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Based on observation, the facility failed to maintain the integrity of the corridor doors as evidenced by the failure to provide doors with devices suitable for keeping the doors closed, and by the failure to keep impediments from obstructing the closing of doors. This could result in the spread of smoke and fire throughout the facility, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 12 smoke compartments at Inland Valley Medical Center, and 3 of 12 smoke compartments at Rancho Springs Medical Center.

Findings:

During the facility tour with the facility staff on August 27, 2012 through August 30, 2012, the corridor doors were observed.

On August 27, 2012 at Inland Valley Medical Center:

1. At 2:15 p.m., the self-closing corridor door failed to positive latch to Storage Room 5 by the Nurse's Station.

2. At 2:30 p.m., the self-closing corridor door failed to positive latch to the Nurse's Station Storage Room.

On August 29, 2012 at Rancho Springs Medical Center:

1. At 11:20 a.m., the corridor door failed to latch shut to Patient Room 123.

2. At 11:27 a.m., the self-closing corridor door failed to latch shut to Patient Room 128.

3. At 11:35 a.m., the corridor door failed to latch shut to the ante-chamber to Patient Room 162.

4. At 11:40 a.m., the self-closing corridor door failed to latch shut to the Cath Lab Prep Room.


29665

On August 27, 2012 at Inland Valley Medical Center - 2nd Floor:

1. At 9:41 a.m., the door to Room 258, in the 2 West Department, was obstructed from closing by an overbed table.

2. At 9:55 a.m., the self-closing door to the 2 West housekeeping closet, across from Room 276A, failed to latch. There were tissues in the latching hardware on the door frame, that prevented the door from latching.

Based on observation and interview, the facility failed to ensure that exits were marked by approved and visible signs, as evidenced by one stairwell that was missing exit signs. This could result in a delay in evacuation, in the event of a fire or emergency. This affected two of three smoke compartments on the second floor of the Women's Center at the Rancho Springs Medical Center.

Findings:

During a tour of the facility with the Director of Plant Operations on August 27, 2012 through August 30, 2012, the exits were observed at the Rancho Springs Medical Center.

On August 29, 2012 at the Women's Center - 2nd Floor:

At 9:59 a.m., the door into Stairwell 2 was marked as an exit. Stairwell 2 contained stairs going upstairs to the roof, and stairs going downstairs to the first floor. There was no sign that indicated that the exit was downstairs on the first floor. There was no exit sign on the exit door at the bottom of the stairs on the first floor.

During an interview at 10:00 a.m., the Rancho Springs Plant Operations Manager confirmed that the exit path out of Stairwell 2 is downstairs on the first floor, and that there were no exit signs in the stairwell.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls to provide a one-hour fire resistance rating as evidenced by a penetration in a smoke barrier wall. This could result in the spread of smoke and fire from one smoke compartment to another smoke compartment, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 12 smoke compartments at Inland Valley Medical Center.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 the facility tour and interview with the facility staff on August 27, 2012 through August 30, 2012, the smoke barrier walls were observed, and staff was interviewed.

On August 27, 2012 at Inland Valley Medical Center:

At 9:38 a.m., there was an approximately 1/2 inch unsealed penetration surrounding a conduit in the smoke barrier wall in the attic space above the ceiling by the Bathroom wall for Room 239. Engineer 1 stated that the penetration was sealed two weeks before as evidenced by a picture taken, and dislodged by a vendor.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by one smoke barrier door that failed to close and latch. This could result in the spread of fire and smoke from one smoke compartment to another, in the event of a fire. This affected 2 of 12 smoke compartments at the Inland Valley Medical Center.

Findings:

During a tour of the facility with the facility staff on August 27, 2012 through August 30, 2012, the smoke barrier doors were observed.

On August 28, 2012 at Inland Valley Medical Center - 1st Floor:

At 2:02 p.m., the fire alarm system was activated and the smoke barrier double doors, near the cafeteria, were released from their magnetic automatic-closing devices. The right leaf of the double doors failed to close fully and latch. The door was obstructed from closing by the top of the door frame.

Based on observation and interview, the facility failed to arrange patient doors such that the doors can be opened from the inside. This was evidenced by patient bathroom doors with locks, and no available keys. This could result in a delayed response to a fire, and increase the risk of injury to patients, visitors and staff. This affected 1 of 12 smoke compartments at Inland Valley Medical Center.

Findings:

During the facility tour with the the facility staff on August 27, 2012 through August 30, 2012, the patient room doors were observed, and staff was interviewed.

On August 27, 2012 at Inland Valley Medical Center:

At 11:05 a.m., there were key locks on twenty patient bathroom doors in the 2 East wing. In an interview with the Manager of the Unit and Nurse Staff 1, staff were not able to provide an immediately available key to demonstrate how to unlock the doors.

On August 28, 2012 at Inland Valley Medical Center:

At 9:55 a.m., the manual pull station was blocked by a cart and equipment in the Kitchen.


On August 28, 2012 at the Wound Care Clinic:

At 11:55 a.m., the Fire Alarm Control Panel displayed the time as 1347. Engineer I confirmed the time as 1155.

On August 29, 2012 at Rancho Springs Medical Center:

At 9:40 a.m., the Fire Alarm Control Panel displayed the time as 0735 in the Emergency Room Nurse Station. Engineer Staff II confirmed the time as 0940.










29665

Based on observation, the facility failed to maintain their fire alarm system, as evidenced by incorrect times displayed on fire alarm panels, by obstructed pull stations, and by alarm notification devices that failed. This could result in a delay in notification and staff response, in the event of a fire. This affected 1 of 12 smoke compartments at Inland Valley Medical Center, 1 of 12 smoke compartments at the Rancho Springs Medical Center, and 1 of 1 smoke compartments at the Wound Care Clinic.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the fire alarm system was observed and tested.

Based on observation, the facility failed to maintain their fire alarm system, as evidenced by an obstructed manual fire alarm pull station, and by an alarm notification device that failed. This could result in a delay in notification and staff response, in the event of a fire. This affected 2 of 7 smoke compartments at the Women's Center at Rancho Springs Medical Center.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the fire alarm system was observed and tested.

On August 29, 2012 at the Women's Center- 1st Floor:

At 2:09 p.m., the fire alarm system was activated, and the alarm notification device inside the pharmacy hallway did not emit an audible alarm.

On August 29, 2012 at the Women's Center- 2nd Floor:

At 2:47 p.m., the manual fire alarm pull station at the Labor and Delivery Nurses Station was obstructed by a crash cart.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system, as evidenced by one tamper switch that failed. This could result in delay of extinguishing a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected the exterior storage building for 1 of 2 hospital campuses.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the fire alarm system was tested.

On August 29, 2012 at Rancho Springs Medical Center Exterior Materials Storage Building:

At 2:30 p.m., the fire alarm panel did not receive a signal when Engineer 2 closed the Post-Indicator Valve completely. Engineer 2 tested the tamper switch on the Post-Indicator Valve twice, and confirmed that no supervisory signal was received at the fire alarm panel.

During an interview at 2:32 p.m., the Director of Plant Operations stated that the smoke detectors and pull stations in the storage building were connected to the Rancho Springs Medical Center fire alarm system. He stated that the sprinkler system was not connected to the main hospital's fire alarm system.

On August 30, 2012 at Rancho Springs Medical Center Exterior Materials Storage Building:


During an interview at 10:56 a.m., the fire alarm vendor removed the box cover of the tamper switch on the Post-Indicator Valve, and indicated that the lever on the switch was obstructed from moving by a wire. The vendor repaired the issue, and tested the tamper switch. A supervisory signal was received at the fire alarm panel when the valve was closed half a turn.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained as evidenced by an escutcheon ring that were not flush to the ceiling and missing escutcheon rings. This could prevent the automatic sprinkler system from operating as designed and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 12 smoke compartments at Rancho Springs Medical Center, and 1 of 12 smoke compartments at Inland Valley Medical Center.

Findings:

During a tour of the facility with the facility staff on August 27, 2012 through August 30, 2012, the automatic sprinkler system was observed.

On August 29, 2012:

At 11:30 a.m., there were 2 of 2 fire sprinklers missing the sprinkler skirts in the the Crash Cart Storage Room.

August 27, 12 at Inland Valley Medical Center - 2nd Floor:

At 10:19 a.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling, around the sprinkler head in the 2 Central clean utility closet.

On August 28, 2012 at Inland Valley Medical Center:

At 10:00 a.m., the K fire extinguisher was blocked by a cart and equipment in the Kitchen.



29665

Based on observation, the facility failed to maintain their fire extinguishers, as evidenced by two fire extinguishers that were obstructed. This could result in delay of extinguishing a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 12 smoke compartments at the Inland Valley Medical Center.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility with plant operations staff from August 27, 2012 through August 30, 2012, the fire extinguishers were observed.

On August 28, 2012 at Inland Valley Medical Center - 1st Floor:

At 9:59 a.m., there was a soiled linen bin in front of the fire extinguisher cabinet, across from the PACU nurses station, that obstructed access to the fire extinguisher.

Based on record review and interview, the facility failed to maintain the heating, ventilation and air conditioning systems as evidenced by the failure to provide follow-up repairs for the testing of the fire dampers. This could result in the failure of the dampers to operate in the event of a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire.
This affected 12 of 12 smoke compartments at Rancho Springs Medical Center.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection devices(s) within.
2-3.4.5 Openings is walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs.
3-4.7* Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

*Waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of 6 years rather than 4 years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital's testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protective and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The 6-year testing interval shall commence on the date of the last documented damper test.


During document review and interview with the facility staff on August 27, 2012 through August 30, 2012, the fire/smoke damper inspection records were reviewed, and staff was interviewed.

On August 27, 2012:

At 3:00 p.m., a damper inspection report dated 11/09/2009, for Rancho Springs Medical Center was provided for review. The Deficiency note stated "RSW-1-SD 07 inaccessible- need to remove wire and pipe." There was no follow-up work order provided. The Rancho Springs Medical Center Plant Operations Manager stated that there was no follow-up repair order.

Based on observation, the facility failed to ensure that portable space heating devices are not used in patient care areas. This was evidenced by one portable heating device that was in an office located on a patient floor. This could result in a fire, and increase the risk of injury to patients, visitors and staff. This affected one of four smoke compartments on the second floor of the Inland Valley Medical Center.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the facility was observed for portable space heating devices.

August 27, 2012 at Inland Valley Medical Center - 2nd Floor

At 9:59 a.m., there was a portable space heating device under the desk of the 2 West manager's office. The office is located in a smoke compartment with patient rooms.

Based on observation, the facility failed to maintain their piped-in medical gas systems, as evidenced by one emergency shut-off valve that was obstructed. This could result in a delay in shutting off the medical gas lines, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 1 of 3 smoke compartments on the second floor of the Women's Center at the Rancho Springs Medical Center.

NFPA 99, Standard for Health Care 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.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a tour of the facility with plant operations on August 27, 2012 through August 30, 2012, the piped-in medical gas systems were observed.

On August 29, 2012 at Rancho Springs Medical Center - 2nd Floor:

At 2:54 p.m., the emergency shut-off valves for the piped-in medical gas system, in the non-sterile side of the delivery rooms, was obstructed and obscured from view by an anesthesia machine.

During observation, record review and interview, the facility failed to maintain their emergency generator. This was evidenced by no battery-powered lighting in one generator enclosure, and by generator batteries that were past due to be changed. This affected 12 of 12 smoke compartments at the Rancho Springs Medical Center, and could result in the failure of the generator during a power outage.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.4 Administration (Type 1 Essential Electrical Systems)
3-4.4.1.3 Maintenance of Batteries. Storage batteries in connection with essential electrical systems shall be inspected at intervals not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects (see NFPA 70, National Electrical Code, Section 700-4).


NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.


Findings:

During a tour of the facility with the Director of Plant Operations on August 27, 2012 through August 30, 2012, the generators were observed.

On August 29, 2012 at Rancho Springs Medical Center:

At 9:26 a.m., three of three batteries for Generator 2 were dated April 2008.
During an interview at 9:27 a.m., the Rancho Springs Plant Operations Manager stated that the manufacturer recommends that the batteries be changed every 36 months.

At 9:29 a.m., there were no battery-powered emergency lights in the room housing Generator 1. During an interview at 9:30 a.m., the Rancho Springs Plant Operations Manager stated that the lights in the room run on emergency power, and no battery-powered lights were available in the room.

On August 30, 2012 at Rancho Springs Medical Center:

At 10:00 a.m., documents from a vendor who performed preventative maintenance for the three generators that supply emergency power to the Rancho Springs Medical Center were provided. Preventative maintenance was last performed on 5/29/12. Under the "Recommendations" section of the inspection document, the vendor recommended that the batteries on Generator 2 be replaced "due to age" during the next scheduled inspection. The vendor also recommended that the batteries on Generator 1 be replaced "due to weak cells and load test", and the blockheater hoses on Generator 4 be replaced "due to condition", during the next scheduled inspection.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by high wattage electrical appliances plugged into surge protectors and not directly into electrical outlets, and by missing or broken cover plates. This could result in an electrical fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 6 of 12 smoke compartments at Inland Valley Medical Center, and 3 of 12 smoke compartments at Rancho Springs Medical Center.

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

NFPA 70 Section 400-8 1999 Ed. 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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the facility staff on August 27, 2012 through August 30, 2012, the electrical wiring and connections were observed.

On August 29, 2012 at Rancho Springs Medical Center:

1. At 11:05 a.m., there was a refrigerator plugged into a surge protector and not directly into the wall in the Staffing House Supervisor Office.

2. At 11:57 a.m., there were two water coolers plugged into a surge protector and not directly into the wall in the Peri-Op Staff Lounge.


29665

On August 29, 2012 at Rancho Springs Medical Center - 1st Floor:

1. At 1:41 p.m., there was a refrigerator plugged into a six-plug surge protector in the cafeteria.

On August 28, 2012 at Inland Valley Medical Center:

At 10:05 a.m., there were 2 refrigerated vending machines plugged into a surge protector and not directly into the wall, in the Cafeteria.



29665

On August 27, 2012 at Inland Valley Medical Center- 1st Floor:

1. At 10:26 a.m., there was an approximately 3 inch by 3 inch electrical box with no cover, in the center of the smoke barrier wall above the ceiling in Building C, near the old exam room.

2. At 10:47 a.m., there was an approximately 1 foot by 1 foot electrical box with a hinged cover that was open, on the left side of the smoke barrier wall above the ceiling in Building H, between the lobby and radiology department.

On August 28, 2012 at Inland Valley Medical Center- 1st Floor:

1. At 9:47 a.m., there was a microwave plugged into a six-plug surge protector in the Receiving's Storage Room.

2. At 10:02 a.m., there were two electrical outlets with broken faceplates in the empty supply room (Door IV1322) outside the PACU department.

3. At 10:06 a.m., there was a microwave plugged into an extension cord in the emergency manager's office. The extension cord was plugged into a six-plug surge protector.

Based on observation, the facility failed to maintain its electrical equipment and wiring as evidenced by an electrical box that was missing a cover plate. This could result in an electrical fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 7 smoke compartments at the Women's Center at Rancho Springs Medical Center.

Findings:

During the facility tour with the facility staff on August 27, 2012 through August 30, 2012, the electrical wiring and connections were observed.

On August 29, 2012 at the Women's Center- 2nd Floor:

At 2:52 p.m., the cover plate for the data cables electrical box, behind the anesthesia machine in the non-sterile side of the delivery rooms, had fallen off the wall, and was hanging by the wires.

Based on observation, the facility failed to ensure that Alcohol Based Hand Rub (ABHR) dispensers are not stored over ignition sources, as evidenced by a ABHR dispenser that was installed directly over a light switch. This could result in an electrical fire, and increase the risk of injury to patients, visitors ans staff in the event of a fire. This affected 1 of 12 smoke compartments at the Inland Valley Medical Center.

Findings:

During a tour of the facility with facility staff on August 27, 2012 through August 30, 2012, the ABHR dispensers were observed.

On August 28, 2012 at Inland Valley Medical Center- 1st Floor:

At 10:45 a.m., there was an ABHR dispenser installed directly over a light switch in Room 1 of Building C.

Based on observation, the facility failed to maintain the integrity of the corridor doors as evidenced by the failure to provide doors with devices suitable for keeping the doors closed, and by the failure to keep impediments from obstructing the closing of doors. This could result in the spread of smoke and fire throughout the facility, and increase the risk of injury to patients, visitors and staff due to smoke and fire. This affected 2 of 12 smoke compartments at Inland Valley Medical Center, and 3 of 12 smoke compartments at Rancho Springs Medical Center.

Findings:

During the facility tour with the facility staff on August 27, 2012 through August 30, 2012, the corridor doors were observed.

On August 27, 2012 at Inland Valley Medical Center:

1. At 2:15 p.m., the self-closing corridor door failed to positive latch to Storage Room 5 by the Nurse's Station.

2. At 2:30 p.m., the self-closing corridor door failed to positive latch to the Nurse's Station Storage Room.

On August 29, 2012 at Rancho Springs Medical Center:

1. At 11:20 a.m., the corridor door failed to latch shut to Patient Room 123.

2. At 11:27 a.m., the self-closing corridor door failed to latch shut to Patient Room 128.

3. At 11:35 a.m., the corridor door failed to latch shut to the ante-chamber to Patient Room 162.

4. At 11:40 a.m., the self-closing corridor door failed to latch shut to the Cath Lab Prep Room.


29665

On August 27, 2012 at Inland Valley Medical Center - 2nd Floor:

1. At 9:41 a.m., the door to Room 258, in the 2 West Department, was obstructed from closing by an overbed table.

2. At 9:55 a.m., the self-closing door to the 2 West housekeeping closet, across from Room 276A, failed to latch. There were tissues in the latching hardware on the door frame, that prevented the door from latching.

Based on observation and interview, the facility failed to ensure that exits were marked by approved and visible signs, as evidenced by one stairwell that was missing exit signs. This could result in a delay in evacuation, in the event of a fire or emergency. This affected two of three smoke compartments on the second floor of the Women's Center at the Rancho Springs Medical Center.

Findings:

During a tour of the facility with the Director of Plant Operations on August 27, 2012 through August 30, 2012, the exits were observed at the Rancho Springs Medical Center.

On August 29, 2012 at the Women's Center - 2nd Floor:

At 9:59 a.m., the door into Stairwell 2 was marked as an exit. Stairwell 2 contained stairs going upstairs to the roof, and stairs going downstairs to the first floor. There was no sign that indicated that the exit was downstairs on the first floor. There was no exit sign on the exit door at the bottom of the stairs on the first floor.

During an interview at 10:00 a.m., the Rancho Springs Plant Operations Manager confirmed that the exit path out of Stairwell 2 is downstairs on the first floor, and that there were no exit signs in the stairwell.

Based on observation and interview, the facility failed to maintain the integrity of their smoke barrier walls to provide a one-hour fire resistance rating as evidenced by a penetration in a smoke barrier wall. This could result in the spread of smoke and fire from one smoke compartment to another smoke compartment, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 12 smoke compartments at Inland Valley Medical Center.

8.3.6.1., Pipes, conduits, bus ducts, cables, wires, air ducts, pneumatic tube and ducts, and similar building services 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 of 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:
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 the facility tour and interview with the facility staff on August 27, 2012 through August 30, 2012, the smoke barrier walls were observed, and staff was interviewed.

On August 27, 2012 at Inland Valley Medical Center:

At 9:38 a.m., there was an approximately 1/2 inch unsealed penetration surrounding a conduit in the smoke barrier wall in the attic space above the ceiling by the Bathroom wall for Room 239. Engineer 1 stated that the penetration was sealed two weeks before as evidenced by a picture taken, and dislodged by a vendor.

Based on observation, the facility failed to maintain their smoke barrier doors, as evidenced by one smoke barrier door that failed to close and latch. This could result in the spread of fire and smoke from one smoke compartment to another, in the event of a fire. This affected 2 of 12 smoke compartments at the Inland Valley Medical Center.

Findings:

During a tour of the facility with the facility staff on August 27, 2012 through August 30, 2012, the smoke barrier doors were observed.

On August 28, 2012 at Inland Valley Medical Center - 1st Floor:

At 2:02 p.m., the fire alarm system was activated and the smoke barrier double doors, near the cafeteria, were released from their magnetic automatic-closing devices. The right leaf of the double doors failed to close fully and latch. The door was obstructed from closing by the top of the door frame.

Based on observation and interview, the facility failed to arrange patient doors such that the doors can be opened from the inside. This was evidenced by patient bathroom doors with locks, and no available keys. This could result in a delayed response to a fire, and increase the risk of injury to patients, visitors and staff. This affected 1 of 12 smoke compartments at Inland Valley Medical Center.

Findings:

During the facility tour with the the facility staff on August 27, 2012 through August 30, 2012, the patient room doors were observed, and staff was interviewed.

On August 27, 2012 at Inland Valley Medical Center:

At 11:05 a.m., there were key locks on twenty patient bathroom doors in the 2 East wing. In an interview with the Manager of the Unit and Nurse Staff 1, staff were not able to provide an immediately available key to demonstrate how to unlock the doors.

On August 28, 2012 at Inland Valley Medical Center:

At 9:55 a.m., the manual pull station was blocked by a cart and equipment in the Kitchen.


On August 28, 2012 at the Wound Care Clinic:

At 11:55 a.m., the Fire Alarm Control Panel displayed the time as 1347. Engineer I confirmed the time as 1155.

On August 29, 2012 at Rancho Springs Medical Center:

At 9:40 a.m., the Fire Alarm Control Panel displayed the time as 0735 in the Emergency Room Nurse Station. Engineer Staff II confirmed the time as 0940.










29665

Based on observation, the facility failed to maintain their fire alarm system, as evidenced by incorrect times displayed on fire alarm panels, by obstructed pull stations, and by alarm notification devices that failed. This could result in a delay in notification and staff response, in the event of a fire. This affected 1 of 12 smoke compartments at Inland Valley Medical Center, 1 of 12 smoke compartments at the Rancho Springs Medical Center, and 1 of 1 smoke compartments at the Wound Care Clinic.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the fire alarm system was observed and tested.

Based on observation, the facility failed to maintain their fire alarm system, as evidenced by an obstructed manual fire alarm pull station, and by an alarm notification device that failed. This could result in a delay in notification and staff response, in the event of a fire. This affected 2 of 7 smoke compartments at the Women's Center at Rancho Springs Medical Center.

NFPA 101, Life Safety Code, 2000 Edition.
9.6.1.7 To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.

NFPA 72, National Fire Alarm Code, 1999 Edition.
2-8.2.1 Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.
7-1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this code, shall conform to the equipment manufacturer's recommendations, and shall verify correct operation of the fire alarm system.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the fire alarm system was observed and tested.

On August 29, 2012 at the Women's Center- 1st Floor:

At 2:09 p.m., the fire alarm system was activated, and the alarm notification device inside the pharmacy hallway did not emit an audible alarm.

On August 29, 2012 at the Women's Center- 2nd Floor:

At 2:47 p.m., the manual fire alarm pull station at the Labor and Delivery Nurses Station was obstructed by a crash cart.

Based on observation and interview, the facility failed to maintain their automatic sprinkler system, as evidenced by one tamper switch that failed. This could result in delay of extinguishing a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected the exterior storage building for 1 of 2 hospital campuses.

NFPA 101, Life Safety Code, 2000 Edition
9.7.2.1 Supervisory Signals. Where supervised automatic sprinkler systems are required by another section of this Code, supervisory attachments shall be installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm Code, and a distinctive supervisory signal shall be provided to indicate a condition that would impair the satisfactory operation of the sprinkler system. Monitoring shall include, but shall not be limited to, monitoring of control valves, fire pump power supplies and running conditions, water tank levels and temperatures, tank pressure, and air pressure on dry-pipe valves. Supervisory signals shall sound and shall be displayed either at a location within the protected building that is constantly attended by qualified personnel or at an approved, remotely located receiving facility.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the fire alarm system was tested.

On August 29, 2012 at Rancho Springs Medical Center Exterior Materials Storage Building:

At 2:30 p.m., the fire alarm panel did not receive a signal when Engineer 2 closed the Post-Indicator Valve completely. Engineer 2 tested the tamper switch on the Post-Indicator Valve twice, and confirmed that no supervisory signal was received at the fire alarm panel.

During an interview at 2:32 p.m., the Director of Plant Operations stated that the smoke detectors and pull stations in the storage building were connected to the Rancho Springs Medical Center fire alarm system. He stated that the sprinkler system was not connected to the main hospital's fire alarm system.

On August 30, 2012 at Rancho Springs Medical Center Exterior Materials Storage Building:


During an interview at 10:56 a.m., the fire alarm vendor removed the box cover of the tamper switch on the Post-Indicator Valve, and indicated that the lever on the switch was obstructed from moving by a wire. The vendor repaired the issue, and tested the tamper switch. A supervisory signal was received at the fire alarm panel when the valve was closed half a turn.

Based on observation, the facility failed to ensure that the automatic sprinkler system was maintained as evidenced by an escutcheon ring that were not flush to the ceiling and missing escutcheon rings. This could prevent the automatic sprinkler system from operating as designed and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 12 smoke compartments at Rancho Springs Medical Center, and 1 of 12 smoke compartments at Inland Valley Medical Center.

Findings:

During a tour of the facility with the facility staff on August 27, 2012 through August 30, 2012, the automatic sprinkler system was observed.

On August 29, 2012:

At 11:30 a.m., there were 2 of 2 fire sprinklers missing the sprinkler skirts in the the Crash Cart Storage Room.

August 27, 12 at Inland Valley Medical Center - 2nd Floor:

At 10:19 a.m., there was an approximately 1/2 inch gap between the escutcheon ring and the ceiling, around the sprinkler head in the 2 Central clean utility closet.

On August 28, 2012 at Inland Valley Medical Center:

At 10:00 a.m., the K fire extinguisher was blocked by a cart and equipment in the Kitchen.



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Based on observation, the facility failed to maintain their fire extinguishers, as evidenced by two fire extinguishers that were obstructed. This could result in delay of extinguishing a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 2 of 12 smoke compartments at the Inland Valley Medical Center.

NFPA 10, Standard for Portable Fire Extinguishers, 1998 Edition
1.6.3 Fire extinguishers shall be conspicuously located where they will be readily accessible and immediately available in the event of fire. Preferably, they shall be located along normal paths of travel, including exits from areas.
1.6.6 Fire extinguishers shall not be obstructed or obscured from view.

Findings:

During a tour of the facility with plant operations staff from August 27, 2012 through August 30, 2012, the fire extinguishers were observed.

On August 28, 2012 at Inland Valley Medical Center - 1st Floor:

At 9:59 a.m., there was a soiled linen bin in front of the fire extinguisher cabinet, across from the PACU nurses station, that obstructed access to the fire extinguisher.

Based on record review and interview, the facility failed to maintain the heating, ventilation and air conditioning systems as evidenced by the failure to provide follow-up repairs for the testing of the fire dampers. This could result in the failure of the dampers to operate in the event of a fire, and increase the risk of injury to patients, visitors and staff in the event of a fire.
This affected 12 of 12 smoke compartments at Rancho Springs Medical Center.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 Edition
2-3.4.2 Service openings shall be identified with letters having a minimum of 1/2 in. (1.27 cm) to indicate the location of the fire protection devices(s) within.
2-3.4.5 Openings is walls or ceilings shall be provided so that service openings in air ducts are accessible for maintenance and inspection needs.
3-4.7* Maintenance. At least every 4 years, fusible links (where applicable) shall be removed; all dampers shall be operated to verify that they close fully; the latch, if provided, shall be checked; and moving parts shall be lubricated as necessary.

*Waiver pursuant to 42 CFR 482.41(b)(2) to permit a testing interval of 6 years rather than 4 years for the maintenance testing of fire and smoke dampers in hospital heating and ventilating systems, so long as the hospital's testing system conforms to the requirements under 2007 edition of NFPA 80: Standard for Fire Doors and Other Opening Protective and the 2007 edition of NFPA 105: Standard for the Installation of Smoke Door Assemblies. The 6-year testing interval shall commence on the date of the last documented damper test.


During document review and interview with the facility staff on August 27, 2012 through August 30, 2012, the fire/smoke damper inspection records were reviewed, and staff was interviewed.

On August 27, 2012:

At 3:00 p.m., a damper inspection report dated 11/09/2009, for Rancho Springs Medical Center was provided for review. The Deficiency note stated "RSW-1-SD 07 inaccessible- need to remove wire and pipe." There was no follow-up work order provided. The Rancho Springs Medical Center Plant Operations Manager stated that there was no follow-up repair order.

Based on observation, the facility failed to ensure that portable space heating devices are not used in patient care areas. This was evidenced by one portable heating device that was in an office located on a patient floor. This could result in a fire, and increase the risk of injury to patients, visitors and staff. This affected one of four smoke compartments on the second floor of the Inland Valley Medical Center.

Findings:

During a tour of the facility with plant operations staff on August 27, 2012 through August 30, 2012, the facility was observed for portable space heating devices.

August 27, 2012 at Inland Valley Medical Center - 2nd Floor

At 9:59 a.m., there was a portable space heating device under the desk of the 2 West manager's office. The office is located in a smoke compartment with patient rooms.

Based on observation, the facility failed to maintain their piped-in medical gas systems, as evidenced by one emergency shut-off valve that was obstructed. This could result in a delay in shutting off the medical gas lines, in the event of a fire and increase the risk of injury to patients, visitors and staff. This affected 1 of 3 smoke compartments on the second floor of the Women's Center at the Rancho Springs Medical Center.

NFPA 99, Standard for Health Care 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.
(m) A shutoff valve shall be located immediately outside each vital life-support or critical care area in each medical gas line, and located so as to be readily accessible in an emergency. Valves shall be protected and marked in accordance with 4-3.5.4.2.

Findings:

During a tour of the facility with plant operations on August 27, 2012 through August 30, 2012, the piped-in medical gas systems were observed.

On August 29, 2012 at Rancho Springs Medical Center - 2nd Floor:

At 2:54 p.m., the emergency shut-off valves for the piped-in medical gas system, in the non-sterile side of the delivery rooms, was obstructed and obscured from view by an anesthesia machine.

During observation, record review and interview, the facility failed to maintain their emergency generator. This was evidenced by no battery-powered lighting in one generator enclosure, and by generator batteries that were past due to be changed. This affected 12 of 12 smoke compartments at the Rancho Springs Medical Center, and could result in the failure of the generator during a power outage.

NFPA 99, Standard for Health Care Facilities, 1999 Edition.
3-4.4 Administration (Type 1 Essential Electrical Systems)
3-4.4.1.3 Maintenance of Batteries. Storage batteries in connection with essential electrical systems shall be inspected at intervals not more than 7 days and shall be maintained in full compliance with manufacturer's specifications. Defective batteries shall be repaired or replaced immediately upon discovery of defects (see NFPA 70, National Electrical Code, Section 700-4).


NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition.
5-3.1 The Level 1 or Level 2 EPS equipment location shall be provided with battery-powered emergency lighting. The emergency lighting charging system and the normal service room lighting shall be supplied from the load side of the transfer switch.


Findings:

During a tour of the facility with the Director of Plant Operations on August 27, 2012 through August 30, 2012, the generators were observed.

On August 29, 2012 at Rancho Springs Medical Center:

At 9:26 a.m., three of three batteries for Generator 2 were dated April 2008.
During an interview at 9:27 a.m., the Rancho Springs Plant Operations Manager stated that the manufacturer recommends that the batteries be changed every 36 months.

At 9:29 a.m., there were no battery-powered emergency lights in the room housing Generator 1. During an interview at 9:30 a.m., the Rancho Springs Plant Operations Manager stated that the lights in the room run on emergency power, and no battery-powered lights were available in the room.

On August 30, 2012 at Rancho Springs Medical Center:

At 10:00 a.m., documents from a vendor who performed preventative maintenance for the three generators that supply emergency power to the Rancho Springs Medical Center were provided. Preventative maintenance was last performed on 5/29/12. Under the "Recommendations" section of the inspection document, the vendor recommended that the batteries on Generator 2 be replaced "due to age" during the next scheduled inspection. The vendor also recommended that the batteries on Generator 1 be replaced "due to weak cells and load test", and the blockheater hoses on Generator 4 be replaced "due to condition", during the next scheduled inspection.

Based on observation, the facility failed to maintain its electrical equipment and wiring in accordance with NFPA 70. This was evidenced by high wattage electrical appliances plugged into surge protectors and not directly into electrical outlets, and by missing or broken cover plates. This could result in an electrical fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 6 of 12 smoke compartments at Inland Valley Medical Center, and 3 of 12 smoke compartments at Rancho Springs Medical Center.

NFPA 70 (1999 Edition) 240-4, Flexible cord, including tinsel cord and extension cords, and fixture wires shall be protected against overcurrent.
A. Ampacities. Flexible cord shall be protected by an overcurrent device in accordance with its ampacity as specified.

NFPA 70 Section 400-8 1999 Ed. 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 a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

Findings:

During the facility tour with the facility staff on August 27, 2012 through August 30, 2012, the electrical wiring and connections were observed.

On August 29, 2012 at Rancho Springs Medical Center:

1. At 11:05 a.m., there was a refrigerator plugged into a surge protector and not directly into the wall in the Staffing House Supervisor Office.

2. At 11:57 a.m., there were two water coolers plugged into a surge protector and not directly into the wall in the Peri-Op Staff Lounge.


29665

On August 29, 2012 at Rancho Springs Medical Center - 1st Floor:

1. At 1:41 p.m., there was a refrigerator plugged into a six-plug surge protector in the cafeteria.

On August 28, 2012 at Inland Valley Medical Center:

At 10:05 a.m., there were 2 refrigerated vending machines plugged into a surge protector and not directly into the wall, in the Cafeteria.



29665

On August 27, 2012 at Inland Valley Medical Center- 1st Floor:

1. At 10:26 a.m., there was an approximately 3 inch by 3 inch electrical box with no cover, in the center of the smoke barrier wall above the ceiling in Building C, near the old exam room.

2. At 10:47 a.m., there was an approximately 1 foot by 1 foot electrical box with a hinged cover that was open, on the left side of the smoke barrier wall above the ceiling in Building H, between the lobby and radiology department.

On August 28, 2012 at Inland Valley Medical Center- 1st Floor:

1. At 9:47 a.m., there was a microwave plugged into a six-plug surge protector in the Receiving's Storage Room.

2. At 10:02 a.m., there were two electrical outlets with broken faceplates in the empty supply room (Door IV1322) outside the PACU department.

3. At 10:06 a.m., there was a microwave plugged into an extension cord in the emergency manager's office. The extension cord was plugged into a six-plug surge protector.

Based on observation, the facility failed to maintain its electrical equipment and wiring as evidenced by an electrical box that was missing a cover plate. This could result in an electrical fire, and increase the risk of injury to patients, visitors and staff in the event of a fire. This affected 1 of 7 smoke compartments at the Women's Center at Rancho Springs Medical Center.

Findings:

During the facility tour with the facility staff on August 27, 2012 through August 30, 2012, the electrical wiring and connections were observed.

On August 29, 2012 at the Women's Center- 2nd Floor:

At 2:52 p.m., the cover plate for the data cables electrical box, behind the anesthesia machine in the non-sterile side of the delivery rooms, had fallen off the wall, and was hanging by the wires.