HospitalInspections.org

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This could result in the spread of smoke or fire to other locations in the facility. This affected the 2nd floor at Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the building construction was observed.

On 2/27/12 at 3:24 P.M., in Room D2049 on the 2nd floor there were two penetrations in the right wall that were each approximately one inch in diameter.

Based on observation the facility failed to maintain the corridor doors as evidenced by failure to keep doors clear from impediments to closing in the event of a fire. This has the potential for the spread of smoke and flames in the event of a fire. This affected 1 of 6 smoke compartments at Riverside County Regional Medical Center D/P Adult Psychiatric Hospital (APH).

Findings:

On March 1, 2012, during testing the of the fire alarm system the doors were observed.

At 1:38 p.m., on Unit D, the Treatment team room door was held in the open position by a chair being placed in front of it. The door was equipped with a self-closing device.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to positive latch, and were blocked from closing. This had the potential to allow the migration of smoke causing harm to patients and staff. This affected the Lower Level, 1st, 2nd, and 3rd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the corridor doors were observed.

1. On 2/27/12 at 1:12 P.M., the door to Room 3124 on the 3rd floor was impeded from closing by a trash placed up against the door.

2. On 2/27/12 at 1:30 P.M., the door to Room C3084 on the 3rd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

3. On 2/27/12 at 1:35 P.M., the door to Room 3512 on the 3rd floor was impeded from closing by a trash placed up against the door.

4. On 2/27/12 at 2:05 P.M., the door to Room B3073 on the 3rd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

5. On 2/27/12 at 2:18 P.M., the door to Room B3083 on the 3rd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

6. On 2/27/12 at 3:26 P.M., the door to Room 2029 on the 2nd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

7. On 2/28/12 at 9:00 A.M., the door to Room F2013 on the 2nd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

8. On 2/28/12 at 9:10 A.M., the door to Room F2018 on the 2nd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

9. On 2/28/12 at 11:10 A.M., the door to Room E1110 on the 1st floor was propped open with a door wedge.

10. On 2/28/12 at 11:32 A.M., the door to Room E1051 "Hyperbaric Medicine" on the 1st floor failed to latch due to a business card taped over the latching mechanism.

11. On 2/28/12 at 2:49 P.M., the door to Room E0007 on the Lower Level had electrical tape over the latching mechanism that prevented the door from positively latching.

12. On 2/28/12 at 3:15 P.M., the door to Room E0077 on the Lower Level failed to latch.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, 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.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls as evidenced by a penetration in a smoke barrier wall. This could result in the increased risk of injury to the patients and staff due to smoke and fire. This affected the Lower Level of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the smoke barrier walls were observed.

On 2/28/12 at 2:55 P.M., on the Lower Level, there was a penetration approximately one inch round in the smoke barrier wall above the fire doors by Room E0160.

5. At 1:27 p.m., the right leaf of the smoke barrier doors on the 4th floor by room 4124 failed to latch upon automatic closure.

6. At 3:40 p.m., the two sets of fire/smoke barrier doors C 1038, the left leaf on the left side failed to latch and the right leaf on the right side failed to latch upon automatic closure in the Family Care Area on the 1st floor.




27961

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested. This could result in the spread of smoke and/or fire. This affected the Lower Level, 1st, 3rd, and 4th floor of Riverside County Regional Medical Center.

Findings:

During fire alarm testing with the Hospital Staff on February 29, 2012, the smoke barrier doors were observed.

1. On 2/29/12 at 2:01 P.M., the smoke barrier door to the Work Area, Room C3083 on the 3rd floor failed to positive latch after activation of a manual pull station.

2. On 2/29/12 at 2:03 P.M., the smoke barrier door to B3082 on the 3rd floor failed to positive latch after activation of a manual pull station.

3. On 2/29/12 at 3:50 P.M., the smoke barrier door by Room F1038 on the 1st floor failed to positive latch on the left side after activation of a smoke detector.

4. On 2/29/12 at 3:51 P.M., the smoke barrier door by Room F1034 on the 1st floor failed to positive latch on the left side after activation of a smoke detector.

NFPA 101®, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated,
factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

Based on observation, the facility failed to protect hazardous areas with self-closing doors. This was evidenced by hazardous areas with doors that did not have a self closing device. This could potentially allow the spread of smoke and fire from hazardous areas to other areas and increase the risk of injury to patients and staff. This affected the 1st and 2nd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the hazardous areas were observed.

1. On 2/28/12 at 9:40 A.M., Room B1014 in the Kitchen on the 1st Floor was approximately 15 ft x 15 ft and contained supplies, paper and boxes stacked around the walls and under the desk. The door failed to have a self-closing device.

2. On 2/29/12 at 2:40 P.M., the door to Room F2122 on the 2nd floor was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure. The room contained 21 E-Oxygen Tanks.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by crash carts and a Computer On Wheels (COW) in the exit access that leads to the corridor. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During the tour of the facility with Hospital Staff on February 27, 2012 through March 2, 2012, the exits were observed.

On 2/28/12 at 2:00 P.M., in the Emergency Department on the 1st floor, there was a COW and two crash carts next to the fire doors leading to the corridor and the ambulance entrance outside.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the emergency lighting was observed and tested.

On 2/28/12 at 2:13 P.M., the emergency lighting labeled EBL5106F04 in the stairwell on the 1st floor failed to illuminate when tested.

NFPA 101, 1999 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on observation, the facility failed to maintain exit/directional signs as evidenced by a missing "Exit" sign. This could have the potential for delaying evacuation of patients during an emergency. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, exits, exit signs and their illumination was observed.

On 2/28/12 at 1:55 P.M., on the 1st floor there was no " Exit " sign over the doors leading from the emergency department to the ambulance entrance outside.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Based on observation and testing, the facility failed to provide effective warning of fire as evidenced by strobes and chimes that failed to alarm. This could result in potential harm to patients, visitors and staff if the alarms failed to notify patients, visitors and staff of a fire in the facility. This affected the 1st floor of Riverside County Regional Medical Center.

During alarm testing with Hospital Staff on February 29, 2012, the alarms were observed and tested.

1. On 2/29/12 at 3:42 P.M., on the 1st floor the fire alarm notification devices were activated, and the chime between the Pediatric waiting area and the Infusion waiting area failed to activate after testing of a manual pull station.

2. On 2/29/12 at 4:09 P.M., on the 1st floor the fire alarm notification devices were activated, and the strobe in the Catering area of the Kitchen failed to activate after testing of a manual pull station.

Based on document review and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by no accurate count of smoke detectors in the facility, and not all devices were tested annually. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P Adult Psychiatric Hospital (APH).

Findings:

On March 1, 2012, during document review the Inspection, Testing, and Maintenance, document for the Annual Certification dated April 13, 2011, was reviewed.

On page 1 of 4, it listed 82 smoke detectors (this includes the Children's Treatment building which was not part of this survey). The document titled "Smoke Detector Locations: Mental Health Treatment", provided by the facility Building Maintenance Superintendent, listed the location of 79 smoke detectors. The documentation lists 32 Horn/Strobes in the facility. The following horn/strobes are listed in the report, but did not indicate that the device was tested during the annual certification by an "X" next to the device under test.
AD-8C (HS)
AD-20C (HS)
D-21 (HS)
D-32C (HS)
C-2C (HS)
C-22(HS)
C-27C (HS)
B-24C (HS)
S2-LE (HS)
S2-LW (HS)
OP-2C (HS)
OP-6C (HS)
OP-18C (HS)
OP-18C (HS)
ET-6C (HS)
ET-7 (HS)
A-5C (HS)
A-14 (HS)
A-16 (Strobe)
A-29C (HS)
B-2C (HS)
ET-35 (HS)
ET-ELS (HS)
ET-20 (HS)
SB-1E (HS)
SB-1E (Strobe)

The Inspection, Testing and Maintenance document dated April 13, 2012, lists 24 Duct Detectors. The annual certification lists 23 duct detectors that were tested, and included the Children's Treatment Area (not part of this survey). The Smoke Detector Location document that was provided by the facility lists 18 duct detectors.

The facility confirmed they did not have an accurate account of all devices in the facility. Not all devices were tested during the past year as required. At 1:08 p.m., documentation for Smoke Detector Sensitivity testing was requested. The Building Maintenance Superintendent stated they did not have this information.

Based on observation the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by warning devices that failed to activate upon activation of the fire alarm system. This affected the 2nd floor and the Lower Level of Riverside County Regional Medical Center.

Findings:

On February 29, 2012, during testing of the fire alarm system the audible visual devices were observed.

1. At 3:03 p.m., in the Respiratory Therapy Department on the 2nd floor, 2 of 2 audio/visual devices failed. Chime strobe L2E-4 in the hallway, and L2E-5, failed upon activation of the fire alarm system.

Lower Level:
2. At 4:26 p.m., the audio/visual device DOO36, failed to activate a chime when testedc.
3. At 4:22 p.m., the audio/visual device LLD-32, failed to activate a chime when tested.
4. At 4:44 p.m., the audio/visual device LLF-36, failed to activate a chime when tested.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: The requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using an device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on interview and document review, the facility failed to provide documentation of smoke detector sensitivity testing, in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by the failure ot provide records of sensitivity testing for the smoke detectors. This may result in the smoke detectors not functioning in the event of a fire. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

On March 1, 2012, at 1:08 p.m., documentation for smoke detector sensitivity testing was requested. The Building Maintenance Superintendent stated they did not have this documentation.

At 2:23 p.m., no documentation was provided for smoke detector sensitivity testing.

Based on observation, the facility failed to maintain their battery operated smoke detectors as evidenced by two smoke detectors that were covered in dust and debris. This could result in the failure of the smoke detector in the event of a fire, and affected the 3rd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on 2/27/12 through March 2, 2012, the smoke detectors were observed.

On 2/27/12 at 2:00 P.M., on the 3rd floor there were two smoke detectors by the north elevators that were covered in dust and debris.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Base Fire Protection Systems, 1998 Edition
1-4.4 The owner or occupant promptly shall correct or repair
deficiencies, damaged parts, or impairments found while performing
the inspection, test, and maintenance requirements
of this standard. Corrections and repairs shall be performed
by qualified maintenance personnel or a qualified contractor.

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-3.2* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

Based on document review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition. This was evidenced by deficiencies that were not corrected. This may result in the sprinkler system not functioning as designed in the event of a fire. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

On March 1, 2012, during document review, the Inspection Testing and Maintenance Fire Sprinkler System, dated February 15, 2012, was reviewed.

At 9:31 a.m., the report indicated gauges are out of sequence with each other by 5 lbs or more, and replacement was recommended. The PIV (post indicator valve) did not isolate 100%, and the 1 1/4 inch drain check valve will need to be replaced as it is passing during main drain test. The riser is in need of (1) normally open valve, (1) test valve sign, and (1) control valve sign.

At 9:42 a.m., during an interview with the Building Maintenance Superintendent, when asked if the repairs had been made staff stated the repairs had not been done, but that they had bids for the job. When asked if the gauges had been replaced, staff stated that they had not been replaced. Staff did not know if they had ever been calibrated.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers with escutcheon rings that were missing, and sprinklers that were not free of debris, and by failing to maintain clearance below a sprinkler head. These could result in the fire sprinkler system not functioning as designed, and increased risk of injury to patients and staff. This affected the Lower Level, 1st, 2nd, 3rd and 4th floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the sprinkler system was observed.

1. On 2/27/12 at 10:05 A.M., Room 4102 on the 4th floor had a sprinkler covered in dust/debris which was hanging down from the ceiling approximately two inches.

2. On 2/27/12 at 2:19 P.M., Room B3084 on the 3rd floor had a sprinkler missing 1 of 1 escutcheon rings.

3. On 2/27/12 at 3:14 P.M., Room E2048 on the 2nd floor had a stack of picture frames within six inches of a sprinkler head.

4. On 2/28/12 at 10:05 A.M., in the Cafeteria on the 1st floor there were 1 of 2 sprinklers without a cap.

5. On 2/28/12 at 10:25 A.M., Room A1014 on the 1st floor there was 1 of 1 sprinklers missing the escutcheon ring.

6. On 2/28/12 at 2:30 P.M., in Room D0088 on the Lower Level, there was an escutcheon ring hanging down from the ceiling in the closet.

7. On 2/29/12 at 2:36 P.M., Room F2095 on the 2nd floor had 1 of 1 sprinklers missing an escutcheon ring.

Based on observation, the facility failed to ensure that their portable fire extinguishers were maintained. This was evidenced by a fire extinguisher that was dented. This could result in a fire extinguisher that could fail which would delay response to a fire and increase the risk of injury to patients, visitors and staff due to fire. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with Hospital Staff on February 27, 2012 through March 2, 2012, the fire extinguishers were observed.

On 2/28/12 at 10:03 A.M., in the Kitchen on the 1st floor there was a K Type fire extinguisher with a dent on the side of the can.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition
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 fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on document review and interview the facility failed to maintain the dampers in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition. This was evidenced by dampers that were not tested, and by the failure to provide documentation for the total number and location of dampers in the facility. This may result in the passage of smoke and flames in the event of a fire if the damper malfunctions. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

1. On March 1, 2012, at 10:51 a.m., the facility was not able to provide documentation of where the dampers are located, or the number of dampers in the facility. The Building Maintenance Superintendent was asked how many dampers, staff stated they did not know, and would have to look at the plans. During document review of the Inspection, Testing and Maintenance form dated April 13, 2011, it showed 18 dampers, but only 17 were tested as evidenced by an "x" mark next to the damper number.

2. On March 2, 2012, at 10:00 a.m., the Assistant Hospital Administrator stated the facility had 16 Dampers. The Assistant Hospital Administrator stated the Building Maintenance Superintendent stated the last time the dampers were tested was in 2008, but could not provide documentation of the testing result.

NFPA 101, Life Safety Code (2000 Edition) 19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities (1999 Edition).
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder
storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not
communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be
stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches,
and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]. 1999 Edition

Based on observation, the facility failed to ensure that the oxygen cylinders were not stored with combustible materials, had proper precautionary signs displayed on each door in accordance with NFPA 99. This was evidenced by oxygen cylinders stored next to combustible items, and by no precautionary signs displayed on doors to oxygen storage rooms. This could cause harm to patients and staff in the event the flammable materials ignited. This affected the Lower Level, 1st, 2nd, and 3rd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the oxygen storage areas were observed.

1. On 2/27/12 at 1:16 P.M., Room A3085 on there 3rd floor had two E-Oxygen Tanks stored within six inches of combustible material.

2. On 2/27/12 at 3:05 P.M., Room C2085 on the 2nd floor had three E-Oxygen Tanks in a room that did not have a precautionary sign.

3. On 2/27/12 at 3:06 P.M., Room C2086 on the 2nd floor had three E-Oxygen Tanks in a room that did not have a precautionary sign.

4. On 2/28/12 at 9:15 A.M., Room F2063 on the 2nd floor had four E-Oxygen Tanks stored in a Biohazardous Waste Storage Area within six inches of biohazardous waste bins and was not stored in a room with a precautionary sign.

5. On 2/28/12 at 11:15 A.M., Room E1063 on the 1st floor had one E-Oxygen Tank stored in the room but failed to have a precautionary sign.

6. On 2/28/12 at 2:45 P.M., Room C0013 on the Lower Level had three E-Oxygen Tanks stored in front of an electrical outlet and one E-Oxygen Tank stored next to combustible boxes and supplies.

7. On 2/28/12 at 2:49 P.M., Room E0007 on the Lower Level failed to have a precautionary sign.

8. On 2/29/12 at 2:40 P.M., Room F2122 on the 2nd floor had 21 E-Oxygen Tanks stored in a room that failed to have a precautionary sign.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation, the facility failed to ensure that the oxygen cylinders were not stored with combustible materials, and by the failure to provide precautionary signs displayed on each door where oxygen was stored. This was evidenced by oxygen cylinders stored next to combustible items, and by no precautionary signs on doors to locations where oxygen was stored. This could result in an increased risk of fire, and affected 1 of 6 smoke compartments ast Riverside County Regional Medical Center D/P APH.

Findings:

During a tour of the facility with the Hospital Staff on March 1, 2012, the oxygen storage areas were observed.

On 3/1/12 at 9:00 A.M., Room AM-15 had four E-Tanks stored within six inches of a seven shelf unit containing reams of paper, ink cartridges and boxes of supplies. The door did not have a precautionary sign stating that the room was used for oxygen storage.

Based on document review and interview, the facility failed to maintain the humidity levels in 13 of 13 operating rooms at equal to or greater than 35 percent, and failed to have a written policy and procedure for humidity levels and the procedure to follow when out of range. This was evidenced by the failure ot maintain the humidity levels, and by the failure to provide a written policy to follow when the humidity was out of range. This could result in an increased risk of fire and injury to patients and staff. This affected the entire Riverside County Regional Medical Center facility.

Findings:

On February 28, 2012 through February 29, 2012, the Panel Point Log Report and Humidity Readings were reviewed, and staff was interviewed.

1. On February 28, 2012, at 4:06 p.m., during an interview with the Supervising Stationary Engineer, it was stated that the humidity levels are monitored by sensors in the Heating, Ventilation and Air Conditioning (HVAC) units and if the humidity is out of range the AC staff go to the operating rooms with the hand held meter ( Fluke) and try to adjust the humidity.

2. On February 28, 2012, at 4:08 p.m., a policy and procedure for the humidity levels was requested. The Safety Manager stated that the hospital does not have one. Staff was asked what range they use for the humidity levels and the Stationary Engineer stated that it was 30 percent to 60 percent.

3. On February 29, 2012, at 10:02 a.m., during an interview with the Facility Director and review of the daily humidity readings, the humidity levels began to fall below 35 percent on November 22, 2011. The Facility Director stated that when they noticed it they ordered new sensors. Staff stated that HVAC staff would go the operating rooms with a hand held Fluxe (calibrated 1/13/2012), and take the humidity readings, but they kept no logs of the readings. They would compare the readings from the computer and the hand held Fluke.

4. On February 29, 2012, at 10:28 a.m., during an interview with the operating room nurse supervisor when asked at what point would they cancel/delay surgery due to humidity levels being low, staff stated at around 20 percent they would have to discuss it with the doctors, and then they would try and find another operating room with acceptable humidity range. There are no gauges or other devices to inform operating room staff of the humidity levels in the operating rooms, they must rely on the HVAC staff to inform them of the low levels. The operating room nurse supervisor was asked if it is posted anywhere in the operating room area's what the range was for the humidity level, and she stated no.

On March 6, 2012, a letter was received from the Assistant Hospital Administrator, Executive Administration staff explaining that when they noticed accuracy issues with the sensors, new sensors were ordered. While waiting for the parts, Plant Operations took readings in several parts of the room with the certified reader. The Crosswalk was the difference between what was read on the computer and what was taken with the certified meter. It was noted that each sensor was off by varying amounts, the range being up to 15-18 percent in some instances. The new sensors were ordered on December 5, 2012, per invoice 5442286062 from vendor.

Humidity Levels were as follows:
November 22, 2011, through November 30, 2011:
OR 1 - 6 of 30 days humidity level was below 35 percent.
OR 2 - 6 of 30 days humidity level was below 35 percent.
OR 3 - 9 of 30 days humidity level was below 35 percent.
OR 4 - 7 of 30 days humidity level was below 35 percent.
OR 5 - 6 of 30 days humidity level was below 35 percent.
OR 6 - 9 of 30 days humidity level was below 35 percent.
OR 7 - 9 of 30 days humidity level was below 35 percent.
OR 8 - 9 of 30 days humidity level was below 35 percent.
OR 9 - 5 of 30 days humidity level was below 35 percent.
OR 10 - 8 of 30 days humidity level was below 35 percent.
OR 11 - 9 of 30 days humidity level was below 35 percent.
OR 12 - 8 of 30 days humidity level was below 35 percent.
OR 13 - 8 of 30 days humidity level was below 35 percent.

December 2011:
OR 1 - 27 of 31 days humidity level was below 35 percent.
OR 2 - 31 of 31 days humidity level was below 35 percent.
OR 3 - 31 of 31 days humidity level was below 35 percent.
OR 4 - 31 of 31 days humidity level was below 35 percent.
OR 5 - 29 of 31 days humidity level was below 35 percent.
OR 6 - 31 of 31 days humidity level was below 35 percent.
OR 7 - 31 of 31 days humidity level was below 35 percent.
OR 8 - 31 of 31 days humidity level was below 35 percent.
OR 9 - 30 of 31 days humidity level was below 35 percent.
OR 10 - 31 of 31 days humidity level was below 35 percent.
OR 11 - 31 of 31 days humidity level was below 35 percent.
OR 12/C-Section - 29 of 31 days humidity level was below 35 percent.
OR 13/ C-Section -30 of 31 days humidity level was below 25 percent.

January 2012:
OR 1 - 26 of 31 days humidity level was below 35 percent.
OR 2 - 28 of 31 days humidity level was below 35 percent.
OR 3 - 30 of 31 days humidity level was below 35 percent.
OR 4 - 29 of 31 days humidity level was below 35 percent.
OR 5 - 25 of 31 days humidity level was below 35 percent.
OR 6 - 30 of 31 days humidity level was below 35 percent.
OR 7 - 31 of 31 days humidity level was below 35 percent.
OR 8 - 30 of 31 days humidity level was below 35 percent.
OR 9 - 29 of 31 days humidity level was below 35 percent.
OR 10 - 28 of 31 days humidity level was below 35 percent.
OR 11 - 30 of 31 days humidity level was below 35 percent.
OR 12 - /C-Section- 25 of 31 days humidity level was below 35 percent.
OR 13 - C-Section - 26 of 31 days humidity level was below 35 percent.

February 2012:
OR 1 - 18 of 29 days humidity level was below 35 percent.
OR 2 - 25 of 29 days humidity level was below 35 percent.
OR 3 - 28 of 29 days humidity level was below 35 percent.
OR 4 - 26 of 29 days humidity level was below 35 percent.
OR 5 - 20 of 29 days humidity level was below 35 percent.
OR 6 - 27 of 29 days humidity level was below 35 percent.
OR 7 - 29 of 29 days humidity level was below 35 percent.
OR 8 - 28 of 29 days humidity level was below 35 percent.
OR 9 - 22 of 29 days humidity level was below 35 percent.
OR 10 - 25 of 29 days humidity level was below 35 percent. On February 10, 12, 13, 14 and 15th the humidity level was recorded as -24.92.
OR 11 - 29 of 29 days humidity level was below 35 percent.
OR 12 - C-Section - 20 of 29 days humidity level was below 35 percent.
OR 13 - C-Section - 25 of 29 days humidity level was below 35 percent.

No documentation for humidity levels was provided for February 11, 2012, for 13 of 13 operating rooms.

During review of documentation, the Maintenance Work Orders for January, 2012, and February, 2012 were reviewed. Work orders provided did not list the humidity levels when taken with the hand held meter.

The facility staff did not provide further documentation for 13 of 13 operating rooms humidity levels when taken with the hand held meter.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a 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.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
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.
6-4.3 Load tests of generator sets shall include complete cold starts.

Based on document review, the facility failed to maintain the emergency generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition. This was evidenced by failure to provide documentation of load bank testing in accordance with NFPA 110. This may result in the emergency generator not functioning properly in the event of an emergency. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

On March 1, 2012 during review of the annual load bank test dated November 18, 2011, the test was not conducted in accordance with NFPA 110. The test began at 9:00 a.m., at 80 percent, and ended at 1:00 p.m., at 80 percent. The generator ran at 80 percent during the entire test, and not at 25 percent for 30 minutes, 50 percent of 30 minutes, and 75 percent for 60 minutes.

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by broken electrical components, and exposed energized parts. This could result in an increased risk of electrical fire and potential injury to residents and staff. This affected 1 of 6 smoke compartments ast Riverside County Regional Medical Center D/P APH.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the facility's electrical wiring and equipment was observed.

On 3/1/12 at 2:30 P.M., in the Conference Room there were two electrical outlets with broken ground ports.

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
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

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by electrical appliances plugged into multi-plug power strips and not directly into an electrical outlet, and by broken electrical components and exposed energized parts. This could result in an increased risk of electrical fire and potential injury to residents and staff. This affected the Lower Level, 1st, 2nd, and 4th floors of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff 1 on February 27, 2012 through March 2, 2012, the facility's electrical wiring and equipment was observed.

1. On 2/27/12 at 11:00 A.M., Room 4228 on the 4th floor had a nurse call light missing the cover plate.

2. On 2/27/12 at 11:02 A.M., Room B4077 on the 4th floor had a microwave plugged into a surge protector, and not directly into an electrical outlet in the wall.

3. On 2/27/12 at 3:53 P.M., Room A2009 on the 2nd floor had a refrigerator plugged into a surge protector, and not directly into the wall outlet.

4. On 2/28/12 at 11:00 A.M., in Room A1024 on the 1st floor there was an extension cord used to plug in a television.

5. On 2/28/12 at 11:03 A.M., in Room C1090 on the 1st floor there was an electrical outlet missing the cover plate.

6. On 2/28/12 at 11:32 A.M., Room E1073 on the 1st floor there was microwave plugged into a surge protector.

7. On 2/28/12 at 2:50 P.M., Room E0006 on the Lower Level had a microwave and refrigerator plugged into a surge protection strip.

Based on observation, the facility failed to maintain the integrity of their building construction as evidenced by unsealed penetrations in the facility walls and ceilings. This could result in the spread of smoke or fire to other locations in the facility. This affected the 2nd floor at Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the building construction was observed.

On 2/27/12 at 3:24 P.M., in Room D2049 on the 2nd floor there were two penetrations in the right wall that were each approximately one inch in diameter.

Based on observation the facility failed to maintain the corridor doors as evidenced by failure to keep doors clear from impediments to closing in the event of a fire. This has the potential for the spread of smoke and flames in the event of a fire. This affected 1 of 6 smoke compartments at Riverside County Regional Medical Center D/P Adult Psychiatric Hospital (APH).

Findings:

On March 1, 2012, during testing the of the fire alarm system the doors were observed.

At 1:38 p.m., on Unit D, the Treatment team room door was held in the open position by a chair being placed in front of it. The door was equipped with a self-closing device.

Based on observation, the facility failed to maintain corridor doors to resist the passage of smoke as evidenced by corridor doors that failed to positive latch, and were blocked from closing. This had the potential to allow the migration of smoke causing harm to patients and staff. This affected the Lower Level, 1st, 2nd, and 3rd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the corridor doors were observed.

1. On 2/27/12 at 1:12 P.M., the door to Room 3124 on the 3rd floor was impeded from closing by a trash placed up against the door.

2. On 2/27/12 at 1:30 P.M., the door to Room C3084 on the 3rd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

3. On 2/27/12 at 1:35 P.M., the door to Room 3512 on the 3rd floor was impeded from closing by a trash placed up against the door.

4. On 2/27/12 at 2:05 P.M., the door to Room B3073 on the 3rd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

5. On 2/27/12 at 2:18 P.M., the door to Room B3083 on the 3rd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

6. On 2/27/12 at 3:26 P.M., the door to Room 2029 on the 2nd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

7. On 2/28/12 at 9:00 A.M., the door to Room F2013 on the 2nd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

8. On 2/28/12 at 9:10 A.M., the door to Room F2018 on the 2nd floor was equipped with a self closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure.

9. On 2/28/12 at 11:10 A.M., the door to Room E1110 on the 1st floor was propped open with a door wedge.

10. On 2/28/12 at 11:32 A.M., the door to Room E1051 "Hyperbaric Medicine" on the 1st floor failed to latch due to a business card taped over the latching mechanism.

11. On 2/28/12 at 2:49 P.M., the door to Room E0007 on the Lower Level had electrical tape over the latching mechanism that prevented the door from positively latching.

12. On 2/28/12 at 3:15 P.M., the door to Room E0077 on the Lower Level failed to latch.

NFPA 101, Life Safety Code, 2000 Edition
8.3.6.1 Pipes, conduits, 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.

Based on observation, the facility failed to maintain the integrity of the fire resistance rated construction of its smoke barrier walls as evidenced by a penetration in a smoke barrier wall. This could result in the increased risk of injury to the patients and staff due to smoke and fire. This affected the Lower Level of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the smoke barrier walls were observed.

On 2/28/12 at 2:55 P.M., on the Lower Level, there was a penetration approximately one inch round in the smoke barrier wall above the fire doors by Room E0160.

5. At 1:27 p.m., the right leaf of the smoke barrier doors on the 4th floor by room 4124 failed to latch upon automatic closure.

6. At 3:40 p.m., the two sets of fire/smoke barrier doors C 1038, the left leaf on the left side failed to latch and the right leaf on the right side failed to latch upon automatic closure in the Family Care Area on the 1st floor.




27961

Based on observation, the facility failed to maintain its smoke barrier doors to continuously serve as a smoke barrier to prevent the spread of smoke and/or fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch when tested. This could result in the spread of smoke and/or fire. This affected the Lower Level, 1st, 3rd, and 4th floor of Riverside County Regional Medical Center.

Findings:

During fire alarm testing with the Hospital Staff on February 29, 2012, the smoke barrier doors were observed.

1. On 2/29/12 at 2:01 P.M., the smoke barrier door to the Work Area, Room C3083 on the 3rd floor failed to positive latch after activation of a manual pull station.

2. On 2/29/12 at 2:03 P.M., the smoke barrier door to B3082 on the 3rd floor failed to positive latch after activation of a manual pull station.

3. On 2/29/12 at 3:50 P.M., the smoke barrier door by Room F1038 on the 1st floor failed to positive latch on the left side after activation of a smoke detector.

4. On 2/29/12 at 3:51 P.M., the smoke barrier door by Room F1034 on the 1st floor failed to positive latch on the left side after activation of a smoke detector.

NFPA 101®, 2000 Edition
19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with 8.4.1. The automatic extinguishing shall be permitted to be in accordance with 19.3.5.4. Where the sprinkler option is used, the areas shall be separated from other spaces by smoke-resisting partitions and doors. The doors shall be self-closing or automatic-closing. Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Soiled linen rooms
(6) Trash collection rooms
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardous by the authority having jurisdiction
(8) Laboratories employing flammable or combustible materials in quantities less than those that would be considered a severe hazard.
Exception: Doors in rated enclosures shall be permitted to have nonrated,
factory- or field-applied protective plates extending not more
than 48 in. (122 cm) above the bottom of the door.

Based on observation, the facility failed to protect hazardous areas with self-closing doors. This was evidenced by hazardous areas with doors that did not have a self closing device. This could potentially allow the spread of smoke and fire from hazardous areas to other areas and increase the risk of injury to patients and staff. This affected the 1st and 2nd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the hazardous areas were observed.

1. On 2/28/12 at 9:40 A.M., Room B1014 in the Kitchen on the 1st Floor was approximately 15 ft x 15 ft and contained supplies, paper and boxes stacked around the walls and under the desk. The door failed to have a self-closing device.

2. On 2/29/12 at 2:40 P.M., the door to Room F2122 on the 2nd floor was equipped with a self-closing device. The door was held open to the fullest extent and allowed to close, but failed to positive latch upon closure. The room contained 21 E-Oxygen Tanks.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by crash carts and a Computer On Wheels (COW) in the exit access that leads to the corridor. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During the tour of the facility with Hospital Staff on February 27, 2012 through March 2, 2012, the exits were observed.

On 2/28/12 at 2:00 P.M., in the Emergency Department on the 1st floor, there was a COW and two crash carts next to the fire doors leading to the corridor and the ambulance entrance outside.

Based on observation, the facility failed to maintain their emergency lighting. This was evidenced by emergency lighting units that failed to illuminate when tested. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the emergency lighting was observed and tested.

On 2/28/12 at 2:13 P.M., the emergency lighting labeled EBL5106F04 in the stairwell on the 1st floor failed to illuminate when tested.

NFPA 101, 1999 Edition
19.2.10 Marking of Means of Egress.
19.2.10.1 Means of egress shall have signs in accordance with Section 7.10.

SECTION 7.10 MARKING OF MEANS OF EGRESS
7.10.1 General.
7.10.1.1 Where Required. Means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42.
7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

Based on observation, the facility failed to maintain exit/directional signs as evidenced by a missing "Exit" sign. This could have the potential for delaying evacuation of patients during an emergency. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, exits, exit signs and their illumination was observed.

On 2/28/12 at 1:55 P.M., on the 1st floor there was no " Exit " sign over the doors leading from the emergency department to the ambulance entrance outside.

NFPA 101, Life Safety Code, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
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.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Based on observation and testing, the facility failed to provide effective warning of fire as evidenced by strobes and chimes that failed to alarm. This could result in potential harm to patients, visitors and staff if the alarms failed to notify patients, visitors and staff of a fire in the facility. This affected the 1st floor of Riverside County Regional Medical Center.

During alarm testing with Hospital Staff on February 29, 2012, the alarms were observed and tested.

1. On 2/29/12 at 3:42 P.M., on the 1st floor the fire alarm notification devices were activated, and the chime between the Pediatric waiting area and the Infusion waiting area failed to activate after testing of a manual pull station.

2. On 2/29/12 at 4:09 P.M., on the 1st floor the fire alarm notification devices were activated, and the strobe in the Catering area of the Kitchen failed to activate after testing of a manual pull station.

Based on document review and interview, the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by no accurate count of smoke detectors in the facility, and not all devices were tested annually. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P Adult Psychiatric Hospital (APH).

Findings:

On March 1, 2012, during document review the Inspection, Testing, and Maintenance, document for the Annual Certification dated April 13, 2011, was reviewed.

On page 1 of 4, it listed 82 smoke detectors (this includes the Children's Treatment building which was not part of this survey). The document titled "Smoke Detector Locations: Mental Health Treatment", provided by the facility Building Maintenance Superintendent, listed the location of 79 smoke detectors. The documentation lists 32 Horn/Strobes in the facility. The following horn/strobes are listed in the report, but did not indicate that the device was tested during the annual certification by an "X" next to the device under test.
AD-8C (HS)
AD-20C (HS)
D-21 (HS)
D-32C (HS)
C-2C (HS)
C-22(HS)
C-27C (HS)
B-24C (HS)
S2-LE (HS)
S2-LW (HS)
OP-2C (HS)
OP-6C (HS)
OP-18C (HS)
OP-18C (HS)
ET-6C (HS)
ET-7 (HS)
A-5C (HS)
A-14 (HS)
A-16 (Strobe)
A-29C (HS)
B-2C (HS)
ET-35 (HS)
ET-ELS (HS)
ET-20 (HS)
SB-1E (HS)
SB-1E (Strobe)

The Inspection, Testing and Maintenance document dated April 13, 2012, lists 24 Duct Detectors. The annual certification lists 23 duct detectors that were tested, and included the Children's Treatment Area (not part of this survey). The Smoke Detector Location document that was provided by the facility lists 18 duct detectors.

The facility confirmed they did not have an accurate account of all devices in the facility. Not all devices were tested during the past year as required. At 1:08 p.m., documentation for Smoke Detector Sensitivity testing was requested. The Building Maintenance Superintendent stated they did not have this information.

Based on observation the facility failed to maintain the fire alarm system in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by warning devices that failed to activate upon activation of the fire alarm system. This affected the 2nd floor and the Lower Level of Riverside County Regional Medical Center.

Findings:

On February 29, 2012, during testing of the fire alarm system the audible visual devices were observed.

1. At 3:03 p.m., in the Respiratory Therapy Department on the 2nd floor, 2 of 2 audio/visual devices failed. Chime strobe L2E-4 in the hallway, and L2E-5, failed upon activation of the fire alarm system.

Lower Level:
2. At 4:26 p.m., the audio/visual device DOO36, failed to activate a chime when testedc.
3. At 4:22 p.m., the audio/visual device LLD-32, failed to activate a chime when tested.
4. At 4:44 p.m., the audio/visual device LLF-36, failed to activate a chime when tested.

NFPA 72, National Fire Alarm Code, 1999 Edition
7-3.2.1* Detector sensitivity shall be checked within 1 year after installation and every alternate year thereafter. After the second required calibration test, if sensitivity tests indicate that the detector has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years. If the frequency is extended, records of detector-caused nuisance alarms and subsequent trends of these alarms shall be maintained. In zones or in areas where nuisance alarms show any increase over the previous year, calibration tests shall be performed.
To ensure that each smoke detector is within its listed and marked sensitivity range, it shall be tested using any of the following methods:
(1) Calibrated test method
(2) Manufacturer's calibrated sensitivity test instrument
(3) Listed control equipment arranged for the purpose
(4) Smoke detector/control unit arrangement whereby the detector causes a signal at the control unit where its sensitivity is outside its listed sensitivity range
(5) Other calibrated sensitivity test methods approved by the authority having jurisdiction
Detectors found to have a sensitivity outside the listed and marked sensitivity range shall be cleaned and recalibrated or be replaced.
Exception No. 1: Detectors listed as field adjustable shall be permitted to be either adjusted within the listed and marked sensitivity range and cleaned and recalibrated, or they shall be replaced.
Exception No. 2: The requirement shall not apply to single station detectors referenced in 7-3.3 and Table 7-2.2.
The detector sensitivity shall not be tested or measured using an device that administers an unmeasured concentration of smoke or other aerosol into the detector.

Based on interview and document review, the facility failed to provide documentation of smoke detector sensitivity testing, in accordance with NFPA 72, National Fire Alarm Code, 1999 Edition. This was evidenced by the failure ot provide records of sensitivity testing for the smoke detectors. This may result in the smoke detectors not functioning in the event of a fire. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

On March 1, 2012, at 1:08 p.m., documentation for smoke detector sensitivity testing was requested. The Building Maintenance Superintendent stated they did not have this documentation.

At 2:23 p.m., no documentation was provided for smoke detector sensitivity testing.

Based on observation, the facility failed to maintain their battery operated smoke detectors as evidenced by two smoke detectors that were covered in dust and debris. This could result in the failure of the smoke detector in the event of a fire, and affected the 3rd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on 2/27/12 through March 2, 2012, the smoke detectors were observed.

On 2/27/12 at 2:00 P.M., on the 3rd floor there were two smoke detectors by the north elevators that were covered in dust and debris.

NFPA 25, Standard for the Inspection, Testing and Maintenance of Water Base Fire Protection Systems, 1998 Edition
1-4.4 The owner or occupant promptly shall correct or repair
deficiencies, damaged parts, or impairments found while performing
the inspection, test, and maintenance requirements
of this standard. Corrections and repairs shall be performed
by qualified maintenance personnel or a qualified contractor.

2-3.2* Gauges. Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. Gauges not accurate to within 3 percent of the full scale shall be recalibrated or replaced.

9-3.2* Each control valve shall be identified and have a sign indicating the system or portion of the system it controls.

Based on document review and interview, the facility failed to maintain the automatic sprinkler system in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, 1998 edition. This was evidenced by deficiencies that were not corrected. This may result in the sprinkler system not functioning as designed in the event of a fire. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

On March 1, 2012, during document review, the Inspection Testing and Maintenance Fire Sprinkler System, dated February 15, 2012, was reviewed.

At 9:31 a.m., the report indicated gauges are out of sequence with each other by 5 lbs or more, and replacement was recommended. The PIV (post indicator valve) did not isolate 100%, and the 1 1/4 inch drain check valve will need to be replaced as it is passing during main drain test. The riser is in need of (1) normally open valve, (1) test valve sign, and (1) control valve sign.

At 9:42 a.m., during an interview with the Building Maintenance Superintendent, when asked if the repairs had been made staff stated the repairs had not been done, but that they had bids for the job. When asked if the gauges had been replaced, staff stated that they had not been replaced. Staff did not know if they had ever been calibrated.

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers with escutcheon rings that were missing, and sprinklers that were not free of debris, and by failing to maintain clearance below a sprinkler head. These could result in the fire sprinkler system not functioning as designed, and increased risk of injury to patients and staff. This affected the Lower Level, 1st, 2nd, 3rd and 4th floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the sprinkler system was observed.

1. On 2/27/12 at 10:05 A.M., Room 4102 on the 4th floor had a sprinkler covered in dust/debris which was hanging down from the ceiling approximately two inches.

2. On 2/27/12 at 2:19 P.M., Room B3084 on the 3rd floor had a sprinkler missing 1 of 1 escutcheon rings.

3. On 2/27/12 at 3:14 P.M., Room E2048 on the 2nd floor had a stack of picture frames within six inches of a sprinkler head.

4. On 2/28/12 at 10:05 A.M., in the Cafeteria on the 1st floor there were 1 of 2 sprinklers without a cap.

5. On 2/28/12 at 10:25 A.M., Room A1014 on the 1st floor there was 1 of 1 sprinklers missing the escutcheon ring.

6. On 2/28/12 at 2:30 P.M., in Room D0088 on the Lower Level, there was an escutcheon ring hanging down from the ceiling in the closet.

7. On 2/29/12 at 2:36 P.M., Room F2095 on the 2nd floor had 1 of 1 sprinklers missing an escutcheon ring.

Based on observation, the facility failed to ensure that their portable fire extinguishers were maintained. This was evidenced by a fire extinguisher that was dented. This could result in a fire extinguisher that could fail which would delay response to a fire and increase the risk of injury to patients, visitors and staff due to fire. This affected the 1st floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with Hospital Staff on February 27, 2012 through March 2, 2012, the fire extinguishers were observed.

On 2/28/12 at 10:03 A.M., in the Kitchen on the 1st floor there was a K Type fire extinguisher with a dent on the side of the can.

NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition
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 fully close; the latch, if provided, shall be
checked; and moving parts shall be lubricated as necessary.

Based on document review and interview the facility failed to maintain the dampers in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, 1999 edition. This was evidenced by dampers that were not tested, and by the failure to provide documentation for the total number and location of dampers in the facility. This may result in the passage of smoke and flames in the event of a fire if the damper malfunctions. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

1. On March 1, 2012, at 10:51 a.m., the facility was not able to provide documentation of where the dampers are located, or the number of dampers in the facility. The Building Maintenance Superintendent was asked how many dampers, staff stated they did not know, and would have to look at the plans. During document review of the Inspection, Testing and Maintenance form dated April 13, 2011, it showed 18 dampers, but only 17 were tested as evidenced by an "x" mark next to the damper number.

2. On March 2, 2012, at 10:00 a.m., the Assistant Hospital Administrator stated the facility had 16 Dampers. The Assistant Hospital Administrator stated the Building Maintenance Superintendent stated the last time the dampers were tested was in 2008, but could not provide documentation of the testing result.

NFPA 101, Life Safety Code (2000 Edition) 19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

NFPA 99, Standard for Health Care Facilities (1999 Edition).
8-3.1.11.2 Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a)11e with respect to temperature limitations. (f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a)11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b)13.
(h) Cylinder or container restraint shall meet 4-3.5.2.1(b)27.
(i) Smoking, open flames, electric heating elements and other sources of ignition shall be prohibited within storage locations and within 20 ft (6.1 m) of outside storage locations.
(j) Cylinder valve protection caps shall meet 4-3.5.2.1(b)14.

8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:

CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

4-3.1.1.1 Cylinder and Container Management.
2.* Enclosures shall be provided for supply systems cylinder
storage or manifold locations for oxidizing agents such as oxygen and nitrous oxide. Such enclosures shall be constructed of an assembly of building materials with a fire-resistive rating of at least 1 hour and shall not
communicate directly with anesthetizing locations. Other nonflammable (inert) medical gases may be stored in the enclosure. Flammable gases shall not be
stored with oxidizing agents. Storage of full or empty cylinders is permitted. Such enclosures shall serve no other purpose.
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocation.
4. The electric installation in storage locations or manifold enclosures for nonflammable medical gases shall comply with the standards of NFPA 70, National Electrical Code, for ordinary locations. Electric wall fixtures, switches,
and receptacles shall be installed in fixed locations not less than 152 cm (5 ft) above the floor as a precaution against their physical damage.
5. Storage locations for oxygen and nitrous oxide shall be kept free of flammable materials [see also 4-3.1.1.2(a)7]. 1999 Edition

Based on observation, the facility failed to ensure that the oxygen cylinders were not stored with combustible materials, had proper precautionary signs displayed on each door in accordance with NFPA 99. This was evidenced by oxygen cylinders stored next to combustible items, and by no precautionary signs displayed on doors to oxygen storage rooms. This could cause harm to patients and staff in the event the flammable materials ignited. This affected the Lower Level, 1st, 2nd, and 3rd floor of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the oxygen storage areas were observed.

1. On 2/27/12 at 1:16 P.M., Room A3085 on there 3rd floor had two E-Oxygen Tanks stored within six inches of combustible material.

2. On 2/27/12 at 3:05 P.M., Room C2085 on the 2nd floor had three E-Oxygen Tanks in a room that did not have a precautionary sign.

3. On 2/27/12 at 3:06 P.M., Room C2086 on the 2nd floor had three E-Oxygen Tanks in a room that did not have a precautionary sign.

4. On 2/28/12 at 9:15 A.M., Room F2063 on the 2nd floor had four E-Oxygen Tanks stored in a Biohazardous Waste Storage Area within six inches of biohazardous waste bins and was not stored in a room with a precautionary sign.

5. On 2/28/12 at 11:15 A.M., Room E1063 on the 1st floor had one E-Oxygen Tank stored in the room but failed to have a precautionary sign.

6. On 2/28/12 at 2:45 P.M., Room C0013 on the Lower Level had three E-Oxygen Tanks stored in front of an electrical outlet and one E-Oxygen Tank stored next to combustible boxes and supplies.

7. On 2/28/12 at 2:49 P.M., Room E0007 on the Lower Level failed to have a precautionary sign.

8. On 2/29/12 at 2:40 P.M., Room F2122 on the 2nd floor had 21 E-Oxygen Tanks stored in a room that failed to have a precautionary sign.

NFPA 99, Standard for Health Care Facilities, 1999 Edition
8-3.1.11.3 Signs. A precautionary sign, readable from a distance of 5 ft (1.5 m), shall be conspicuously displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum:
CAUTION
OXIDIZING GAS(ES) STORED WITHIN
NO SMOKING

Based on observation, the facility failed to ensure that the oxygen cylinders were not stored with combustible materials, and by the failure to provide precautionary signs displayed on each door where oxygen was stored. This was evidenced by oxygen cylinders stored next to combustible items, and by no precautionary signs on doors to locations where oxygen was stored. This could result in an increased risk of fire, and affected 1 of 6 smoke compartments ast Riverside County Regional Medical Center D/P APH.

Findings:

During a tour of the facility with the Hospital Staff on March 1, 2012, the oxygen storage areas were observed.

On 3/1/12 at 9:00 A.M., Room AM-15 had four E-Tanks stored within six inches of a seven shelf unit containing reams of paper, ink cartridges and boxes of supplies. The door did not have a precautionary sign stating that the room was used for oxygen storage.

Based on document review and interview, the facility failed to maintain the humidity levels in 13 of 13 operating rooms at equal to or greater than 35 percent, and failed to have a written policy and procedure for humidity levels and the procedure to follow when out of range. This was evidenced by the failure ot maintain the humidity levels, and by the failure to provide a written policy to follow when the humidity was out of range. This could result in an increased risk of fire and injury to patients and staff. This affected the entire Riverside County Regional Medical Center facility.

Findings:

On February 28, 2012 through February 29, 2012, the Panel Point Log Report and Humidity Readings were reviewed, and staff was interviewed.

1. On February 28, 2012, at 4:06 p.m., during an interview with the Supervising Stationary Engineer, it was stated that the humidity levels are monitored by sensors in the Heating, Ventilation and Air Conditioning (HVAC) units and if the humidity is out of range the AC staff go to the operating rooms with the hand held meter ( Fluke) and try to adjust the humidity.

2. On February 28, 2012, at 4:08 p.m., a policy and procedure for the humidity levels was requested. The Safety Manager stated that the hospital does not have one. Staff was asked what range they use for the humidity levels and the Stationary Engineer stated that it was 30 percent to 60 percent.

3. On February 29, 2012, at 10:02 a.m., during an interview with the Facility Director and review of the daily humidity readings, the humidity levels began to fall below 35 percent on November 22, 2011. The Facility Director stated that when they noticed it they ordered new sensors. Staff stated that HVAC staff would go the operating rooms with a hand held Fluxe (calibrated 1/13/2012), and take the humidity readings, but they kept no logs of the readings. They would compare the readings from the computer and the hand held Fluke.

4. On February 29, 2012, at 10:28 a.m., during an interview with the operating room nurse supervisor when asked at what point would they cancel/delay surgery due to humidity levels being low, staff stated at around 20 percent they would have to discuss it with the doctors, and then they would try and find another operating room with acceptable humidity range. There are no gauges or other devices to inform operating room staff of the humidity levels in the operating rooms, they must rely on the HVAC staff to inform them of the low levels. The operating room nurse supervisor was asked if it is posted anywhere in the operating room area's what the range was for the humidity level, and she stated no.

On March 6, 2012, a letter was received from the Assistant Hospital Administrator, Executive Administration staff explaining that when they noticed accuracy issues with the sensors, new sensors were ordered. While waiting for the parts, Plant Operations took readings in several parts of the room with the certified reader. The Crosswalk was the difference between what was read on the computer and what was taken with the certified meter. It was noted that each sensor was off by varying amounts, the range being up to 15-18 percent in some instances. The new sensors were ordered on December 5, 2012, per invoice 5442286062 from vendor.

Humidity Levels were as follows:
November 22, 2011, through November 30, 2011:
OR 1 - 6 of 30 days humidity level was below 35 percent.
OR 2 - 6 of 30 days humidity level was below 35 percent.
OR 3 - 9 of 30 days humidity level was below 35 percent.
OR 4 - 7 of 30 days humidity level was below 35 percent.
OR 5 - 6 of 30 days humidity level was below 35 percent.
OR 6 - 9 of 30 days humidity level was below 35 percent.
OR 7 - 9 of 30 days humidity level was below 35 percent.
OR 8 - 9 of 30 days humidity level was below 35 percent.
OR 9 - 5 of 30 days humidity level was below 35 percent.
OR 10 - 8 of 30 days humidity level was below 35 percent.
OR 11 - 9 of 30 days humidity level was below 35 percent.
OR 12 - 8 of 30 days humidity level was below 35 percent.
OR 13 - 8 of 30 days humidity level was below 35 percent.

December 2011:
OR 1 - 27 of 31 days humidity level was below 35 percent.
OR 2 - 31 of 31 days humidity level was below 35 percent.
OR 3 - 31 of 31 days humidity level was below 35 percent.
OR 4 - 31 of 31 days humidity level was below 35 percent.
OR 5 - 29 of 31 days humidity level was below 35 percent.
OR 6 - 31 of 31 days humidity level was below 35 percent.
OR 7 - 31 of 31 days humidity level was below 35 percent.
OR 8 - 31 of 31 days humidity level was below 35 percent.
OR 9 - 30 of 31 days humidity level was below 35 percent.
OR 10 - 31 of 31 days humidity level was below 35 percent.
OR 11 - 31 of 31 days humidity level was below 35 percent.
OR 12/C-Section - 29 of 31 days humidity level was below 35 percent.
OR 13/ C-Section -30 of 31 days humidity level was below 25 percent.

January 2012:
OR 1 - 26 of 31 days humidity level was below 35 percent.
OR 2 - 28 of 31 days humidity level was below 35 percent.
OR 3 - 30 of 31 days humidity level was below 35 percent.
OR 4 - 29 of 31 days humidity level was below 35 percent.
OR 5 - 25 of 31 days humidity level was below 35 percent.
OR 6 - 30 of 31 days humidity level was below 35 percent.
OR 7 - 31 of 31 days humidity level was below 35 percent.
OR 8 - 30 of 31 days humidity level was below 35 percent.
OR 9 - 29 of 31 days humidity level was below 35 percent.
OR 10 - 28 of 31 days humidity level was below 35 percent.
OR 11 - 30 of 31 days humidity level was below 35 percent.
OR 12 - /C-Section- 25 of 31 days humidity level was below 35 percent.
OR 13 - C-Section - 26 of 31 days humidity level was below 35 percent.

February 2012:
OR 1 - 18 of 29 days humidity level was below 35 percent.
OR 2 - 25 of 29 days humidity level was below 35 percent.
OR 3 - 28 of 29 days humidity level was below 35 percent.
OR 4 - 26 of 29 days humidity level was below 35 percent.
OR 5 - 20 of 29 days humidity level was below 35 percent.
OR 6 - 27 of 29 days humidity level was below 35 percent.
OR 7 - 29 of 29 days humidity level was below 35 percent.
OR 8 - 28 of 29 days humidity level was below 35 percent.
OR 9 - 22 of 29 days humidity level was below 35 percent.
OR 10 - 25 of 29 days humidity level was below 35 percent. On February 10, 12, 13, 14 and 15th the humidity level was recorded as -24.92.
OR 11 - 29 of 29 days humidity level was below 35 percent.
OR 12 - C-Section - 20 of 29 days humidity level was below 35 percent.
OR 13 - C-Section - 25 of 29 days humidity level was below 35 percent.

No documentation for humidity levels was provided for February 11, 2012, for 13 of 13 operating rooms.

During review of documentation, the Maintenance Work Orders for January, 2012, and February, 2012 were reviewed. Work orders provided did not list the humidity levels when taken with the hand held meter.

The facility staff did not provide further documentation for 13 of 13 operating rooms humidity levels when taken with the hand held meter.

NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition
6-4.2* Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a 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.
6-4.2.1 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
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.
6-4.3 Load tests of generator sets shall include complete cold starts.

Based on document review, the facility failed to maintain the emergency generator in accordance with NFPA 110, Standard for Emergency and Standby Power Systems, 1999 Edition. This was evidenced by failure to provide documentation of load bank testing in accordance with NFPA 110. This may result in the emergency generator not functioning properly in the event of an emergency. This affected 6 of 6 smoke compartments at Riverside County Regional Medical Center D/P APH.

Findings:

On March 1, 2012 during review of the annual load bank test dated November 18, 2011, the test was not conducted in accordance with NFPA 110. The test began at 9:00 a.m., at 80 percent, and ended at 1:00 p.m., at 80 percent. The generator ran at 80 percent during the entire test, and not at 25 percent for 30 minutes, 50 percent of 30 minutes, and 75 percent for 60 minutes.

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by broken electrical components, and exposed energized parts. This could result in an increased risk of electrical fire and potential injury to residents and staff. This affected 1 of 6 smoke compartments ast Riverside County Regional Medical Center D/P APH.

Findings:

During a tour of the facility with the Hospital Staff on February 27, 2012 through March 2, 2012, the facility's electrical wiring and equipment was observed.

On 3/1/12 at 2:30 P.M., in the Conference Room there were two electrical outlets with broken ground ports.

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
400-7 Uses Permitted.
(a) Uses. Flexible cords and cables shall be used only for the following:

(1) Pendants
(2) Wiring of fixtures
(3) Connection of portable lamps, portable and mobile signs, or appliances
(4) Elevator cables
(5) Wiring of cranes and hoists
(6) Connection of stationary equipment to facilitate their frequent interchange
(7) Prevention of the transmission of noise or vibration
(8) Appliances where the fastening means and mechanical connections are specifically designed to permit ready removal for maintenance and repair, and the appliance is intended or identified for flexible cord connection
(9) Data processing cables as permitted by Section 645-5
(10) Connection of moving parts
(11) Temporary wiring as permitted in Sections 305-4(b) and 305-4(c)

NFPA 70, National Electrical Code, 1999 Edition. An International Electrical Code (Trademark) Series
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

NFPA 99, Standard for Health Care Facilities, 1999 Edition
3-3.2.1.1 Electrical Installation. Installation shall be in accordance with NFPA 70, National Electrical Code.

Based on observation, the facility failed to maintain the electrical wiring and equipment as evidenced by electrical appliances plugged into multi-plug power strips and not directly into an electrical outlet, and by broken electrical components and exposed energized parts. This could result in an increased risk of electrical fire and potential injury to residents and staff. This affected the Lower Level, 1st, 2nd, and 4th floors of Riverside County Regional Medical Center.

Findings:

During a tour of the facility with the Hospital Staff 1 on February 27, 2012 through March 2, 2012, the facility's electrical wiring and equipment was observed.

1. On 2/27/12 at 11:00 A.M., Room 4228 on the 4th floor had a nurse call light missing the cover plate.

2. On 2/27/12 at 11:02 A.M., Room B4077 on the 4th floor had a microwave plugged into a surge protector, and not directly into an electrical outlet in the wall.

3. On 2/27/12 at 3:53 P.M., Room A2009 on the 2nd floor had a refrigerator plugged into a surge protector, and not directly into the wall outlet.

4. On 2/28/12 at 11:00 A.M., in Room A1024 on the 1st floor there was an extension cord used to plug in a television.

5. On 2/28/12 at 11:03 A.M., in Room C1090 on the 1st floor there was an electrical outlet missing the cover plate.

6. On 2/28/12 at 11:32 A.M., Room E1073 on the 1st floor there was microwave plugged into a surge protector.

7. On 2/28/12 at 2:50 P.M., Room E0006 on the Lower Level had a microwave and refrigerator plugged into a surge protection strip.