Los Angeles County Harbor-UCLA Medical Center's response to 2-18-11 inspection

8/2/2019 Los Angeles County Harbor-UCLA Medical Center's response to 2-18-11 inspection

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? T ! ! A . . ' .. .. . . . .cr",ICAL CENTER

L os A ng ele s C ou ntyBoar d o f Su pe rv is or s

Glori a Mol inaF i rst D i s tr i ct

Mark R id ley -ThomasSecond D i st ri ct

Zev YaroslavskyTh ir d D i st ri ct

D o n K na beF ou rt h D i st ri ct

Michae l D . Antonovi chF i ft h D is tr i ct

Miguel Or t iz-MarroquinCh ie f E x ec u~ v e O ff ic erGa il V . A nders on , J r., MD

Ch ie f M e di ca l O ff ic erPeggy Naza re y, RN

Ch ie f N u rs in g O ff ic er

1000 Wes t Car son S tr ee tTor rance, CA 90502T el: ( 3 10 ) 2 2 2 -2 1 0 1

Fa x: ( 3 1 0 ) x x x . x x x x

T o im p ro ve h ea ltht h ro u g h l ea d e rsh ip ,

s er vic e a nd e du ca tio n

June 29, 2011

CMS Certification Number (CCN): 05-0376Rufus Arther, ManagerNLTC Survey, Certification & Enforcement BranchDivision of Survey and CertificationSan Francisco Regional Office90 - yth Street, Suite 5-300 (5W)San Francisco, CA 94103-6707Dear Mr. Arther:This is in response to your letter and Statement of Deficiencies (Form CMS-2567) dated June 10, 2011. For your consideration, enclosed is a Plan ofCorrection that provides credible evidence that required improvements havebeen made to ensure correction of the identified deficiencies in our InfectionControl Program.The Plan of Correction addresses compliance in the following Conditions ofParticipation (COPs):42 C.F.R. 482.4242 C.F.R. 482.51 Infection ControlSurgical ServicesPlease contact me or Julie Rees, our Accreditation and Licensing Administrator,at (310) 222-2106 if any additional information is necessary or if you have anyquestions regarding the information provided.Sincerely,

' l 1 ifldrA 4 / 1 1 c ,v' t - ' AMiguel Ortiz-MarroquinChief Executive OfficerMOM:jr

c: Kim McKenzieCalvin Kwan


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DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES

PRINTED: 06/10/201FORM APPROVEOMB NO 0938-039ATEMENT OF DEFICIENCIES

ND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

050376NAME OF PROVIDER OR SUPPLIER

LAC/HARBOR-UCLA MED CENTER

02/18/2011

(X2) MULTIPLE CONSTRUCTIONA. BUILDING 01 - MAIN BUILDING 01B. WING _

(X3) DATE SURVEYCOMPLETED

STREET ADDRESS, CITY, STATE, ZIP CODE1000 W CARSON STTORRANCE, CA 90509

(X4) IDPREFIXTAG

(X5)COMPLETIDATESUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCy)

IDPREFIXTAG

K 000 INITIAL COMMENTS

Representing the California Department of PublicHealth:Maxine McKaig, HFEIISPatricia Hardy, HFE1Zeina Naser, HFE1

K 012 NFPA 101 LIFE SAFETY CODE STANDARD

BORATORY DIRECTOR'S fR PROVIDERISUPP~"'REPRESENTATlVE'S SIGNATURE TITLE (X6) DATEV l1 ~ ? t JeLi'\. l ! l1cvIfOt.., r{ tJ t Chief Executive Officer 6/29/11

K3 Building: 01, 02, 03K6 Plan Approval: Main Building - 1960

Family Medical Clinic -N-24 - 1940 Upgraded in 2010K7 Survey Under: 2000 ExistingSTRUCTURE TYPE: Main Building - Type I,partially sprinklered.

Clinic Buildings - Type V,Family Medical Clinic is sprinklered.The following reflects the findings of the CaliforniaDepartment of Public Health, during a FullValidation Life Safety Code survey. The findingsare in accordance with the NFPA (National FireProtection Association) 101, Life Safety Code2000 edition (existing). The facility was surveyedin accordance with 42 CFR (Code of FederalRegulations) 483.70 (a) for Long Term CareFacilities.The facility is not in compliance with 42 CFR483.70 (a).Census:February 15, 2011: 360February 16, 2011: 377February 17, 2011: 380

K O O O

K012

" . 'ficien'cy statement ending with an a"'sterisk (*) d~tes a deficiency which the institution may be excused from correct ing providing it is determined tha, ........feguards provide suf ficient protection to the patients. (See instruct ions.) Except for nursing homes, the findings stated above are disclosable 90 daymm"ng the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14s following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correct ion is requisite to continuedgram participation.

RM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2QK121 Facility ID: CA060000027 If continuation sheet Page 1 o


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DEPARTIVIENT OF HEALTH AND HUMAN SERV ICESCENTERS FOR MED ICARE & M E DIC AID S ER VICE S

r"l1~ I cu. UO/IU/'::U IF O RM A PP RO VE DOMS NO 0 9 3 8-0 3 9 1S TA TE M E NT O F D E FIC IE N CIE S ( X 1 ) P ROV I DER /SUPP L IER / el lA ( X2 ) M U LT IP LE C O N ST R UC TIO N (X3 ) D AT E S UR VE YAN D P LAN O F C OR RE CT IO N ID E N TIF IC AT IO N N U M BE R : COMPL ET EDA . B U IL D IN G 01 - MAIN BUILDING 01

0 5 0 376 B .W ING 02/18/2011-I, .e O F P RO VID ER O R SU PP LIE R STR EE T AD DR ESS , C ITY , STATE , Z IP C OD ELAC/HAR BO R-UCLA M ED CE NTE R 1000 W CARSON STTO RRAN CE , CA 9 0 5 0 9( X4 ) ID S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S ID P RO V ID E R'S P LA N O F C O RR E CT IO N (XS)PREF IX (E AC H D EF IC IE NCY M UST BE P RE CE DE D BY F ULL PREF IX (E ACH C OR RE CT IV E ACT IO N SH OULD BE COMPLETIOTAG R E GU LA TO R Y O R L SC ID E NT IF YIN G IN F OR M AT IO N ) T AG C RO SS -R EF ER EN CE D T O T HE A PP RO PR IAT E DATEDEF IC IENCY }

K 0 1 2 Continued F rom page 1 K 0 1 2 K 0 1 2Build ing construc tion type and heigh t m eets one N FP A 1 01 LIF E S AF ET Y C OD E S TA ND AR Dof the fo llow ing. 1 9.1 .6 .2 , 1 9.1 .6 .3 , 1 9.1 .6 .4,19 . 3 . 5 . 1 CORRE C TIV E A C T IO N S

A. New lRev ised P ro cesses & ProceduresN A

Th is STANDARD is not m et as evidenced by: B . Repair lReplacement~ Mi t iga te th rough sea li ng pene tra ti ons ,Based on observation, the fac ility failed to repai r/ rep lacement o f ce i li ng t il es,m ainta in th e integrity of th e b uild ing c onstruc tion. r epa ir /r ep la c ement o f f lo o r t il es for t h eTh is was evidenced by penetrations in the walls fol lowing:and ceilings. Th is affec ted two of eigh t floors in 7 tt tF l oo r: M i s si ng ce il in g t ile i n Room 02 /15 /11the m ain hospita l and one of two c lin ics. Th is 7W - 2 7 W o rk o rd er # 46 48 4could result in the spread of sm oke and fire, in 5 tt tF loo r: Ce i li ng pene tra ti on around 02 /15 /11th e e ve nt (If C 1 fire. c o nd uit a b ov e ICU c h ar tin g s ta tio n .F indings: W o rk o rd er # 46 48 2 2 4 th F l oo r: W a ll p en et ra tio ns in Room 4E - 02 /16 /11D U rin g-th e-fa cility to ur w ith s ta Tf,ffO m 2715/11 - 1 5 a ndH o om4E -1 7 ; c eilin gp en etra tio ns in R o om R .R . 4 0 1 W o rk2/17/11, the walls and ceilings in the m ain o rde r #4518 92hospita l and two outpatient c lin ic s were observed. 3 rd F lo or: W a ll p en etra tio n in R o om 3 E -7 02 /16 /11F loors 2 th rough 8 of the hospita l were surveyed a nd R o om 3 E -1 1 , w all p en etr atio ns inR oo m 3W - 29 . W o rk o rd er # 45 1 96 6on 2/15/11. 2 nd F l oo r: Ce il in g pene tr at ion i n mo rgue , 06/24/117 th F lo or- At 1 0 :3 3 a.m ., a ceiling tile was m isS ing in R oom wa ll pene tr at ions i n mo rgue , wa ll7W -2 7 , c lean side utility room . Th is exposed an p en et ra tio ns in Room 2W -6, w a llapprox im ately 1 0 x 1 0 inch penetration in the pene tr at ions i n OR2 , c e il in g pene tr a tionsceil ing. i nOR2 1 st F l oo r: W a ll pene tr at ions in D i etar y 02 /16 /115 th F lo or- Re tail O f fi ce , wa ll p ene tr at ions i n RoomAt 1 1 : 0 1 a.m ., there was an approx im ately 1/2 x 1 1 C- 1 . W o rk o rd er # 45 2 0 3 9inch penetration around a conduit in the leu Basemen t : B roken /damaged ce il in g t ile s 02 /16 /11ceiling above the charting station. i n s te ri le p ro cess ing a rea , wa ll ,p en et ra tio n b e hin d d oo r o f Ro om 8 -1 5 4 ,4 th F lo or- c e ilin g p en et ra tio n in r oom 8 -1 1 6 , w a llA t 1 : 0 9 p.m ., there were two approx im ately 1/2 x

p en et ra tio ns in Room 8 -2 0 6 , w a ll1 inch penetrations in the righ t wall, beh ind the p en etra tio n in R o om B -2 0 5 . W o r k o rd er#441968

ORM CM S-2 5 67 (0 2 -9 9 ) P rev ious V ers ions O bso le te E ven t 1 0 :2 QK 1 2 1 F a c il it y 1 0 : CA 0 6 0 0 0 0 0 27 If continuation sheet Page 2 of50


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D EP AR TM EN T O F H EALTH AN D H UM AN SE RV IC ES. CE NT ER S F OR M E DIC AR E & ME D I CA ID S E R V IC E S

PR I N T E D : 06/10/201FORM APPROVEDO MB NO 0 9 3 8 -0 3 9S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

( X 1 ) P ROV I DER / SUPP L IER / C LI AID E N TIF IC A TIO N N U M BE R :

I-N AM E O F P RO VID ER O R SUP PL IE RLAC/HARBORUCLA MED CENTER

( X2 ) M U LT IP LE C O N ST R UC TIO NA. BUILDING 01 - MAIN BUILDING. 01

(X3 ) D AT E S UR VE YCOMPLET ED

02/18/2011B . W ING _ST RE ET A DD RE SS , C IT Y, S TA TE , Z IP C OD E1000 W CARSON STTORRANCE, CA 90509

(X4) IDPREF IXTAG

C ontinued F rom pa ge 2bed in R oom 4E -1 5 .A t 1 :1 0 p .m . , th ere w as a n a pp ro xim a te ly 3112 x3 inc h pene tra tion b eh ind B ed A in R oom 4E -1 7.A t 1 :1 2 p .m . , th ere w ere tw o a pp ro xim a te ly 1/2-3/ 4 in ch p en etra tio ns in th e c eilin g in R o om R.R .4 0 1 .

Clinic Building N -2 4: W all penetrations inM odule BR oom 2 2, p enetration in loftarea , c eiling p ene tra tion b y R oo m 3 2 ,p en etr atio ns a bo ve e ntra nc e to R oomRR-9 , w all p en etratio n in R oom 1 C 1 .Wo rk o rd er # #4 41 9 68

(X5)COMPLETIONDATE

S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE PR ECE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN F OR M AT IO N )

K 0 1 2

3 rd F lo or-A t 1 :3 3 p .m ., th e re w as an approx im ate ly 1 x 2in ch dam aged area on the w all b eh ind B ed A inR oom 3 E-7 .A t 2 :0 1 p .m ., th ere w as an app rox im a te ly 1 /2 inc hp en etra tio n a ro un d a w ate r p ip e in B ath ro om3E - 1 1 .2 n d F lo or-A t 2 :3 5 p .m ., th ere w as a n a pp ro xim a te ly 1/2 inch-penetrat ion-around-b lue1 : :omputer 'w i re- in- the-r igh ts id e o f th e m o rg ue c eilin g.T h ere w as a n a pp ro xim a te ly 1/2 x 3/4 inchp en etra tio n a ro un d o ne sid e o f a c op pe r p ip e o nth e rig ht w all o f th e m o rg ue .T he re w ere th re e u ns ea le d c op pe r p ip es o n th erig ht w a ll. T h ere w as a n a pp ro xim a te ly 1/8 inchp en etra tio n a ro un d e a ch p ip e.A t 3 :5 4 p .m . , th ere w ere tw o a pp ro xim a te ly 1/8 -1/4 in ch p en etra tio ns in th e rig ht w a ll o f R o om2 W - 6. T he p en etra tio ns w ere b elo w th e b lo odp re ss ure m a c h in e.O n 2/16/11, th e 1 st flo or a nd B as em e nt a re asw e re o b se rv ed .1 s t f lo o r -A t 9 :2 1 a .m . , th ere w ere tw o a pp ro xim a te ly 1/8-1/ 4 in ch p en etra tio ns in th e fro nt w all a bo ve th elig ht s witc h p la te , in th e d ie ta ry re ta il o ffic e. T h eo ffic e is lo ca te d in th e c afe te ria k itc he n a re a.

F O RMCMS 2 5 67 (0 2 -9 9 ) P re vio us V e rs io ns O b so le te E v en t I D :2 Q K 12 1 .

IDPREF IXTAG

P R OV ID E R'S P LA N O F C O RR E CT IO N(E ACH C OR RE CT IV E AC TIO N SHO ULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEFICIENC'f)

K 0 1 2

C . Pe r sonne lT r a in ing /No t if ic a t ion E duc ate key staff (Services D irectors,

M e dic al D epar tme nt C h airs , a nd N ur sin gLe ade rs hip C oun cil) b y m ea ns ofManagemen t Bul le tin a nd p re senta ti ona t O per atio ns M a na gemen t C ou nc ilme etin g o f n ec es sity - a nd a pp ro pr ia tew ay - to rep ort safety lapses in th ephys ica l env ironment.

QUA L IT Y IM P ROV EM E NTA . P la l1 n i_1 l9 .. _ .__ __

M onitor as part of docum entedinterdisc ipl ina ry HazardSur ve il la nce /E n vi ro nment al Rounds fo ro cc ur re nc e o f life s afe ty la ps es( in c lu di ng wal l a nd ce ili ng penet ra tio ns )in th e p hy sic al e nv ir onmen t a ndper fo rmance o f r equ ir ed co rr ec tiv ea c ti on s. I ni ti at e t ime ly co rr ec tiv e a c tio ns ,as appropr ia te.

B . M on ito ring F ac ilities M anagem ent, E nvironm ental

S er vi ce s, In fe c ti on Cont ro l a nd Hospi ta lA dm in is tr atio n to a ) c on du ct w ee klyHazard Surve i llance/Env ironmenta lR ou nd s o f fa cility fo r o cc ur re nc e o f lifes afe ty la ps es in th e p hy sic ale nv ir onmen t, b ) c omp le tio n o f life s afe tyco rrec t ive ac tions . Fac il it ie sM an ag eme nt to re po rt life s afe ty r es ults

02 /16/11

6/22 /11

F a d li ty I D ; CA 0 6 0 0 0 0 0 27 If continuation sheet Page 3 of 5


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PR I N T ED : 06/10/2011FORM APPROVEDO MB N O 0 9 38 -0 3 91D EP AR TM EN T O F H EALTH AN D H UM AN SE RV ICE SC EN TE RS F OR M E DIC AR E & MED I CA ID S E R V IC E S

( X3 ) D AT E S UR VE YCOMP LE TEDS TA TE M EN T O F D E FIC IE NC IE SAN D P LA N O F C OR RE CT IO N ( X2 ) M U L TIP L E C O N STR U CT IO NA . BUILD ING 01 M A IN B UIL D IN G 01( X l) P ROV ID ER / SU P P L IE R / CL IAID E N T IF IC A TIO N N UM B ER :

B . W ING _050376 02/18/2011-N AM E O F P RO VID ER O R S UP PLIE R ST RE ET AD DR ESS, C IT Y, ST AT E, Z IP C OD E1000 W CARSON STTORRANCE, CA 90509LAC/HARBORUCLA MED CENTER

P RO VID E R'S P LA N O F C OR RE CT IO N(E AC H CO RR ECT IV E AC TIO N SH OU LD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEF IC I ENCy )

S UM M AR Y S TA TE M E NT O F D E F IC IE N CIE S(E AC H D EF IC IE NCY M US T BE P RE CE DE D B Y F ULLR E G UL AT O RY O R L SC ID E N TIF YIN G IN F OR M AT IO N )

1 0PREF IXTAG

(X5)COMPLETIONDATE

(X4) IDPREF IXTAG

K 0 1 2 C ontin ue d F rom p ag e 3Basement-A t 1 0 :5 0 a .m ., th ere w ere th re e to fou r b rok ena nd d am a ged c eilin g tile s in th e a re a a bov e th es te riliz e r, in th e b a sem e nt s te rile a re a.A t 1 :2 2 p .m ., th ere w as a n a pp ro xim a te ly 1/8 inchp en etra tio n a ro un d th e m a gn etic h old , b eh m d th ed oo r B 1 5 4.A t 1 :3 0 p .m ., th ere w as an ap pro xim a te ly 3 inc hp en etra tio n a ro un d a p ho ne lin e, in sid e th e p ip es le ev e, in th e c eilin g o f R oom B 1 1 6 .

K 0 1 2 q ua rte rly to th e E nv iro nm en t o f C areCommittee.

R ES PON S IB L E POSIT ION (S ) F acilities M anagem ent D irector

2 /1 7111 - C lin ic B u ild in g N 2 4A t 3 :0 3 p .m ., th ere w ere tw o a pp ro xim a te ly 1/4in ch p en etra tio ns in th e w all a bo ve th e d oo r, a tR oom 2 2 , M odule B .A t 3 :0 5 p .m ., th ere w as an ap prox im ate ly 3 x 11/2 inc h p ene tra tion ab ov e R oom 3 0 in th e lo fta rea . "The re W a s a rr app ro x im a f ely 1 1 2 - i nc h..p en etra tio n a ro un d a w ire b u nd le in th e c e ilin gou ts ide of R oom 3 2 .1 s t F l oo r-A t 9 :3 0 a .m . , th ere w ere tw o a pp ro xim a te ly 1/4inc h p ene tra tio ns n ea r th e s ink o n th e e as t w all o f1 C 1 .2/17 /11 - 2 nd F loo r - O R areaA t 8 :3 0 a .m ., th ere w as an ap prox im ate ly 6 x 1/2in ch p en etra tio n a lo ng th e b as e b oa rd in th ec en ter o f th e righ t w all in O R 2 .A t 8 :47 a .m ., th ere w as an ap prox im ate ly 3 x 3/4in ch p en etr atio n in th e c eilin g a b ov e th ee m erg en cy lig ht in O R 2 .A t 8 :5 0 a .m ., th ere w e re fo ur a pp ro xim a te ly 1/2in ch p en etra tio ns in th e c e nte r o f th e c e ilin g,a ro un d c ords , in O R 2 . T he p en etra tio ns w erecon firm ed b y O R S ta ff I, O R S ta ff" and O R S ta ffIII.A t 9 :1 2 a .m ., in O R 2 , th e re w as an

If continuation sheet Page 4 of 5(}a c ilit y I D : C A 0 6 0 0 0 0 0 2 7v en t ID :2 Q K 12 lO R M CM S 2 5 6 7{ 02 .9 9 ) P re vio us V e rs io ns O b so le te


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PR INTED : 06/10/2011F OR M A PP R OV EDOMB NO 0938-039S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

0 5 0 3 7 6

( X 1 ) P ROV I DER / SUPP L lER / C Ll AID E N TIF IC A TIO N N U M BE R :

-N AM E O F P RO VID ER O R SU PPL IE RLA C/H AR BO R-U CLA M E D C EN TE R(X4) IDPREF IXTAG

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN FO R MA TIO N )

(X3 ) D AT E S UR VE YCOMPLET ED( X2 ) M U LT IP LE C O N ST R UC T IO NA . B U IL D IN G 01 - MAIN BUILDING 01

B . W ING _

P RO V ID E R'S P LA N O F C OR R EC TIO N(E ACH CO RR ECT IV E AC TIO N SH OULD BEC RO SS -R E FE R EN CE D T O T HE A PP RO P RIA TE

DEFICIENCY}

ST RE ET A DD RE SS , C IT Y, S TA TE , Z IP C OD E1000 W CARSON STTO RR AN CE , CA 9 0 5 0 9

IDPREF IXTAG

K 012 Continued From page 4 K 012approximately 1 X 1/2 inch penetration by the.emergency switch on the left wall.N-24 ClinicAt 3:01 p.m . , there were two 1/ 2 inch unsealedpenetrations above the entrance to the Men'sRestroom RR9.

2/15 /11 - 3rd FloorAt 1:50 p.m., there were four approximately 112inch penetrations, in the left wall of Room 3W -29.

K017

2/10/11 -Basement -At 12:57 p.rn., there were eight approximately 3/ 4inch penetrations in the left wall of Room 8-206.At 1:00 p.m., there was an uncovered junctionbox, creating an approximately 3 x 3 inchpenetration in the right wall of Room 8-205.NFPA 101 LIFE SAFETY CODE STANDARDCorridors are separated from use areas by wallsconstructed with at least Y2hour fire resistancerating. In sprinklered buildings, partitions are onlyrequired to resist the passage of smoke. Innon-sprinklered buildings, walls properly extendabove the ceiling. (Corridor walls may terminateat the underside of ceilings where specificallypermitted by Code. Charting and clerical stations,waiting areas, dining rooms, and activity spacesmay be open to the corridor under certainconditions specified in the Code. Gift shops maybe separated from corridors by non-fire ratedwalls if the gift shop is fully sprinklered.)

F O RM CMS -2 5 67(0 2 -9 9 ) P rev ious V ers ions O bso le te E ven t1 D :2 QK 1 2 1

K017 K017N FP A 1 01 LIFE SAFE TY CO DE ST AN DAR DCORRECT / VEACT /ONSA . N ew /R ev is ed P ro ce sse s & P ro ce du re s

N A

B . R e pa ir/R e pla ce m en tM itig ate th ro ug h s ea lin g p en etra tio ns fo r th efollowing: 6 th F lo or: P en etra tio n in c orrid or wall b y

R oom 6E -3 . W o rk o rde r # 441 9 68C . P e rs o nn e l T r ai nin g lNo t if ic a tio n

E ducate k ey staff (S ervic es D irec tors,F a c il it y 1 0 : CA 0 6 0 00 0 0 2 7

02/18/2011

(X5)COMPLETIONDATE

If continuation sheet Page 5 of 5

02/16/11

6122111


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D EPARTMENT O F HEALTH AND HUMAN SERV ICESCENTERS FO R MED ICARE & M E DICA ID S ER VIC ES

PRINTED: 06/10/2011FORM APPROVEDOM B NO 0 9 3 8-0 3 9 1S TA TE M EN T O F D E FIC IE NC IE SA ND P LAN O F C OR RE CT IO N

050376

( J


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DEPARTMENT O F HEALTH AND HUMAN SERV ICESCENTERS FOR MED ICARE & M ED ICA ID S ER VICE S

PR I N T ED : 06/10/2011F O RM A PP R OV EDOMS NO 0 9 3 8-0 3 9 1S TA TE M E NT O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

( X 1 ) P ROV I DER /SUPP L IER / C LI AID E N TIF IC AT IO N N U M BE R :

-N AM E O F P RO VID ER O R SUP PL IE RLAC/HARBOR-UCLA MED CENTER

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NC Y M UST BE PR ECE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN FO R MA TIO N )

Th is STANDARD is not m et as evidenced by: 5 th F lo or: R e pla ce la tc h c ov er o f 5 E as t 02/15/11c o nv en ie nc e d oo rs , r emo ve s to ra ge~--~ 2/15111 - 5 th F loor . i tems obs t ruc t ing_door f romopen ing jnAf1 0:46 a.m ., ttierE lwas a latch cover plate R o om 5 #GCRC -2 0 1 , re mov e tra sh c anm issing from the 5 E ast convenience doors. A im p ed in g c lo su re o f d oo r to a nd re pa irround penetration was exposed in one door.

A t 1 0:5 8 a.m ., storage beh ind the door obstruc ted d oo r h ard wa re a t R o om 5 E -2 1 . re m ov er ub b er g lo ve s impedin g c lo su re o f 5the door from opening in Room 5#G CRC-2 0 . I Ea st c or rid or d oo r, r ep air d oo r la tc hThe door opened at an approx im ately 5 0 degree Iangle. I p la te o n R o om 5 E -1 2 d oo r, re pa ir d oo rA t 1 1 a.m ., the door to R oom 5E -2 1 was held to R oo m 5 E -1 0 . W o rk o rd er # 45 1 83 5open w ith a trash can. W hen the trash can was 4 th F l oo r: Remo ve s to ra ge it ems 02115/11rem oved the door hardware obstruc ted the door o b st ru ct in g d oo r f rom openin g in Roomfrom closing and latch ing. 4E -3 3 .Wo rk o rd er #4 5 1 89 4At 1 1 : 0 7 a.m ., the East corridor door was held 2 nd F lo or : Remo ve s to ra ge it ems 06/28/11open by a rubber glove stuffed at the bottom of I o b st ru c tin g d oo r f rom openin g in Roomth e d oo r. I 2 - 5 - 1 , r epa ir /enab le se lf -c lo s ing devic eA t 1 1 : 0 8 a.m ., the door to R oom 5E -1 2 fa iled to o n s elf- clo sin g d oo r to R o om 2 -5 -3 2 .latch . The latch plate was b roken. re pa ir d oo r la tc h to R o om 2 -A -8 . re mov eAt 1 1 :1 2 a.m ., the door to R oom 5E -1 0 c losed but c art im p ed in g c lo su re o f d oo r to R o omfailed to latc h. 2 B - 6. W o rk o rd er # 46 47 71 1 st F lo or : Remo ve c a rt o b st ru c tin g t he 02 /16 /114 th F lo or- do or in R oo m 1 J-6 . W o rk o rd er # 46 47 95At 1 :2 1 p.m ., storage beh ind the door obstruc ted 8th F l oo r: Repa ir se lf -c lo s ing door toRoom LC -8 0 1 . r olle r la tc h es p erm it te d

F O RM CMS -2 5 67 (0 2 -9 9 ) P re vio us V e rs io ns O b so le te E v en t I D :2 Q K 1 21 Fac i l i ty 1 0 : CA06 0 0 0 0 0 2 7 If continuation sheet Page 7 of 5

(X4 ) IDPREF IXTAG

K 0 1 8 Continued F rom page 6are provided w ith a m eans suitab le for keepingthe door c losed. D utch doors m eeting 1 9.3 .6 .3 .6are perm itted. 1 9 .3 .6 .3R oller latches are proh ib ited by C MS regulationsin a ll h ea lth c are fa cilitie s.

(X 3) D A TE S UR VE YCOMPLET ED( X2 ) M U L TI PL E CO N S TR U C T IO NA. BUILDING 01 - MAIN BUILDING 01B . W ING _

P RO V ID E R'S P LA N O F C OR R EC TIO N (E AC H CO RR ECT IV E AC TIO N SHO ULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEFTCfEIIlCY)

ST RE ET AD DR ESS . C ITY . STATE . Z IP CO DE1000 W CARSON STTORRANCE, CA 90509

IDPR EF I XTAG

K 0 1 8 K 0 1 8NFPA 1 0 1 LIF E SAF ETY CO DE ST AN DAR DCORR EC T IV E A C TIO NSf 6 , . New /Rev ised P rocesses & Procedures

NAB . R e pa ir lR e pla cemen t

M i tig at e t hr ou gh r ep air o f d oo rs , r emo val o fo b st ru c tio ns t o d oo rs o pe nin g, r ep air o f la tc hp la te s , r emova l o f i tems impend ing c lo sure o fdoor s, r emova l o f i tems ho ld ing se lf -c lo s ingd oo rs o pe n, a nd s ea lin g o f p en et ra tio ns f orthe fo ll ow ing :

02/1812011

(X5)COMPLETIONDATE


9/62

DEPARTMENT OF HEALTH AND HUM AN SERV ICESRE & M ED IC AID SE RV IC ES

PR IN T E D : 06/10/201F O RM A PP R OV EOMB NO 09 3 8-0 3 9 1ENTERS FOR M ED ICAS TA TE M E NT O F D E FIC IE N CIE S ( Xl ) P R O V ID E R /S U P PL IE R /C L IA ( X2 ) M U LT IP LE C O N ST R UC T IO N (X3 ) D AT E S UR VE YCOMPLET EDND PLAN O F CO R RECT IO N ID E N T IF ICAT IO N NUM BER : A. BU ILD ING 01 - MAIN BUILDING 01

B .W ING 02/18/201150376f-S TR EE T A DD RE SS , C IT Y, S TA TE , Z IP C OD EAM E O F P RO VID ER O R SUP PLIE R1000 W CARSON STLAC/HARBOR-UCLA MED CENTER TORRANCE, CA 90509

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S 10 P RO V ID E R'S P LA N O F C OR R EC TIO N (X5)X4 ) 10(E ACH CO RR ECT IV E ACT IO N SH OULD BE COMPLETIONPREF I X (E ACH D EF IC IE NC Y M UST BE P RE CE DE D BY F ULL PREF IX C RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TE DATETAG R E GU LA TO R Y O R L SC ID E NT IF YIN G IN FO R MA TIO N ) T AG DEF IC IENCy }

K0 18 on non- co rr id o r d oor s on ly , s ea lK 0 1 8 Continued F rom page 7 p en etra tio n in d oo r to R oom 8W -1 0 .the door from opening in R oom 4E -3 3 . The door W o r k o rd er # 45 1 8 64 02 / 15 / 1 1pened approx im ate ly 2 4 inches. 61 hF lo o r: R epair d oor t o Conf er en c eR o om 6 L-2 , rem ov e item im p ed in g2 nd F loor- c lo su re o f d oo r to R oom 6W -1 4, re m oveA t 2 :2 7 p.m ., s torage beh ind the door obstruc ted item s im p ed in g c lo su re o f d oo r to R o om 6/22 /11he door from opening in R oom 2 -S -1 . T he door 6W - 1 6, rem ov e item im p ed in g c lo su re o fopened approx im ate ly 2 8 inches. d oo r to R oom 6W -2 9 , re pa ir d oo r toA t 2 :42 p.m ., the se lf-c losing device was d isab led R o om 6W - 2 0 , rem ov e item im p ed in gon the door to locker room 2S-3 2 . c lo su re o f d oo r to ro om 6W -2 , re m oveA t 4:0 1 p .m ., the door to the cast room , 2 A -8, item im p ed in g c lo su re o f d oo r to ro om 0 2 / 1 6 / 1 1losed but fa iled to latch . 6 E -4 2C, rem ov e ru bb er w e dg e im p ed in gA t 4:0 7 p.m ., the door to R oom 2B-6 was c lo su re o f d oo r to R oom 6 -E -2 9 . W o rkobstruc ted from c los ing by a urology cart. o rd e r # 4 5 1 9 3 5 0 3 / 0 3 / 1 1 1 s 1 F lo o r: R emove k ic k st and h o ld in g2 / 1 6 1 1 1 - 1 st F loor - o pe n s elf- clo sin g d oo r to R o om CLC -A t 9 :47 a.m ., a persona l pro tec tive equipm ent 2 0 1 , s ea l p en etra tio n to d oo r o f R o om(PPE ) cart was obstruc ting the door, 1 J-6. D uring 1F : 12 , r ~ p_a irs e lf -c lo~ il1g doo rt o Room---- arrin1 eN ieW 'a f9 :4Ta.m ., direc t care sta ff 1 G -4 8. W o r k o rd er # 45 2 5 6 8reported that the PPE cart stays in th is location , in B as em e nt: R em ov e w e dg e im p ed in g 0 2 / 1 6 / 1 1front of the door. c lo su re o f s elf- clo sin g d oo r to R o om B -2 1 1 5 1 1 1 - 8 th F loo r 1 0 9 , rem ov e item im p ed in g c lo su re o fA t 1 1 :1 0 a .m ., the self-c los ing doub le door to LC s elf -c lo sin g door to R oom B -0 1 7 /E x am80 1 fa iled to fully c lose and positive la tch . RoomA5 . 0 3 / 0 1 / 1 1t 1 1 : 1 5 a .m ., eigh t patien t room s had ro lle r 2 nd F lo o r: R epair s elf -c lo sin g door t ola tches on bath room doors, in the P sych ia tric R oom 2 E -1 2 . W o rk o rd er # 45 3 72 7Unit, 8W . The FM Staff 2 confirm ed that there N 24 C lin ic : R emove k ic k sta nd h o ld in g 0 2 / 1 6 / 1 1were roller latc hes on 8 of 8 bath room doors. Room RR~ 9open, repa ir se lf -c l osi nqA t 1 1 :3 0 a.m ., in R oom 8W 10 , there was an door fr om Reg is tr at io n A t o R eg is tr at io napproximately 1 /2 inc h penetration th rough the B , rem ov e k ic ks ta nd h o ld in g o pe n s elf-door, above the door knob . c lo sin g d oo r to R o om B -1 7 . 0 2 / 1 5 / 1 1 7 1 hF lo or: R e pa ir d oo r la tc h to R o om 7 E -6th F loo r- 14 , r epa ir s e lf -c los ing doo r la t ch 0 RoomAt 1 : 0 0 p .m ., the se lf-c losing door to Conference 7W - 3 9 . W o r k o rd er # 45 1 8 68R oom , 6L2 , fa iled to positive latch . 5 th F lo or: R e pa ir d oo r to 5W - 5 .A t 1 :1 5 p .m ., the door to Patient R oom , 6W 14, 41hF l oo r : Repa ir s e lf -c los ing doo r l at c h 0 2 / 1 6 / 1 1was tied open w ith a cord .

to R oom 4W - 2 6.A t 1 :2 0 p. m ., the door to Patien t R oom 6W 16 was 3 rd F lo o r: R emove t ra sh b in im ped in g 0 2 / 1 5 / 1 1obstruc ted from c los ing by a cha ir and a m onitor. c lo su re o f s elf- clo sin g d oo r to R o om 3 L -4 ...CMS -2 5 67 (0 2 -9 9 ) P re vi ou s V e rs io ns O b so le te E v en t ID : 2 QK 1 2 1 FaCil i ty 10 . CA06 0 0 0 0 0 2 7 If continuation sheet Page 8 of 50


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DEPARTMENT OF HEALTH AND HUMAN SERV ICESCENTERS FOR MED ICARE & M ED IC AID SE RV IC ES

P RIN TE D : 0 6/1 0/2 01 1F OR M A PP RO VE DOMS NO 0 9 3 8-0 3 9 1S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

( Xl) P R O V ID E R /S U P PL IE R /C L IAID E N TIF IC A TIO N N U M BE R :

~N AM E O F PR OV ID ER O R SU PP LIE RLAC/HARBOR-UCLA MED CENTER

( X4 ) 1 0PREF IXTAGS UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN FO R MA TIO N )

( X2 ) M U LT IP LE C O NS T RU C TIO NA . BU IL D I NG 01 - MAIN BUILDING 01B . W ING _

S TR EE T A DD RE SS, C IT Y, S TA TE , Z IP C OD E1000 W CARSON STTORRANCE, CA 90509


02/18/2011

1 0 P R OV ID E R'S P LA N O F C OR R EC TIO N (X5)PREF I X (E AC H C OR RE CT IV E AC TIO N SH OULD BE COMPLETIONTAG C RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TE DATEOEAC IENc y ) -zr'u rmor ; 't:JIIUVI:: wt:0!:lt: flUIOIII!:l-upe1Ts elf -c lo sin g d oo r t o Room 2 0 6 , r emo ve 02 /15 /11K 0 1 8 wedge h o ld in g o pe n s elf -c lo sin g d oo r t o

R o om 2 0 2 -6 , re m ov e c art h old in g o pe ns elf -c lo sin g d oo r t o Room 2 - 0 -2 . 1 st F l oo r: Repa ir se lf -c lo s ing door la tc ht o s to ra ge c lo se t in PCDC Reg is tr at io n, 02 / 15 / 11r emove " ta ke -a - ti cke t" numbe r d ispensers ta nd h o ld in g o pe n s elf -c lo sin g d oo r t oPCDC reg is t ra t ion . Basemen t : Repa ir se lf -c lo s ing door l at chto R oo m 8 -2 5 8. W o rk o rd er # 45 3 72 3 02 /16 /11 N - 2 4 C lin ic : Remo ve wedge h o ld in go pe n d oo r to R oo m 3 0 . W o rk ord er 02 /16 /11#441968

K 0 1 8 Continued F rom page 8The power cord ex tended from the corridor toinside of the room .A t 1 :2 5 p.m ., the door latch to O ffice 6W 29 wastaped over preventing the door from positivelatching.A t 1 :3 0 p.m ., the door to P atient R oom , 6W 20 ,fa iled to positive latc h.A t 1 :40 p.m ., the door to the 6W 2 Nurses Loungewas obstruc ted from c losing by a trash can.At 2 :0 5 p.m ., the door to the 6E42C wasobstruc ted from c losing by a chair.A t 2 :3 5 p.m ., the door to O ffice 6E 2 9 wasobstruc ted from closing by a rubber wedge.

2 /1 6/1 1 -1 st F loorAt 9 :1 5 a.m ., the self-c losing door to CLC2 0 1 washeld open w ith a k ick stand.Af9 :2 2-a:m ~: in-O ffice 1 'F 1 2,there was anapprox imately 1/4 inch penetration th rough thedoor above the door knob .At 9 :5 0 a.m ., the self-c losing door to 1G4BM ulti-E xam R oom failed to fu lly c lose and positivelatch.Basem ent -A t 1 0 :1 5 a.m ., the self-c losing door to 81 0 9 washe ld openw it h awedge.A t 1 1 :0 0 a.m ., the self-c losing door to 80 1 7 E xamRoom AS was held open w ith a chair.2/17 /11 - 2 nd F loorAt 8 :3 0 a.m ., the self-c losing door to 2 E 1 2 , theO R dirty linen room , fa iled to fu lly c lose andp os itiv e la tc h.2/17/11 - N24 Clin ic -A t 3 :0 0 p.m ., the door to the M en's R estroomRR9 was held open w ith a k ic k stand.

F O RM CMS -2 5 67 (0 2 -9 9 ) P re vi ou s V e rs io ns O b so le te E v en t I D :2 Q K 12 1

C . P e rs on ne l T ra in in g/No tif ic a tio n E du ca te k ey s ta ff ( Se rvic es D ire cto rs ,

Med ic a l D e pa rtmen t C h air s, a nd Nu rs in g_ .Lead,ersh ipCounc ll ) by meansot ,Managemen t Bu lle ti n and p resen ta ti ona t Ope ra ti ons Managemen t Counc ilme e tin g o f n ec e ss it y - a nd a pp ro pr ia tew ay - to re po rt s afe ty la ps es in th ephysical envi ronment.

QUA LIT Y IM P ROV EM EN TA. P lanning

M onitor as part of docum entedinterd isc ip l inary HazardSurvei ll ance /Env ironmenta l Rounds fo ro c c ur ren ce o f l if e sa fe ty l apses( in c lud ing imped imen ts to door open ingso r c lo s ings) i n t h e phys ic a l envi ronmen tand pe rformance o f r equ ir ed co rr e ct iveac t ions . In it ia te t ime ly co r rec t ive ac t ions ,as appropr ia te .

B , M onitoring F ac ilitie s Ma na gemen t, E n viro nme nta l

F a c il it y 1 0 : CA 0 6 0 0 0 0 02 7 If contlnuation sheet Page 9 ot 5


11/62

PR IN T E D : 06/10/2011F O RM A PP R O VE DO MS N O 0 9 3 8 -0 3 9 1D EP AR TM EN T O F HE ALTH AN D HUM AN SE RV ICE SC EN TE RS F OR M ED IC AR E & ME D IC A ID S E R V IC E S

S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N ( X2 ) M U LT IP LE C O NS TR U CT IO NA. BUILDING 01 - MAIN BUILDING 01(X3 ) D AT E S UR VE Y

COMPLET ED( X 1) P ROV I DER /SUPP LI ER /C L IAID E N TIF IC AT IO N N U MB E R:

B . W ING _0 5 0 3 7 6 02/18/2011. . .N AM E O F PR OV ID ER O R SUP PL IE R STR EE T AD DR ESS , C ITY , STATE , Z IP CO DE

1000 W CARSON STTO RR AN CE . CA 9 05 09A C/H AR BO R -U CLA M E D C EN TE R

P RO VID E R'S P LA N O F C OR RE CT IO N(E ACH CO RR ECT IV E ACT IO N SHO ULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IAT EDEFICIEIt tC1')

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE PR ECE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN FO R MA TIO N )

IDPREF IXTAG

(X5)COMPLET I ONDA TE

( X4 ) IDPREF IXTAG

ser vic e s, in re cn on conno i anaHOSp i t a lAdm in is t rationo a) conduc tweek lyHazardSurvei l lance/Env i ronmenta lRo undsof fac i li tyfor occu rrenceof l ifesafety lapsesin the phys ica lenv i ronment ,b ) com plet ionof l ife safetycorrect iveact ions.Faci l i t iesM anagem ento repor t li fe safetyresul tsquar ter lyto Envi ronm ento fCa reCommi t tee .

K 0 1 8 C ontinued F rom page 9A t 3 :2 0 p .m ., th e self-c lo sing do or fro mR e gis tra tio n A to R e gis tra tio n 8 fa ile d to fu llyc lo se a nd p ositive la tc h w he n re lea se d fro m th em a gn etic lo ck d urin g fire a la rm te stin g.A t 3 :2 5 p .m ., th e se lf-c los ing door to R oom 81 7,th e d oc to rs c on fere nc e ro om , w as h eld o pen w itha k ic k sta nd.

K 0 1 8

R ES PON S IB L E POSIT ION (S ) F a cilitie sM a na gem en tDi rectorB a se d o n o b se rv atio n a nd in te rv ie w , th e fa c ilityfa ile d to m a in ta in th eir c orrid or d oo rs . T his w ase vid en ced b y d oo rs th at fa ile d to la tc h, an d b yd oo rs th at w ere ob stru cted fro m c los in g. T hisa ffe cte d e ig ht o f e ig ht flo ors , th e b as em e nt, a ndth e N -2 4 c lin ic , a nd c ould re su lt in th e sp re ad ofsm okeanc ffire ,- ih th e even tot a-fire~ - .._ -N F PA 1 0 1, L ife S afe ty C od e, 2 0 00 E ditio n.7 .2 .1 .8 .1 A d oo r no rm a lly re qu ire d to b e k eptc lo se d sh all n ot b e se cu red in th e o pe n p ositio na t a ny tim e a nd sh all b e se lf-c lo sin g ora utom a tic -c lo sin g in a cc o rd an ce w ith 7 .2 .1 .8 .2 .F ind ings:D u rin g th e fa c ility to ur w ith fa cilit ie s m a n ag em e n ts ta ff , f rom 2/15 /11 - 2/17 /11, th e fa c ilit y d o or sw e re o b se rv e d.O n 2/15/11, F lo ors 2 th ou gh 8 of th e h osp ita lw e re s u rv e ye d .7 th F lo or-A t 1 0 :0 7 a.m ., th e door to R oom 7E -1 4 fa iled top o sitiv e la tc h .A t 1 0:1 7 a .m ., th e door to R oom 7W -3 9 was

If continuat ion sheet Page. ; 10 of 50a c il it y I D : CA 0 60 0 0 0 0 2 7v e nt I D :2 QK 1 2 1O RM CMS -2 5 67 (0 2 -9 9 ) P re vio us V e rs io ns O b so le te


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PR IN T E D : 0 6 /1 0 /2 0F O RM A P P R O V EO MS N O 0 9 3 8 -0 3 9D EP AR TM EN T O F HE ALTH AN D H UM AN SE RV ICE SCE NTE RS F OR M ED ICAR E & ME D I CA ID S E R V IC E S

S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N ( X2 ) M U LT IP LE C O NS T RU C TIO NA. BU ILD ING 01 - MAIN BUILDING 01B . W IN G _

( X 1 ) P ROV l DER /SUPP L IER / C LI AID E N TIF IC A TIO N N U M BE R :


0 5 0 3 7 6 02/18/2011I-N AM E O F P RO VID ER O R SUP PL IE R ST RE ET AD DR ESS , C ITY , STATE , Z IP C OD E1000 W CARSON STTO RR AN CE , CA 9 05 09L AC /H AR BO R -U CL A M E D C EN TE R

S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R LS C ID E NT IF YIN G IN FO R MA TIO N )

P R OV ID E R'S P LA N O F C OR R EC TIO N(E ACH CO RR ECT IV E ACT IO N SHO ULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEF I C I ENCY )

IDPREF IXTAG( X4 ) IDPREF I XTAG

(X5)COMPLETION

DATE

K 0 1 8 C ontinued F rom page 1 0e qu ip pe d w ith a se lf-c lo se r. T he d oo r c lo se d b utfa ile d to la tc h .

K 0 1 8

5 th F lo or-A t 1 0 :48 a .m ., th e door to R oom 5 W -5 c losed bu tfa ile d t o p o sit iv e la tc h .4 th F lo or -A t 1 :1 0 p .m ., th e door to R oom 4W -2 6 w ase qu ip pe d w ith a s elf-c lo se r. T he d oo r c lo se d b utfa ile d to la tc h .3 rd F loo r ~A t 1 :3 7 p .m ., th e door to R oom 3 L-4 w ase qu ip pe d w ith a se lf-c lo se r. T he d oo r w as h eldo pe n w ith a tra sh b in th at o bs tru cte d th e d oo rfr om c lOS in g .2 n d F lo or-A t 3 :5 1 p .m ., th e doo r to R oom 2 06 w as equ ippedw ith a se lf-c lose r. T he door w as h eld open w ith aru b be r w e dg e.A t 3 :5 5 p .m ., th e door to R oom 2 02 -6 w ase qu ip pe d w ith a se lf-c lo se r. T he d oo r w as h eldo pe n w ith a ru bb er w ed ge .A t 4 :0 6 p .m ., th e door to R oom 2 -D -2 w ase qu ip pe d w ith a s elf-c lo se r. T he d oo r w as h eldo pe n w ith a p ro te ctiv e e qu ip m en t c art.2 /16111 - 1 st F lo orA t 1 0 :0 6 a .m ., th e door to th e sto rage c lo se t, inth e P C DC re gis tra tio n o ffic e, c lo se d b ut fa ile d tola tc h. T h e d oo r w as e qu ip pe d w ith a s elf-c lo sin gdev i ce .A t 1 0 :0 9 a .m ., th e doo r from th e w aitin g area toth e P C D C re gis tra tio n o ffic e, w as h eld o pe n b y a

Fac i l i ty 1 0 : CA0 6 0 0 0 0 0 2 7 If continuation sheet Page 11 of 5ORM CMS -2 5 67 (0 2 -9 9 ) P re vio us V e rs io ns O b so le te E v en t ID : 2 QK 1 2 1


13/62

D EPARTMENT O F HEALTH AND HUM AN SERV ICESCENTERS FOR M ED ICARE & MED ICA ID SERV ICES

PR I N T ED : 06/10/2011F O RM A PP R OV E DOM B NO 0 9 3 8-0 3 9 1

S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

(X 1 ) P ROV I DER /SUPP lI ER /C lI AID E N TIF IC AT IO N N U M BE R :

I-N AM E O F PR OV ID ER O R SU PP LIE RLAC/HARBORUCLA MED CENTER

S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E ACH D EF IC IE NC Y M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R LS C ID E NT IF YIN G IN FO R MA TIO N )(X4) IDPREF IXTAG

K 0 1 8 Continued F rom page 1 1"take-a -tic ke t" num ber dispenser stand. The doorwas equipped w ith a self-c losing device .Basem ent -A t 1 :1 9 p .m ., th e door to R oom B-2 5 8 wasequipped w ith a self-c loser. T he door c losed bu tfa iled to latc h.

K 0 2 0

2 /1 7/1 1 - N -2 4A t 3 :1 6 p.m ., the door to R oom 3 0 was held openby a rubber wedge .N FPA 1 0 1 LIF E SAFE TY CO DE STANDARDS tairw ays, e leva tor sh afts, lig ht and ven tila tionsha fts, ch utes, and o ther vertica l openingsbetw een floors a re enc losed w ith construc tionh ay in g a fire re ~ is t~ l1 c e r atin go f_ atJ e~ l5 t0 l'! ehour. An atrium m ay be used in accordance w ith8.2 .5 .6 . 1 9 .3 .1 .1 .

Th is STANDARD is not m et as evidenced by:O n 2 /1 7 /1 1 , the N -2 4 c lin ic and the F am ilyM ed ic al C lin ic w ere s urve yed.At 1 :2 5 p.rn., there were two approx im ately 1 /4-1 /2 inc h pene tra tions in th e front wa ll, above thedoor, ex iting from the South sta irway in theF am ily M edic al C lin ic .A t 2 :1 5 p .m ., th ere was an approx im ately 1 /8 -1 /4 inch penetration in th e 2 N orth sta irway .Based on observation, th e fac ility fa iled tom ainta in the ir ve rtica l openings. Th is wasevidenced by penetra tions in th ree sta irw ayenc losures. T his a ffec ted one of th ree s ta irwe llson the 4th floo r of the m ain hospita l, and two of

CMS -2 5 67 (0 2 -9 9 ) P re vi ou s V e rs io ns O b so le te E ve ntlD : 2 Q K1 2 1

(X3 ) D AT E S UR VE YCOMPLET ED(X2) MU L TI PL E CO N S TR U C TI O NA. BUi lD ING 01 MAIN BUILDING 01B . W ING _

P RO VID ER 'S P LA N O F C OR RE CT IO N(E AC H CO RR ECT IV E AC TIO N SHO ULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEF IC IENCy )

STR EE T AD DR ESS, C IT Y, STATE , Z IP C OD E1000 W CARSON STTORRANCE, CA 90509

IDPREF IXT AG

K 0 1 8 K 020N FPA 1 01 LIFE SAFE TY CO DE ST AN DAR DCORRE C T IV E A C TIO N SA . New lRe v is e d P r o ce s se s & Procedures

N A

K 0 2 0

B . R e pa irlR e pla ce m en tM i ti ga te t h rough sea li ng penet ra t ions fo r t h efol lowing: F am ily M ed ic in e C lin ic : S ea l w a ll

penet ra t ions b y the Sou th s ta irway,s e alin g p e ne tr at io n in t he 2 No rt hs ta ir wa y . W o rk o rd e r # 4 5 3 5 2 8

4th F loor: S eal pen etration s in W e st W a llo f th e W e st s ta irw ell e nc lo su re o n t he4 th f lo or . W o rk o rd er # 44 1 9 68

C . P e r so n ne l T r ain in g lNo t if ic a tio n E duc ate k ey staff (S ervic es D irec to rs,

Med ic a l D e p ar tmen t C h a ir s, a n d Nu rs in gL ea d er sh ip Coun c il) b y means o fManagemen t Bu ll et in and p resentat iona t Op e ra tio ns Management Coun c ilme e tin g o f n e ce s sit y - a n d a p pr op ria tew ay - to re po rt s afe ty la ps es in th ephys ica l env ironment .

QUA L IT Y IM P ROV EM E NTA . Planning

M onito r as part o f docum entedinterd isc ip l inary HazardSurve il lance /Env i ronmenta l Rounds fo ro c c u rr ence o f l if e sa fe t y l apses( in c lud ing wa ll and ce il in g penet ra ti ons )in t he p h ys ic a l e n v ir onment a n dpe rformance o f r equ ir ed co rr e ct iveac ti ons . I ni ti at e t ime l y c o rr e ct ive ac tions ,as appropr ia te .

F a c il it y I D : CA 0 6 0 0 0 00 2 7

02/18/2011

(X5)COMPLETION

DATE

02 /16 /11

02 /16 /11

6 /22 /11



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D EPAR TM EN T O F HE ALTH AN D HUM AN SE RV ICE SC EN TE RS F OR M ED IC AR E & MED IC A ID S E RV IC E S

PR INTED : 06/10/201F O RM A PP RO V EO MB NO 09 3 8-0 3 9S TA TE M EN T O F D E FIC IE N CIE SAN D P LAN O F C OR RE CT IO N

050376

( X1 ) P ROV I DER /SUPP lI ER /C ll AI D E NT IF IC A TI O N N UM B ER :

-N AM E O F P RO VID ER O R SUP PL IE RLAC/HARBOR-UCLA MED CENTER

( X2 ) M U LT IP LE C O NS TR U CT IO NA. BU ilD ING 0 1 - M AIN BU ILD ING 0 1B . W ING _

( X3 ) D AT E S UR VE YCOMPLET ED

ST RE ET A DD RE SS, C IT Y, S TAT E, Z IP C OD E1 0 0 0 W CAR SO N STTORRANCE, CA 90509

02/18/2011

(X5)COMPLET I ONDATE(X 4) 1 0PREF IXTA G

A c ce (: ;~ to _e xits is l1 1 a rk ~ d ~ a pp ro ve d, re ad ily _vis ib le signs in a ll c ases w here th e ex it o r w ay tore ac h e xit is n ot re ad ily a pp are nt to th eoccupants . 7 .1 0 .1 .4

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR E GU LA TO RY O R LS C ID E NT IF YIN G IN FO R MA TIO N )

K 0 2 0 C ontinued F rom page 1 2tw o sta irw ay s in th e U C LA -H arb or F am ily M e dic alC lin ic . T his c ou ld resu lt in th e spread of sm ok ean d fire th at c ou ld a ffe ct e va cu atio n, in th e e ve ntof a fire .F ind ings :D u rin g th e fa cility to ur w ith F M S ta ff, fro m 2/15/11to 2/17/11, th e s ta ir wa ys we re o b se rv ed .

K 0 2 2

4 th F lo or-O n 2/15/11, at 1 :1 5 p .m ., there w as anapprox im ate ly 1 inc h penetra tion in th e W e st w allo f th e W e st sta irw ay .N FP A 1 0 1 LIF E SAF ETY CO DE STAN DAR D

Th is ST AN DAR D is not m et as evidenced by:B as ed o n o bs erv atio n, th e fa cility fa ile d tom ain ta in . th e ex it s igns in 1 o f 1 sm ok ec om partm ent a t th e F am ily M ed ic al C lin ic . T hisw as e vid en ce d b y a d ire ctio na l s ig n p oin tin g aw ayfro m th e e xit p ath . T h is c ou ld d ela y e va cu atio na nd in cre ase d th e risk o f in ju ry to p atie nts,v is ito rs and sta ff in th e event of a fire .FORM CMS 2 56 7 (0 2 9 9) t :'r ev io u s V e rs io n s O b s ol et e E v e nt I D :2 QK t2 t

1 0PREF IXTAG

K 0 20 ~'

K 0 2 2

P RO V ID E R'S P LA N O F C OR RE CT IO N(E ACH CO RR ECT IV E ACT IO N SHO ULD BEC RO SS -R EF E RE N CE D T O T HE A PP RO PR IA TEDEF IC IENCy )

Monitor ing F a cilitie sM a na gemen t,Env i ronmenta lServices,Infect ionControland Hosp ita lAdm in is t ra t iono a) conductweeklyHazardSurvei l lance/EnvironmentalRoundsof fac il it y fo r occur renceof l ifesa fe ty lapsesin the phys ica lenv i ronment ,b) com ple tionof l ife sa fe tycorrectiveactions.Facil it iesM anagem ento repor t li fe sa fe ty resu l tsquar te rlyto Env i ronmento f CareCommi t t ee .

q E SPON S IB LE POS IT IO N(S JFaci l i t iesManagementDi rec tor

F a c il it y 1 0 : CA 0 6 00 0 0 0 2 7

_



15/62


PRINTED: 06/10/2011FORM APPROVEDOMB NO 0938-0391S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N ( X 1 ) P ROV I DER / SUPP L IER / C LI AID E N TIF IC AT IO N N U M BE R :

~fl.... to O F P RO VID ER O R S UP PL IE R

050376


(X3) D AT E S UR VE YCOMPLET ED( X2 ) M U LT IP LE C O N ST R UC T IO NA BU ILD ING 01 - MA IN B U IL DIN G 01B . W ING _ 02/18/2011

(X4 ) IDPR EF I XTAG

S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E ACH D EF IC IE NC Y M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN F OR M AT IO N )

(XS)COMPLET I ONDATE

K 020 Continued From page 12two stairways in the UCLA-Harbor Family MedicalClinic. This could result in the spread of smokeand fire that could affect evacuation, in the eventof a fire.Findings:During the facil ity tour with FM Staff, from 2/15/11to 2/17/11, the stairways were observed.4th Floor-On 2/15/11, at 1:15 p.m., there was anapproximately 1 inch penetration in the West wallof the West stairway.

K 022 f\iFPP,10-1liFE SAFETY CODE STA!\!DARDAccess to exits is marked by approved, readilyvisible~ignsinallcases where the-exit or-way to -reach exit is not readily apparent to theoccupants. 7.10.1.4

This STANDARD is not met as evidenced by:Based on observation, the facility failed tomaintain the exit signs in 1 of 1 smokecompartment at the Family Medical Clinic. Thiswas evidenced by a directional sign polntinq awayfrom the exit path. This could delay evacuationand increased the risk of injury to patients,visitors and staff in the event of a fire.

Personnel Tra ining/Not i fication E ducate key staff (Services D irec tors,

Me dic al D e pa rtme nt C ha irs , a nd Nu rs in gL ea de rs hip C ou nc il) b y m e an s o fManagemenfBuiletin-and-presentationa t O p era tio ns Mana gemen t C ou nc ilm e etin g o f n ec es sity - a nd a pp ro pria tew ay - to report safety lapses in thephysical envi ronment.

02/16/11

ORM CMS-2 5 67(0 2 -9 9 ) P rev ious V ers ions O bsolete E ven t ID :2 QK 1 2 1

STR EE T AD DR ESS , C ITY . STATE , Z IP CO DE1000 W CARSON STTORRANCE, CA 90509

1 0PREF IXTAG

P RO VID E R'S P LA N O F C OR RE CT IO N(E ACH CO RRE CT IV E ACT IO N SHO ULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEFICIENCy)

K 020 K022N FPA 1 01 LIF E SAFE TY CO DE STAN DAR DCOR R EC TIV E A C TIO NSA. N ew /R evised P rocesses & P rocedures

N A

B . Repair lReplacementM i ti ga te t hr ough r epai r ( re posi ti on ing) e x its ig n f or t he f ol low ing: F am ily M edic ine C linic : R eposition ex it

sign by M en's R estroom M odule A to theex it s ta irway .

QUA L IT Y IM P ROV EM E NTA. P lanning

M onitor as part of docum entedinterdisciplinary-HazardSu rvei ll an c e/Env ir onment al Rounds f orlife s afe ty la ps es ( in clu din g n on -fu nc tio na l o r im p ro pe rly p os it io ne d e xit ss ig ns ) in th e p hy sic al e nv iro nm en t a ndper fo rmance o f r equ ir ed co rr ec ti vea c ti on s. I ni ti at e t ime ly c o rr ec ti ve a c ti on s,as appropr iate.

B . Monitor ing F ac ilities M anagem en t, E nvironm entalSe rv ic e s, I nf ec ti on Cont ro l and Hosp it al

Fac i l i ty 1 0 : CA06 0 0 0 0 0 2 7 If continuation sheet Page 13 of 50


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D EP AR TM EN T O F H EALTH AN D HU MAN SE RV ICE SC EN TE RS F OR M E DIC AR E & M E DIC AID S ER V IC ES

P RIN TE D: 0 6/1 0/2 01 1F OR M AP PR OVE DO MB N O 0 9 3 8 -0 39S TA TE M E NT O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N (X l) P ROV ID ER / SU P P L IE R / CL IAID E N T IF IC A TIO N N UM B ER :

-N AM E O F P RO VID ER O R SU PP LIE R050376


( X2 ) M U L TIP L E C O N STR U CT IO NA. BUILD ING 01 - MAIN BUILDING 01B . W ING _

ST RE ET AD DR ESS, C IT Y, ST AT E, Z IP C OD E1000 W CARSON 51TORRANCE, CA 90509

( X3 ) D AT E S UR VE YCOMP LE TED

02/18/2011

S UM M AR Y S TA TE M E NT O F D E F IC IE N CIE S(E ACH D EF IC IE NC Y M UST B E P RE CE DE D BY F ULLR E GU LA TO R Y O R lS C ID E N TIF Y IN G IN F OR M AT IO N )(X5)

COMPLETIONDATE

(X4) IDPREF IXTAG1 0PREF IXTAG

P RO VID E R'S P LA N O F C OR RE CT IO N(E ACH CO RR ECT IV E A CT IO N S HO ULD B EC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEOEFlCtENCV)

K 0 2 2 C on tinued F rom page 1 3F indings:D u rin g th e fa cility to ur w ith F M S ta ff 3 , o n2/17111, th e e x it d ire c tio na l s ig ns w e re o b se rv eda t th e F a m ily M e dic al C lin ic .A t 2 :1 0 p .m ., th e ex it s ig n b y th e M en 'sR e stro om , M o du le A , w a s p oin tin g to w ard s th ec lin ic in ste ad o f to th e e xit s ta irw ay . F M S ta ff 3c o nfir m e d th a t th e d ire c tio n a rro w w a s p oin tin ga wa y fro m th e e xit.

K 0 2 5 N F PA 1 0 1 L IF E SAF E TY CO DE STAN DARDI Sm o ke b arrie rs a re c on stru cte d to prov i de a tle as t a o ne h alf h ou r fire re sis ta nc e ra tin g ina cc ord an ce w ith 8 .3 . S m ok e b arrie rs m a yt erm ina te a ran~ tr ium wa ll. -W ln 'd owsar e -p ro te c te d b y fire -ra te d g la zin g o r b y w ire d g la sspane ls and s tee l fra mes . A m in im um of tw os ep ara te c om p artm e nts a re p ro vid ed o n e ac hflo or. D a m pe rs a re n ot re qu ire d in d uc tp e ne tr atio n s o f sm o ke b a rr ie rs in fu lly d u cte dh e a tin g , v e ntila tin g , a n d a ir c o n dit io n in g s y stems .19 .3 .7 .3 ,19 .3 .7 .5 ,19 .1 .6 .3 ,19 .1 .6 .4

T his S TAN D AR D is no t m et as ev idenc ed by :B a se d o n o b se rv atio n, th e fa c ility fa ile d tom a in ta in th e ilJ te grity o f sm o ke b a rrie r w a lls , a se vid en ce d b y p e ne tra tio ns in th e w a lls . T h isc ou ld re su lt in th e sp re ad o f s m ok e a nd fire fro m. one sm ok e c om partm en t to an oth er. T hisa ffe cte d tw o o f e ig ht flo ors a nd th e b ase m en t inth e m a in h os pita l, a nd o ne o f tw o o utp atie ntc l in ics .

K 0 2 2Adm in is tra tio n to a ) c on du ct weeKlYHazard Survei llance/Environmenta lR ou nd s o f fa cility fo r o cc urre nc e o f lifes afe ty la ps es in th e p hy sic ale nv iro nment, b ) c omp le tio n o f life s afe tyco rrec ti ve ac tions . Fac il it iesMana gemen t to re po rt life s afe tyq ua rte rly to E n viro nment o f C areCommittee.

> :?ESPONSIBLE POSIT ION(S )Faci li ti es Managemen t D i re c to r

K 0 2 5 < 0 2 5N FPA 1 01 LIF E SAF ETY CO DE STAN DAR DrORRECTIVE ACT IONS.__ _ _ . __~ . N ew /R evise d P ro ce sse s & Procedures

N A

2 nd F lo or: S ea l s mo ke b arrie r pe ne tra tio n 0 2 /1 6/1 1in C hem lab, C C2 -9 . W o rk order#4519711 st F loor : Sea l smoke bar ri er penet ra ti ona t R oom 1 -P -1 , s eal s mo ke b arrie rp en etra tion a bo ve th e s ou th s ide o f th eEmerg en cy De pa rtme nt. Wo rk o rd er#464791Bas ement: S ea l smok e b arrie rp en etra tio n a cro ss from Room B -4 09 ,s ea l smok e b arrie r p en etra tio n o n th ele ft s ide of th e m ain k itc he n do ors , s ea lsmok e b arrie r p en etra tio n a t th e

~ . R ep air/R ep la ce m en tM itig ate th ro ug h s ea lin g p en etra tio ns fo r th efollowing:

P2/16/11

02/16/11

FORM CMS - 2 5 67 ( 0 2 -9 9 ) P re v io u s V e rs io n s O b s o le te E v e nt I D :2Q K 1 2 l F ac il it y I D : CA060 0 0 0 0 2 7 If continuation sheet Page 14 of 5


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PR IN T E D : 06/10/2011F O RM A PP R O VE DOM B NO 0 9 3 8-0 3 9 1

D EPARTMENT O F HEALTH AND HUMAN SERV ICESCENTERS FO R MED ICARE & M E DIC AID S ER VIC ES

S TA TE M EN T O F D E FIC IE N CIE SA ND P LAN O F C OR RE CT IO N

( X2 ) M U LT IP LE C O NS TR U CT IO NA . BUILDING 01 - MAIN BUILDING 01B . W ING _

(X3 ) D AT E S UR VE YCOMPLET ED( X l) P ROV I DER /SUPP LI ER /C L IAID E N TIF IC AT IO N N U MB E R:

050376 02/18/2011f-N AM E O F P RO VID ER O R SUP PL IE R STR EE T AD DR ESS, C ITY , STATE . Z IP CO DE1000 W CARSON STTORRANCE, CA 90509LAC/HARBOR-UCLA MED CENTER

P RO VID E R'S P LA N O F C OR RE CT IO N(E ACH CO RR ECT IVE ACT IO N SHO ULD BEC RO SS -R EF E RE NC ED T O T HE A PP RO P RIA TEDEF IC IENc y )

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E AC H D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR EG ULA TO R Y O R LS C ID E NT IF YIN G IN FO R MA TIO N )1 0PREF IXTAG

(X4) 1 0PREF IXTAG

(X5)COMPLET I ONDA TE

VIlI""vuna uuu, ~t;CI'"iliUM;; UClII't;'p e ne tr at io n b y Room B - 0 6- 1 6, s e alsm ok e b arrie r p en etra tio n b y R o om B -1 5 7 . W o rk o rd e r # 46 468 6

F am ily H ealth C lin ic : S ea l s m ok e b arrie rp e ne tr at io n in f ro n t o f Module A sign,s e al smo k e b a rr ie r p e ne tr at io n a t t hee nd o f M o d ule A c orr id or b y t he Me n'sRe s tr oom , s ea l t he smo k e b a rr ie rp en e tr at io n b y te W omen 's Re s tr oom ,s ea l t he smo k e b a rr ie r p en e tr at io n b yth e e ntra nc e to th e Mo d ule B w aitin gr oom , s ea l t he smo k e b a rr ie r p e ne tr at io nb y th e e xit s ig n in th e Mo du le C c orr id or .W o rk o rd er # 441 9 6 8

K 0 2 5 Continued F rom page 1 4 K 0 2 5Findings:D uring the fac ility tour w ith F ac ilities M anagem entS taff, from 2 /1 5 /1 1 - 2 /1 7/1 1 , the sm oke barrierw alls w ere ob serve d.

0 2 / 1 6 / 1 1

2 /1 5 /1 1 - 2 nd F loorA t 3 :0 4 p .m ., there was an approx im ately 1 /2 -3 /4 inch penetration around a pipe sleeve, in thesm oke barrie r at the Chern Lab , CC2 -9 . T hepenetration was to th e righ t s ide of the wa ll.2 /1 6 /1 1 - 1 st F loo rAt 9 :42 a.m ., the re was an approx im ately 1 /2 -3 /4 inch pene tra tion around a pipe sleeve, in thesm oke barrier at 1 -P -1 , on the righ t wall.

-A ffO :2 1a :m ~,there-w as anapprox lm afely 5 X 6inch penetra tion around p ipe sleeves, in thesm oke barrier above the sou th side of th ee m erg en cy d ep artm e nt.

~ . P e rs on n el T r ain in g /No tif ic a tio n E ducate key sta ff (Serv ic es D irec to rs, ~ /2 2 /1 1

Med ic a l D e p ar tmen t C h a ir s, a nd Nu rs in g-. Leade[sh ip_CQunc iJ)_b_ym eal1! lf ..Managemen t Bu ll et in and p resen ta ti ona t Op e ra tio ns Management Coun c ilme e tin g o f n e ce ss it y - a nd a p pr op ria tew ay - to rep ort safety l ap ses i n th ephys ica l env ironment .Basement -A t 1 :1 5 p .m ., there was an approx im ate ly 2 1 /2 -

3 inch penetration around a condu it in the righ twall of th e sm oke barrie r ac ross from B-40 9 .T he~ e was an approx im ately 3 inch penetra tionaround a conduit on the le ft s ide o f the m aink itchen doors. The sm oke barrier wall wasaccessed above the ce iling tiles, in the k itc hencorridor.A t 1 :3 7 p.m ., there was an approx im ate ly 1 /2 -3/4 inch pene tra tion between two pipes, in th erigh t s ide of the sm oke barrier wa ll a t th e U ltraS ound U nit.A t 1 0 :0 5 a.m ., the re was an approx im ately 1 /2 x 1inch penetration , by a condu it, above the droppedce iling on the righ t cente r of the sm oke barrier

'QUA L IT Y /MPROVEMENT~ . P lann ing

M onito r a s part o f documentedin terd isc ip linary HazardSurve il lance /Env i ronmenta l Rounds fo ro c c ur ren ce o f li fe safety lapses( in c lud ing wa ll and ce ili ng penet ra ti ons )in th e physi ca l envi ronmen t andpe rformance o f r equ ir ed co rr e ct iveac t ions . In it ia te t ime ly co r rec t ive ac t ions ,as appropr ia te .

B . M on itorin g F ac ilitie s M a na ge m en t, E nv iro nm e nta l

CMS 2 5 67 (0 2 -9 9 ) P re vi ou s V e rs io ns O b so le te E v e nt I D :2 QK 1 2 l F a c il it y 1 0 : CA 0 6 0 0 0 0 0 2 7 If continuation sheet Page 15 of 50


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D EPARTM ENT O F HE ALTH AND HUM AN SE RV ICE SCE NTE RS FO R M ED ICAR E & M ED ICA ID SE RV ICE S

PR I N TED : 06/10/201FORM APPROVEOM 8 NO 0 9 3 8-0 3 9S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

( X2 ) M U L TI PL E CO N S TR U C TI O NA. BUILDING 01 M AIN B UIL DIN G 01B . W ING _

(X3 ) D AT E SU RV EYCOMPLET ED

02/18/2011

( Xl) P R O V ID E R /S U P PL IE R /C L IAID E N TIF IC AT IO N N U M BE R :

-N AM E O F P RO VID ER O R SU PPL IE RLAC/HARBOR-UCLA MED CENTER

S TR EE T A DD RE SS, C IT Y, S TA TE , Z IP C OD E1000 W CARSON STTORRANCE, CA 90509 .

S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E AC H D EF IC IE NC Y M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN F OR M AT IO N )

( X4 ) 1 0PREF IXTAG

K 0 2 5 Continued F rom page 1 5w all b y R oom 80 6-1 6.1 1 :0 5 a .m ., th ere w as an approx im ate ly 1 x 1 1 2in ch p en etra tio n, ne ar th e lo we r c on du its , o n th ele ft c en ter o f th e sm ok e b arrie r w all b y R oom81 5 7 .2 /1 7 /1 1 - F am ily H ealth C lin icA t 1 :2 6 p .m ., there w as an approx im ate ly 3 x 1 /2in ch p ene tra tio n in th e sm o ke b arrie r w all, in th ec orridor in fron t o f th e M odu le A sign, ab ove th ed ropped ce il in g .A t 1 :3 0 p .m ., there w as an approx im ate ly 4 x 6in ch c ut-o ut p en etra tio n in th e s m ok e b arrie r w alla t the end of the M odu le A corridor, b y the M en 'sRest room.A t 1 :45 p .m ., th ere w as an approx im ate ly 8 foo tb y - 3 - fo o t c u t=ou f p ene tr at io n f n th -e s m o k e - ca rrie r .w all, b y th e W o m en 's R estroom .A t 1 :5 0 p.m ., th ere w as an approx im ate ly 3 inchc irc ula r p en etra tion in th e s m ok e b arrie r w all infron t o f th e entranc e to th e M odu le 8 w aitingroom.A t 1 :5 5 p .m ., there was an approx im ate ly 6 x 6inc h penetra tion in th e sm ok e b arrie r w all b y th eex it s ign in th e M odu le C c orridor.K 0 2 7 N FPA 1 0 1 LIF E SAFE TY CO DE STANDARDD oor open ings in sm ok e b arrie rs h ave at leas t a2 0 -m inu te fire p ro te ctio n ra tin g o r a re at le ast1% -in ch th ic k s olid b on de d wood c o re . N o n- ra te dp ro te ctive p la te s th at d o n ot e xc ee d 4 8 in ch esfrom th e b ottom of th e door are perm itted .H o riz on ta l s lid in g d oo rs c om p ly w ith 7 .2 .1 .1 4 .D o ors a re se lf-c lo sin g o r a uto m atic c lo sin g inac cordanc e w ith 1 9 .2 .2 .2 .6 . S wing ing doors are

F O RM CMS -2 5 6 7( 0 2- 99 ) P re vi ou s V e rs io ns O b so le te E v en t I D :2 Q K 12 l

1 0PREF IXTAG

K 0 2 5

K 0 2 7

P RO V ID E R'S P LA N O F C OR R EC TIO N(E AC H CO RR ECT IV E AC TIO N SHO ULD BEC RO SS R E FE R EN CE D T O T HE A PP R OP RIA TEDEF IC IENCy )

Ser vice s, I nf ec tio n Cont ro l a nd Hosp it alA dm in is tr atio n to a ) c on du ct w ee klyHazard Surve i llance/Env ironmenta lR ou nd s o f fa cility fo r o cc ur re nc e o f lifes afe ty la ps es in th e p hy sic ale nv ir onmen t. b ) c omp le tio n o f life s afe tyco rr ec tiv e a c tio ns . Repo rt r esul tsq uarte rly to th e E nvironm ent of C arecommittee.

R E S PON SIB L E PO SIT IO N (S I F ac ilities M anagem ent D irector

F a c il it y I D : CA 0 6 0 0 0 0 0 27

(X5)COMPLETIONDATE



19/62

PR I N T ED : 06/10/2011F O RM A PP RO V EDO MB N O 0 9 38 -0 39D EP AR TM EN T O F H EALT H AN D H UM AN SE RV ICE SC EN TE RS F OR M E DIC AR E & MED I CA ID S E R V IC E S

S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N ( X2 ) M U LT IP LE C O N ST R UC TIO NX 1 ) P ROV I DER /SUPP L IER / C LI AID E N TIF IC AT IO N N U M BE R : (X3 ) D AT E SU RV EYCOMPLET EDA. BU ILD ING 01 MAIN BUILDING 01B . W ING _050376 02/18/2011I-N AM E O F P RO VID ER O R SUP PL IE R ST RE ET AD DR ESS , C IT Y, ST AT E, Z IP C OD E

1000 W CARSON STTORRANCE, CA 90509LAC/HARBORUCLA MED CENTER

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NC Y M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R LS C ID E NT IF YIN G IN FO R MA TIO N )

P RO VID ER 'S P LA N O F C OR RE CT IO N(E ACH CO RR ECT IVE ACT IO N SHO ULD BEC RO SS R EF ER EN CE D T O T HE A PP RO PR IA TEDEF IC IENc y )

IDPREF IXT AG

(X4)IDPREF IXTAG

(X5)COMPLETIONDATE

K 0 2 7 K027N FPA 1 01 LIFE SAFE TY COD E STAN DAR DCORR EC TIV E AC T /ON S~ . N ew /R evise d P ro cesse s & P roc edures

NA

K 0 2 7 Con tinued F rom page 1 6n ot re qu ire d to s w in g w ith e gre ss a nd p os itiv ela tc hin g is no t req uire d. 1 9 .3 .7 .5 , 1 9 .3 .7 .6 ,19 . 3 . 7 . 7

T his ST AN DAR D is not m et as ev idenced by :B a se d o n o b se rv atio n a nd in te rv ie w , th e fa c ilityfa ile d to e ns ure th at s m ok e b arrie r d oo rs a rec ap ab le to re sist th e p as sag e o f s m ok e, th atd oo rs a re s elf-c lo sin g, a nd th at d oo rs a rep ro vid ed w ith a m e an s s uita ble fo r k ee pin g th edo or c lo sed . T his w as ev id en ced b y d oo rs th atfa ile d to la tc h a fte r c lo sin g a nd b y o ne d oo r th atfa ile d to o pe n. T h is a ffe cte d tw o o f e ig ht flo orsan d th e b as em e nt, an d c ou ld res ult in th e sp re ad9 ! ~ l 1 ] o _ ~ e _1 :I n9 fir e, in th e e ve _n ~?!~fire:_Find ings:

B . R e pa ir/R e pla ceme ntM itig ate th ro ug h re pa ir o f d oors , re mo va l o fit ems obs tr uc ti ng doo r c lo su re , sea li ngpene trat ions for the fol low ing : 2 nd F lo or: R em ov e a strag al to a llo w 0 2 / 1 6 / 1 1

sm ok e b arrier door at C C2 7 to openus in g p an ic h ardw are. W o rk o rd er#464780

71hF loor: R epair sm oke barrier door at P 2 / 1 6 / 1 1_CC~ 74. .w ork_Q[der#460 4_7_80 .. _

3 rd F loor: Repair sm oke barrier door at - b2/16/11CC3 -3 . W o rk o rd er #441 9 68

8asem ent: R epair sm oke barrier door at 0 2 / 1 6 / 1 1CC8 -4, re mov e tra sh c an im pe dingc los ure o f smok e b arrie r do ors to R oom83 03 -0 , repair sm ok e b arrier door atroom 81 51 . W o rk order #441 968

Du rin g th e fa cility to ur w ith s ta ff fro m 2/15/11 -2/17/11 th e s m ok e b arrie r d oo rs w ere o bs erv ed .2/15 /11 - 2 n d F lo orA t 3 :2 6 p .m ., th e s m ok e b arrie r d oors at C C-2 -7w ere c lo se d. T he righ t s id e do or fa iled to o pe nw h en th e p an ic h ardw are w as d ep re sse d. T hed oo r h ard wa re w a s a ctiv ate d th re e tim e s b ut th ed oo r re m a in ed c lo se d.

C . Personne l Tra in ing/No t if ica t ion E ducatekeystaff (Services D irec tors,

Me dic al D e pa rtme nt C ha irs , a nd Nurs in gL ea de rsh ip C ou nc il) b y m ea ns o fManagemen t Bul le ti n and p re sent ati ona t O p era tio ns Mana gemen t C ou nc ilm e etin g o f n ec es sity - a nd a pp ro pria tew ay - to report safety lapses in th ephysica l environment .

D uring a n in te rv ie w a t 3 :2 8 p .m ., F M S ta ff 1e xp la in ed th at th e a stra ga l o n th e le ft d oo r h eldth e righ t door c losed. W h en th e le ft door w aso pe ne d firs t th e rig ht d oo r c ou ld b e o pe ne d.2/17/11 - 7 th F lo orA t 7 :2 9 a .m ., th e s m ok e b arrie r do ors C C-7 4,w ere o bs erv ed d urin g fire a la rm te stin g. T h e QU A LIT Y /M PROVEMEN TA . P lann ing 6 / 2 2 / 1 1 M onitor as part of docum ented

ORM CMS 2 5 6 7( 0 2- 99 ) P re vio us V e rs io ns O b so le te E ven t ID :2 QK 1 2 1 F ac ility ID : C A0 60 0 0 0 0 2 7 If continuation sheet Page 17 of 5


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D EPARTM ENT O F HE ALTH AND HUM AN SERV ICE SCENTERS FO R M ED ICARE & M ED ICA ID SER VICE S

PR IN T ED : 0 6 /1 0 /2 0 1 1FORM APPROVEDO M8 NO 0 9 3 8-0 3 9 1( X 1 ) P ROV lD ER / SU P P L lE R / CL lAID E N T IF IC A TIO N N UM B ER :S TA TE M E NT O F D E F IC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376N AM E O F P RO VID ER O R S UP PLIE RL AC /H AR BO R -U CL A M E D C EN TE R

( X2 ) M U L T IP L E C O N STR U CT IO NA . BU ILD ING 01 - M A IN B UIL D IN G 01B. W ING _

( X3 ) D AT E S UR VE YCOMP LE TED

S TR EE T AD DR ESS. C IT Y. ST AT E. Z IP C OD E1000 W CARSON STT OR RAN CE , C A 90509

02/18/2011

S UM M A RY S TA TE M E NT O F D E FIC IE N CIE S(E AC H D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF Y IN G IN F OR M AT IO N )(X5)COMPLET IONDATE(X 4) 1 0PREF IXTAG

K 027 C ontinued F rom page 1 7doors c losed b ut fa iled to la tch in four o f fourattempts.3 rd F lo or-A t 8:09 a.m ., th e sm ok e b arrie r doors C C3 -3 ,c losed b ut failed to la tc h inth re e o f th re e a tte m pts .Basement -A t 1 0 :0 2 a.m ., the doors C CB-4 c losed but failedto la tch . T he doors w ere re tested and fa iled tola tc h th e 2 nd tim e.At 9 :40 a.m ., th e righ t s ide door w as he ld openw ith a trash c an, of th e sm ok e b arrier doub ledoors to the linen room 83 03 D .

K 0 2 9

A t 9 :5 0 a .m ., th e le ft s ide door fa iled to fully c losea n a pos it ive laten wh-en -- re feasec f fr om th e -m agnetic h old , o f th e sm ok e b arrie r doors a t8 1 5 1 .N FPA 1 0 1 LIFE SAFE TY CO DE STAND AR DO n e h our fire rate d c on struc tio n (w ith % hourfire-rate d d oo rs) o r an ap prove d a uto m atic firee xtin gu is hin g s ys te m in a cc ord an ce w ith 8 .4 .1a nd /or 1 9 .3 .5 .4 p ro tec ts h az ardo us area s. W h e nth e a pp ro ve d a uto m atic fire e xtin gu is hin g sy ste mo ption is use d, th e area s a re sep arate d fromo th er sp ac es b y sm o ke resistin g p artitio ns a nddoors. D oors are se lf-c losing and non-rated orfie ld -a pp lie d p ro te ctiv e p la te s th at d o n ot e xc ee d48 inches from the bottom of the door areperm itted. 1 9.3 .2 .1

Th is ST AN DAR D is not m et as evidenced by:

1 0PREF IXTAG

K 0 2 7

P R OV ID E R 'S P LA N O F C O RR E CT IO N(E AC H C OR RE CT IV E AC TIO N SH OU LD BEC RO SS R EF ER EN CE D T O T HE A PP RO PR IA TEOEFTC IEN 'cy )

interdisciplinaryHaz ardS urveil lance /Env i ronmenta lRoundsforoccur renceofl i fesafety lapses( includingsmokebar r ie rsdoors tha t are impededor notfu l ly funct ional)in the physicalenvironmentand performanceofrequiredcorrectiveactions.Init iatet imelycorrect iveact ions,as appropr iate.B . M o nito rin g Fa c ilit ie sManagemen t,En v ir onmen ta lServices,Infect ionControland Hospita lAdm in is t ra t iono a) conductweeklyHazardSurvei l lance/EnvironmentalRoun dsof faci l ity foroc currenceof l ifesa fe ty lapsesin the phys ica lenvironment,b) com plet ionof l ife safetycorrectiveactions.Facil it ies-M anagem enl- to report .l i fesafetyresul tsto Env i ronm ento f CareC omm i ttee .

K 0 29 R E S PON SIB L E POS IT IO N (S ) Fa c ilit ie sManagemen tD i re c to r

CMS -2 5 6 7 (0 2 - 9 9 ) P r ev iO U SV e rs io n s O b s o le te E v en tlD : 2 Q K1 2 1 Fac il it y 1 0 : CA 060 0 0 0 0 2 7 If cont inuation sheet Page __8 of 50


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DEPARTMENT OF HEALTH AND HUMAN SERV ICESCENTERS FOR MED ICARE & M E DIC AID S ER VIC ES

PRINTED : 06/10/2011F OR M A PP RO VE DO MS NO . 0 9 3 8-0 3 9 1S TA TE M E NT O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

( X2 ) M U LT IP LE C O N ST R UC TIO N01 - MAIN BUILDING 01

(X3 ) D AT E SU RV EYCOMPLET ED( X 1 ) P ROV I DER / SUPP L IER / C LI AI D E N TI FI CA T IO N N UM B ER :

I-N AM E O F P RO VID ER O R SUP PL IE RLAC/HARBOR-UCLA MED CENTER(X4) IDPREF IXTAG

S UM M AR Y S TA TE M E NT O F D E FIC IE N CIE S(E ACH D EF IC IE NC Y M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN F OR M AT IO N )

K 0 2 9 Continued F rom page 1 82/15/11 - 5 th F loorAt 1 1 :1 6 a.m ., there were six 3 2 gallon soiledlinen b ins in Shower room 5E -1 9 . T here was noself-c losing device on the door.2 nd F loorAt 2 :47 p.m ., the hazardous m ateria ls storageroom was greater than 5 0 square feet in size.The room contained m ore than 5 0 cardboardboxes of supplies and containers of hazardouswaste. There was no self-c losing device on thedoor.A t 3 :3 4 p.m ., the storage room at 2W R-5 wasgreater than 5 0 square feet in size. There was noself-c losing device on the door.A t 4 p.m ., the storage room 2A7S was greaterthan 5 0 square feet in size. T he door self c losed-bU lTaile-ato latch -~ ---- - - _ - -2/16/11 - B asem ent (K itchen A rea)~ t 1 1:1 1 a.m ., there was an approx im ately 1/2Inch penetration in righ t w all near the vegetab leprep area.A t 1 1:1 2 a.m ., there was an approx im ately 2112 x3/ 4 inch penetration around one pipe sleeve,above the ansul system , in the ceiling above therigh t wall. T here w as an approx im ately _1x3/4inch penetration around a second pipe sleeve.T here w as an approx im ately 1/4 in ch a ro un delec trica l conduits and an approx im ately 1 x 2inch penetration along one side of the contro lhead box .D uring an interview at 1 1 :1 3 a.m ., FM Staff 1reported the ansul system w as insta lledapprox im ately two years ago.A t 1 1 : 3 0 a.m ., there was an approx im ately 1/2

F O RM CM S 2 5 67(0 2 -9 9 ) P rev ious V ers ions O bsolete E vent 1 D :2 QK 1 2 1

5 th F loor: Insta ll s elf-c losing devic e on )2 11 61 11d oo r to S ho we r R om 5 E -1 9 . W o rk o rd er#464818

2 nd F loor: Insta ll se lf-c losing devic e on )61 281 11door to hazardous ma te ri al s s to rage

_ __ _r oom .J n st ells elf -c lo sin q d ev ic e o n d oo r _ ,to S torage R oom 2 W R -5 . W o rk order#464777

Basem ent (K itchen Area): Seal w all P 2 1 1 61 1 1pene tr at ion near t h e vege tab le p repa rea , seal c e il in g pene tr at ion abovea ns ul s ys tem , s ea l p en et ra tio n b ysecond p ipe s leeve , seal pene tr at ionsa lo ng s id e o f th e c on tro l h ea d b ox , s ea lp en et ra tio n a ro un d e ac h o f f ou r p ip es le ev es ab ov e a ns ul s ys tem in b ak es ho p a re a. W o rk o rd er # 44 1 96 8

Basem ent (M echanical Area) : Seal wall 0 21 161 11p en et ra tio n in Me c h an ic a l Ro om 1Sout h, s ea l w a ll p en et ra tio ns in t hes te riliz e r a cc e ss r oom ME - 2 2 3 .

F am ily M edic al C lin ic : Insta ll se lf-c losing 0 21 171 11d ev ic e o n in te rio r d oo r t o P h a rma c ys to rage room.

8 th F loor: Insta ll s elf-c losing devic e on 0 6/2 8/1 1d oor to 8 W -2 1 L au nd ry R oo m . W o rkorder #464624

A. BUILDINGB . W ING _

ST RE ET AD DR ESS . C ITY . STATE . Z IP C OD E1000 W CARSON STTORRANCE, CA 90509

P RO V ID E R'S P LA N O F C O RR E CT IO N(E ACH C OR RE CT IV E ACT IO N SH OULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IAT EDEFTC IENc y )

IDPREF IXTAG

K 0 2 9 k 0 2 9NFPA 1 0 1 LIF E SA FE TY CO DE ST AN DAR D'r -O RRECTIV E ACT IONS~ . N ew /R evise d P ro ce sse s & Procedures

NA3 . R e pa ir/R e pla cem en t

Mi t iga te th rough insta ll a ti on o f se lf -c los ingd ev ic e o n d oo rs , r ep air o f d oo rs , p en et ra tio nsea li ng fo r the fo ll ow ing :

F a c il it y 1 0 : CA 0 6 0 0 0 0 0 2 7

02/18/2011

(X5)COMPLETIONDATE



22/62

P RIN TE D: 0 61 10/20F OR M AP PR O VEOMB NO 0938-039D EP AR TM EN T O F HE ALTH AN D HUM AN SE RV ICE SCE NT ER S F OR M ED IC AR E & ME D IC A ID S E R V IC E S

( X2 ) M U L TI PL E CO N S TR U C TI O NA. BU ILD ING 01 - MAIN BUILDING 01

S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N ( Xl) P R O V ID E R /S U P PL IE R /C L IAID E N TIF IC A TIO N N U M BE R :(X3 ) D AT E S UR VE YCOMPLET ED

B . W IN G _050376 02/18/2011-N AM E O F P RO VID ER O R SU PPL IE R STR EE T AD DR ESS , C ITY , STATE , Z IP CO DE1000 W CARSON STTORRANCE, CA 90509LAC/HARBOR-UCLA MED CENTER

P RO VID ER 'S P LAN O F C OR RE CT IO N(E ACH CO RR ECT IV E ACT IO N SH OULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TEDEF fC fENCY )

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE P RE CE DE D BY F ULLR EG ULA TO RY O R LS C ID EN TIF YIN G IN F O RM A T IO N)1 0PREF I XTAG

(X4)IDPREF IXT AG(X5)

COMPLETIONDATE

6 1h F loor: Install self-c losing device on 0 2/1 6/1 1d oo r to O ffic e 6 E-40 , s ea l p en etra tio n in6W - 38 S to ra ge Ro om , re pa ir s elf- clo sin gdoor to R oom LC -6 01 . W o rk order#451989

1 st F loor: Install self-c losing device on :1 2/1 6/1 1d oo r to C hild L ife C en te r s to ra ge ro om .Wo r k o rd er # 46 47 86

3 rd F loor: Install self-c losing device on b6/2 8/1 1door to R oo m 83 40 A O ffic e A , installself-c lo sing devic e on d oor to R oom 8-3 40A O ff ic e D , in sta ll s elf- clo sin g d ev ic eon doo r to R oom B -3 40 A D oc tor O ffic eG, in sta ll s elf- clo sin g d ev ic e o n d oo r toR oom B -3 40 A D oc to r O ffic e H , in sta lls elf-c lo sin g d ev ic e o n d oo r toA ne sth es io lo gy S to ra ge A , in sta ll s elf-c lo sin g d ev ic e o n d oo r to,Ane_st hesi ol ogy S10 rage_B ., Wo r k o rc 1e r ,#452189 ,#452192 ,#452197 ,#452193 ,#452195

K 0 2 9 Con tinued F rom page 1 9in c h p en etra tio n a ro un d fo ur p ip e s le ev es , a b ov ethe ansul system in th e b ake shop area . T herew as a p en etra tio n a ro un d e ac h p ip e s le ev e.

K 0 2 9

B as em e nt M e ch an ic al A re aA t 1 2 :5 5 p .m . , th ere w as a n a pp ro xim a te ly 1/2-3/4 in ch p en etra tion aro un d a w hite p ip e on th erigh t w all o f M ec han ic al R oom 1 S outh . T hep en etra tio n w a s n ea r th e e ntra nc e .A t 1 : 1 7 p .m . , th ere w ere fo ur a pp ro xim a te ly 3/4in c h p en etr atio n in th e fro nt w a ll o f th e s te riliz erac cess room , M E 2 23 . T he pene trations w ere inth e a re a a cc es sin g th e b ac k o f th e s te riliz ers .2/17 /1 1 - F am ily M e d ic al C lin icA t 1 :3 0 p .m ., th e in te rio r d oor to th e p ha rm a cysto ra ge ro om w as o bse rved . T he ro om is g re ate rthaiioO'squareleerilfsizeartd'cbntainedshelvesw ith c ard bo ard b ox es a nd p ap er a nd p la sticpa ck ag es o f m e dic atio ns a nd su pp lie s. T he do orw as n ot e qu ip pe d w ith a s elf-c lo se r. C , Personnel Tra in ing/Not i fication

Educate key staff (Services D irec tors, ~ /2 2 /1 1Medic al D e pa rtme nt C ha irs , a nd Nu rs in gL ea de rs hip C ou nc il) b y m ea ns o fManagemen t Bu ll et in and p re sent at io na t O p era tio ns Mana gemen t C ou nc ilmeeting of n ec es sit y - a nd a pp ro pria tew ay - to rep ort sa fety lapses in th ephysical env ir onment.

Ba se d o n o bs erv atio n a nd in te rv ie w , th e fa cilityfa iled to m a in ta in h az ard ou s a rea s w ith 1 h ou rra te d c o ns tru c tio n a nd fa ile d to e ns ure h az ard ou sa rea s are se para te d from o th er sp ac es b y sm o kere sis tin g p artitio ns a nd s elf c lo sin g d oo rs . T h isw as e vid en ce d b y h az ard ou s a re as w ithp en etra tio ns a nd w ith d oo rs th at fa ile d to s elfc lo se a nd latc h. T his a ffec te d s ix o f e ig ht flo orsan d th e b asem e nt, a nd c ou ld re sult in th e sp re ado f fire from a h az ardous area to o th er areas o fthe fac il it y .

Q .UA L IT Y IM PROVEMENTA. P lanning

M onitor as part of docum entedinterdisc ipl ina ry HazardSu rvei ll an c e/Env ir onment al Rounds f oro cc urre nc e o f life s afe ty la ps es( in c lud ing f un c ti onal se lf -c lo si ng doo rs i nh az ard ou s a re as ) in th e p hy sic al

If continuation sheet Page 20 of 5v en 1 1D : 2QK1 2 1 F a c il it y I D : CAOS 0 0 0 0 0 2 7O RM CMS .2 5 S 7( 0 2- 9 9) P re vi ou s V e rs io ns O b so le te


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D EP AR TM EN T O F H EALTH AN D HU MAN SE RV ICE SC EN TE RS F OR M E D IC AR E & MED I CA ID S E R V IC E S

PRINTED: 06/10/2011FORM APPROVEDO MS NO 0 9 3 8 -0 3 9S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

( X 1 ) P ROV I DER / SUPP L IER / C LI AID E N TIF IC AT IO N N U M BE R :

t-N AM E O F P RO VID ER O R SUP PL IE RLAC/HARBOR-UCLA MED CENTER

( X2 ) M U LT IP LE C O N ST R UC TIO NA. BU ILD ING 01 - M AIN B UIL DIN G 01


B . W ING _

S TR EE T AD D RE SS , C IT Y, S TAT E, Z IP C OD E1000 W CARSO N STTORRANCE, CA 90509

02/18/2011

(X5)COMPLETIONDATE

( X4 ) IDPREF IXTAG

2/15 111 - 8 th F lo orA t 1 1 :1 2 a .m ., th e 8 W 2 1 Laund ry R oomm easu red over 5 0 sq ua re fee t in siz e. T he doo rfa ile d to h av e a s elf c lo sin g d ev ic e.

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E AC H D EF IC IE NC Y M UST BE P RE CE DE D BY F ULLR E GU LA TO R Y O R L SC ID E NT IF YIN G IN FO R MA TIO N )

K 0 2 9 Continued F rom page 2 0Find ings:D u rin g th e fa cility to ur fro m 2 /1 5 /1 1 - 2116/11, th eh az ard ou s a re as w e re o bs erv ed in th e m a inh o sp ita l. S oile d lin en a nd tr as h s to ra ge a re as ,a nd c om b u stib le s to ra ge ro om s g re ate r th an 5 0s q ua re fe et in s iz e, a re c on sid ere d h a za rd ou sareas.

6 th F lo or-A t 2 :1 5 p .m ., O ffic e 6 E40 m easured ove r 5 0sq uare fee t in s iz e. T here w ere q ua ntitie s ofc ombus t ib l e ma te ri al s such as - lo o se -paper s ,- . -.b o ok s b in de rs , file s, a nd p ap er m a te ria ls s ta ck eda ro un d th e offic e. T here w as n o s elf-c los ure o nth e d oo r.A t 2 :2 0 p .m ., in th e 6 W 3 8 S torage R oom , th erew as an a pp ro xim a te ly 1% in c h pe ne tr at io n a ro u nda p ip e on th e N orth W e st w all.A t 2 :3 0 p .m ., th e s elf-c lo sing d oo r to LC 60 1 ,C le an L in en O n ly , fa ile d to fu lly c lo se a nd p os itiv ela tc h. T he room w asgreaterth an 5 0 sq uare feetin s iz e.2 /1 6/1 1 - 1 st F loorA t 9 :1 8 a.m ., th e C hild L ife C enter s tora ge ro om ,m easu red ove r 5 0 sq uare fee t in siz e. T herew as no se lf-c lo sin g de vic e on th e d oor. T hes to ra ge ro om c o nta in ed a n c om b u s tib le m a te ria lss uc h a s p ap ers , b oo ks , to ys , c ard bo ard b ox esa n d p la s tic ma t er ia ls .3 rd F lo or-

F O RM CMS 2 5 67 (0 2 -9 9 } P re vio us V e rs io ns O b so le te E v e nt I D : 2QK 1 2 1

IDPREF I XTAG

K 0 2 9

P R OV ID E R'S P LA N O F C O RR E CT IO N(E ACH CO RR ECT IV E AC TIO N SH OULD BEC RO SS -R EF ER EN CE D T O T HE A PP RO PR IA TE

OEFIC!ENCY)

env iro nm en t a nd p erform an ce o fr equi re d co rr ec ti ve a c ti on s. In it ia tet ime ly co rr ec ti ve a c tio ns , a s a pp ro pr ia te .

~ . M o nito rin g F ac ilities M anagem ent. E nvironm ental

S er vi ce s, I nf ec ti on Cont ro l a nd Hosp it alA dm in is tr atio n to a ) c on du ct w ee klyHazard Surve i llance/Env ironmenta lR ound s of fac ility for oc currenc e of lifes afe ty la ps es in th e p hy sic ale nv ir onmen t, b ) c omp le tio n o f life s afe tyco rrec t ive ac tions . Fac il it ie sM a na gemen t to re po rt life s afe ty r es ultsq ua rte rly to E n viro nme nt o f C areCommittee.

R E S PON SIB L E POS IT IO N (S ). _ Fac il it ie s_Managemen tD i re c toL

F a c il it y I D : CA 0 6 0 0 0 0 0 27 If continuation sheet Page 21 of 5


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PR IN T E D : 06/10/201F O RM A PP R O VEO MB NO 0 9 3 8 -0 3 9D EP AR TM EN T O F H EALTH AN D HUM AN SE RV ICE SCE NTE RS F OR M ED ICAR E & M ED ICA ID SE RV IC ES

(xi) MU L T IP L E C O N S TR U C T IO NA BUILD ING 01 - MAIN BUILDING 01B. W ING _

S TA T EM E N T O F D E F IC IE N CIE SA ND P LA N O F C OR RE CT IO N (X 3) D AT E S UR VE YCOMP LE TED(X l) P ROV I D ER /SU P P L IE R / C LI AID E N T IF IC A T IO N N UM B E R :

050376 02/18/2011I-N AM E O F P RO VID ER O R S UP PLIE R S TR EE T AD D RE SS, C IT Y, S TAT E, Z IP C OD E1000 W C AR SO N S TTORRANCE, CA 90509LAC/HARBOR-UCLA MEO CENTER

P R OV ID E R 'S P LA N O F C O RR E CT IO N(E AC H C OR RE CT IV E A CT IO N SH OU LD B EC RO SS -R EF E RE N CE D T O T HE A PP RO PR IA TEDEFJCtENCY)

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E AC H D EF IC IE NC Y M UST B E P RE CE DE D BY F ULLR E G UL AT O R Y O R L SC ID E N TIF Y IN G IN F O RM A TIO N )IDPREF IXTAG

(X4)IDPREF IXTAG(X5)

COMPLET IONDATE

K 0 29 Con tinued F rom page 2 1A t 1 2 :5 5 p .m ., in B 340 A, O ffic e A , th ere w erec om b us tib le m a te ria ls , in c lu d in g lo os e p ap er s,b oo ks b in de rs , file s, c ard bo ard b ox es o f p ap erm a te ria ls , a nd sh elv es in th e o ffic e a re a. T heo ffic e fa ile d to h av e a s elf-c lo su re o n th e d oo r.

K 0 2 9

A t 1 :0 0 p .m ., in B 340 A, O ffic e 0, th e re w e rec om b us tib le m a te ria ls in c lu din g lo o se p a pe rs ,b o ok s, b in de rs , file s, p ap e r m a te ria ls , a n dsh elves in th e o ffic e a rea . T here w as nos elf- clo su re o n th e d oo r.A t 1 :1 0 p .m ., in B 340 A, D oc to r O ffic e G , th erew e re c om b u stib le m a te ria ls s uc h a s lo os ep a pe rs , b o ok s, file s, b in d ers , a n d p ap er m a te ria lss tac ked arou nd th e o ffic e. T here w as nos elf-c lo su re o n th e d oo r.A t 1 :1 5 p .m ., in B 340 A, D oc to r O ffic e H , th erew e re c om b u stib le m a te ria ls s uc h a s lo os ep ap ers , b oo ks , b in de rs , file s a nd s ta ck s o f p ap erma te r i a l s s ta ck ed a ro un d th e o ffic e. T he re w asn o s elf-c lo su re o n th e d oo r.A t 1 :3 5 p .m . , in A ne sth es io lo gy S to ra ge A , th erew e re c om b u stib le m a te ria ls s uc h a s b ox es ,s up p lie s, p la stic s , a nd p ap er m a te ria ls s ta c ke da ro un d th e o ffic e. T he re w as n o s elf-c lo su re o nth e d o or.A t 1 : 40 p .m . , in A ne sth es io lo gy S to ra ge B , th erew ere c om b u stib le m a te ria ls s uc h a s b ox es ,s up p lie s, p la stic s , a nd p ap er m a te ria ls s to re d inth e o ffic e. T he re w as n o s elf-c lo su re o n th e d oo r.T hese ro om s w ere la rge r th an 5 0 sq uare fee t ins iz e a nd c on ta in ed c om b u stib le s to ra ge . T h eya re c o ns id e re d h a za rd ou s a re as .

If continuation sheet Page 22 of 5a c il it y 1 0 : CA 0 6 0 0 0 0 0 2 7ORM CMS - 2 5 6 7( 0 2 - 9 9 ) P rev iOUS Ve rs io n s Ob so le te Event I D : 2QK 12 1


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DEPARTMENT OF HEALTH AND HUMAN SERV ICESCENTERS FOR MED ICARE & M ED IC AID SE RV IC ES

PR INTED : 06/10/201F OR M AP PR OV EDOM S NO 0 9 3 8-0 3 9 1S TA TE M EN T O F D E FIC IE N CIE SA ND P LA N O F C OR RE CT IO N

050376

(X 1 ) P ROV I DER /SUPP L IER / C LI AID E N TIF IC AT IO N N U M BE R :

I-N AM E O F P RO VID ER O R SU PP LIE RLAC/HARBOR-UCLA MED CENTER(X4) IDPREF IXTAG

S UM M AR Y S TA TE M EN T O F D E FIC IE N CIE S(E ACH D EF IC IE NCY M UST BE PR ECE DE D BY F ULLR E GU LA T OR Y O R L SC ID E NT IF Y IN G IN F OR M AT IO N )

K 0 3 8 NFPA 1 0 1 LIFE SAFETY CODE STANDARDE x it access is arranged so that ex its are read ilyaccessib le at all tim es in accordance w ith sec tion7 .1 . 1 9 .2 .1

Th is STANDARD is not m et as ev idenced by:Based on observation , the fac ility failed tom ain ta in ex it access as evidenced by obstruc tedex its. T h is a ffec ted two of eigh t floors and thebasem ent. T h is cou ld de lay evacuation in theevent o f an em ergency and inc rease the risk o fin ju ry to patien ts, visitors and sta ff.

_ F ind ings :D uring ob servations w ith F ac ilities M anagem entS taff 4, from 2 /1 5 /1 1 th rough 2 /1 7/1 1 , the ex itac cess was observed in the m ain hospital.2 /1 5 /1 1 - 6th F loorAt 2 :2 5 p.m ., the em ergency ex it door in 6E -ICE ,was b locked by a 64 gallon gray trash cart.2 /1 6/1 1 - B asem en tA t 2 :2 5 p .m ., in the Anesthes io logy O ffic e Area,the ex it door ac ross from O ffic e I w as b locked byboxes .2 /1 7/1 1 - 2 nd F loorA t 9 :2 0 a.m ., on the inside of the OR entrance,the righ t door was b locked by a gurney.

K 046 NFPA 1 0 1 LIF E SAFETY CODE STANDARDEm ergency ligh ting of a t least 1 Y 2 hour duration is

FORM CMS - 2 5 67 ( 0 2- 9 9 ) P r ev io u s V e rs io n sp b so le te E v en t I D :2 Q K 1 21

(X3 ) D AT E S UR VE YCOMPLET ED( X2 ) M U L TI PL E CO N S TR U C T IO NA. BUILDING 01 - MAIN BUILDING 01B . W ING _

P RO V ID E R'S P LA N O F C OR R EC TIO N(E AC H CO RR ECT IV E ACT IO N SHO ULD BEC RO SS-R EF ER EN CE D T O T HE AP PR OP RIA TE

DEFICIENCY)

STR EE T AD DR ESS , C IT Y, ST ATE , Z IP CO DE1000 W CARSON STTORRANCE, CA 90509

IDPREF IXT AG

K 0 3 8 1< 03 8~ FP A 1 01 LIF E SAF ET Y C OD E ST AN DAR D"O RR E CT /V E A C T/O NSf\ . N ew/R e vis ed P ro ce ss es & P ro ce du re s

NA~ . R e pa ir/R e pla cem en t

M i tiga te t h rough r emova l/ re lo ca ti on o f i temsob st ru c tin g e x it a c c es s f or t he f ollow in g : 6 th F lo o r: R emove t ra sh c a rt o b st ru c tin g

em erg en cy e xit d oo r in 6 E - ICU . Wo r korder #441968

B ase me nt: R em ove b ox es ob stru ctinge xit d oo r a cro ss from O ffic e I inA nes th e sio lo g y O f fic e A rea . W o rk o rd e r_ _ i i # 1 9 E l ~ _ _ _ _ _ _ _

2 nd F lo o r: R emove gu rn e y ob st ru c tin grig ht d oo r in sid e o f th e OR e ntra nc e. -~ . P e rs onnel T ra in in g /N o tif ic a tio n

E du ca te k ey staff (S erv ic es D ire cto rs,M ed ic a l D epar tm en t Cha ir s, a nd Nu rs in gL ea de rs hip C o un cil) b y m e an s o fManagemen t Bu lle t in and p resentat iona t Ope ra tio n s Managemen t Coun c ilmee t il lg - of necess it y ' -and app rop ri at ew ay - to re po rt s afe ty la ps es in th ephys ica l env ironment .

QU A LIT Y /M PROVEMEN T( I . . Planning

M onitor as part o f docum entedin terd isc ip l inary Hazard

K 0 46 Surve illance/E nv ironm ental R ounds foro c c ur re n ce o f lif e s afe ty la p se s( in c lu d in g b lo c ked e x it d o or s) in t hephy si cal env ir onmen t and p

Documents

Los Angeles County Harbor-UCLA Medical Center's response to 2-18-11 inspection