HospitalInspections.org

Based on observation, document review, and interview, the facility failed to maintain the integrity of the building construction. This was evidenced by the use of a waterproof membrane to repair an exterior leak that caused flooding to an area inside the building. The membrane was not installed in accordance with manufacturer's specifications. This was also evidenced by one unsealed penetration in the ceiling. This affected two of four smoke compartments in the main hospital and could result in the faster spread of smoke and fire and increased risk of flooding.

NFPA 101, Life Safety Code, 2012 Edition.
19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the walls and ceilings were observed.

1. At 11:02 a.m., on 2/27/17, outside the continuing care area of the main hospital, there was an approximately 10 foot area at the bottom of the exterior wall that was covered with a black-colored membrane. An approximately 6 inch portion of the membrane, to the right of the gutter drain, was peeling off the wall and there were pebbles between the membrane and the wall. The gutter was attached to an extension hose, with tape to direct water away from the drain and into the parking lot.

During an interview at 11:03 a.m., Plant Ops 2 stated that there was a little water seeping in through the floor of continuing care during the rain. He said that he and Plant Ops 1 installed the membrane and gutter extension hose recently to prevent water from flooding the building. He stated that the facility was planning to patch over the membrane.

During the LSC exit conference at 11:55 a.m., on 3/2/17, Plant Ops 1 stated that the membrane was the permanent fix to prevent the flooding and stated he would send the specifications.

At 11:43 a.m., on 3/3/17, Plant Ops 1 sent the specifications of the membrane used. Under "Application Procedures" the specifications stated:

"Surface Preparation
Surfaces should be structurally sound and free of voids, spalled areas, loose aggregate and sharp protrusions. Remove contaminants such as grease, oil and wax from exposed surfaces. Remove dust, dirt, loose stone and debris. Concrete must be properly dried (minimum 7 days for normal structural concrete and 14 days for lightweight structural concrete)."

The entire length of the membrane was not free from loose stones.

The second paragraph of the "Application Procedures" stated:

"If time is critical, Bituthene Primer B2 or Bituthene Primer B2 LVC may be used to allow priming and installation of membrane on damp surfaces or green concrete. Priming may begin in this case as soon as the concrete will maintain structural integrity. Use form release agents which will not transfer to the concrete. Remove forms as soon as possible from below horizontal slabs to prevent entrapment of excess moisture. Excess moisture may lead to blistering of the membrane. Cure concrete with clear, resin-based curing compounds which do not contain oil, wax or pigment. Except with Bituthene Primer B2 or Bituthene Primer B2 LVC, allow concrete to thoroughly dry following rain. Do not apply any products to frozen concrete."

The facility staff did not state if the concrete was dried since the membrane was installed to prevent entrapment of excess moisture.

The "Protection of Membrane" section stated:
Protect Bituthene membranes to avoid damage from other trades, construction materials or finishes. Place protection immediately in temperatures above 77°F (25°C) to avoid potential for blisters." The same section also stated: "Cover any exposed Bituthene membranes with weather resistant flashing such as copper, aluminum or neoprene. Install protection the same day the membrane is applied or immediately after 24 hour flood testing. No waiting before backfill or application of wearing course is necessary."

The membrane was not protected from weather when observed during all four days of the survey.

2. At 1:05 p.m., on 2/27/17, there was an approximately 3 inch penetration, around a water pipe, in the ceiling behind the sterilizers of the surgical department.

Based on observation and interview, the facility failed to maintain their means of egress. This was evidenced by exit pathways that were obstructed and by one exit door that required excessive force to open. This affected two of four smoke compartments and the upper administrative floor. This could result in a delay in evacuation and an increased risk of injury to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2 through 19.2.11.

19.2.2 Means of Egress Components.
19.2.2.2 Doors.
19.2.2.2.1 Doors complying with 7.2.1 shall be permitted.

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

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

7.1.10.2.2 No obstruction by railings, barriers, or gates shall divide the means of egress into sections appurtenant to individual rooms, apartments, or other occupied spaces. Where
the authority having jurisdiction finds the required path of travel to be obstructed by furniture or other movable objects, the authority shall be permitted to require that such objects be
secured out of the way or shall be permitted to require that railings or other permanent barriers be installed to protect the path of travel against encroachment.

7.2.1.4.5 Door Leaf Operating Forces.
7.2.1.4.5.1 The forces required to fully open any door leaf
manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lbf (67 N) to open the leaf to the minimum required width, unless otherwise specified as follows:
(1) The opening forces for interior side-hinged or pivoted-swinging door leaves without closers shall not exceed 5 lbf (22 N).
(2) The opening forces for existing door leaves in existing buildings shall not exceed 50 lbf (222 N) applied to the latch stile.
(3) The opening forces for horizontal-sliding door leaves in detention and correctional occupancies shall be as provided in Chapters 22 and 23.
(4) The opening forces for power-operated door leaves shall be as provided in 7.2.1.9.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the means of egress were observed.

1. At 11:08 a.m., on 2/27/17, there was an approximately 8 foot 4 inch wide trailer parked outside on the east side of the hospital and in close proximity to the northeast exit door. The width of the paved exit pathway was approximately 12 foot 10 inches. The presence of the trailer reduced the width of the exit pathway to approximately 4 feet 6 inches.

During an interview at 11:09 a.m., Plant Ops 2 stated that this trailer contained disaster supplies and this was its designated location.

2. At 11:04 a.m., on 2/28/17, the east exit door next to the second floor IT server room did not open readily when the panic bar was pushed. Excessive force was used by Plant Ops 2 to push the door open and once it was opened, it would not close.

During an interview at 11:05 a.m., Plant Ops 2 confirmed that the door required adjustment.

3. At 2:15 p.m., on 2/28/17, the main exit pathway on the west side of the building, near ED, was obstructed by a portable MRI trailer (see K700) in the parking spaces in front of it and a portable generator to the south of it.

Based on observation, the facility failed to ensure that exits were marked by approved, illuminated exit signs. This was evidenced by one exit sign that required a bulb replacement, two exits that were not marked by illuminated signs, and two self-luminous exit signs that were past due for replacement. This affected two of four smoke compartments and the Keeler Outpatient Clinic. This could result in a delay in evacuation, in the event of a fire or other emergency.

NFPA 101, Life Safety Code, 2012 Edition.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10, unless otherwise permitted by 19.2.10.2, 19.2.10.3, or 19.2.10.4.

7.10.1.2.1 Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access.

7.10.5.2 Continuous Illumination.
7.10.5.2.1 Every sign required to be illuminated by 7.10.6.3, 7.10.7, and 7.10.8.1 shall be continuously illuminated as required under the provisions of Section 7.8, unless otherwise provided in 7.10.5.2.2.

7.10.5.2.2 Illumination for signs shall be permitted to flash on and off upon activation of the fire alarm system.

7.10.7.1 Listing. Internally illuminated signs shall be listed in accordance with ANSI/UL 924, Standard for Emergency Lighting and Power Equipment, unless they meet one of the following criteria:
(1) They are approved existing signs.
(2) They are existing signs having the required wording in legible letters not less than 4 in. (100 mm) high.
(3) They are signs that are in accordance with 7.10.1.3 and 7.10.1.6.

7.10.7.2 Photoluminescent Signs. The face of a photoluminescent sign shall be continually illuminated while the building is occupied. The illumination levels on the face of the photoluminescent sign shall be in accordance with its listing. The charging illumination shall be a reliable light source, as determined by the authority having jurisdiction. The charging light source, shall be of a type specified in the product markings.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the exit signs were observed.

1. At 2:20 p.m., on 2/27/17, the door from the surgical hallway to the main corridor was marked with a thin plastic exit sign that was not illuminated.

2. At 2:29 p.m., on 2/27/17, the two bulbs in the exit sign above the main north east exit door were not illuminated.

3. At 3:36 p.m., on 2/28/17, the door from the radiology suite into the west exit corridor had an approximately 4 inch by 2 inch sign with the word "OUT." The door was not labeled with an approved illuminated exit sign.

4. At 2:08 p.m., on 3/1/17, the self-luminous exit sign near the break room of the Keeler Clinic had a sticker that stated "replace before July 2014."

5. At 2:09 p.m., on 3/1/17, the self-luminous exit sign above the main entrance door of the Keeler Clinic waiting room had a sticker that stated "replace before July 2014."

Based on record review and interview, the facility failed to maintain a safe environment in their anesthetizing locations. This was evidenced by the failure to document monitoring of temperature and humidity since 1/12/17 in the ORs and by no records of corrective actions taken when the humidity levels fell outside of the desired range. This affected two of two ORs and could result in the increased risk of an OR fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.5.8 Maintenance. 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 maintained, unless the Code exempts such maintenance.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

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

On 4/19/13, CMS released a memorandum S&C: 13-25-LSC & ASC titled "Relative Humidity (RH): Waiver of Life Safety Code (LSC) Anesthetizing Location Requirements." Section E of the memorandum stated:
"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."

A follow up memorandum was released by CMS on 2/20/15, S&C:15-27-Hospital, CAH & ASC titled "Potential Adverse Impact of Lower Relative Humidity (RH) in Operating Rooms (ORs)" to clarify requirements for maintaining relative humidity levels in accordance with equipment instructions for use (IFUs).

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the anesthetizing locations were observed.

1. At 11:27 a.m., on 2/27/17, Plant Ops 2 and 3 showed that the computerized system which monitored temperature and humidity in ORs 1 and 2 had a set humidity range from 30% to 55%.

During an interview at 11:28 a.m., Plant Ops 3 stated that the system was designed to adjust conditions in the ORs when the humidity and temperature fell out of range. He and Plant Ops 2 both said that their department did not check the ambient conditions in the ORs every day and that they would be called by OR staff if there was a problem. They stated that OR staff maintained a daily log of the conditions.

During an interview at 12:56 p.m., on 2/27/17, OR RN 1 stated that the OR staff stopped recording the temperature and humidity in ORs 1 and 2 since their accreditation survey because the thermometers in the OR could could not be calibrated.

At 2:42 p.m., on 2/27/17, the "Temp & Humidity, MH Cart, Warming Cabinets, IV & Irrigation Solutions" log was provided. The log showed that OR staff stopped recording the temperature and humidity levels in ORs 1 and 2 on 1/12/17.

Plant Ops 1 provided a print-out of the humidity trends from 2/20/17 to 2/24/17 as shown by their computerized system. The print-out showed that the relative humidity levels decreased gradually to approximately 10% in OR 1 on 2/23/17. It also showed that the relative humidity levels decreased gradually to approximately 15% in OR 2. The graph was not time-stamped.

There were no records of temperature and humidity levels starting from 1/12/17 to 2/19/17 and from 2/25/17 to 2/26/17. There were no records of corrective actions for the drop in humidity levels on 2/23/17.

During an interview at 8:52 a.m., on 2/28/17, Plant Ops 1 stated that engineering would start recording the temperature and humidity levels in the ORs daily from now on. He stated that he could not print any of the humidity and temperature trends from before 2/20/17.

During an interview at 2:32 p.m., on 3/1/17, Plant Ops 1 stated that he had been checking the temperature and humidity in the ORs daily but not recording the values.

2. Plant Ops 1 provided a print-out of the humidity trends from 2/20/17 to 2/24/17 as shown by their computerized system. The print-out showed that the relative humidity levels decreased gradually to approximately 10% in OR 1 on 2/23/17. It also showed that the relative humidity levels decreased gradually to approximately 15% in OR 2. The graph was not time-stamped. There were no records of corrective actions for the drop in humidity levels on 2/23/17.

During an interview at 10:27 a.m., on 3/2/17, Plant Ops 2 stated that the HVAC system was being worked on when the humidity values dropped on 2/23/17. He stated that the facility was still working on gathering documentation to show that.

During an interview at 10:40 a.m., on 3/2/17, OR RN 2 stated that there were three procedures performed in the ORs on 2/23/17, the day the humidity levels fell out of range.

During the exit conference at 11:55 a.m., on 3/2/17, the "Temperature and Humidity Monitoring: Special Environments, Refrigeration Unit/Warmer Storage" policy, Control Number HS-QM221, was provided. Under Section 4 titled "Procedure", Part H, the policy stated that items requiring manual or automated daily temperature/humidity observation and daily record keeping included the operating rooms. Part J stated that relative humidity is to be maintained between 30% to 60% and that readings were to be maintained by engineering. The policy stated that when the temperature and humidity were noted outside the parameters, they were to be reported for assessment and mitigation. Section 5 titled "Documentation" was left blank. Section 6 titled "Procedure Synopsis and Comments/Helpful hints" had an outline for maintaining temperature logs and documenting actions taken when the temperatures are out of range for refrigerators. The policy did not include instructions regarding documentation of temperature and humidity levels in the ORs.

Based on observation, record review, and interview, the facility failed to maintain their fire alarm system and devices. This was evidenced by incomplete records of smoke detector sensitivity testing, by no records of testing smoke alarms in accordance with their manufacturer's specifications, and by the failure to replace a smoke alarm in accordance with manufacturer's specifications. This affected four of four smoke compartments and the upper floor of the main hospital. This also affected the outpatient Oakview Clinic. These deficiencies could result in the increased risk of smoke detector failure and could result in a delay in notification of a fire to patients, visitors, and staff.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 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 and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

NFPA 72, National Fire Alarm and Signaling Code, 2010 Edition.
10.2 Purpose. The purpose of the fire alarm and signaling systems shall be primarily to provide notification of alarm, supervisory, and trouble conditions; to alert the occupants; to summon aid; and to control emergency control functions.

10.3.2 System components shall be installed, tested, and maintained in accordance with the manufacturer's published instructions and this Code.

14.4.5.3 In other than one- and two-family dwellings, sensitivity of smoke detectors and single- and multiple-station smoke alarms shall be tested in accordance with 14.4.5.3.1 through 14.4.5.3.7.

14.4.5.3.1 Sensitivity shall be checked within 1 year after installation.

14.4.5.3.2 Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.

14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device 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.

14.4.5.3.3.1 If the frequency is extended, records of nuisance alarms and subsequent trends of these alarms shall be maintained.

14.4.5.3.3.2 In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.

14.4.5.3.4 To ensure that each smoke detector or smoke alarm 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/fire alarm control unit arrangement whereby the detector causes a signal at the fire alarm control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction

14.4.5.3.5 Unless otherwise permitted by 14.4.5.3.6, smoke detectors or smoke alarms found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.

14.4.5.3.6 Smoke detectors or smoke alarms listed as field adjustable shall be permitted to either be adjusted within the listed and marked sensitivity range, cleaned, and recalibrated, or be replaced.

14.4.5.3.7 The detector or smoke alarm sensitivity shall not be tested or measured using any device that administers an unmeasured concentration of smoke or other aerosol into the detector or smoke alarm.

Findings:

During a facility tour with staff from 2/27/16 to 3/2/17, the fire alarm system was observed and maintenance records were requested.

1. At 9:36 a.m., on 2/28/17, Plant Ops 1 provided a print-out from the fire alarm panel that showed what percent dirt accumulation each smoke detector in the main hospital had. The percentages ranged from 0% to 36%. Information about the required listed sensitivity ranges were not provided and there was no indication on the print-out if the smoke detectors passed or failed.

During an interview at 10:28 a.m., on 3/2/17, Plant Ops 2 stated that the facility was still working on getting information to clarify the smoke detector sensitivity status. No information was provided.

2. At 1:30 p.m., on 3/1/17, there were three battery-powered smoke alarms in the nonsprinklered Oakview Outpatient Clinic. All three had manufacturer's instructions for weekly testing. There were no records of testing the smoke alarm batteries weekly.

3. At 1:37 p.m., on 3/1/17, the smoke alarm outside the nursing office in the Oakview Clinic had a sticker that stated "replace in 10 years" and the date "2002 Mar. 14." The smoke alarm was approximately five years past due for replacement.

Based on observation, record review, and interview, the facility failed to maintain their automatic sprinkler system. This was evidenced by no records of inspecting the sprinkler system in the outpatient Keeler Clinic since March 2016. This was also evidenced by the failure to correct deficiencies noted by a vendor during an annual inspection, which included sprinkler heads over 50 years old that were due for testing or replacement, a painted sprinkler head, a sprinkler head installed in the wrong orientation, and a sprinkler head with part of the escutcheon fitting missing. This affected four of four smoke compartments in the main hospital and the outpatient Keeler clinic. These deficiencies could result in the increased risk of sprinkler system malfunction and a delay in extinguishing a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.

9.7.1.1 Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following:
(1) NFPA 13, Standard for the Installation of Sprinkler Systems
(2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes
(3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height

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

NFPA 13, Standard for Installation of Sprinkler Systems, 2010 Edition.
3.6.2 Installation Orientation. The following sprinklers are defined according to orientation.

3.6.2.3 Pendent Sprinkler. A sprinkler designed to be installed in such a way that the water stream is directed downward against the deflector.

3.6.2.6 Upright Sprinkler. A sprinkler designed to be installed in such a way that the water spray is directed upwards against the deflector.

8.3.1.1 Sprinklers shall be installed in accordance with their listing.

8.3.1.3 Upright sprinklers shall be installed with the frame arms parallel to the branch line, unless specifically listed for other orientation

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 2011 Edition.
4.1.4.1 The property owner or designated representative shall correct or repair deficiencies or impairments that are found during the inspection, test, and maintenance required by this standard.

4.1.4.2 Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor.

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

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

5.2.5 Waterflow Alarm and Supervisory Devices. Waterflow alarm and supervisory alarm devices shall be inspected quarterly to verify that they are free of physical damage.

5.3.1.1 Where required by this section, sample sprinklers shall be submitted to a recognized testing laboratory acceptable to the authority having jurisdiction for field service testing.

5.3.1.1.1 Where sprinklers have been in service for 50 years, they shall be replaced or representative samples from one or more sample areas shall be tested.

5.3.1.1.1.1 Test procedures shall be repeated at 10-year intervals.

5.3.3.1 Mechanical waterflow alarm devices including, but not limited to, water motor gongs, shall be tested quarterly.

5.3.3.2 Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

5.3.3.3 Testing waterflow alarm devices on wet pipe systems shall be accomplished by opening the inspector's test connection.

13.3.2.1 All valves shall be inspected weekly.

13.3.2.1.1 Valves secured with locks or supervised in accordance with applicable NFPA standards shall be permitted to be inspected monthly.

13.3.2.1.2 After any alterations or repairs, an inspection shall be made by the property owner or designated representative to ensure that the system is in service and all valves are in the normal position and properly sealed, locked, or electrically supervised.

13.3.2.2 The valve inspection shall verify that the valves are in the following condition:
(1) In the normal open or closed position
(2) Sealed, locked, or supervised
(3) Accessible
(4) Provided with correct wrenches
(5) Free from external leaks
(6) Provided with applicable identification

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

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the sprinkler system was observed and maintenance records were requested.

1. At 8:57 a.m., on 2/28/17, records showed that a 5-year sprinkler inspection was conducted for the Keeler outpatient building on 3/21/16. There were no records of quarterly inspections of the sprinkler system.

During an interview at 8:58 a.m., Plant Ops 1 stated that he would check with the Keeler building property manager if the quarterly inspections were done.

During an interview at 10:30 a.m., on 3/2/17, Plant Ops 2 confirmed that only the 5-year inspection had been conducted at the Keeler Clinic.

There were no records of quarterly inspections conducted since the 5-year inspection in March 2016.

2. At 9:06 a.m., on 2/28/17, records showed that a vendor conducted an annual inspection of the sprinkler system at the main hospital on 12/15/16. The vendor indicated that the system failed the inspection. The deficiencies included 128 sprinkler heads in the facility were over 50 years old that should be replaced or have a 1% sample tested. The vendor also stated that the sprinkler head in the pharmacy storage room was painted, that an upright sprinkler head was installed in the pendant position in the ICU clean/dirty area, and that one sprinkler head in ICU Room 4 was missing part of its escutcheon fitting. There were no records of correcting the deficiencies noted.

During an interview at 9:20 a.m., Plant Ops 1 stated that the facility was working with another vendor to replace all the old heads.

2A. At 11:16 a.m., on 2/28/17, the sprinkler head in the pharmacy storage closet had white paint marks as indicated by the annual inspection report by the vendor.

2B. At 11:21 a.m., on 2/28/17, one of two sprinkler heads in ICU Room 4 was missing a part of its escutcheon fitting (skirt) as indicated by the annual inspection report by the vendor.

2C. At 11:22 a.m., on 2/28/17, the upright sprinkler head in the ICU clean/dirty area was installed in the pendant position, as indicated by the vendor during the annual inspection. The upright sprinkler head was installed in the wrong orientation.

3. At 4:01 p.m., on 2/28/17, the escutcheon skirt in the blood-drawing station, outside the laboratory, was upside down such that the wide brim was pointing down instead of being flush to the ceiling.

Based on observation and interview, the facility failed to maintain their portable fire extinguishers. This was evidenced by one portable fire extinguisher that was freestanding and unsecured. This affected the service yard of the main hospital and could result in a delay in extinguishing a fire near the generator enclosure.

NFPA 101, Life Safety Code, 2012 Edition.
19.3.5.12 Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1.

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

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

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

6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the fire extinguishers were observed.

1. At 11:37 a.m., on 2/27/17, there was one ABC-Class fire extinguisher at the main generator enclosure that was not mounted. Extinguisher 26 was freestanding on a pile of traffic cones and its mounting bracket and screws were on the ground next to it.

During an interview at 11:38 a.m., Plant Ops 2 stated that a storage shed was placed in the service yard against the wall where the extinguisher used to be mounted so it was removed. The facility was still determining where to place the displaced extinguisher.

Based on observation, record review, and interview, the facility failed to ensure that all fire and smoke dampers were tested and maintained not less than every 6 years. This was evidenced by no records of testing, inspecting, cleaning and lubricating motorized dampers. This affected four of four smoke compartments in the main hospital and could result in the faster spread of smoke and fire through the HVAC system.

NFPA 101, Life Safety Code, 2012 Edition.
19.5.2.1 Heating, ventilating, and air-conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications, unless otherwise modified by 19.5.2.2.

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

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 2012 Edition.
5.4.8.1 Fire dampers and ceiling dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives.

7.1 General.
7.1.1 An acceptance test shall be performed to determine that the protective measures required in this standard function when needed in order to restrict the spread of fire and smoke.

7.1.2 Records shall be maintained on acceptance test results.

7.1.2.1 Records shall be available for inspection.

NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition.
19.3.1 Dynamic Fire Dampers. After the installation of a damper is completed, an operational test shall be conducted.

19.3.1.1 The damper shall fully close from the open position.

19.3.1.2 When equipped with smoke detection activation, the smoke detector shall be activated in accordance with the requirements of NFPA 72, National Fire Alarm and Signaling Code.

19.3.1.3 For dynamic dampers, it shall be verified that the system airflow where the damper is installed is within the velocity rating of the damper listing.

19.3.1.4 The operational test shall verify that there are no obstructions to the operation of the damper.

19.3.1.5 The operational test shall verify that there is full and unobstructed access to the fire damper and all listed components.

19.3.1.6 All indicating devices shall be verified to work and report to the intended location.

19.3.1.7 The fusible link operating temperature shall be in accordance with NFPA 90A, Standard for the Installation of Air- Conditioning and Ventilating Systems, and ANSI/UL 33, Standard for Heat Responsive Links for Fire-Protection Services, temperature classifications and ratings.

19.3.2 Combination Fire/Smoke Dampers. After the installation of a dynamic combination fire/smoke damper is complete, an operational test shall be conducted.

19.3.2.1 The test shall determine that the system has been installed and functions as intended.

19.3.2.2 The operational test shall be conducted under nonfire HVAC airflow conditions as well as static flow conditions.

19.4* Periodic Inspection and Testing.
19.4.1 Each damper shall be tested and inspected 1 year after installation.

19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

19.4.2 All tests shall be completed in a safe manner by personnel wearing personal protective equipment.

19.4.3 Full unobstructed access to the fire or combination fire/smoke damper shall be verified and corrected as required.

19.4.5 The operational test of the damper shall verify that there is no damper interference due to rusted, bent, misaligned, or damaged frame or blades, or defective hinges or other moving parts.

19.4.6 The damper frame shall not be penetrated by any foreign objects that would affect fire damper operations.

19.4.7 The damper shall not be blocked from closure in any way.

19.4.9 All inspections and testing shall be documented, indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.

19.4.9.1 The documentation shall have a space to indicate when and how the deficiencies were corrected.

19.4.10 All documentation shall be maintained and made available for review by the AHJ.

Findings:

During record review with staff from 2/27/17 to 3/2/17, records of testing the fire dampers were requested. Motorized fire dampers could be heard during the fire alarm testing on 3/1/17.

1. At 10:30 a.m., on 2/27/17, records of testing the fire and/or smoke dampers were requested from Plant Ops 1. The documents were requested again from Plant Ops 2 and 3 at 3:00 p.m. on 3/1/17.

During an interview at 3:14 p.m., Plant Op 2 and 3 stated that the facility had motorized dampers to designed to activate with the fire alarm system but no fusible link dampers.

During an interview at 10:32 a.m., on 3/2/17, Plant Ops 2 stated that the fire alarm vendor was testing the dampers during their fire alarm inspections but was not documenting it.

At 10:55 a.m., on 3/2/17, Plant Ops 2 provided a large packet of documents and stated that the damper testing records were in the packet. All documents in the packet were for the Continuing Care Center and not the main hospital. Plant Ops 1 and 2 were asked to provide the damper testing for the main hospital but none were provided.

Based on observation, record review, and interview, the facility failed to ensure that their mobile MRI unit was approved by the authority having jurisdiction. This was evidenced by no documentation provided to show that the mobile MRI trailer was approved by OSHPD and licensed by L&C, by no reliable power source for the unit (see K911), by no fire safety procedures established for the unit, and by the failure to meet the requirements of the California Health and Safety Code. This affected all patients and staff who utilize the MRI trailer and any person who uses the west parking lot. These deficiencies could result in sudden loss of power to the mobile unit, increased risk of a fire and other hazardous conditions, delayed egress from the unit and the west side of the hospital, and a delay in staff response, in the event of an emergency in the trailer.

NFPA 101, Life Safety Code, 2012 Edition.
19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

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

4.6.1.4.1 The authority having jurisdiction shall be permitted to require a review by an approved independent third party with expertise in the matter to be reviewed at the submitter's expense.

4.6.1.4.2 The independent reviewer shall provide an evaluation and recommend necessary changes of the proposed design, operation, process, or new technology to the authority having jurisdiction.

4.6.1.4.3 The authority having jurisdiction shall be authorized to require design submittals to bear the stamp of a registered design professional.

4.8.2.1 Emergency plans shall include the following:
(1) Procedures for reporting of emergencies
(2) Occupant and staff response to emergencies
(3) Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)
(4) Appropriateness of the use of elevators
(5) Design and conduct of fire drills
(6) Type and coverage of building fire protection systems
(7) Other items required by the authority having jurisdiction

4.8.2.2 Required emergency plans shall be submitted to the authority having jurisdiction for review.

4.8.2.3 Emergency plans shall be reviewed and updated as required by the authority having jurisdiction.

1.4.2 Approval. The system, method, or device shall be approved for the intended purpose by the authority having jurisdiction.

California Health and Safety Code
HSC § 1765.110 The purpose of this chapter is to provide for the use of mobile units to provide medical, diagnostic, and treatment services, in order to help ensure the availability of quality health care services for patients who receive care in remote or underserved areas and for patients who need specialized types of medical care provided in a cost-effective way.

HSC § 1765.120 Compliance with all of the following criteria shall be required prior to licensure:
(a) The mobile unit shall comply with the applicable requirements of the Vehicle Code, and shall have a vehicle identification number.
(b) The mobile unit shall bear an insignia issued by the Department of Housing and Community Development pursuant to Section 18026.

HSC § 1765.130 (a) Any applicant under this chapter shall file with the state department an application. The application shall be on forms prescribed and furnished by the state department that shall contain any information as may be required by the state department for the proper administration and enforcement of this chapter.
(b) An applicant health facility or clinic pursuant to this chapter shall submit an application to the licensing and certification district office of the state department stating with specificity all of the following:
(1) The proposed service to be provided.
(2) The expected hours and days of operation.
(3) The type and the manufacturer of the mobile unit contemplated.
(4) The proposed area or areas where the mobile unit will be providing services.
(c) An applicant for licensure as an independently licensed clinic under this chapter shall submit a verified application to the state department on the appropriate forms for the type of clinic for which it wishes to obtain licensure.
(d) Prior to granting approval to an applicant parent facility for operation of a mobile unit under the parent facility's existing licensure pursuant to this chapter, or prior to granting license for an independent mobile unit, the state department shall conduct an onsite inspection, including, but not limited to, a review of policies and procedures.
(e) Supplemental services offered via mobile units shall be listed by the state department as an approved or supplemental service on the license of the parent facility.
(f) Licenses issued by the state department authorizing operation of a mobile unit as an addition to existing parent facility licensure shall be posted at the parent facility. Licenses authorizing operation of a clinic as a mobile unit shall be posted at the administrative headquarters of the licensee. A true copy of the license shall be posted within the mobile unit.

HSC § 1765.140 (a) Mobile units that provide services as an addition to the existing license of a parent facility shall be subject to the same requirements and regulations as the parent facility, except that, instead of complying with the physical plant requirements applicable to the parent facility, they shall comply with the mobile unit requirements contained in this chapter.

HSC § 1765.150 (a) The mobile unit shall be of sufficient size and shall be arranged in a manner that is appropriate for the provision of those health care services that it is licensed to provide.
(b) The mobile unit shall be equipped with appropriate utilities for the comfort and safety of patients. The Office of Statewide Health Planning and Development shall review and approve hospital-provided utility connections for mobile units that require utility hookups with general acute care hospitals.
(c) The mobile unit shall be maintained in good repair and in a clean and sanitary manner.
(d) All proposed modifications to previously approved services and procedures shall be reviewed and approved by the state department before they are implemented. Modifications to the mobile service unit shall be approved by the Department of Housing and Community Development pursuant to Section 18029.
(e) The licensee shall report to the department the location of the site at least 24 hours prior to the operation of a mobile unit at any site for the first time.
(f) Notification required by subdivision (e) shall be waived when the mobile unit operates at any site for the first time at the request of federal, state, or local authorities for the purposes of responding to state or locally declared emergencies as defined in subdivisions (a), (b), and (c) of Section 8558 of the Government Code, federally declared emergencies, and declared public health emergencies as defined in Section 101080 for the duration of the emergency.

HSC § 1765.155 (a) The licensed parent facility or clinic shall be responsible for obtaining approvals for the site or sites of the mobile unit as required by the local planning, zoning, and fire authorities.
(b) The mobile unit shall be situated for safe and comfortable patient access. The mobile unit shall comply with all local parking laws. Any parking restrictions developed by a parent facility or clinic for mobile units shall be strictly enforced by the parent facility or clinic.

HSC § 1765.160 Any licensee using mobile services pursuant to this chapter shall do all of the following:
(a) Have written policies established by the governing body of the licensee, to govern the services that the mobile unit provides. The policies shall include, but shall not be limited to, policies related to patient care, personnel training and orientation, personnel supervision, and evaluation of services provided by the mobile unit.
(b) Have written policies regarding patient selection criteria.
(c) Develop and implement the written policies and procedures for the mobile unit in consultation with other appropriate health care professionals.
(d) Ensure that the written policies and procedures are consistent with the policies and procedures of the parent facility, if any.
(e) Ensure that the policies and written procedures shall be approved by the governing body, administration, and medical staff of the licensee, where appropriate.
(f) Ensure that the written policies and procedures include, but are not limited to, all of the following:
(1) Scope of services.
(2) Procedures for the performance of the services provided.
(3) Quality assurance.
(4) Infection control.
(5) Medical record documentation of services provided, as appropriate.
(6) Transport of patients, including, but not limited to, method, special equipment, necessary personnel, and protection from inclement weather.
(7) Emergency services and evacuation plan for the mobile unit:
(A) A licensee using mobile services pursuant to this chapter shall specify in writing policies and procedures for emergencies including fire, natural disaster, and medical emergencies. In its policies and procedures, the mobile unit shall address the emergency plan required of the parent facility and state how the plans shall be coordinated.

HSC § 1765.170 The mobile unit shall comply with all of the following:
(a) It shall have supplies and equipment to meet the needs of the patients served.
(c) The mobile unit shall have fire safety equipment as specified by the fire authority having jurisdiction, including but not limited to, at least two fire extinguishers of 2A:20 BC rating.
(d) Documented evidence of preventative maintenance and calibration procedures of mobile unit equipment shall conform to the manufacturer's specifications.

Findings:

During the facility tour with staff from 2/27/17 to 3/2/17, the mobile MRI trailer was observed.

1. At 8:40 a.m., on 2/28/17, the mobile MRI trailer was observed onsite in the west parking lot outside ED. The MRI trailer was connected to and powered by a portable diesel generator (see K911). A cable bundle from the generator to the unit was unprotected on the ground of the parking lot and in the travel pathway of cars.

During an interview at 9:51 a.m., the radiology technician in the trailer stated that they would be using the trailer until 6 p.m. today (2/28/17). He stated that the trailer was used for both outpatients and inpatients.

During a telephone interview at 10:50 a.m., on 2/28/17, the OSHPD CO stated that the facility's CT trailer was approved by OSHPD years ago but he did not recall approving the MRI trailer.

2. At 3:15 p.m., on 2/28/17, the facility was asked to provide documentation of OSHPD and CDPH approval for the MRI Trailer. Radiology Staff 1 showed a sticker from the State of California Department of Housing and Community Development on the circuit breaker inside the trailer which stated "a department insignia shall not have its fire and life safety, plumbing, electrical, or mechanical equipment or installations, altered or converted unless approval is first obtained by the department." No OSHPD or CDPH approval documents were provided.

During an interview at 3:16 p.m., Radiology Staff 1 stated that the MRI trailer was onsite on Tuesdays and Fridays.

At 10:28 a.m., on 3/1/17, it was confirmed with CDPH, L&C, Ventura District Office, that the facility did not have a license, or license application, for use of the MRI trailer on file.

During an interview at 11:29 a.m., on 3/1/17, after an IJ for the use of the MRI trailer without documentation of a license or safety approvals, Adm 1 stated that the facility would cancel all MRI appointments until all approvals and licenses have been obtained.

During an interview at 2:37 p.m., on 3/1/17, Plant Ops 1 stated that the facility's IOR told him that the MRI trailer was approved with the use of its own built-in generator but not with the use of the portable generator. Documentation of the approval was requested but never received.

During a telephone interview at 3:22 p.m., on 3/1/7, the OSHPD CO stated that he received a call from the IOR but the IOR could not provide him with a project number related to the MRI trailer. He said he could not track any documents related to the trailer without a project number.

During the LSC exit conference at 11:45 a.m., on 3/2/17, Radiology Staff 1 stated that the portable generator was brought in June of last year by the imaging group because the built-in generator on the trailer was not sufficient. He stated that the trailer ran solely on the portable generator.

The facility failed to provide a copy of the license and any proof of approval as required by HSC § 1765.130(f). The facility failed to ensure that utilities were provided to the trailer or that OSHPD approval has been obtained for the portable generator in accordance with HSC § 1765.150(b). The facility failed to provide documentation to show that the location of the trailer was approved by local planning, zoning, and fire authorities in accordance with HSC § 1765.155. The facility failed to provide a fire and disaster plan specific to the mobile unit in accordance with HSC § 1765.160 7(A).

3. At 2:15 p.m., on 2/28/17, the mobile trailer was parked on two handicap parking spaces outside the hospital's west exit door, near the ED waiting area. The portable generator was located to the south and an affixed CT trailer was located to the north of the MRI trailer. The only means of egress for occupants of the MRI trailer would be to head east, past the CT trailer and running diesel generator, towards the hospital before turning south.

4. At 10:11 a.m., on 3/1/17, the "MRI Safety, Transport & Screening Guidelines" policy, Control Number HS-DIS130, was provided. The policy included evacuation instructions in the event of a quench. A quench was defined as "when the magnet core becomes warm and a complete boil-off of the liquid helium occurs, filling the room with helium gas, thus displacing all of the oxygen in the room almost immediately." In addition to this hazard, there was no policy regarding staff response in the event of a fire in the MRI unit.

Based on record review and interview, the facility failed to ensure that fire drills were conducted in accordance with NFPA 101. This was evidenced by the failure to transmit a fire alarm signal during fire drills conducted between the hours of 6:00 a.m. and 9:00 p.m. This was also evidenced by the failure to document the scenario and location of the fires simulated during the drills. This affected all patients, visitors, and staff and could result in a delay in staff response, in the event of a fire.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.1.4 Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.5 Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

19.7.1.6 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.

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.

Findings:

During record review with staff from 2/27/17 to 3/2/17, the fire drill records were reviewed. Per the documentation provided, Plant Ops 2 conducted the fire drills. The drill form used had a section titled pull station, to indicate which fire alarm device was activated during the drill, and a section to indicate the location of the drill.

1. At 10:11 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 2/29/16 at 9:40 a.m., was left blank.

2. At 10:12 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 3/31/16 at 1:51 p.m., was left blank. The document stated "ABC Fire Simulated" but the location of the drill was not documented.

3. At 10:13 a.m., on 2/28/17, the fire drill document, for the drill conducted on 4/30/16 at 11:15 p.m., did not include the location or type of fire stimulated.

4. At 10:14 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 5/27/16 at 1:07 p.m., was left blank.

5. At 10:15 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 6/30/16 at 3:00 p.m., was labeled "N/A".

6. At 10:16 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 8/31/16 at 9:18 a.m., was labeled "N/A".

7. At 10:17 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 10/30/16 at 6:30 a.m., was labeled "N/A".

8. At 10:18 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 11/30/16 at 2:12 p.m., was left blank.

9. At 10:19 a.m., on 2/28/17, the pull station section on the fire drill form, conducted on 12/30/16 at 3:17 p.m., was left blank. The document stated "Trash Fire" but the location of the drill was not documented.

During an interview at 3:06 p.m., on 2/28/17, Plant Ops 2 confirmed that when the pull station section is left blank or is labeled "N/A" on the form, this meant that the fire alarm system was not activated during the drill. He also confirmed that some of the information regarding scenarios and locations of the simulated fires were missing.

Based on observation, the facility failed to ensure that hazardous locations were marked with precautionary signage. This was evidenced by the absence of precautionary "NO SMOKING" signs at the main shut-off for the natural gas lines and a room where oxygen cylinders were stored. This affected one of four smoke compartments and the north side exterior of the main hospital. This could result in the increased risk of a hazardous condition.

NFPA 101, Life Safety Code, 2012 Edition.
19.7.4 Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:
(1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted.

NFPA 99, Health Care Facilities Code, 2012 Edition.
Chapter 11 Gas Equipment
11.3.4 Signs.
11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure.

11.3.4.2 The sign shall include the following wording as a minimum:
CAUTION:
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the hazardous areas were observed. The hospital was a non-smoking facility.

1. At 11:25 a.m., on 2/27/17, the emergency shut-off location for the main natural gas lines were observed outside the Support Services Office. There was no sign indicating that this was the main gas shut-off and to warn of the presence of a hazard. The location, and the area within close proximity, was not equipped with a precautionary "NO SMOKING" sign.

2. At 3:29 p.m., on 2/28/17, the respiratory therapy room housed six oxygen E-cylinders. Oxygen cylinders were observed in the room daily during the survey (until 3/2/17). The corridor door to the room did not have precautionary "NO SMOKING" signs.

Based on record review, the facility failed to determine their risk category classification in accordance with NFPA 99. This was evidenced by no records of a building systems risk assessment that classified risks in accordance with NFPA 99. This affected all patients, visitors, and staff and could result in a prolonged duration of unsafe conditions due to insufficient assessment of critical building systems.

NFPA 99, Health Care Facilities Code, 2012 Edition.
3.3.138 Patient Care Room. Any room of a health care facility wherein patients are intended to be examined or treated. (MED)

3.3.138.1 Basic Care Room. Room in which the failure of equipment or a system is not likely to cause injury to the patients or caregivers but can cause patient discomfort (Category 3). (MED)

3.3.138.2 Critical Care Room. Room in which failure of equipment or a system is likely to cause major injury or death of patients or caregivers (Category 1). (MED)

3.3.138.3 General Care Room. Room in which failure of equipment or a system is likely to cause minor injury to patients or caregivers (Category 2). (MED)

3.3.138.4 Support Room. Room in which failure of equipment or a system is not likely to have a physical impact on patients or caregivers (Category 4). (MED)

4.1 Building System Categories. Building systems in health care facilities shall be designed to meet system Category 1 through Category 4 requirements as detailed in this code.

4.1.1 Category 1. Facility systems in which failure of such equipment or system is likely to cause major injury or death of patients or caregivers shall be designed to meet system Category 1 requirements as defined in this code.

4.1.2 Category 2. Facility systems in which failure of such equipment is likely to cause minor injury to patients or caregivers shall be designed to meet system Category 2 requirements as defined in this code.

4.1.3 Category 3. Facility systems in which failure of such equipment is not likely to cause injury to patients or caregivers, but can cause patient discomfort, shall be designed to meet system Category 3 requirements as defined in this code.

4.1.4 Category 4. Facility systems in which failure of such equipment would have no impact on patient care shall be designed to meet system Category 4 requirements as defined in this code.

4.2 Risk Assessment. Categories shall be determined by following and documenting a defined risk assessment procedure.

4.3 Application. The Category definitions in Chapter 4 shall apply to Chapters 5 through 11.

Chapter 5 Gas and Vacuum Systems

Chapter 6 Electrical Systems

Chapter 9 Heating, Ventilation, and Air Conditioning (HVAC)

Chapter 10 Electrical Equipment

Chapter 11 Gas Equipment

Findings:

During record review with staff from 2/27/17 to 3/2/17, a documented risk assessment was requested.

1. At 11:59 a.m., on 2/27/17, a Hazard and Vulnerability Assessment Tool, created for the Year 2017, was provided by Plant Ops 1. The document defined Score 0 as N/A, Score 1 as Low, Score 2 as Moderate, and Score 3 as High. The Technological Events portion of the tool contained scores for Human Impact (defined as "possibility of death and injury" by the facility) for electrical failure, generator failure, HVAC failure, and medical gas failure among other events.

The tool designated a score of 0 (or N/A) to the human impact of electrical failure and a score of 1 (or Low) to the human impact of generator failure and medical gas failure for the entire hospital. The hospital had critical care rooms including four ICU rooms and two ORs.

The facility failed to provide a risk assessment in accordance with NFPA 99.

Based on record review and interview, the facility failed to maintain their piped-in medical gas system. This was evidenced by discrepancies of the system identified by a vendor two years in a row and not corrected or addressed. This affected two of two ORs and the vacuum pump in the electrical room. This could result in the increased risk of medical gas system failures.

NFPA 99, Health Care Facilities Code, 2012 Edition.
5.1.3.7.8 Operating Alarms. Medical-surgical vacuum systems shall activate a local alarm when the backup or lag pump is running per 5.1.9.5. This signal shall be manually reset.

5.1.4.8.7 A zone valve shall be located immediately outside each vital life-support area, critical care area, and anesthetizing location of moderate sedation, deep sedation, or general anesthesia, in each medical gas or vacuum line, or both, and located so as to be readily accessible in an emergency.

5.1.4.8.7.2 Zone valves shall be so arranged that shutting off the supply of gas to any one operating room or anesthetizing location will not affect the others.

Findings:

During record review with staff from 2/27/17 to 3/2/17, the medical gas inspection records were requested.

1. At 3:41 p.m., on 2/27/17, the inspection report from 1/21/16 was provided and the "Discrepancies" section was reviewed. Item 2 stated "unable to locate zone valves for medical air and vacuum in OR 1 and OR 2." Item 8 stated "medical vacuum system located in the fire floor electrical room does not alarm locally when lag pump is running. This is a requirement per NFPA." All other discrepancies listed were corrected per the report.

At 1:21 p.m., on 2/28/17, the inspection for 2/1/17 was provided and the "Discrepancies" section was reviewed. Item 1 stated "unable to locate zone valves for medical air and vacuum in OR 1 and OR 2." Item 4 stated "medical vacuum system located in the fire floor electrical room does not alarm locally when lag pump is running. This is a requirement per NFPA." All other discrepancies listed were corrected per the report.

The two discrepancies were listed two years in a row. Facility staff was asked to clarify these discrepancies with the vendor but no follow up information was provided.

During an interview at 10:33 a.m., on 3/2/17, Plant Ops 2 stated they were still getting more information about the two discrepancies above. He believed that the facility did not have medical air or vacuum outlets in the ORs but needed to make sure.

Based on observation, record review, and interview, the facility failed to maintain their electrical systems. This was evidenced by a mobile MRI unit (See K700) that was powered by a portable diesel generator that was not approved by the authority having jurisdiction, not anchored against seismic events, and with a cable that was not guarded against vehicles and foot traffic. These deficiencies could result in the increased risk of electrical shocks, hazards, and fires and increase risk of injury to patients, staff, and visitors. This affected all patients and staff who use the MRI trailer and all persons who use the west parking lot.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

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

NFPA 70, National Electrical Code, 2011 Edition
Article 100. Definitions.
Authority Having Jurisdiction (AHJ). An organization, office, or individual responsible for enforcing the requirements of a code or standard, or for approving equipment, materials, an installation, or a procedure. Informational Note: The phrase "authority having jurisdiction," or its acronym AHJ, is used in NFPA documents in a broad manner, since jurisdictions and approval agencies vary, as do their responsibilities. Where public safety is primary, the authority having jurisdiction may be a federal, state, local, or other regional department or individual such as a fire chief; fire marshal; chief of a fire prevention bureau, labor department, or health department; building official; electrical inspector; or others having statutory authority.
For insurance purposes, an insurance inspection department, rating bureau, or other insurance company representative may be the authority having jurisdiction. In many circumstances, the property owner or his or her designated agent assumes the role of the authority having jurisdiction; at government installations, the commanding officer or departmental official may be the authority having jurisdiction.

110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved.

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

300.4 Protection Against Physical Damage. Where subject to physical damage, conductors, raceways, and cables shall be protected.

517.35 Sources of Power. (C) Location of Essential Electrical System Components.
Careful consideration shall be given to the location of the spaces housing the components of the essential electrical
system to minimize interruptions caused by natural forces common to the area (e.g., storms, floods, earthquakes, or hazards created by adjoining structures or activities). Consideration shall also be given to the possible interruption of normal electrical services resulting from similar causes as well as possible disruption of normal electrical service due to internal wiring and equipment failures.

590.2 All Wiring Installations.
(A) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations.
(B) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation.

590.4 General. (H) Protection from Accidental Damage. Flexible cords and cables shall be protected from accidental damage. Sharp corners and projections shall be avoided. Where
passing through doorways or other pinch points, protection shall be provided to avoid damage.
(J) Support. Cable assemblies and flexible cords and cables shall be supported in place at intervals that ensure that they will be protected from physical damage. Support shall be in the form of staples, cable ties, straps, or similar type fittings installed so as not to cause damage.

590.6 Ground-Fault Protection for Personnel. Ground-fault protection for personnel for all temporary wiring installations shall be provided to comply with 590.6(A) and (B). This section shall apply only to temporary wiring installations used to supply temporary power to equipment used by personnel during construction, remodeling, maintenance, repair, or demolition of buildings, structures, equipment, or similar activities. This section shall apply to power derived from an electric utility company or from an on-site-generated power source.
(B) (2) Assured Equipment Grounding Conductor Program. A written assured equipment grounding conductor program continuously enforced at the site by one or more designated
persons to ensure that equipment grounding conductors for all cord sets, receptacles that are not a part of the permanent wiring of the building or structure, and equipment connected by cord and plug are installed and maintained in accordance with the applicable requirements of 250.114, 250.138, 406.4(C), and 590.4(D).
(a) The following tests shall be performed on all cord sets, receptacles that are not part of the permanent wiring of the building or structure, and cord-and-plug-connected equipment required to be connected to an equipment grounding conductor:
(1) All equipment grounding conductors shall be tested for continuity and shall be electrically continuous.
(2) Each receptacle and attachment plug shall be tested for correct attachment of the equipment grounding conductor. The equipment grounding conductor shall be connected to its proper terminal.
(3) All required tests shall be performed as follows:
a. Before first use on site
b. When there is evidence of damage
c. Before equipment is returned to service following any repairs
d. At intervals not exceeding 3 months.
(b) The tests required in item (2)(a) shall be recorded and made available to the authority having jurisdiction.

590.7 Guarding. For wiring over 600 volts, nominal, suitable fencing, barriers, or other effective means shall be provided to limit access only to authorized and qualified personnel.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the electrical equipment was observed.

1. At 11:00 a.m., on 2/27/17, a portable generator was observed parked in the lot outside the west exit near ED. The portable generator was on a wheeled trailer bed and there were two wheel chocks in use to prevent the bed from rolling forward. The trailer was chained to an approximately 3 foot pole. The pole had a base that was damaged and coming off the ground. The generator was not anchored against seismic events.

During an interview at 11:01 a.m., Plant Ops 2 stated that the generator was continuously parked onsite to power the mobile MRI trailer that comes onsite two days a week.

At 8:40 a.m., on 2/28/17, the mobile MRI trailer was observed onsite in the main parking lot outside ED. The MRI trailer was connected to and powered by the portable diesel generator. The generator remained ON throughout the day.

2. At 9:50 a.m., on 2/28/17, the needle on the fuel gauge of the portable diesel generator indicated that the tank was empty even though the generator was running. The cable bundle connecting the generator to the trailer was laying on the ground around the trailer and in the travel pathway for cars and people in the parking. The cable was not protected.

During an interview at 9:51 a.m., the radiology technician in the trailer stated that they would be using the trailer until 6 p.m. today (2/28/17).

3. At 11:52 a.m., on 2/28/17, the facility provided records of two quarterly services conducted by the vendor on the portable generator. The services were conducted on 1/19/17 and 11/7/16 and both were for an oil and filter service.

At 1:44 p.m., on 2/28/17, the facility provided maintenance records for their main generator, which included a permit from the Ventura County Air Pollution Control District that was valid until 3/31/17. There were no records of a Ventura County Air Pollution Control District permit for the portable generator and no records of weekly inspections of the portable generator.

4. At 10:35 a.m., on 2/28/17, there was no OSHPD permit provided for the use and installation of the portable generator.

During a telephone interview at 10:50 a.m., the OSHPD CO stated that the facility's CT trailer was approved by OSHPD years ago but he did not recall approving the MRI trailer or the portable generator.

5. During an interview at 2:37 p.m., on 3/1/17, Plant Ops 1 stated that the facility's IOR said that the MRI trailer was approved with the use of its own built-in generator but not with the use of the portable generator.

6. During a telephone interview at 3:22 p.m., on 3/1/7, the OSHPD CO stated that he received a call from the IOR but the IOR could not provide him with a project number related to the MRI trailer. He said he could not track any documents related to the trailer without a project number. He also confirmed that cables laying on the ground were required to have protective barriers.

7. During the exit conference at 11:45 a.m., on 3/2/17, Radiology Staff 1 stated that the portable generator was brought in June of last year by the imaging group because the built-in generator on the trailer was not sufficient. He stated that the trailer runs solely on the portable generator.

No records were provided to show that the portable generator was connected to the trailer in an approved manner and no records of testing were provided as required by Section 590.6 of NFPA 70, 2011 Edition. The generator cable connection was not safeguarded against damage and not properly secured against seismic events as required.

Based on observation and interview, the facility failed to maintain their electrical equipment. This was evidenced by visual indicators for line isolation monitors (LIM) that were not functioning. This affected two of two ORs and could result in a delay in notification, in the event of an issue with the ground circuits.

NFPA 99, Health Care Facilities Code, 2012 Edition.
6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the LIM circuit test switches and alarm indicators were observed. The facility was equipped with two LIM circuits, one for each OR, and each OR had two local visual indicators. Records showed that Plant Ops 3 tested the LIM test switches in the electrical room on a daily basis. Each OR had two local visual alarm indicators inside the rooms.

1. At 1:13 p.m., on 2/27/17, the two LIM visual indicators in OR 2 were observed. The alarms were accompanied by the following message: "Ungrounded circuits: accidental ground will be indicated by red light." One of the two green lights was illuminated.

During an interview at 1:14 p.m., OR RN 1 and Plant Ops 2 both stated that the both indicator lights should be illuminated green. Plant Ops 2 stated that the bulb in the indicator needed to be replaced.

2. At 1:22 p.m., on 2/27/17, both LIM visual indicators in OR 1 were not illuminated green.

During an interview at 1:23 p.m., Plant Ops 2 stated that the bulbs needed to be replaced.

Based on observation and interview, the facility failed to ensure that electrical equipment was installed with the required safeguards. This was evidenced by two pharmaceutical dispensers that were not anchored or braced to withstand a seismic event. This could result in the sudden detachment of these large appliances from their electrical outlets during an earthquake and could increase the risk of an electrical fire and injury. This affected one of four smoke compartments in the main hospital.

NFPA 101, Life Safety Code, 2000 Edition
19.5.1.1 Utilities shall comply with the provisions of Section 9.1.

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

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

NFPA 70, National Electrical Code, 2011 Edition.
90.7 Examination of Equipment for Safety. For specific items of equipment and materials referred to in this Code, examinations for safety made under standard conditions provide a basis for approval where the record is made generally available through promulgation by organizations properly equipped and qualified for experimental testing, inspections of the run of goods at factories, and service value determination through field inspections. This avoids the necessity for repetition of examinations by different examiners, frequently with inadequate facilities for such work, and the confusion that would result from conflicting reports on the suitability of devices and materials examined for a given purpose.
It is the intent of this Code that factory-installed internal wiring or the construction of equipment need not be inspected at the time of installation of the equipment, except to detect alterations or damage, if the equipment has been listed by a qualified electrical testing laboratory that is recognized as having the facilities described in the preceding paragraph and that requires suitability for installation in
accordance with this Code.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the electrical equipment was observed.

1. At 11:12 a.m., on 2/28/17, the over 6 foot tall Pyxis supply machine in the pharmacy was not anchored against seismic events. The seismic anchors were on the floor next to the machine.

During an interview at 11:13 a.m., Pharm 2 stated that the floor in the pharmacy was changed a few months ago and the earthquake brackets were removed.

2. At 3:11 p.m., on 2/28/17, one of two Pyxis supply machines in the kitchenette was not anchored against seismic events.

Based on observation and interview, the facility failed to maintain their electrical wiring connections. This was evidenced by the use of power strips, extension cords, and multi-plug adaptors as substitutes for fixed wiring. This affected two of four smoke compartments in the main hospital and the outpatient Keeler Clinic. This could result in the increased risk of an electrical fire.

NFPA 99, Health Care Facilities Code, 2012 Edition.
10.2.3.6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cartmounted, provided that all of the following conditions are met:
(1) The receptacles are permanently attached to the equipment assembly.
(2) The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets.
(3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code.
(4) The electrical and mechanical integrity of the assembly is regularly verified and documented.

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

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the power strips and extension cords were observed.

1. At 11:14 a.m., on 2/28/17, the pharmacy flow hood was plugged into a power strip. The power strip was plugged into a heavy-duty extension cord.

2. At 11:19 a.m., on 2/28/17, there was a microwave oven and water cooler plugged into a three-plug adaptor near the staff bathroom in the ICU.

During an interview at 11:20 a.m., Plant Ops 2 removed the adaptor and stated that this was not approved for use in the hospital.

3. At 3:33 p.m., on 2/28/17, there was equipment in the X-Ray 2 Fluoro Room that was plugged into a power strip. The power strip was plugged into an extension cord.

4. At 2:06 p.m., on 3/1/17, there were two vaccine refrigerators plugged into a six-plug power strip in the Keeler Clinic.

Based on interview and observation, the facility failed to ensure that OR personnel were familiar with the fire safety equipment in the OR. This was evidenced by OR staff that did not know the classification of the fire extinguishers in the ORs. This affected two of two ORs and could result in a delay in extinguishing a fire.

NFPA 99, Health Care Facilities Code, 2012 Edition.
15.13 Fire Loss Prevention in Operating Rooms.
15.13.1 Hazard Assessment.
15.13.1.1 An evaluation shall be made of hazards that could be encountered during surgical procedures.

15.13.1.2 The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment.

15.13.1.3 Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.

15.13.3.9 Emergency Procedures.
15.13.3.9.1 Procedures for operating room/surgical suite emergencies shall be developed.

15.13.3.9.2 Procedures shall include alarm actuation, evacuation, and equipment shutdown procedures and provisions for control of emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.

15.13.3.9.4 Emergency procedures shall be established for extinguishing drapery, clothing, or equipment fires.

15.13.3.10 Orientation and Training.
15.13.3.10.1 New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use.

15.13.3.10.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.

NFPA 10, Standard for Portable Fire Extinguishers, 2010 Edition
5.2.1 Class A Fires. Class A fires are fires in ordinary combustible materials, such as wood, cloth, paper, rubber, and many
plastics.

5.2.2 Class B Fires. Class B fires are fires in flammable liquids, combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases.

5.2.3 Class C Fires. Class C fires are fires that involve energized electrical equipment.

Findings:

During a facility tour with staff from 2/27/17 to 3/2/17, the ORs were observed and OR staff were interviewed.

1. At 1:19 p.m., on 2/27/17, OR 2 was equipped with a BC-Class fire extinguisher that was to be used for flammable liquid fires and electrical fires. OR 2 contained shelves and cabinets of combustible supplies placed in boxes as well as other combustible materials such as soiled linens. Fires involving these supplies would be classified as Class A fires.

During an interview at 1:20 p.m., OR RN 1, OR RN 2, and SP 1 were asked what they would do in the event of a fire involving the combustible supplies in the OR shelves. Three of them stated they would attempt to extinguish the fire using the extinguisher inside the OR. The three OR staff did not know that the extinguisher inside the OR was classified for only Class B (flammable liquid) and Class C (electrical) fires.

OR 1 was also equipped with a BC-Class fire extinguisher. There was an ABC-Class fire extinguisher in the surgical hallway directly outside the ORs.