The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|AURORA LAS ENCINAS||2900 E DEL MAR BLVD PASADENA, CA 91107||Sept. 27, 2018|
|VIOLATION: Cooking Facilities||Tag No: K0324|
|NFPA 17A Standard for Wet Chemical Extinguishing Systems 2009 Edition
18.104.22.168 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.
7.2.2 At a minimum, this "quick check" or inspection shall include verification of the following:
(1) The extinguishing system is in its proper location.
(2) The manual actuators are unobstructed.
(3) The tamper indicators and seals are intact.
(4) The maintenance tag or certificate is in place.
(5) No obvious physical damage or condition exists that might prevent operation.
(6) The pressure gauge(s), if provided, shall be inspected physically or electronically to ensure it is in the operable range.
(7) The nozzle blowoff caps, where provided, are intact and undamaged.
(8) Neither the protected equipment nor the hazard has not been replaced, modified, or relocated.
NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations 2011 Edition
10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer's instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A
22.214.171.124 All deep-fat fryers shall be installed with at least a 406 mm (16 in.) space between the fryer and surface flames from adjacent cooking equipment.
126.96.36.199 Where a steel or tempered glass baffle plate is installed at a minimum 203 mm (8 in.) in height between the fryer and surface flames of the adjacent appliance, the requirement for a 406 mm (16 in.) space shall not apply.
188.8.131.52.1 If the fryer and the surface flames are at different horizontal planes, the minimum height of 203 mm (8 in.) shall be measured from the higher of the two.
These Standards were not met as evidenced by:
Based on observation and interview the facility failed to maintain the kitchen's wet chemical fire-extinguishing system's nozzle blowoff caps intact as designed, and by not having a 16-inch space or a steel or tempered glass baffle at a minimum 8 inches in height between a fryer and surface flames from adjacent cooking equipment.
The deficiencies had the potential to allow the entrance of grease vapors, moisture, or other foreign materials into the nozzle piping of the wet chemical fire-extinguishing system and for the system to not work as designed in the event of a fire, and had the potential of igniting a kitchen fire. Oil could splash and come into contact with an open flame from an adjacent piece of cooking equipment.
1. On 9/25/18 at 9:50 a.m., the evaluator observed that two of nine blow off caps were not placed on the nozzles of the suppression system located above the cooking area at the Kitchen.
During an interview at the same time as the observation, the Plant Operations Director acknowledged that the caps needed to be placed on the nozzles.
2. On 9/25/18 at 9:50 a.m., the evaluator observed a deep fryer located next to a natural gas fueled charbroiler. The deep fryer was 12 inches from the stove, and there was no baffle plate between the deep fryer and charbroiler.
The Plant Operations Director and the Dietary Manager were informed of the deficiency during an interview at the same time as the observation.
|VIOLATION: Sprinkler System - Installation||Tag No: K0351|
|NFPA 13 Standard for the Installation of Sprinkler Systems 2010 Edition
184.108.40.206 Unless the requirements of 220.127.116.11, 18.104.22.168, or 22.214.171.124 are met, sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width.
This Standard was not met as evidenced by:
Based on observation and interview the facility failed to sprinkler an exterior roof.
The deficiency had the potential to support fire propagation at the exterior roof during a fire emergency.
On 9/26/18 at 11:05 a.m., at the sprinklered Type V wood framed construction Briar building the evaluator observed an eight foot by eleven foot wood framed exterior roof at the front of the building.
At the same time as the observation the Plant Operations Director acknowledged the exterior roof was not sprinklered.
|VIOLATION: Corridor - Doors||Tag No: K0363|
|NFPA 101 Life Safety Code 2012 Edition
126.96.36.199.13 Dutch doors shall be permitted where they conform to 188.8.131.52 and meet all of the following criteria:
(1) Both the upper leaf and lower leaf are equipped with a latching device.
(2) The meeting edges of the upper and lower leaves are equipped with an astragal, a rabbet, or a bevel.
(3) Where protecting openings in enclosures around hazardous areas, the doors comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives.
This Code was not met as evidenced by:
Based on observation the hospital failed to ensure that three of three corridor Dutch doors had astragals, rabbets, or bevels.
The deficiency had the potential to permit the spread of smoke.
1. On 9/25/18 at 10:18 a.m., the evaluator observed that the corridor door of medication room 2 at the Main Hospital was a Dutch door that did have an astragal, rabbet, or bevel where the top and bottom leaves met.
During an interview at the same time of the observation the Plant Operations Lead Staff stated that an astragal, rabbet, or bevel could be placed at the door.
2. On 9/25/18 at 10:25 a.m., the evaluator observed that the corridor door of the nurses station at 2 South of the Main Hospital was a Dutch door that did have an astragal, rabbet, or bevel where the top and bottom leaves met.
During an interview at the same time of the observation the Plant Operations Director stated that the door was going to be replaced.
3. On 9/26/18 at 11:05 a.m., the evaluator observed the corridor doors of patient sleeping rooms 362 and 367 at the Briar building were Dutch doors that did have an astragals, rabbets, or bevels where the top and bottom leaves met.
During an interview at the same time of the observation the Plant Operations Director acknowledged that the doors did not have astragals, rabbets, or bevels.
|VIOLATION: Electrical Systems - Essential Electric Syste||Tag No: K0916|
|NFPA 99 Health Care Facilities Code 2012 Edition
184.108.40.206.17 Alarm Annunciator. A remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see 700.12 of NFPA 70, National Electrical Code). The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power
source as follows:
(1) Individual visual signals shall indicate the following:
(a) When the emergency or auxiliary power source is operating to supply power to load
(b) When the battery charger is malfunctioning
(2) Individual visual signals plus a common audible signal to warn of an engine?generator alarm condition shall indicate
(a) Low lubricating oil pressure
(b) Low water temperature (below that required in 220.127.116.11.11)
(c) Excessive water temperature
(d) Low fuel when the main fuel storage tank contains less than a 4-hour operating supply
(e) Overcrank (failed to start)
18.104.22.168.17.1* A remote, common audible alarm shall be provided as specified in 22.214.171.124.17.4 that is powered by the storage battery and located outside of the EPS service room at a work site observable by personnel. [110:5.6.6]
This Code was not met as evidenced by:
Based on observation and interview, the facility failed to ensure that an EPS (emergency power supply)(emergency power generator) audible alarm was located at a work site observable by personnel.
The deficiency had the potential of not providing audible notification to staff, or result in delayed awareness to an alarm condition of the emergency power generator.
On 9/25/18 between 10:30 a.m. and 10:45 a.m., the evaluator observed an emergency generator in an outside enclosure (barricade) next to the back of the Main Hospital building.
On 9/26/18 at 11:20 a.m., the evaluator observed an emergency generator in an outside enclosure (barricade) next to the side of the Mariah West building.
On 9/26/18 at 11:20 a.m., during an interview the Plant Operations Director stated that their were no remote alarms for both emergency power generators that would provide an audible alarm at a work site observable by personnel.
On 9/27/18 at 2:45 p.m., during an interview the Plant Operations Director stated that the facility had a type 1 essential electrical system.
|VIOLATION: Electrical Systems - Essential Electric Syste||Tag No: K0918|
|NFPA 110 Standard for Emergency and Standby Power Systems 2010 Edition
8.1.1 The routine maintenance and operational testing program shall be based on all of the following:
(1) Manufacturer's recommendations
(2) Instruction manuals
(3) Minimum requirements of this chapter
(4) The authority having jurisdiction
8.2.1 At least two sets of instruction manuals for all major components of the EPSS shall be supplied by the manufacturer(s) of the EPSS and shall contain the following:
(1) A detailed explanation of the operation of the system
(2) Instructions for routine maintenance
(3) Detailed instructions for repair of the EPS and other major components of the EPSS
(4) An illustrated parts list and part numbers
(5) Illustrated and schematic drawings of electrical wiring systems, including operating and safety devices, control panels, instrumentation, and annunciators
8.2.2 For Level 1 systems, instruction manuals shall be kept in a secure, convenient location, one set near the equipment, and the other set in a separate location.
This Standard was not met as evidenced by:
Based on document review and interview the facility staff failed to maintain an instruction manual for the emergency generator.
The deficient practice could result in the failure of the facility to conduct routine maintenance and operational testing program of the EPSS Which is based in part, on the manufacturer's recommendations and instruction manual.
On 9/25/18 at 12:45 p.m., during document review the evaluator noted that there was no emergency power supply (generator) owner's manual.
During an interview at the same time as the document review, the Plant Operations Lead Maintenance staff stated that they did not have an owner's manual for both generators, and that the inspection, testing and maintenance of the generators were based on the standards of their accreditation organization and not the manufacturer's instruction manuals.
|VIOLATION: Electrical Equipment - Power Cords and Extens||Tag No: K0920|
|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
400.9 Splices. Flexible cord shall be used only in continuous lengths without splice or tap where initially installed in applications permitted by 400.7(A). The repair of hard-service cord and junior hard-service cord (see Trade Name column in Table 400.4) 14 AWG and larger shall be permitted if conductors are spliced in accordance with 110.14(B) and the completed splice retains the insulation, outer sheath properties, and usage characteristics of the cord being spliced.
This Code was not met as evidenced by:
Based on observation and interview the facility failed to ensure that the electrical wiring and equipment was in accordance with NFPA 70 by using extension cords as permanent wiring.
To meet power supply needs in buildings with an inadequate supply of readily available electrical receptacles, extension cords and/or power strips are often interconnected ("daisy chained") to provide more receptacles and/or reach greater distances. Interconnecting these devices can cause them to become overloaded, leading to their failure and a possible fire. Because electrical resistance increases with increased power cord length, interconnecting cords increases the total resistance and resultant heat generation. This creates an additional risk of equipment failure and fire.
On 9/25/18, 9/26/18 and 9/27/18 the evaluator observed that the board room on the 1st floor of the Main Hospital had a "daisy-chaining" of extension cords by having two power strips connected to two extension cords that were then connected to wall electrical receptacles.
On 9/27/18 during an interview at the same time as the observation, the Facilities Manager acknowledged the daisy-chaining of the power strips and extension cords.