors in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
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.
7.10.9.1 Inspection. Exit signs shall be visually inspected for operation of the illumination sources at intervals not to exceed 30 days.

Findings:

During a tour of the facility with staff from 4/7/14 to 4/10/14, the exit signs were observed.

Building 01 Main Hospital -

Seventh Floor -

1. On 4/8/14, at 8:58 a.m., the exit sign next to the Medical Library was not fully illuminated. One of two light bulbs was not illuminated.

First Floor -

2. On 4/8/14, at 2:36 p.m., the exit sign near the microbiology laboratory was not fully illuminated. One of two light bulbs was not illuminated.

Based on document review and interview, the facility failed to ensure that at least one semi-annual disaster drill rehearsed a mass casualty response for health care facilities. This was evidenced by records for one table-top disaster drill and by incomplete documentation for a second disaster drill. This could result in a delayed staff response to a disaster emergency. This affected all patients, staff, and visitors in eight of eight floors of the main hospital.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
Chapter 11 Health Care Emergency Preparedness
11-5.3.9 Drills. Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Findings:

During document review and interview with staff from 4/7/14 to 4/10/14, the disaster drill records were reviewed.

Building 01 Main Hospital -

1. On 4/7/14, at 3:22 p.m., documents were provided for a table-top disaster drill held on 8/21/13. When a second disaster drill was requested, the facility provided a flyer stating that the facility participated in a state-wide "shake out" drill on 9/26/13. A list of signatures who participated in the shake out drill was attached to the flyer. No information about the facility's response was provided.

During an interview, on 4/9/14 at 3:23 p.m., Administrative Staff 2 stated that no other disaster drills were held at the facility and that there was no additional documentation for the shake out drill.

Based on record review and interview, the facility failed to ensure that fire drills at their ambulatory surgery center were conducted at a minimum of once per shift per quarter. This was evidenced by no records of a fire drill conducted during the last quarter (October to December) of 2013. This affected the MOB and could result in a delayed staff response to a fire emergency.

NFPA 101, Life Safety Code, 2000 Edition
Chapter 21 Existing Ambulatory Health Care Occupancies
21.7.1.2 Fire drills in ambulatory health care facilities shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Findings:

During record review with staff from 4/7/14 to 4/10/14, the fire drill records were reviewed.

Building 02 MOB -

1. On 4/7/14, at 12:00 p.m., records indicated that there were no fire drills conducted between 9/13/13 and 3/26/14 at MOB, which houses the Same Day Surgery Center on the second floor.

During an interview at 12:01 p.m., Engineering Staff 3 stated that the hospital's safety officer retired in the summer of 2013 and, since then, the drills have not been conducted quarterly.

Based on observation, record review, and interview, the facility failed to maintain the fire alarm system. This was evidenced by an incomplete report for the annual certification of the fire alarm system, by no documentation for the repairs noted in the annual report, and by the failure of audible notification devices during fire alarm testing. This could result in a delayed notification of a fire alarm activation to patients and staff, in the event of a fire. This affected eight of eight floors in the main hospital and the Same Day Surgery Center in the MOB.

NFPA 101, Life Safety Code, 2000 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
19.3.4.3.1 Occupant Notification. Occupant notification shall be accomplished automatically in accordance with 9.6.3.
Exception No. 1: In lieu of audible alarm signals, visible alarm indicating appliances shall be permitted to be used in critical care areas.
Exception No. 2: Where visual devices have been installed in patient sleeping areas in place of the audible alarm, they shall be permitted where accepted by the authority having jurisdiction.

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.
9.6.1.7 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.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

NFPA 72, National Fire Alarm Code, 1999 Edition.
1-6.3 Records. A complete, unalterable record of the tests and operations of each system shall be kept until the next test and for 1 year thereafter. The record shall be available for examination and, if required, reported to the authority having jurisdiction. Archiving of records by any means shall be permitted if hard copies of the records can be provided promptly when requested.
Exception: If off-premises monitoring is provided, records of all signals, tests, and operations recorded at the supervising station shall be maintained for not less than 1 year.

7-1.6.2.1 Reacceptance testing shall be performed after any of the following:
(1) Added or deleted system components
(2) Any modification, repair, or adjustment to system hardware or wiring
(3) Any change to site-specific software.
All components, circuits, systems operations, or site-specific software functions known to be affected by the change or identified by a means that indicates the system operational changes shall be 100 percent tested. In addition, 10 percent of initiating devices that are not directly affected by the change, up to a maximum of 50 devices, also shall be tested, and correct system operation shall be verified. A revised record of completion in accordance with 1-6.2.1 shall be prepared to reflect any changes.

7-3.2 Testing. Testing shall be performed in accordance with the schedules in Chapter 7 or more often if required by the authority having jurisdiction. If automatic testing is performed at least weekly by a remotely monitored fire alarm control unit specifically listed for the application, the manual testing frequency shall be permitted to be extended to annual. Table 7-3.2 shall apply.
Exception: Devices or equipment that are inaccessible for safety considerations (for example, continuous process operations, energized electrical equipment, radiation, and excessive height) shall be tested during scheduled shutdowns if approved by the authority having jurisdiction but shall not be tested more than every 18 months.

Number 19 (Alarm Notification Appliances) parts a, b, and c, in Table 7-3.2 (Testing Frequencies) require that audible devices, audible textual notification appliances, and visible devices be tested on an annual basis.

Findings:

During document review and interview with staff from 4/7/14 to 4/10/14, the fire alarm maintenance and testing reports were reviewed and the fire alarm system was tested.

Building 01 Main Hospital -

1. On 4/7/14, at 11:58 a.m., the facility provided a report dated 11/21/13, for the annual certification of the fire alarm system. The vendor noted audible and visual notification devices were not tested.

During an interview, at 11:59 a.m. on 4/7/14, Engineering Staff 1 confirmed that the notification devices were not tested during the annual test and were instead tested periodically by engineering staff.

The facility failed to provide documents for testing the 36 bells, 8 chimes, 26 strobes, and 47 combination horn-strobe devices connected to the fire alarm system.

2. On 4/7/14, at 12:00 p.m., the vendor noted on the annual certification report that three smoke detectors and one duct detector failed during the inspection on 11/21/13.

During an interview, at 12:01 p.m. on 4/7/14, Engineering Staff 1 stated that the three smoke detectors and one duct detector that failed during the annual inspection were repaired. The facility failed to provide documentation confirming the repairs.

Third Floor -

3. On 4/9/14, at 10:04 a.m., the fire alarm notification bell in the corridor outside the Critical Care Unit failed to activate during fire alarm testing.

Second Floor -

4. On 4/9/14, at 10:35 a.m., the combination horn-strobe notification device, next to Labor and Delivery Room A, failed to activate during fire alarm testing.

First Floor -

5. On 4/9/14, at 12:47 p.m., the fire alarm chime next to the main exit door in the Laboratory failed to activate during fire alarm testing.

Building 02 MOB -

6. On 4/9/14, at 1:35 p.m., the fire alarm chime next to Operating Room A in the Same Day Surgery Center failed to active during fire alarm testing.

Based on record review and interview, the facility failed to maintain their smoke detectors. This was evidenced by incomplete records of smoke detector sensitivity testing and by single station battery powered smoke detectors that were not tested in accordance with manufacturer's specifications. This affected eight of eight floors at the main hospital and three of eleven offsite buildings. This could result in a delayed notification of smoke or fire to patients, staff, and visitors.

NFPA 101, Life Safety Code, 2000 Edition
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.

9.6.2.10.1 Where required by another section of this Code, single-station smoke alarms shall be in accordance with the household fire-warning equipment requirements of NFPA 72, National Fire Alarm Code, unless they are system smoke detectors in accordance with NFPA 72, National Fire Alarm Code, and are arranged to function in the same manner.

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.

7-5.2 Maintenance, Inspection, and Testing Records.
7-5.2.2 A permanent record of all inspections, testing, and maintenance shall be provided that includes the following information regarding tests and all the applicable information requested in Figure 7-5.2.2.
(1) Date
(2) Test frequency
(3) Name of property
(4) Address
(5) Name of person performing inspection, maintenance, tests, or combination thereof, and affiliation, business address, and telephone number
(6) Name, address, and representative of approving agency(ies)
(7) Designation of the detector(s) tested, for example, " Tests performed in accordance with Section __________. "
(8) Functional test of detectors
(9) Functional test of required sequence of operations
(10) Check of all smoke detectors
(11) Loop resistance for all fixed-temperature, line-type heat detectors
(12) Other tests as required by equipment manufacturers
(13) Other tests as required by the authority having jurisdiction
(14) Signatures of tester and approved authority representative
(15)Disposition of problems identified during test (for example, owner notified, problem corrected/successfully
retested, device abandoned in place)


Findings:

During record review with staff from 4/7/14 to 4/10/14, the smoke detector testing records were requested.

Building 01 Main Hospital -

1. On 4/9/14, at 2:45 p.m., facility staff provided documentation for smoke detector sensitivity testing. The report indicated that 36 smoke detectors were tested in 2012. The hospital was equipped with 159 smoke detectors and 31 duct detectors, as noted on the annual fire alarm certification report. The facility failed to conduct sensitivity testing for all smoke and duct detectors.

Building 02 MOB -

2. On 4/7/14, at 3:41 p.m., records indicated that 27 of 35 smoke detectors were tested on 2/7/11 and 18 of 35 smoke detectors were tested on 11/28/12. 15 of the 18 smoke detectors tested in 2012 were also tested in 2011. There were no records of smoke detector sensitivity testing for 5 of 35 smoke detectors at MOB.

During an interview at 3:42 a.m., Engineering Staff 1 stated that he tests a portion of the detectors in the building every year. Engineering Staff 1 stated that he missed testing detectors in 2013 because the device that reads sensitivity of the detectors had to be repaired and recalibrated.

Building 04 Ashwood CFH -

3. On 4/7/14, at 2:00 p.m., a record indicated that the batteries for the battery-operated smoke detectors at Ashwood were last replaced in June 2012. There were no records of testing the detectors.

During an interview at 2:01 p.m., Engineering Staff 3 stated that he maintains the offsite clinics and he tests the battery-powered smoke detectors every month.

On 4/8/14, at 2:12 p.m., the verbiage "push to test weekly" was etched around the test buttons of the battery-powered smoke detectors. No records for weekly testing of the detectors was provided.

Building 06 Fillmore CFH -

4. On 4/9/14, at 7:59 a.m., the verbiage "push and hold to test weekly" was etched around the test buttons of the battery-powered smoke detectors in Fillmore. No records for weekly testing of the detectors was provided.






29665

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by deficiencies noted during vendor inspections that were not corrected, by no quarterly inspection records for three offsite clinics, by missing escutcheon rings and sprinkler cover caps, and by sprinkler heads that were not free of debris and foreign materials. This affected two of eight floors and the basement in the main hospital and six of six sprinklered offsite buildings. This could result in a malfunctioning automatic sprinkler system, in the event of a fire.

NFPA 101, Life Safety Code, 2000 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.

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.


NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 1998 Edition.
1-4.4 The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

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.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the automatic sprinkler system was observed and maintenance records were requested.

Building 01 Main Hospital -

Basement -

1. On 4/8/14, at 9:16 a.m., two of two sprinkler heads above the east folding machine, in the laundry room, were completely covered in lint.

Second Floor -

2. On 4/8/14, at 12:47 p.m., the sprinkler escutcheon ring was missing in LDR 5 Housekeeping Closet.

First Floor -

3. On 4/8/14, at 2:52 p.m., the cover caps for two of three sprinkler heads in Cath Lab Room 3 were missing. The missing caps revealed approximately 2 1/2 inch penetrations in the hard lid ceiling around the two sprinklers.

Building 02 MOB -

4. On 4/7/14, at 2:21 p.m., records of a quarterly sprinkler system inspection conducted on 2/19/14 were provided. Under the "comments" section, the vendor stated the "tamper switch in the pump room. Stem was broken during annual pump test. Waiting for office to approve repair." There were no records of the repair of the valve stem provided.

During an interview, at 1:26 p.m. on 4/8/14, Engineering Staff 1 confirmed that the stem of one of the tamper valves in the fire pump room was broken. Engineering Staff 1 stated that it has still not been repaired.

5. On 4/10/14, at 9:31 a.m., records showed that the vendor conducted the five-year certification inspection from 1/13/14 to 1/14/14. The "Deficiencies and Comments" sections for Risers 2, 5, 6, and 7 indicated that multiple repairs were required.

For Riser 2, the vendor states that there was a "broken hanger in B1 by elevator lobby."

For Riser 5, the vendor states that there was plastic on the sprinkler head in the trash room of Same Day Surgery, multiple sprinkler heads were painted, and that the facility "needs to add an extension on the sprinkler head in care area where the tile keeps dropping."

For Riser 6, the vendor states "missing escutcheon, lower two heads and add two heads."

For Riser 7, the vendor states "missing escutcheon."

There were no records confirming the deficiencies had been repaired. During an interview at 9:32 a.m., Facilities Staff 1 stated that the deficiencies noted during the five year inspection have not yet been repaired. Facilities Staff 1 stated that the vendor will not certify the system until the repairs have been made. Facilities Staff 1 said he scheduled the vendor to come out to the facility on 4/17/13 for the repairs.

Building 03 MAP -

6. On 4/8/14, at 3:10 p.m., the sprinkler head located on the second floor of the East Stairwell was missing an escutcheon ring.

Building 05 Main Street CFH -

7. On 4/7/14, the quarterly sprinkler testing for the Main Street CPH was requested. The testing records were not provided during the survey.

Building 07 Santa Paula CFH -

8. On 4/7/14, the quarterly sprinkler testing for the Santa Paula CPH was requested. The testing records were not provided during the survey.

Building 09 Airport-Marina CFH -

9. On 4/7/14, the quarterly sprinkler testing for the Airport-Marina CFH was requested. The testing records were not provided during the survey.

Building 11 Saviers CFH -

10. On 4/9/14, at 11:25 a.m., the sprinkler head in the fire alarm control panel room was missing an escutcheon ring.


29665

Based on observation, record review, and interview, the facility failed to maintain their cooking areas. This was evidenced by a kitchen hood fire suppression system that was not certified and the facility's continued use of the cooking equipment. This affected the basement of the main hospital and could result in the increased risk of a 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
Chapter 7 Fire-Extinguishing Equipment
7-9 Review and Certification
7-9.1 Where required, complete drawing of the system installation, including the hood(s), exhaust duct(s), and appliances, along with the interface of the fire-extinguishing system detectors, piping, nozzles, fuel shutoff devices, agent storage container(s), and manual activation device(s), shall be submitted to the authority having jurisdiction.
7-9.2 Installation of systems shall be performed only by persons properly trained and qualified to install the specific system being provided. The installer shall provide certification to the authority having jurisdiction that the installation is in agreement with the terms of the listing and the manufacturer's instructions and/or approved design.

Chapter 8 Procedures for the Use and Maintenance of Equipment
8-1.6 Cooking equipment shall not be operated while its fire-extinguishing system or exhaust system is nonoperational or otherwise impaired.
8-2.1 All actuation components, including remote manual pull stations, mechanical or electrical devices, detectors, actuators, and fire-actuated dampers, shall be checked for proper operation during the inspection in accordance with the manufacturer's listed procedures. In addition to these requirements, the specific inspection requirements of the applicable NFPA standard shall also be followed.
8-2.3 If required, certificates of inspection and maintenance shall be forwarded to the authority having jurisdiction.

Chapter 9 Minimum Safety Requirements for Cooking Equipment
9-1.2.2 Cooking appliances requiring protection shall not be moved, modified, or rearranged without prior reevaluation of the fire-extinguishing system by the system installer or servicing agent, unless otherwise allowed by the design of the fire-extinguishing system.
Exception: Cooking appliances moved to perform maintenance and cleaning provided the appliances are returned to their original positioning prior to cooking operations, and any disconnected fire-extinguishing system nozzles attached to the appliances are reconnected in accordance with the manufacturer's listed design manual.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the kitchen hoods in the cafeteria and kitchen were observed. Maintenance records for both were requested.

Building 01 Main Hospital -

1. On 4/8/14, at 10:36 a.m., the fire suppression system for the main hood in the kitchen was not tagged and certified.

"Wet Chemical Suppression System Inspection Report" records dated 5/14/13 and 11/26/13 were provided. During these inspections, the vendor noted "small griddle changed to fryer - need to adjust nozzle for proper coverage. Waiting for approval from OSHPD. System serviced but cannot be tagged."

Records from the Office of Statewide Health Planning and Development (OSHPD) official website indicated that the facility applied for a "Kitchen Speed Line Hood System Upgrade" on 10/29/13. A description of Project S132402-56-00 indicated that the facility plans to "delete one nozzle where the griddle was removed and then install 2 nozzles to cover fryers that were added in place of the griddle. About 12" of pipe and 2 nozzles."

On 4/8/14, at 10:37 a.m., there was one nozzle over the deep fryer in the main kitchen hood.

On 4/10/14, at 8:15 a.m., Facilities Staff 1 provided the most recent letter from the OSHPD Fire Life Safety Officer (FLSO), dated 4/9/14. The FLSO requested "sets of corrected construction documents and return the remarked document" before the project can proceed.

2. On 4/8/14, at 10:38 a.m., Administrative Staff 1 and Dietary Staff 1 confirmed that the deep fryer in the main kitchen is used frequently.

Based on observation and interview, the facility failed to ensure that mobile trash receptacles were stored in a room protected as a hazardous area. This was evidenced by unattended trash receptacles, greater than 32 gallons in size, that were not stored in a room with a self-closing door. This affected the basement of the main hospital and the large amount of trash exposed to the corridor could result in the faster spread of smoke and fire, in the event of a 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.

19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated, factory- or field-applied protective plates extending not more than 48 in. (122 cm) above the bottom of the door.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the soiled linen and trash receptacles were observed.

Building 01 Main Hospital -

1. On 4/8/14, at 9:30 a.m., two 100-gallon trash receptacles were stored in the freight elevator next to the kitchen. One receptacle was overflowing with trash and the manually-operated elevator door was left open. The elevator door is not self-closing and the trash was exposed to the corridor.

During an interview at 9:31 a.m., Materials Management Staff 1 stated that the trash receptacles are stored in the elevator until the receptacles are full and then are taken up to the first floor for disposal.

There was a full 100-gallon trash receptacle observed in the same freight elevator on 4/10/14 at 9:56 a.m. The door to the elevator was in the fully open position.

Based on record review and interview, the facility failed to maintain their anesthetizing locations. This was evidenced by a policy to maintain relative humidity below 35% without evidence of electing to use the categorical waiver in accordance with S&C 13-25. This was also evidenced by an entire week where the humidity fell out of range in 4 of 15 anesthetizing locations and by the failure to provide humidity logs for 11 of 15 anesthetizing locations. This affected the main hospital and the Same Day Surgery clinic in MOB. This could result in an increased risk of a fire due to electrostatic charges in an oxygen rich environment.

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

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
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.

On April 19, 2013, the Center for Medicare & Medicaid Services (CMS) released a memorandum, Ref: S&C-13-25-LSC, regarding the requirements for maintaining relative humidity in anesthetizing locations.

Sections of the memorandum state:

B. Categorical Waiver for RH Levels in Anesthetizing Locations
The 2012 edition of NFPA 99 has adopted the 2008 edition of the American Society for Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) Standard 170, Ventilation of Health Care Facilities. Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent.

In light of NFPA's recent adoption of the ASHRAE Standard 170, as well as in response to industry feedback that the minimum 35 percent RH level is unduly burdensome, we are issuing via this memorandum a categorical waiver to permit hospitals and Critical Access Hospitals (CAHs) with new and existing ventilation systems supplying anesthetizing locations, as defined by the 1999 edition of NFPA 99, to operate with a RH level of ?20 percent.

C. Waiver Does Not Apply If:
More stringent RH levels are required under State or local laws and regulations; or
The reduction of RH would negatively affect ventilation system performance.

D. Facilities Option to Elect to Use the Waiver
Facilities that elect to use the categorical waiver must document their decision to do so. If a hospital or CAH conforms to the above requirements, they will not need to apply in advance to CMS, nor will they need to wait until being cited for a deficiency in order to apply to use this waiver. At the entrance conference for any survey assessing LSC compliance, a facility that has elected to use this waiver must notify the survey team of this fact, as well as the fact that it meets the minimum RH standard of ?20 percent. The facility must provide documentation of its prior election to apply the waiver option. The absence of such evidence provided at the start of a survey means that the facility may be issued a citation if not in conformance with the 2000 LSC edition. It is not acceptable for a healthcare facility to first notify surveyors of waiver election after a citation related to RH has been issued, except as part of a plan of correction in response to the citation.

E. Ongoing Requirements
Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20 percent. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital's or CAH's ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.

Findings:

During record review with staff from 4/7/14 to 4/10/14, the facility's policy on maintaining relative humidity at anesthetizing locations and the corresponding humidity logs were requested. The main hospital's anesthetizing locations consisted of six operating rooms (ORs), two cardiac surgery rooms, and two labor and delivery (L&D) rooms. The Same Day Surgery clinic at MOB had five ORs.

1. On 4/10/14, at 8:52 a.m., the facility provided a policy, dated 10/29/13, titled "Temperature and Humidity Monitoring, Special Environments, Refrigeration Unit/Warmer Storage." Administrative Staff 2 pointed to Section J of Part IV as the facility's policy on maintaining humidity in the anesthetizing locations.

The policy stated:
"Areas requiring temperature/humidity monitoring may have electronic data loggers or charts that have storage capacity for up to three years. Standards for all areas:
1. Relative Humidity 30 - 60%."

No records were presented at any time during the survey showing that the facility is electing to use a categorical waiver to maintain their humidity below 35%.

During an interview, at 9:10 a.m. on 4/10/14, Surgical Services Staff 1 stated that the humidity, in all procedure rooms at the main hospital and MOB, were monitored by devices called "2D1 Thermaviewers". Surgical Services Staff 1 stated each room was equipped with a Thermaviewer that was designed to activate a local audible alarm when the humidity and temperature fell out of the set parameters. Surgical Services Staff 1 stated that the Thermaviewers were currently set to alarm if the humidity fell below 30%.

2. On 4/10/14, at 11:15 a.m., humidity logs were provided for OR 1, OR 2, OR 6, and one of the cardiac surgery rooms. There were no humidity logs provided for the rest of the anesthetizing locations at the hospital and MOB.

During an interview at 11:16 a.m., Surgical Services Staff 1 stated that the OR nurses do not check the humidity. Surgical Services Staff 1 indicated the OR nurses rely on the Thermaviewers to alarm if the humidity falls out of range. Surgical Services Staff 1 stated that the only humidity logs she can provide are printouts from each individual Thermaviewer and to obtain the logs, she must go into each procedure room and hook the thermaviewers up to her laptop. Surgical Services Staff 1 stated she obtained the logs from OR 1, 2, and 6 because they were the only rooms that did not have procedures going on the morning of 4/10/14.

The humidity logs for all procedure rooms at the main hospital and MOB were requested during the first day of survey on 4/7/14 and were requested repeatedly during the survey. No humidity logs were provided for three of six ORs, one of two cardiac surgery rooms, and two of two L&D rooms at the main hospital. No humidity logs were provided for five of five ORs in Same Day Surgery.

3. On 4/10/14, at 11:20 a.m., the humidity logs provided for OR 1, OR 2, OR 6, and the cardiac surgery room showed humidity levels at four-hour intervals for the past 14 months. The logs indicated that during an entire week in January 2014, the humidity levels fell below 35%.

The log for the cardiac surgery room showed that, between 1/12/14 at 6:01 p.m. and 1/20/14 at 6:01 a.m., the humidity levels fluctuated between 13 and 27%.

The log for OR 1 showed that, between 1/13/14 at 2:30 a.m. and 1/20/14 at 8:40 a.m., the humidity levels fluctuated between 12 and 26%.

The log for OR 2 showed that, between 1/13/14 at 3:54 a.m. and 1/20/14 at 9:54 a.m., the humidity levels fluctuated between 15 and 26%.

The log for OR 6 showed that, between 1/13/14 at 4:21 a.m. and 1/20/14 at 10:21 a.m., the humidity levels fluctuated between 15 and 28%.

During an interview at 11:30 a.m. on 4/10/14, Facilities Staff 1 stated that surgeries did occur in these rooms between 1/12/14 and 1/20/14.

Based on observation, the facility failed to maintain their electrical equipment and wiring connections. This was evidenced by the use of extension cords and surge protectors as a substitute for fixed wiring and by one electrical panel with unlabeled circuit breakers. This affected four of eight floors and the basement in the main hospital and two of eleven offsite buildings. This could result in an increased risk of an electrical fire.

NFPA 101, Life Safety Code, 2000 Edition.
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.
370-25 In completed installations, each box shall have a cover, faceplate, or fixture canopy.

384-13. General. All panelboards shall have a rating not less than the minimum feeder capacity required for the load computed in accordance with Article 220. Panelboards shall be durably marked by the manufacturer with the voltage and the current rating and the number of phases for which they are designed and with the manufacturer's name or trademark in such a manner so as to be visible after installation, without disturbing the interior parts or wiring. All panelboard circuits and circuit modifications shall be legibly identified as to purpose or use on a circuit directory located on the face or inside of the panel doors.

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 facility tour with staff from 4/7/14 to 4/10/14, the electrical equipment and wiring connections were observed.

Building 01 Main Hospital -

Basement -

1. On 4/8/14, at 8:32 a.m., there was a six-plug surge protector plugged into another six-plug surge protector under the desk in the Dietary Office.

Fifth Floor -

2. On 4/8/14, at 9:31 a.m., there was a microwave plugged into an extension cord in the employee break room.

Fourth Floor -

3. On 4/8/14, at 9:41 a.m., there was a surge protector plugged into another surge protector under the desk in the Clinical Manager's Office.

4. On 4/8/14, at 9:52 a.m., there were two extension cords, a three-plug adaptor, and a six-plug surge protector all plugged into one six-plug surge protector in the Social Services Office.

Second Floor -

5. On 4/8/14, at 12:32 p.m., there was a surge protector plugged into a surge protector in the classroom next to Patient Room 208.

First Floor -

6. On 4/8/14, at 2:56 p.m., there was a surge protector plugged into a surge protector in the Radiology Physician Dictation Room.

Building 04 Ashwood CFH -

7. On 4/8/14, at 1:55 p.m., all circuit breakers in Electrical Panel C were unlabeled.

Building 09 Airport-Marina CFH -

8. At 10:00 a.m., the examination bed was plugged into a six-plug surge protector in Room 7. The six-plug surge protector was plugged into a second six-plug surge protector and both surge protectors were attached to the wall behind the bed.


29665

Based on observation, the facility failed to ensure that alcohol based hand rub (ABHR) dispensers were not installed over or adjacent to ignition sources. This was evidenced by ABHR dispensers that were installed over and adjacent to electrical outlets and light switches. This affected three of eight floors in the main hospital and one of eleven offsite buildings. This could result in the increased risk of an ABHR ignited fire emergency.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the ABHR dispensers were observed.

Building 01 Main Hospital -

Sixth Floor -

1. On 4/8/14, at 9:05 a.m., the ABHR dispenser in the employee break room was installed approximately 3 feet directly above an electrical outlet. There was evidenced of ABHR spillage on the wall below the dispenser.

Second Floor -

2. On 4/8/14, at 12:09 p.m., the ABHR dispenser in the Blood Gas Laboratory was installed approximately 3 feet above an electrical outlet. There was evidenced of ABHR spillage on the wall below the dispenser.

3. On 4/8/14, at 1:34 p.m., the ABHR dispenser located in GI Lab Room 154 was installed approximately 3 feet above an electrical outlet. There was evidenced of ABHR spillage on the wall below the dispenser.

First Floor -

4. On 4/8/14, at 2:34 p.m., the ABHR dispenser near the Histology Lab was installed adjacent to a light switch. There was evidenced of ABHR spillage on the wall next to the light switch.

Building 12 Arniell CFH -

5. On 4/9/14, at 3:45 p.m., there was an ABHR dispenser installed directly above a light switch in the staff break room. According to the packaging, the solution in the dispenser consisted of 65% ethyl alcohol.


29665

Based on observation, the facility failed to ensure that alcohol based hand rub (ABHR) dispensers were not installed over or adjacent to ignition sources. This was evidenced by ABHR dispensers that were installed over and adjacent to electrical outlets and light switches. This affected three of eight floors in the main hospital and one of eleven offsite buildings. This could result in the increased risk of an ABHR ignited fire emergency.

Findings:

During a facility tour with staff from 4/7/14 to 4/10/14, the ABHR dispensers were observed.

Building 01 Main Hospital -

Sixth Floor -

1. On 4/8/14, at 9:05 a.m., the ABHR dispenser in the employee break room was installed approximately 3 feet directly above an electrical outlet. There was evidenced of ABHR spillage on the wall below the dispenser.

Second Floor -

2. On 4/8/14, at 12:09 p.m., the ABHR dispenser in the Blood Gas Laboratory was installed approximately 3 feet above an electrical outlet. There was evidenced of ABHR spillage on the wall below the dispenser.

3. On 4/8/14, at 1:34 p.m., the ABHR dispenser located in GI Lab Room 154 was installed approximately 3 feet above an electrical outlet. There was evidenced of ABHR spillage on the wall below the dispenser.

First Floor -

4. On 4/8/14, at 2:34 p.m., the ABHR dispenser near the Histology Lab was installed adjacent to a light switch. There was evidenced of ABHR spillage on the wall next to the light switch.

Building 12 Arniell CFH -

5. On 4/9/14, at 3:45 p.m., there was an ABHR dispenser installed directly above a light switch in the staff break room. According to the packaging, the solution in the dispenser consisted of 65% ethyl alcohol.


29665