Angel Medical Center

Based on review policy and procedure, reveiw of Dishmachine Temperature Logs, and staff interview, the hospital staff failed to ensure adequate sanitation of items placed in the automated dishmachine.

The findings include:

Review of policy #F019, DISHMACHINE TEMPERATURES revised 01/2017, revealed ...POLICIES:....The pressure of the final rinse water in a mechanical system shall be within the range specified on the manufacturer's data plate and may not be less than 5 nor more than 30 pounds per square inch [psi]....as measured in the water line immediately adjacent to the final rinse control valve....PROCEDURES:....High Temperature Dishmachine....Once a day, run a test strip through the dishmachine to verify the surface temperature of a dish. Attach the used test strip to the temperature log.

Review of the Dishmachine Temperature Log for December 2017, during tour on 12/13/2017 around 1400, revealed a column labeled Test Strip Results....(Attach Test Strip) and another column labeled Pressure (5-30 psi). Review of the current form did not reveal any notation in the pressure column and did not reveal test strips attached every day. Review of the November 2017 form revealed test strips showing 180 degrees attached for 11/02/2017, 11/06/2017, 11/11/2017, 11/17/2017, 11/22/2017, and 11/28/2017 (6 out of 30). Review did not reveal any test strips monitored or attached on the other 24 days in November. For October, form review revealed test strips measuring 180 degrees attached on 10/01/2017, 10/07/2017 (times two), 10/08/2017, 10/13/2017, 10/14/2017, 10/15/2017, 10/20/2017, and 10/26/2017 (8 of 31 days) but did not reveal any test strip monitoring the other days. Further review failed to reveal any pressure monitoring during October or November 2017.

Interview with Manager #1, on 12/14/2017 at 1430, revealed the policy for monitoring test strips and pressure was not followed.

Based on observations, staff interview, and/or documentation on 12/12/17 at 1:30 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. In the same day surgery there are fifteen flip down trays that open into the corridor projecting more than 7 inches into the corridor when fully opened and are not equipped with self-closing devices.

Reference 2012 NFPA 101: 7.2.1.4.3.1 During its swing, any door leaf in a means of egress shall leave not less than one-half of the required width of an aisle, or corridor, a passageway, or a landing unobstructed and shall project not more than 7 in (180 mm) into the required width of an aisle, a corridor, a passageway, or a landing, when fully open.

2. Staff when question at the pharmacy did not know how to release the magnetically locked exit doors with the master override switch at the door. This door was typical of other doors in the facility.

Reference 2012 NFPA 101 19.7.3.2 Health care occupancies that find it necessary to lock means of egress doors shall, at all times, maintain adequate staff qualified to release locks and direct occupants from the immediate danger area to a place of safety in case of fire or other emergency.

This deficiency affected twelve of twelve smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on 12/12/17 at 1:30 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The kitchen walk in cooler emergency egress handles could not be seen in darkness.

Reference 2012 NFPA 101 19.2.1, 7.2.1.5.10 A latch or other fastening device on a door leaf shall be provided with a releasing device that has an obvious method of operation and that is readily operated under all lighting conditions.

This deficiency affected one of twelve smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on 12/12/17 at 1:30 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The emergency lighting for an exit path to the public way from the outpatient medicine exit near AHU #7 was incomplete. Illumination was provided at the exit but was on normal power. There was not lighting provided on emergency power for the exterior exit beyond the door to the public way in case of emergency.

Reference NFPA 101: 19.2.8, 7.8, 7.8.1.3 The minimum illumination for floors and walking surfaces shall be to values of at lease 1 ft-candle (10.8 lux), measured at the floor. 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

This deficiency affected one of twelve smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on 12/12/17 at 1:30 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. There is not a sprinkler head in the elevator pit for elevators #1 & #2. The facility defines itself as fully sprinklered.

Reference 2012 NFPA 101, 2010 NFPA 13 8-15 Elevator Hoistways and Machine Rooms

8.15.5.1 Sidewall spray sprinklers shall be installed at the bottom of each elevator hoistway not more than 2 ft. (0.61 m) above the floor of the pit. 8.15.5.2 Automatic sprinklers in elevator machine rooms or at the tops of hoistway shall be of ordinary or intermediate temperature rating. 8.15.5.5 The sprinkler required at the top of the elevator hoistway by 8.15.5.4 shall not be required where the hoistway for passenger elevators is noncombustible or limited-combustible and the car enclosure materials meet the requirements of ASME A17.1, Safety Code for Elevators and Escalators. 8.15.5.6 Sprinklers shall be installed at the top and bottom of elevator hoistway where elevators utilize polyurethane-coated steel belts or other similar combustible belt material.

This deficiency affected twelve of twelve smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on 12/12/17 at 1:30 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The supervisory signal for the electronically supervised tamper alarm on the sprinkler control valve at the Fire Alarm Control Panel (FACP) could be silenced permanently when the nearby stairwell valve was in the closed position.

Reference 2012 NFPA 101 Section 9.7.2.1 Where supervised automatic sprinkler systems are required by another section of this code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, AND a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Supervisory signals shall sound and shall be displayed at a location within the protected building that is constantly attended by qualified personnel.

This deficiency affected twelve of twelve smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.

Based on observations, staff interview, and/or documentation on 12/12/17 at 1:30 PM onward the following deficiencies were noted: The standard is non-compliant, specific findings include:

1. The remote generator annunciator for generator #3 and #4 did not provide a signal for loss of : battery charger AC failure when checked.

Reference 2012 NFPA 99: 6.4.1.17, 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. 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 the following:

a. Low lubricating oil pressure

b. Low water temperature (below those required in 6.4.1.1.11)

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)

f. Overspeed

A remote, common audible alarm shall be provided as specified in 6.4.1.1.17.4 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]

Reference 2012 NFPA 99: 6.4.1.1.16.2 (Table item O)

This deficiency affected twelve of twelve smoke compartments.

Failure to comply with minimum standards as referenced increases the risk of death due to smoke and or fire.