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Based on observation, the facility failed to maintain the integrity of their building construction (Main Hospital, Westside Family Health Center) as evidenced by an unsealed penetration in a facility wall in the Main Hospital. This affected 1 of 6 floors in the Main Hospital and could result in the spread of smoke and fire to other locations in the facility and cause potential harm to patients.

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Staff on November 5, 2012, through November 7, 2012, the facility construction was observed.

Arrowhead Medical Center Main Campus
November 7, 2012

At 10:15 a.m., there was an approximate 1 inch unsealed pipe in the North wall of the Electrical Room on the first floor (Room 1B115A).

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that were obstructed from closing and corridor doors that failed to latch. This affected 2 of 6 floors in the Arrowhead Medical Center Campus and could result in a delay to contain smoke and fire to a room.

Findings:

During a tour of the facility with Staff 1a and Staff 2a on November 5, 2012, through November 8, 2012, the doors corridor doors were observed.

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 2:16 p.m., the corridor door to Room 41A156A was impeded from closing with an electrical cord that was connected to a Workstation On Wheels (WOW) in the hallway. The cord was plugged into an outlet in the room and the WOW was in the hallway.

Arrowhead Medical Center Main Campus
November 6, 2012

2. At 10:31 a.m., the self-closing corridor door to Room 4A356A was not latching when tested.

Arrowhead Medical Center Main Campus
November 7, 2012

3. At 3:28 p.m., the self-closing corridor to Room 2B942A (near Operating Room (OR) 3) in the OR was not latching when tested.

4. At 3:40 p.m., the corridor door to OR 16 utility Room was not latching when tested.

5. At 3:58 p.m., the self-closing corridor door to the Cardiac CATHLab (door 2B146A) was not latching when tested.

6. At 4:04 p.m., the self-closing corridor door to the PACU Bathroom (door 2B166A) was not latching wen tested.

Arrowhead Medical Center Main Campus
November 7, 2012

3. At 3:05 p.m., there were two vents penetrating the smoke barrier wall that had approximately 1/4 inch unsealed penetrations around the vents. The smoke barrier wall was located on the second floor next to the surgery suite and above door 2B909A.





26387

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This affected 3 of 6 floors of the Arrowhead Medical Center Main Hospital Campus and could result in the spread of smoke and fire to other smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Staff on November 6, 2012, through November 7, 2012, the facility's smoke barrier walls were observed.

Arrowhead Medical Center Main Campus
November 6, 2012

1. At 9:24 a.m., there was an approximate 1/2 inch unsealed pipe in the smoke barrier wall near Room 6301.

Arrowhead Medical Center Main Campus
November 7, 2012

2. At 11:12 a.m., there were three 3/4 inch pipes in the South Wall near Room 1B245A (outside of MRI Room) with an approximate 1/2 unsealed penetration around the pipes.

Based on observation and interview, the facility failed to protect the corridor from hazardous area. This was evidenced by a self-closing door to a hazardous area that failed to positive latch. This could result in failure to prevent smoke or fire from sprading to the corridor. This affected 1 of 6 floors of the Arrowhead Main Campus.


Findings:


During the facility tour with Staff 3a on 11/5/12 to 11/8/12 at 10:29 a.m., the self-closing corridor door to the Linen Room was not latching when tested. The room was over 100 square feet and contained over twenty 400 gallon linen containers. At 10:30 a.m., Staff 3a said during an interview that he turned the closure device off for the west door. The device was turned back on and the door was not latching.

Based on observation, document review, and interview, the facility failed to maintain their exit signs and emergency lights. This was evidenced by a exit sign that failed to illuminate, the facility's failure to perform monthly and annual tests on 30 exit signs equipped with an internal emergency power supply source, perform monthly and annual tests on their 122 emergency lights, and failing to display exit signs in all egress paths. This affected 3 of 6 floors in the Arrowhead Main Campus and could result in a delay in evacuation due to limited exit sign visibility and potential harm to patients.

NFPA 101, Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a tour of the facility with Staff 1a and Staff 2a on November 5, 2012, through November 8, 2012, the egress paths were observed, exit signs and emergency light testing documents were requested, and a staff person was interviewed.

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 3:03 p.m., there was no exit sign displayed in the West and East egress path in the Emergency Room near Pod D (Doors 1B933A and 1B933B). Staff 1a acknowledged the finding.

Arrowhead Medical Center Main Campus
November 8, 2012

2. At 8:06 a.m., the North Exit sign in the first floor Physical Therapy Outpatient Gym was not illuminating when examined.

3. At 2:32 p.m., there was no documentation of testing the 30 exit signs equipped with a battery source and 122 emergency lights with a battery source.

4. At 2:34 p.m., Staff 1a said during an interview that the facility does not have any documented evidence of testing the lights and exit signs. Staff 1a further said that the test has not been done.

Based on observation and interview, the facility failed to ensure all staff have access to the fire alarm boxes and fire extinguisher cabinets in the event of a fire. This was evidenced by staff that did not have a key in their possession for the fire alarm and fire extinguisher boxes in the Behavioral Health Center. This had the potential for staff not to be able to activate a fire alarm and have access to the fire extinguishers in the event of a fire or other emergency. This would delay the response to a fire and affected patients on 2 of 3 floors in the Behavioral Health.

Life Safety Code 101, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for there evacuation to area of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility and during fire alarm testing with staff on November 5, 2012, through November 8, 2012, the fire alarm devices were observed, and staff were interviewed.

Behavioral Health
November 6, 2012

1. At 8:40 a.m., 2 of 2 staff at the front reception desk were asked if they had keys to activate the fire alarm box or to access a fire extinguisher. Both staff stated they did not have keys to access the fire alarm box or the fire extinguisher.

Behavioral Health
November 8, 2012

2. At 9:32 a.m., 2 of 9 staff (Staff 4a and Staff 5a, one on the North side and one on the South side) on the second floor were interviewed and did not have keys in their possession to access the fire alarm box or fire extinguishers.

At 9:38 a.m., 2 of 6 (Staff 6a and Staff 7a) staff on the first floor were interviewed and did not have keys in their possession. Both staff went into the Nurse Station to retrieve their keys to the fire alarm boxes and fire extinguishers.

Based on document review, the facility failed to conduct fire drills at unexpected times for 10 of 10 second shift fire drills and 11 of 11 third shift fire drills. This had the potential for staff becoming complacent and fail to respond to a fire. This affected the entire main hospital.

Findings:

During document review with the Hospital Staff on November 5, 2012, through November 8, 2012, the fire drills were reviewed.

Arrowhead Medical Center Main Campus
November 7, 2012

At 10:45 A.M., 10 of 10 fire drills for the second shift were conducted between 3:30 P.M. and 3:45 P.M. The fire drill records indicated that the second shift fire drills were conducted as follows:
03/08/12 fire drill was conducted at 3:40 P.M.
03/14/12 fire drill was conducted at 3:35 P.M.
06/13/12 fire drill was conducted at 3:37 P.M.
06/20/12 fire drill was conducted at 3:40 P.M.
06/26/12 fire drill was conducted at 3:35 P.M.
08/16/12 fire drill was conducted at 3:45 P.M.
08/29/12 fire drill was conducted at 3:40 P.M.
09/18/12 fire drill was conducted at 3:45 P.M.
11/17/11 fire drill was conducted at 3:40 P.M.
11/29/11 fire drill was conducted at 3:30 P.M.

At 10:50 A.M., 11 of 11 fire drills for the third shift were conducted between 5:30 A.M. and 5:40 A.M. The fire drill records indicated that the third shift fire drills were conducted as follows:
02/15/12 fire drill was conducted at 5:40 A.M.
03/26/12 fire drill was conducted at 5:30 A.M.
04/30/12 fire drill was conducted at 5:30 A.M.
06/01/12 fire drill was conducted at 5:30 A.M.
06/12/12 fire drill was conducted at 5:30 A.M.
08/28/12 fire drill was conducted at 5:30 A.M.
09/06/12 fire drill was conducted at 5:30 A.M.
09/13/12 fire drill was conducted at 5:30 A.M.
11/15/11 fire drill was conducted at 5:35 A.M.
12/08/11 fire drill was conducted at 5:30 A.M.
12/07/11 fire drill was conducted at 5:30 A.M.

Based on observation, the facility failed to provide a smoke detector in the area where the fire alarm control panel was located. This was evidenced by no smoke detector in the fire alarm control panel room which is not continously attended. This failure affected the entire facility and could result in potential harm to patients and staff in the event of a fire affecting the fire alarm control panel.

NFPA 72 National Fire Alarm Code (1999) Edition
1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Findings:

During a tour of the facility with staff on November 5, 2012, through November 8, 2012, the fire alarm system was observed.

Family Health Center - Fontana
November 7, 2012

At 10:22 a.m., there was no smoke detection device in the area of the fire alarm control panel. This was acknowledged by staff during the survey.

Family Health Center - Fontana
November 07, 2012

2. At 1:24 p.m., the spare sprinkler box was observed to have only 3 spare sprinklers in the spare sprinkler box. Facility staff acknowledged that the facility had approximately 72 sprinklers throughout the facility.



26387

Based on observation, and document review, the facility failed to maintain their automatic sprinkler system. This was evidenced by the facility's failure to maintain an identification label on 12 of 12 Inspector Test Valves in the Main Hospital, Maintain 6 required spare sprinklers in the Family Health Center (Fontana) and conduct quarterly automatic sprinkler flow test for 1 of 4 quarters in Westside Outpatient Clinic. This affected 6 of 6 floors in the Main Hospital, the entire Family Health Center (Fontana), the entire Westside Outpatient Care Clinic, and could result in a delay in identifying an automatic sprinkler system valve, delay in replacing a sprinkler head, and potential sprinkler failure and potential harm to patients.

NFPA 13, Standard for the installation of sprinkler systems, 1999 edition
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection Systems, (1998) Edition
2-4.1.5 the stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers no fewer than 6 sprinklers

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
Findings:

During a tour of the facility with Staff 1a, Staff 2a, Staff, and Hospital Staff on November 5, 2012, through November 8, 2012, the facility's automatic sprinkler system components were observed and sprinkler maintenance documents were reviewed.

Arrowhead Medical Center Main Campus
November 8, 2012

1. At 2:08 p.m., there was no identification signs for twelve of twelve inspector test valves (valves to simulate water flow from a sprinkler) located in the stairwell on each floor. Staff 1a acknowledged the finding.



27961

Outpatient Clinic - Primary Care at Westside
November 8, 2012

3. At 2:00 P.M., the facility failed to provide documentation that the sprinkler test/inspections were conducted for 3rd quarter July, August and/or September 2012.

Based on observation and interview, the facility failed to ensure that their trash receptacles that exceeded 32 gallons were stored in a hazardous room as evidenced by 2 containers were found stored in the hallway. This would fuel a fire and cause potential harm to patients in the event of a fire. This effected 1 of 6 floors in the Arrowhead Main Campus.

Findings:

During a tour of the facility with Staff 1a and Staff 2a on November 5, 2012, the trash receptacles were observed and a staff person was interviewed.

Arrowhead Medical Center Main Campus
November 5, 2012

At 2:38 p.m., there were two (approximately) 300 gallon trash receptacles near the Freight Elevator on the Lower Level unattended. One container was completely fully of trash and the other container was empty. The containers were observed for 15 minutes without being moved or stored in a hazardous area.

A 2:45 p.m., Staff 1a stated during an interview that the container in normally stored in that location where they were found.

Based on observation, document review, and interview, the facility failed to maintain the piped in oxygen gas system. This was evidenced by the facility failure to correct the items identified by the vendor requiring corrections. This included area alarms not labeled or are incorrectly labeled, some alarm panels are not labeled with emergency instructions, vacuum inlets are below the requirement, some audible alarms are not functioning, medical air sensors on the area alarm are not working, some zone valves are mislabeled and there is no power to an area alarm for some areas, and by an impediment in front of emergency oxygen valve. This affected the oxygen gas system in the Arrowhead main campus and could result in delay of personnel from shutting off oxygen during a fire emergency and cause potential harm to patients. This affected 3 of 6 floors.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled ' ' SOURCE VALVE FOR THE (SOURCE NAME). ' '
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Hospital Staff on November 5, 2012, through November 8, 2012, the emergency oxygen shut off valves were observed, vendor inspection/maintenance documents were reviewed, and a staff person was interviewed.

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 2:29 p.m., the emergency Oxygen shut off valve at the Back Nursing Station 2 (near Room 2A151A) was impeded from access with a large wooden recycle bin in front of the device.



27961

Arrowhead Medical Center Main Campus
November 7, 2012

2. At 2:00 P.M., the vendor's report dated October 11, 2011, was reviewed and documents provided stated that some of the area alarms are not labeled or are incorrectly labeled and the vendor recommended labeling alarms with correct areas served, some alarm panels are not labeled with emergency instructions and the vendor recommended labeling alarm panels with emergency instruction, vacuum inlets are below the required 3.0 SCFM flow and the vendor recommended cleaning and modification of vacuum inlets, some audible alarms are not functioning and the vendor recommended repair or replace as soon as possible, medical air sensors on the area alarm are not working and the vendor recommended repair or replace as soon as possible, some zone valves are mislabeled and there is no power to an area alarm for some areas and the vendor recommended labeling with correct room numbers. When interviewed, the Facilities Manager was asked if the repairs had been done from last year (2011) and the Facilities Manager stated that they had not been done.

Based on document review and interview, the facility failed to maintain their generator as evidenced by generator number 2 was not exercised under load for 30 minutes per month for 3 of 12 months, and 3 of 7 generators not tested under load for 30 minutes per month for 5 of 12 months. This could cause possible harm to patients and staff from emergency power malfunction during power outage.
NFPA 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with

NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review with Hospital Engineering Staff on November 5, 2012, through November 8, 2012, the facility generator test and inspection logs were reviewed and staff was interviewed.

Arrowhead Medical Center Main Campus
November 7, 2012

1. At 11:00 A.M., there was no documentation of generator #2 exercised under load for 30 minutes per month for the months of February 2012, March 2012, and April 2012. When interviewed, the Facilities Manager stated that the oil was contaminated and they had to find a vendor to repair it.

2. At 11:10 A.M., the facility failed to maintain generator 1, 2 and 3 as evidenced by generator 1, 2 and 3 run time was under the required 30 minutes per month with a full load. The generator documents provided the following information:

January 4, 2012:
Generator 1 run time was 15 minutes
Generator 2 run time was 15 minutes
Generator 3 run time was 15 minutes

February 1, 2012:
Generator 1 run time was 10 minutes
Generator 3 run time was 10 minutes

March 7, 2012:
Generator 1 run time was 5 minutes
Generator 3 run time was 5 minutes

April 4, 2012:
Generator 1 run time was 5 minutes
Generator 3 run time was 5 minutes

November 2, 2011:
Generator 1 run time was 10 minutes
Generator 2 run time was 10 minutes
Generator 3 run time was 10 minutes

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 National Electrical Code. This was evidenced by the facility's use of an extension cords with no overcurrent protection. This failure affected 2 of 6 floors of the Main Hospital. This would increase the risk of an electrical fire and cause potential harm to patients.
NFPA 70 National Electrical Code (1999) Edition 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b). (a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Staff on November 5, 2012, through November 8, 2012, the electrical system was observed

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 2:48 p.m., there was a white extension cord without overcurrent protection in use in the first floor old Administration Office Room 2C276A.



26387

Arrowhead Medical Center Main Campus
November 7, 2012

2. At 10:34 a.m., there was a white extension cord in use in the Burn Institute Office (Room 4A318A) without over current protection.

Based on observation, the facility failed to maintain the integrity of their building construction (Main Hospital, Westside Family Health Center) as evidenced by an unsealed penetration in a facility wall in the Main Hospital. This affected 1 of 6 floors in the Main Hospital and could result in the spread of smoke and fire to other locations in the facility and cause potential harm to patients.

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Staff on November 5, 2012, through November 7, 2012, the facility construction was observed.

Arrowhead Medical Center Main Campus
November 7, 2012

At 10:15 a.m., there was an approximate 1 inch unsealed pipe in the North wall of the Electrical Room on the first floor (Room 1B115A).

Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridor doors that were obstructed from closing and corridor doors that failed to latch. This affected 2 of 6 floors in the Arrowhead Medical Center Campus and could result in a delay to contain smoke and fire to a room.

Findings:

During a tour of the facility with Staff 1a and Staff 2a on November 5, 2012, through November 8, 2012, the doors corridor doors were observed.

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 2:16 p.m., the corridor door to Room 41A156A was impeded from closing with an electrical cord that was connected to a Workstation On Wheels (WOW) in the hallway. The cord was plugged into an outlet in the room and the WOW was in the hallway.

Arrowhead Medical Center Main Campus
November 6, 2012

2. At 10:31 a.m., the self-closing corridor door to Room 4A356A was not latching when tested.

Arrowhead Medical Center Main Campus
November 7, 2012

3. At 3:28 p.m., the self-closing corridor to Room 2B942A (near Operating Room (OR) 3) in the OR was not latching when tested.

4. At 3:40 p.m., the corridor door to OR 16 utility Room was not latching when tested.

5. At 3:58 p.m., the self-closing corridor door to the Cardiac CATHLab (door 2B146A) was not latching when tested.

6. At 4:04 p.m., the self-closing corridor door to the PACU Bathroom (door 2B166A) was not latching wen tested.

Arrowhead Medical Center Main Campus
November 7, 2012

3. At 3:05 p.m., there were two vents penetrating the smoke barrier wall that had approximately 1/4 inch unsealed penetrations around the vents. The smoke barrier wall was located on the second floor next to the surgery suite and above door 2B909A.





26387

Based on observation, the facility failed to maintain their smoke barrier walls. This was evidenced by unsealed penetrations in the smoke barrier walls. This affected 3 of 6 floors of the Arrowhead Medical Center Main Hospital Campus and could result in the spread of smoke and fire to other smoke compartments.

NFPA 101 Life Safety Code, 2000 edition
8.3.6.1 Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tubes and ducts, and similar building service equipment that pass through floors and smoke barriers shall be protected as follows:
(1) The space between the penetrating item and the smoke barrier shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(2) Where the penetrating item uses a sleeve to penetrate the smoke barrier, the sleeve shall be solidly set in the smoke barrier, and the space between the item and the sleeve shall meet one of the following conditions:
a. It shall be filled with a material that is capable of maintaining the smoke resistance of the smoke barrier.
b. It shall be protected by an approved device that is designed for the specific purpose.
(3) Where designs take transmission of vibration into consideration, any vibration isolation shall meet one of the following conditions:
a. It shall be made on either side of the smoke barrier.
b. It shall be made by an approved device that is designed for the specific purpose.

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Staff on November 6, 2012, through November 7, 2012, the facility's smoke barrier walls were observed.

Arrowhead Medical Center Main Campus
November 6, 2012

1. At 9:24 a.m., there was an approximate 1/2 inch unsealed pipe in the smoke barrier wall near Room 6301.

Arrowhead Medical Center Main Campus
November 7, 2012

2. At 11:12 a.m., there were three 3/4 inch pipes in the South Wall near Room 1B245A (outside of MRI Room) with an approximate 1/2 unsealed penetration around the pipes.

Based on observation and interview, the facility failed to protect the corridor from hazardous area. This was evidenced by a self-closing door to a hazardous area that failed to positive latch. This could result in failure to prevent smoke or fire from sprading to the corridor. This affected 1 of 6 floors of the Arrowhead Main Campus.


Findings:


During the facility tour with Staff 3a on 11/5/12 to 11/8/12 at 10:29 a.m., the self-closing corridor door to the Linen Room was not latching when tested. The room was over 100 square feet and contained over twenty 400 gallon linen containers. At 10:30 a.m., Staff 3a said during an interview that he turned the closure device off for the west door. The device was turned back on and the door was not latching.

Based on observation, document review, and interview, the facility failed to maintain their exit signs and emergency lights. This was evidenced by a exit sign that failed to illuminate, the facility's failure to perform monthly and annual tests on 30 exit signs equipped with an internal emergency power supply source, perform monthly and annual tests on their 122 emergency lights, and failing to display exit signs in all egress paths. This affected 3 of 6 floors in the Arrowhead Main Campus and could result in a delay in evacuation due to limited exit sign visibility and potential harm to patients.

NFPA 101, Life Safety Code, 2000 edition
7.9.3 Periodic Testing of Emergency Lighting Equipment.
A Functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.
7.10.9.2 Exit signs connected to or provided with a battery-operated emergency illumination source, where required in 7.10.4, shall be tested and maintained in accordance with 7.9.3.

Findings:

During a tour of the facility with Staff 1a and Staff 2a on November 5, 2012, through November 8, 2012, the egress paths were observed, exit signs and emergency light testing documents were requested, and a staff person was interviewed.

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 3:03 p.m., there was no exit sign displayed in the West and East egress path in the Emergency Room near Pod D (Doors 1B933A and 1B933B). Staff 1a acknowledged the finding.

Arrowhead Medical Center Main Campus
November 8, 2012

2. At 8:06 a.m., the North Exit sign in the first floor Physical Therapy Outpatient Gym was not illuminating when examined.

3. At 2:32 p.m., there was no documentation of testing the 30 exit signs equipped with a battery source and 122 emergency lights with a battery source.

4. At 2:34 p.m., Staff 1a said during an interview that the facility does not have any documented evidence of testing the lights and exit signs. Staff 1a further said that the test has not been done.

Based on observation and interview, the facility failed to ensure all staff have access to the fire alarm boxes and fire extinguisher cabinets in the event of a fire. This was evidenced by staff that did not have a key in their possession for the fire alarm and fire extinguisher boxes in the Behavioral Health Center. This had the potential for staff not to be able to activate a fire alarm and have access to the fire extinguishers in the event of a fire or other emergency. This would delay the response to a fire and affected patients on 2 of 3 floors in the Behavioral Health.

Life Safety Code 101, 2000 Edition
19.7.1 Evacuation and Relocation Plan and Fire Drills.
19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of a fire, for there evacuation to area of refuge, and for their evacuation from the building when necessary. All employees shall be periodically instructed and kept informed with respect to their duties under the plan. A copy of the plan shall be readily available at all times in the telephone operator's position or at the security center.
The provisions of 19.7.1.2 through 19.7.2.3 shall apply.
19.7.1.3 Employees of Health Care facilities occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility and during fire alarm testing with staff on November 5, 2012, through November 8, 2012, the fire alarm devices were observed, and staff were interviewed.

Behavioral Health
November 6, 2012

1. At 8:40 a.m., 2 of 2 staff at the front reception desk were asked if they had keys to activate the fire alarm box or to access a fire extinguisher. Both staff stated they did not have keys to access the fire alarm box or the fire extinguisher.

Behavioral Health
November 8, 2012

2. At 9:32 a.m., 2 of 9 staff (Staff 4a and Staff 5a, one on the North side and one on the South side) on the second floor were interviewed and did not have keys in their possession to access the fire alarm box or fire extinguishers.

At 9:38 a.m., 2 of 6 (Staff 6a and Staff 7a) staff on the first floor were interviewed and did not have keys in their possession. Both staff went into the Nurse Station to retrieve their keys to the fire alarm boxes and fire extinguishers.

Based on document review, the facility failed to conduct fire drills at unexpected times for 10 of 10 second shift fire drills and 11 of 11 third shift fire drills. This had the potential for staff becoming complacent and fail to respond to a fire. This affected the entire main hospital.

Findings:

During document review with the Hospital Staff on November 5, 2012, through November 8, 2012, the fire drills were reviewed.

Arrowhead Medical Center Main Campus
November 7, 2012

At 10:45 A.M., 10 of 10 fire drills for the second shift were conducted between 3:30 P.M. and 3:45 P.M. The fire drill records indicated that the second shift fire drills were conducted as follows:
03/08/12 fire drill was conducted at 3:40 P.M.
03/14/12 fire drill was conducted at 3:35 P.M.
06/13/12 fire drill was conducted at 3:37 P.M.
06/20/12 fire drill was conducted at 3:40 P.M.
06/26/12 fire drill was conducted at 3:35 P.M.
08/16/12 fire drill was conducted at 3:45 P.M.
08/29/12 fire drill was conducted at 3:40 P.M.
09/18/12 fire drill was conducted at 3:45 P.M.
11/17/11 fire drill was conducted at 3:40 P.M.
11/29/11 fire drill was conducted at 3:30 P.M.

At 10:50 A.M., 11 of 11 fire drills for the third shift were conducted between 5:30 A.M. and 5:40 A.M. The fire drill records indicated that the third shift fire drills were conducted as follows:
02/15/12 fire drill was conducted at 5:40 A.M.
03/26/12 fire drill was conducted at 5:30 A.M.
04/30/12 fire drill was conducted at 5:30 A.M.
06/01/12 fire drill was conducted at 5:30 A.M.
06/12/12 fire drill was conducted at 5:30 A.M.
08/28/12 fire drill was conducted at 5:30 A.M.
09/06/12 fire drill was conducted at 5:30 A.M.
09/13/12 fire drill was conducted at 5:30 A.M.
11/15/11 fire drill was conducted at 5:35 A.M.
12/08/11 fire drill was conducted at 5:30 A.M.
12/07/11 fire drill was conducted at 5:30 A.M.

Based on observation, the facility failed to provide a smoke detector in the area where the fire alarm control panel was located. This was evidenced by no smoke detector in the fire alarm control panel room which is not continously attended. This failure affected the entire facility and could result in potential harm to patients and staff in the event of a fire affecting the fire alarm control panel.

NFPA 72 National Fire Alarm Code (1999) Edition
1-5.6 Protection of Fire Alarm Control Unit(s). In areas that are not continuously occupied, automatic smoke detection shall be provided at the location of each fire alarm control unit(s) to provide notification of fire at that location.

Findings:

During a tour of the facility with staff on November 5, 2012, through November 8, 2012, the fire alarm system was observed.

Family Health Center - Fontana
November 7, 2012

At 10:22 a.m., there was no smoke detection device in the area of the fire alarm control panel. This was acknowledged by staff during the survey.

Family Health Center - Fontana
November 07, 2012

2. At 1:24 p.m., the spare sprinkler box was observed to have only 3 spare sprinklers in the spare sprinkler box. Facility staff acknowledged that the facility had approximately 72 sprinklers throughout the facility.



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Based on observation, and document review, the facility failed to maintain their automatic sprinkler system. This was evidenced by the facility's failure to maintain an identification label on 12 of 12 Inspector Test Valves in the Main Hospital, Maintain 6 required spare sprinklers in the Family Health Center (Fontana) and conduct quarterly automatic sprinkler flow test for 1 of 4 quarters in Westside Outpatient Clinic. This affected 6 of 6 floors in the Main Hospital, the entire Family Health Center (Fontana), the entire Westside Outpatient Care Clinic, and could result in a delay in identifying an automatic sprinkler system valve, delay in replacing a sprinkler head, and potential sprinkler failure and potential harm to patients.

NFPA 13, Standard for the installation of sprinkler systems, 1999 edition
3-8.3 Identification of Valves. All control, drain, and test connection valves shall be provided with permanently marked weatherproof metal or rigid plastic identification signs. The sign shall be secured with corrosion-resistant wire, chain, or other approved means.

NFPA 25, Standard for the Inspection, Testing, and Maintenance of the Water-Based Fire Protection Systems, (1998) Edition
2-4.1.5 the stock of spare sprinklers shall be as follows:
(a) For protected facilities having under 300 sprinklers no fewer than 6 sprinklers

NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 Edition
2-3.3* Alarm Devices. Waterflow alarm devices including, but not limited to, mechanical water motor gongs, vane-type waterflow devices, and pressure switches that provide audible or visual signals shall be tested quarterly.
Findings:

During a tour of the facility with Staff 1a, Staff 2a, Staff, and Hospital Staff on November 5, 2012, through November 8, 2012, the facility's automatic sprinkler system components were observed and sprinkler maintenance documents were reviewed.

Arrowhead Medical Center Main Campus
November 8, 2012

1. At 2:08 p.m., there was no identification signs for twelve of twelve inspector test valves (valves to simulate water flow from a sprinkler) located in the stairwell on each floor. Staff 1a acknowledged the finding.



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Outpatient Clinic - Primary Care at Westside
November 8, 2012

3. At 2:00 P.M., the facility failed to provide documentation that the sprinkler test/inspections were conducted for 3rd quarter July, August and/or September 2012.

Based on observation and interview, the facility failed to ensure that their trash receptacles that exceeded 32 gallons were stored in a hazardous room as evidenced by 2 containers were found stored in the hallway. This would fuel a fire and cause potential harm to patients in the event of a fire. This effected 1 of 6 floors in the Arrowhead Main Campus.

Findings:

During a tour of the facility with Staff 1a and Staff 2a on November 5, 2012, the trash receptacles were observed and a staff person was interviewed.

Arrowhead Medical Center Main Campus
November 5, 2012

At 2:38 p.m., there were two (approximately) 300 gallon trash receptacles near the Freight Elevator on the Lower Level unattended. One container was completely fully of trash and the other container was empty. The containers were observed for 15 minutes without being moved or stored in a hazardous area.

A 2:45 p.m., Staff 1a stated during an interview that the container in normally stored in that location where they were found.

Based on observation, document review, and interview, the facility failed to maintain the piped in oxygen gas system. This was evidenced by the facility failure to correct the items identified by the vendor requiring corrections. This included area alarms not labeled or are incorrectly labeled, some alarm panels are not labeled with emergency instructions, vacuum inlets are below the requirement, some audible alarms are not functioning, medical air sensors on the area alarm are not working, some zone valves are mislabeled and there is no power to an area alarm for some areas, and by an impediment in front of emergency oxygen valve. This affected the oxygen gas system in the Arrowhead main campus and could result in delay of personnel from shutting off oxygen during a fire emergency and cause potential harm to patients. This affected 3 of 6 floors.

NFPA 99 Standard for Healthcare Facilities, 1999 Edition
4-3.1.2.3 Gas Shutoff Valves, Shutoff valves accessible to other than authorized personnel shall be installed in valve boxes with frangible or removable windows large enough to permit manual operation of valves.
Exception: Shutoff valves for use in certain areas, such as psychiatric or pediatric, shall be permitted to be secured to prevent inappropriate access.
(a) Source Valve. A shutoff valve shall be placed at the immediate outlet of the source of supply to permit the entire source including all accessory devices (such as air dryers, final line regulators, etc.), to be isolated from the piping system. The source valve shall be located in the immediate vicinity of the source equipment. It shall be labeled ' ' SOURCE VALVE FOR THE (SOURCE NAME). ' '
(b) Main Valve. The main supply line shall be provided with a shutoff valve. The valve shall be located to permit access by authorized personnel only (e.g., by locating in a ceiling or behind a locked access door). The main supply line valve shall be located downstream of the source valve and outside of the source room, enclosure, or where the main line first enters the building. This valve shall be identified. A main line valve shall not be required where the source shutoff valve is accessible from within the building.
(i) Shutoff Valves (Manual). Manual shutoff valves in boxes shall be installed where they are visible and accessible at all times. The boxes shall not be installed behind normally open or normally closed doors, or otherwise hidden from plain view.

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Hospital Staff on November 5, 2012, through November 8, 2012, the emergency oxygen shut off valves were observed, vendor inspection/maintenance documents were reviewed, and a staff person was interviewed.

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 2:29 p.m., the emergency Oxygen shut off valve at the Back Nursing Station 2 (near Room 2A151A) was impeded from access with a large wooden recycle bin in front of the device.



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Arrowhead Medical Center Main Campus
November 7, 2012

2. At 2:00 P.M., the vendor's report dated October 11, 2011, was reviewed and documents provided stated that some of the area alarms are not labeled or are incorrectly labeled and the vendor recommended labeling alarms with correct areas served, some alarm panels are not labeled with emergency instructions and the vendor recommended labeling alarm panels with emergency instruction, vacuum inlets are below the required 3.0 SCFM flow and the vendor recommended cleaning and modification of vacuum inlets, some audible alarms are not functioning and the vendor recommended repair or replace as soon as possible, medical air sensors on the area alarm are not working and the vendor recommended repair or replace as soon as possible, some zone valves are mislabeled and there is no power to an area alarm for some areas and the vendor recommended labeling with correct room numbers. When interviewed, the Facilities Manager was asked if the repairs had been done from last year (2011) and the Facilities Manager stated that they had not been done.

Based on document review and interview, the facility failed to maintain their generator as evidenced by generator number 2 was not exercised under load for 30 minutes per month for 3 of 12 months, and 3 of 7 generators not tested under load for 30 minutes per month for 5 of 12 months. This could cause possible harm to patients and staff from emergency power malfunction during power outage.
NFPA 99 (1999 Edition) 3-4.4.1 Maintenance and Testing of Essential Electrical System.
3-4.4.1.1 Maintenance and Testing of Alternate Power Source and Transfer Switches.
(a) Maintenance of Alternate Power Source. The generator set or other alternate power source and associated equipment, including all appurtenant parts, shall be so maintained as to be capable of supplying service within the shortest time practicable and within the 10-second interval specified in 3-4.1.1.8 and 3-4.3.1. Maintenance shall be performed in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, Chapter 6.
(b) Inspection and Testing.
1.* Test Criteria. Generator sets shall be tested twelve (12) times a year with testing intervals between not less than 20 days or exceeding 40 days. Generator sets serving emergency and equipment systems shall be in accordance with

NFPA 110 (1999 Edition), 6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly , for minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating.
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer.
The date and time of day for required testing shall be decided by the owner, based on facility operations.

NFPA 110 (1999 Edition) 6-4.2.2 Diesel-powered EPS installations that do not meet the requirements of 6-4.2 shall be exercised monthly with the available EPSS load and exercised annually with supplemental loads at 25 percent of nameplate rating for 30 minutes, followed by 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 2 continuous hours.

Findings:

During document review with Hospital Engineering Staff on November 5, 2012, through November 8, 2012, the facility generator test and inspection logs were reviewed and staff was interviewed.

Arrowhead Medical Center Main Campus
November 7, 2012

1. At 11:00 A.M., there was no documentation of generator #2 exercised under load for 30 minutes per month for the months of February 2012, March 2012, and April 2012. When interviewed, the Facilities Manager stated that the oil was contaminated and they had to find a vendor to repair it.

2. At 11:10 A.M., the facility failed to maintain generator 1, 2 and 3 as evidenced by generator 1, 2 and 3 run time was under the required 30 minutes per month with a full load. The generator documents provided the following information:

January 4, 2012:
Generator 1 run time was 15 minutes
Generator 2 run time was 15 minutes
Generator 3 run time was 15 minutes

February 1, 2012:
Generator 1 run time was 10 minutes
Generator 3 run time was 10 minutes

March 7, 2012:
Generator 1 run time was 5 minutes
Generator 3 run time was 5 minutes

April 4, 2012:
Generator 1 run time was 5 minutes
Generator 3 run time was 5 minutes

November 2, 2011:
Generator 1 run time was 10 minutes
Generator 2 run time was 10 minutes
Generator 3 run time was 10 minutes

Based on observation, the facility failed to maintain its electrical equipment and appliances in accordance with NFPA 70 National Electrical Code. This was evidenced by the facility's use of an extension cords with no overcurrent protection. This failure affected 2 of 6 floors of the Main Hospital. This would increase the risk of an electrical fire and cause potential harm to patients.
NFPA 70 National Electrical Code (1999) Edition 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent by either (a) or (b). (a) Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified in Tables 400-5(A) and (B). Fixture wire shall be protected against overcurrent in accordance with its ampacity as specified in Table 402-5. Supplementary overcurrent protection, as in Section 240-10, shall be permitted to be an acceptable means for providing this protection.
400-8. Uses Not Permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for the fixed wiring of a structure

Findings:

During a tour of the facility with Staff 1a, Staff 2a, and Staff on November 5, 2012, through November 8, 2012, the electrical system was observed

Arrowhead Medical Center Main Campus
November 5, 2012

1. At 2:48 p.m., there was a white extension cord without overcurrent protection in use in the first floor old Administration Office Room 2C276A.



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Arrowhead Medical Center Main Campus
November 7, 2012

2. At 10:34 a.m., there was a white extension cord in use in the Burn Institute Office (Room 4A318A) without over current protection.