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Based on observation, the hospital failed to maintain the integrity of the occupancy separation walls, as evidenced by unsealed penetrations in one wall in the Wound Care Center. This could result in the spread of smoke and fire in the event of a fire affecting four staff and 5-6 patients on any treatment day.

Findings:

On a hospital tour with engineering staff from 1/13/10 to 1/14/10, the occupancy separation walls were observed at the Wound Care Center.

1/13/10 -
At 1624 hours, there was an approximately 1/8 inch penetration around a three inch sprinkler pipe and an approximately 1/4 to 1/2 inch penetration around a three inch sprinkler pipe in the wall above the entry doors to the Wound Care Center. There was an approximately 1/8 inch penetration around a pipe sleeve, an approximately 1/4 inch penetration around wires inside a 3/4 inch pipe sleeve and an approximately 1/8 to 1/4 inch penetration around a three inch pipe. There was an approximately 4 inch by 5 inch penetration in the occupancy separation wall to the right of the entry doors. All penetrations were observed above the drop ceiling from the building corridor.

1/15/10
At 1145 hours, there was an approximately 1 inch x 2 inch penetration around a two inch pipe next to the light fixture. The wall was observed by removing a ceiling tile above the entrance doors to the suite.

Based on observation, the hospital failed to maintain the integrity of the building construction, as evidenced by the failure to seal penetrations in the walls and ceilings. This affected three of three buildings and five smoke compartments, and could result in the spread of smoke from one compartment to another in the event of a fire.

Findings:

On a hospital tour with staff from 1/11/10 to 1/14/10, the ceilings and walls in the facility were observed.

Inland Valley-1/11/10
First Floor
At 0958 hours, there was an approximately 1/4 - 1/2 inch penetration in the ceiling, around the stall support, in the women's bathroom.
At 1005 hours, there was an approximately 2 x 1 1/2 inch penetration around a condensate pipe in the left wall in the environmental services closet, near the lobby.
At 1325 hours, there was an approximately 2 inch round penetration in a ceiling tile in the ICU waiting room.
At 1430 hours, there was an approximately 3/4 - 1 inch penetration around a copper pipe in the right wall of the alcove, adjacent to the dishwashing area, in the kitchen. The O ring was loose and was not flush to the wall.
At 1437 hours, there were two approximately 1/4 inch penetrations in the back wall in Purchasing.

Rancho Springs - 1/12/10
At 1506 hours, there was an approximately 1/2 - 3/4 inch penetration around blue data wires, inside a pipe sleeve, in the data closet out side of the ED (emergency department) waiting room.
At 1511 hours, there were two ceiling tiles with broken corners above the admitting desk in the ED waiting room.
There was an approximately 1/8 inch penetration in the left wall and an approximately 1/4 x 2 inch gap at the top of the outlet cover plate, behind the copier, in the PAS office area.

1/13/10
At 1205 hours, there were three 1/8 - 1/4 inch penetrations in the back wall of the Admissions office. There were four approximately 1/8 - 1/4 inch penetrations in the front wall above the couch.
At 1235 hours, there was an approximately 1 x 1/2 inch penetration behind the door in Room C2, the Pyxis machine room.
There was an approximately 1 1/2 inch penetration around a communication wire and five approximately 1/8 inch penetrations in the wall, to the right of the magnetic hold open device for the door.

Wound Care Center - 1/13/10
At 1640 hours, there was an approximately 2 x 1 inch penetration around two grey wires, above Door 1, to the hyperbaric room. There was an approximately 1/2 x 1/2 inch penetration around a flex conduit and a copper pipe and an approximately 3/4 inch round penetration above the door. The penetrations were observed from the corridor outside of the hyperbaric room.

At 1645 hours, there were two approximately 5 inch by 6 inch penetrations around two oxygen pipes, observed in the corridor wall outside the hyperbaric room. The penetrations were located on the wall opposite the changing room.

At 1646 hours, there was an approximately 12 inch by 12 inch penetration and an approximately 9 inch by 11 inch penetration observed in the corridor wall from inside the hyperbaric room. The penetrations were located around two oxygen pipes.

At 1650 hours, there were two approximately 1/4 inch penetrations in the back wall of the exterior oxygen storage closet. There was an approximately 1 by 2 inch penetration around a copper pipe and an approximately 1/8 inch penetration along one side of the sprinkler pipe, around two wires, in the back wall.

1/14/10
At 0841 hours, there was an approximately 4 1/2 inch penetration around a one inch copper pipe and an approximately 1 1/2 inch by 3 1/4 inch penetration around wires on one side of a copper pipe. There was an approximately 1/4 - 1/2 inch penetration around a 2 inch copper pipe, in the left wall of the office adjacent to the hyperbaric room. The penetrations were observed in the wall above the ceiling tiles.

At 0843 hours, there were two approximately three inch penetrations around two flexible conduits in the back wall, above the ceiling, in the employee break room. There was an approximately 2 inch penetration around a copper pipe and an approximately 2 1/2 inch by 5 inch penetration around a four inch pipe in the same back wall. There was an approximately two inch by four inch penetration around a pipe in the left wall of the break room. The penetrations were observed in the walls above the ceiling tiles.


18995

Inland Valley - 1/11/10
At 1021 hours, there was an approximately 1/4 inch ceiling penetration around a 1/2 inch conduit, an approximately three inch by four inch ceiling penetration around a cable bundle, and an approximately two inch by three inch metal channel ceiling penetration, in the telemetry room to the right of the central nursing station.

Based on observation, the hospital failed to ensure corridor walls are constructed to resist the passage of smoke, as evidenced by penetrations located in corridor walls in two areas of the hospital. This could result in a delay in evacuation and the spread of smoke in the event of a fire, affecting one smoke compartment at Inland Valley and the Administration building at Rancho Springs.

Findings:

During the observation tour, with staff from 1/11/10 - 1/14/10, the corridor walls in the hospital were observed.

Inland Valley - 1/11/10
At 1148 hours, there was an approximately 3/4 inch penetration around blue wires inside a pipe sleeve on the left wall at Radiology.
There was an approximately 1/8 - 1/4 inch penetration around wires inside a pipe sleeve approximately ten feet north of Radiology. The penetrations were observed in the wall above the drop down ceiling.

Administration building Lab-1/14/10
At 1508 hours, there was an approximately 1/2 inch penetration around a conduit, and an approximately 3 1/2 inch wall penetration, in the occupancy separation wall to the right of the entrance doors to the Lab.

At 1512 hours, there was an approximately 1/2 inch by 3/4 inch penetration around a copper pipe, two approximately 1 1/2 inch by 1 1/2 inch penetrations around a copper pipe, and an approximately 3/4 inch penetration around a metal cross bar, to the left of the entrance doors to the Lab. The penetrations were observed in the wall above the drop down ceiling, from the corridor.

Based on observation and interview, the hospital failed to ensure that doors protecting corridor openings shall be provided with a means suitable for keeping the doors closed, and that there are no impediments to closing the doors. This was evidenced by doors that were obstructed from closing. This affected two of four smoke compartments in the Inland Valley facility and one of eleven smoke compartments in the Rancho Springs facility. This could result in the passage of smoke and flames in the event of a fire.

Findings:

On a hospital tour with staff from 1/11/10 to 1/15/10, the corridor doors in the facility were observed.

Inland Valley-1/11/10
Second floor
At 1030 hours, the door to Room 253 was obstructed by a soiled linen container inside the room.

At 1034 hours, the door to Room 267 was obstructed by a trash container inside the room.

Rancho Springs- 1/12/10
At 1515 hours, the self-closing device on the emergency department changing room door was obstructed from automatic closing by an electrical cord for a Computer on Wheels (COW), which was plugged into an electrical outlet inside the room.


21026

Inland Valley - 1/11/10
First floor
At 1325 hours, 1405 hours and 1445 hours, the self-closing door to the ICU waiting room was observed. The door was obstructed from closing by a trash can. During and interview, at 1325 hours, staff removed the trash can. Staff E101 reported visitors for ICU patients prop the door open because the room is small.
At 1405 hours and 1445 hours, the self-closing door to the ICU waiting room was obstructed by the trash can.

Based on observation, the hospital failed to ensure that smoke barrier walls maintain a 1/2 hour fire resistance rating and are constructed in accordance with 8.3. This was evidenced by smoke barrier walls that had unsealed penetrations around pipes or wires.
This affected 4 of 13 smoke compartments at Inland Valley and 3 of 3 smoke compartments in the emergency department (ED) area at Rancho Springs. This could result in the spread of smoke from one compartment to another and in a delay in evacuation to a safe area, in the event of a fire.

8.3.2 - Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous throughout all concealed spaces, such as those found above a ceiling, including interstitial spaces.

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 with facility staff from 1/11/10 - 1/13/10, the smoke barrier walls were observed in the main hospital and at the Inland Valley campus.

Inland Valley, First floor - 1/11/10
At 1025 hours, there was an approximately 3 inch penetration around a 1/2 inch cable, inside of a pipe sleeve, in the ceiling of the C hallway telephone closet.
At 1128 hours, there was an approximately 1/4 - 1/2 inch penetration around cables and a pipe sleeve above the door in the smoke barrier wall at the lab.

Rancho Springs - 1/12/10
At 1600 hours, there was an approximately 5/8 inch penetration inside a pipe sleeve in the smoke barrier wall at the entrance to the ED. There was an approximately 1 inch penetration around a grey wire and an approximately 2 x 1 3/4 inch penetration around a wire in the same smoke barrier wall.


18995

Inland Valley - 1/11/10
First floor
At 1131 hours, there were three approximately 1/4 to 1/2 inch penetrations above a copper pipe, through the smoke barrier wall above the Manager of Emergency Services office.
At 1147 hours, there was an approximately one inch by two inch penetration around a sprinkler pipe through the smoke barrier wall above Room 138.

Second floor
At 1053 hours, there was an approximately 1/2 inch penetration around a six inch water pipe in the smoke barrier wall at the 2 West telemetry room.

Rancho Springs - 1/12/10
At 1550 hours, there were two penetrations in the smoke barrier wall at the entrance to the radiology corridor. There was an approximately 3 x 3 inch square penetration around two blue wires and an approximately 1/4 - 1/2 inch penetration around an orange flexible conduit. The smoke barrier separates the emergency department suite from the radiology department.

Based on observation and interview, the hospital failed to maintain hazardous areas with 1 hour rated construction and failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by one hazardous area with penetrations and two hazardous areas with doors that failed to self close and latch. This affected two of 13 smoke compartments at Inland Valley and one smoke compartment at the Wound Care Center. This could result in the spread of fire from a hazardous area to other areas of the hospital or could result in fire in an unprotected area.

7.2.1.8.1
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the hospital tour with staff on 1/11/10 and 1/13/10, hazardous areas were observed at Inland Valley and at the Wound Care Center.
Inland Valley - 1/11/10
At 1330 hours, there were two approximately 1/8 inch penetrations in the ICU soiled linen room.
At 1433 hours, the kitchen dry storage room was equipped with a self-closing device. The door was obstructed from closing by a coat rack.

The room is greater than 50 square feet in size and contained cardboard boxes and paper packages of food and supplies. The door is required to self close and latch.

Wound Care Center - 1/13/10
At 1645 hours, the changing room at the Wound Care Center was observed. There was an approximately 60 gallon container for soiled linen stored in the room. The container was filled past the top. The gowns in the container were worn in the hyperbaric chamber. The door was not equipped with a self-closing device.

During an interview at 1648 hours, Staff E104 reported that the linen cart was kept in the changing room during the day and was picked up at night.

Soiled linen and trash receptacles greater than 32 gallons in size, when not attended, shall be located in a room protected as a hazardous area. Hazardous areas are required to have self-closing doors.

Based on observation and interview, the hospital failed to maintain the exit access so that exits were readily accessible at all times. This was evidenced by two of two exit corridors that were not fully accessible from the Emergency Department (ED). This could result in a delay in exiting the hospital from the ED in the event of a fire or other emergency affecting 19 ED patients, radiological patients, visitors and staff.

Findings:

During the hospital tour with facility engineering staff from 1/11/10 to 1/14/10, the exit corridors were observed.

Rancho Springs - 1/12/10

1. At 1516 hours, there were six hospital beds lined up along the right side of the corridor from the ED towards the Radiology Department. The corridor was approximately eight feet wide. The hospital gurneys are approximately 32 inches wide. Hospital beds are approximately 39 inches wide. Chairs are approximately 18 inches wide. There was a tri-fold privacy screen, a bedside table, a chair, and a metal table on the right side of the corridor between Bed #15 and Bed #16. At 1517 hours, there was a chair, two blood pressure machines, and a bedside table on the right side of the corridor near Bed #17. At 1519 hours, there were two blood pressure machines, and two chairs on the right side of the corridor near Radiology Room 2. These items combined to obstruct the exit access width to less than four feet.

2. At 1517 hours, there were three hospital beds, three blood pressure machines, two chairs and a tri-fold privacy screen along the left side of the exit corridor from the radiology department towards the East courtyard corridor. The corridor was approximately eight feet wide. The hospital beds were approximately thirty nine inches wide. Gurneys are approximately 32 inches wide. Chairs are approximately 18 inches wide. These items combined to obstruct the exit access width to less than four feet.

3. At 1529 hours, there was a blood draw station with a chair, a chair, a table, and two biohazard containers on the right side of the corridor to the right of the X-ray Room and Bed # 13. The furniture was just outside of the smoke barrier doors protecting the ED. The doorway width was obstructed approximately 34 inches.

4. In an interview at 1533 hours, Staff E15 stated that the hospital maintains eight beds or gurneys in the corridor even if they are not in use or needed.

At 1516 hours, the numbers 13 through 18 were painted on the corridor wall from the Emergency Department towards the Radiology Department. The numbers 11 and 12 were painted on the corridor wall from the Emergency Department towards the East courtyard corridor.
In an interview at 1530 hours, Staff AS8 stated that the numbers had been painted on the walls for approximately fifteen years. Staff AS8 indicated the hospital has used the corridor as an overflow area for the ED on a on-going basis.

In an interview with hospital staff E16 at 1553 hours, staff stated that the beds in the corridor are typically occupied 100 percent of the time during the shift from 7 a.m. to 7 p.m.



21026

5. At 1525 hours, a computer on wheels (COW) was located in the ambulance entry way into the ED. An Atlas heat pump was located on left wall. The heat pump extended 32 inches into the exit access. There was a chair against the right wall of the ambulance entry. These items partially obstructed the exit access out of the ED into the ambulance entry/exit.

During interviews on 1/12/10, hospital staff were asked about fire drill procedures.

At 1545 hours, Staff E17 reported the corridor was usually congested with beds, chairs and equipment daily from 1200 to 0300 hours. The blood draw station is always in the corridor. Sometimes the visitor chairs are cleared out but the beds or gurneys remain at all times. In the event of a fire, Staff E17 would evacuate patients through the corridor but would have to work a pathway through the congestion if the patients were on a bed or gurney.

At 1550 hours, Staff M47 reported patients could be evacuated in the corridor going towards the OR (operating room) or out through the courtyard. Staff M47 reported it can take from 5-7 minutes to get a bed or gurney out of radiology and through the corridor.

Based on record review and interview the hospital failed to ensure fire drills are held at least quarterly on each shift and staff are familiar with fire procedures. This was evidenced by missing fire drills on one shift in 4 of 4 quarters at the Wound Center, and by interviews with other hospital staff. This could result in a delayed response to a fire emergency if hospital staff are unfamiliar with the proper fire emergency procedures and the failure to protect residents in the event of a fire.

19.7.1.2 - Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During record review with hospital staff on 1/12/10, 1/13/10 and 1/14/10, the reports for fire drills were reviewed. During fire alarm testing and the observation tour, hospital staff were interviewed regarding responses to a fire.

On 1/12/10 at 1525 hours, during an interview, a financial staff person in the ED was asked what they would do in a fire. They were unable to remember the actions required using RACE, (rescue, alarm, contain and extinguish or evacuate). The RACE procedure is provided on the back of the card attached to the staff ID badge.

At 1550, during an interview, Staff M47 was asked about fire drill procedures. Staff reported when a fire alarm is activated staff respond with fire extinguishers as if there is a fire. Then there is a 10-15 minute in-service of what to do in the event of a fire. Staff reported there was no actual drill where staff activate the alarm and evacuate the corridors or plan how to move patients in the radiology corridor.

During an interview at 1612 hours, Staff E6 did not know where the closest pull station was located. The pull station was approximately 10 feet away obstructed by a computer on wheels.

On 1/13/10, fire drill reports were requested for the Wound Care Center. Staff E101 indicated a fire drill had been conducted and the hospital would provide a copy of the drill.

During interviews on 1/14/10, Wound Care Center staff were interviewed about fire drill procedures.

At 0810 hours, Staff E104 reported there had been no fire drills that staff remembered since 2004. Staff E104 reported that many patients in the Wound Care Center are not ambulatory. Staff reported that during a previous incident, when the elevator was disabled, paramedics were called to evacuate the patients.

Staff E101 stated four staff are available on site, to evacuate five or six patients in an emergency. The Center is located on the bottom floor of a three story building. The evacuation route requires non-ambulatory patients to be carried up two flights of stairs to the ground level. A backboard is the only equipment available on site to transport the patients.

At 0817 hours, Staff E103 reported remembering the last fire drill was 2-3 years ago. Staff E103 stated evacuation time with potential patient injury, due to the speed of decompression, would be 1 1/2 minutes. During that time staff would have to stay with the decompressing patient and would not be available to assist with other patient evacuations.

During an interview at 0830 hours, Staff E21 reported remembering a fire drill approximately 8 months ago. No other staff confirmed a fire drill during that time.

Staff E101 indicated no fire drill records could be located. No records were provided by the hospital indicating fire drills or evacuation drills were held in the Wound Care Center.

Based on observation and interview, the hospital failed to ensure the fire alarm system is in accordance with NFPA 101 and NFPA 72. This was evidenced by no fire alarm system devices or smoke detection devices in required areas in the Wound Care Center. This affected the entire facility, and could result in a delay in notification, or a delay in evacuation, in the event of a fire or other emergency.

NFPA 101, 2000 edition
21.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

39.3.4.3 Occupant Notification
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions.
(a) It shall activate a general alarm in accordance with 9.6.3 throughout the building.
(b) It shall activate an alarm signal in a continuously attended location for the purpose of initiating emergency action by personnel trained to respond to emergencies. Emergency action shall be initiated by means of live voice public address system announcements originating from the attended location where the alarm signal is received. The system shall be permitted to be used for other announcements, provided that the fire alarm use takes precedence over any other use.
Exception: Any other occupant notification means permitted by 9.6.3 shall be permitted in lieu of live voice public address system announcements.

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

Findings:

On a hospital tour and record review with engineering staff from 1/11/10 to 1/15/10, the fire alarm system was observed, and records for maintenance and testing of the fire alarm system were requested.

Wound Care Center - 1/14/10
During the tour at 0815 hours, there were no smoke detectors located in the Wound Care Center. There was no pull station located in the building. There were two smoke detectors located on the first floor around the pharmacy. There were no annunciation devices located inside the Wound Care Center or the building it occupies. There was no notification device in any area that would notify occupants of a fire.

During an interview at 0815 hours, Staff E21 confirmed there were no fire alarm pull stations inside the Wound Care Center or on the first floor of the building. Staff stated there are no annunciators located within the building.


18995

Wound Care Center- 1/15/10
At 1153 hours, there was no smoke detector observed in the closet where the fire alarm control panel was located. The closet was located in the building corridor, opposite the entrance doors to the Wound Care Center.

Based on observation, record review and interview, the hospital failed to ensure inspection, maintenance and testing of the fire alarm system in accordance with NFPA 72 and NFPA 101. This was evidenced by fire alarm pull stations that were obstructed from use in the emergency department (ED), and by no audible alarm to notify occupants, no smoke detector at the fire alarm panel, and no records of monthly activation of the fire sprinkler alarm system, in the Wound Care Center. This affected two of twenty six fire alarm pull stations in the main hospital building and the entire Wound Care Center. This could result in a delay in activation of the fire alarm system in the event of a fire, and in a delay in notification and evacuation of the patients in the ED and the Wound Care Center.

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

2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

7-2.2 Testing Methods
16. Supervising Station Fire Alarm Systems- Transmission Equipment
a. All Equipment
Tests shall be performed on all system functions and features in accordance with the equipment manufacturer's instructions for correct operation in conformance with the applicable sections of Chapter 5.

Initiating devices shall be actuated. Receipt of the correct initiating device signal at the supervising station within 90 seconds shall be verified. Upon completion of the test, the system shall be restored to its functional operating condition.

Table 7-3.2 Testing Frequencies
Component Frequency
23. Supervising Station Fire Alarm Systems
Receivers Monthly

NFPA 101, 21.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Findings:

During the hospital tour with staff, on 1/12/10, the emergency department was observed.

Rancho Springs - 1/12/10
1. At 1525 hours, there was a computer on wheels (COW) completely obstructing the pull station at the ambulance entrance to the ED.

At 1610 hours, during an interview, Staff E6 was asked what the procedure was in the event of a fire. Staff E6 stated they were trained to call for help. Staff E6 was asked where the closest fire alarm, pull station was located. Staff was unable to locate the pull station which was completely obstructed by the COW.

Wound Care Center - 1/14/10
2. During the tour at 0815 hours, there were no smoke detectors located in the Wound Care Center. There was no pull station located in the building. There were two smoke detectors located on the first floor around the pharmacy. There were no annunciation devices located inside the Wound Care Center or the building it occupies. There was no notification device in any area that would notify occupants of a fire.

During an interview at 0815 hours, Staff E21 confirmed there were no fire alarm devices inside the Wound Care Center or on the first floor of the building.

During the tour at Wound Care Center, on 1/15/10, the sprinkler alarm system was observed and tested.

During an interview on 1/15/10, at 1105 hours, E104 reported there had never been any audible alarms during sprinkler testing and inspection, by an outside vendor.

During a phone interview at 1205 hours, building management staff reported they are notified, by the monitoring company, in the event of activation of a sprinkler alarm. They were asked what would happen after they were notified and if they would notify anyone. Staff stated they would ensure notification of the fire department. The monitoring company is required to notify the fire department initially after receiving the signal that a sprinkler has been activated, before notifying the building management company. After prompting, the building management staff stated they would get a list of tenants and notify them of the possible fire. There was no procedure to ensure tenants of the building would be notified in the event of a fire.



18995

Rancho Springs - 1/12/10
1. At 1612 hours, the COW was obstructing the fire alarm device located to the left of the ambulance entrance to the ED.

In an interview with hospital staff E31 at 1613 hours, staff stated that the COW and chair had been in that location since early December, 2009.

At 1619 hours, there were two hospital beds obstructing the fire alarm pull station located in the radiology corridor between Radiology Room 3 and the Control room.

During the hospital tour at Southwest Healthcare System Wound Care Center, on 1/15/10, the sprinkler alarm system was observed and tested.

2. At 1153 hours, there was no smoke detector provided in the closet where the fire alarm control panel was located.

At 1203 hours, the Inspector's Test Valve (ITV) was tested. There was no audible alarm at the fire alarm control panel, located in the corridor outside the entrance to the Wound Care Center. In an interview with Staff E104, staff stated that they did not hear the alarm from inside the suite during testing.

During record review at 1215 hours, there were no complete records of testing and maintenance of the fire alarm system provided for the Wound Care Center. The record "Inspection and Testing Form" dated 11/2/09 was for an annual test of the fire alarm system. No records of monthly testing of the fire alarm system or quarterly sprinkler testing were provided.

Based on observation, interview and record review, the hospital failed to maintain the integrity of the automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by no records for quarterly inspection and testing of the automatic sprinkler system at the Wound Care Center, for three of four quarters, and by obstructions under the sprinkler heads in one of 13 smoke compartments at Inland Valley and one of 11 smoke compartments at Rancho Springs. This could result in a failure of the sprinkler system or obstruction of the sprinkler spray pattern in the event of a fire.

Findings:

During the hospital tour and record review with engineering staff, from 1/11/10 to 1/15/10, the automatic sprinkler system was observed and records for maintenance and testing of the automatic sprinkler system devices were requested.

Inland Valley-1/11/10
First Floor
At 1121 hours, there was storage within approximately ten inches of the sprinkler head in the storage closet to the left of Room 12.

Rancho Springs - 1/12/10
At 1508 hours, there was computer equipment on a shelf approximately 10 inch below the sprinkler deflector, in the data closet outside of the ED waiting room.


18995

Wound Center-1/14/10
At 0750 hours, there were no records of quarterly testing of the automatic sprinkler system provided for review. The record "Inspection and Testing Form" dated 11/2/09 stated an annual inspection of the sprinkler system had been conducted.

In an interview with Staff E101 at 0755 hours, staff stated that the quarterly sprinkler testing had not been conducted during the first, second and third quarters of 2009.

Wound Center- 1/15/10

At 1203 hours, the Inspector's Test Valve (ITV) was tested. There was no audible alarm at the fire alarm control panel, located in the corridor outside the entrance to the Wound Center suite. In an interview with staff E104, staff stated that they did not hear the alarm from inside the suite during the testing.

Based on observation, the hospital failed to maintain the portable fire extinguishers in the facility in accordance with NFPA 10. This was evidenced by portable fire extinguishers that were stored unsecured, fire extinguisher cabinets that were obstructed, and by a fire extinguisher that was missing monthly checks. This affected one of thirteen smoke compartments at Inland Valley, one of eleven smoke compartments at Rancho Springs, and one of one smoke compartments in the Lab. This could result in a delay in extinguishing a fire.

NFPA 10, 1998 edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

On a hospital tour with engineering staff from 1/11/10 to 1/15/10, the portable fire extinguishers in the facility were observed.

Inland Valley 1/11/10
At 1541 hours, there were nine portable fire extinguishers stored unsecured on the floor in the plant operations shop.

Rancho Springs-1/12/10
At 1454 hours, the portable fire extinguisher cabinet in the Operating Room sterile corridor was obstructed by a clothing rack.

Administration Building- Lab- 1/14/10
At 1456 hours, the portable fire extinguisher cabinet was obstructed by a lab machine.

At 1457 hours, the portable fire extinguisher was missing the monthly inspection checks from October, 2009 to January, 2010. The certification tag was dated 9/11/09.

Based on observation, the hospital failed to maintain the integrity of the building service equipment by permitting the use of a portable space heating device. This was evidenced by a portable space heating device observed in the entryway into the emergency room. This affected one of eleven smoke compartments, and could result in an increased risk of fire.

Findings:

On a hospital tour with engineering staff on 1/12/15, the hospital patient and treatment rooms were observed at Rancho Springs.

At 1134 hours, there was a portable space heating device observed on one side of the ambulance entrance to the emergency department. The Atlas heater was connected to the wall outlet and vented into the open area above the ceiling tiles.

Based on observation and interview, the facility failed to maintain means of egress continuously free of all obstructions or impediments to full instant use in the case of a fire or other emergency. This was evidenced by chairs and tables placed in two of six exit corridors. This failure could lead to an obstruction of the corridor and the exit path during a fire or other emergency, resulting in harm to patients who would be delayed in exiting. This affected two of five smoke compartments.

Findings:

On a hospital tour with hospital engineering staff from 1/11/10 to 1/13/10, the exit corridors were observed.

Inland Valley- 1/11/10
At 1114, 1505 and at 1610 hours, there were four wheelchairs stored in the temporary exit path outside the ambulance entrance to the emergency department. The exit path was six feet wide.

Rancho Springs - 1/12/10
At 1153 hours, there were ten chairs, one round table and one square table in the east corridor across from the emergency department.
At 1154 hours, there were five chairs in the corridor outside of labor and delivery.


21026

Rancho Springs - 1/12/10
At 0935, 1245, and 1505 hours, there were 9 chairs and two tables in the corridor outside of nuclear medicine, across from the emergency department.

At 0935, 1245, and 1505 hours, there were two chairs in the corridor across from the clinical lab. There were five chairs in the corridor across from labor and delivery (L&D).

During an interview at 1506 hours, Staff M46 reported the areas with chairs were used as waiting rooms.

Rancho Springs - 1/13/10
At 0953 hours, there were 20 chairs and two tables in the labor and delivery exit corridor, opposite the corridor entrance to the emergency department (ED).

At 0953 hours there were four chairs in the corridor across from the clinical lab. There were three chairs in the corridor across from labor and delivery.

During an interview at 0955 hours, Staff M46 reported some chairs had been moved into the corridor to make more space in the new triage area.
At 1004 hours, a triage area was observed in the ED waiting room. By using the waiting room as a triage area the patient waiting room seating for the emergency department was reduced.

Based on observation, the hospital failed to maintain the integrity of the storage of medical gas in accordance with NFPA 99. This was evidenced by failing to secure two "E" type oxygen cylinders. This affected two of thirteen smoke compartments, and could result in an increased risk or acceleration of a fire.

NFPA 99
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocations.

Findings:

On a hospital tour with engineering staff on 1/11/10, the oxygen cylinders were observed at Inland Valley.

At 1033 hours, there was one "E" type oxygen cylinder stored in a wheeled cart inside Room 259. The corridor door could not be pulled closed from the corridor without striking the wheeled cart.

At 1542 hours, there was an "E" type oxygen cylinder stored unsecured on the floor in the plant operations shop.

Based on observation, record review and interview, the hospital failed to maintain the integrity of the hyperbaric facility in accordance with NFPA 99 and NFPA 101. This was evidenced by failing to maintain the building construction and the occupancy separation walls, by failing to ensure fire alarm notification, by failing to provide smoke detection devices in required areas, by failing to conduct fire evacuation drills, and by failing to maintain the integrity of the electrical wiring and connections. This could result in an increased risk of fire, delay in notification, delay in evacuation, and possible patient injury or death, in the event of a fire or other emergency.

NFPA 99, 1999 edition
19-3.1.4.6 Fire training drills shall be carried out at regular intervals.

NFPA 101, 2000 edition
21.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

39.3.2.2 High Hazard contents areas, as classified in Section 6.2, shall meet the following criteria:
(1) The area shall be separated from other parts of the building by fire barriers having a fire resistance rating of not less than 1 hour, with all openings therein protected by 3/4-hour fire protection-rated self-closing doors.
(2) The area shall be protected by an automatic extinguishing system in accordance with Section 9.7

39.3.4.3 Occupant Notification
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions.
(a) It shall activate a general alarm in accordance with 9.6.3 throughout the building.
(b) It shall activate an alarm signal in a continuously attended location for the purpose of initiating emergency action by personnel trained to respond to emergencies. Emergency action shall be initiated by means of live voice public address system announcements originating from the attended location where the alarm signal is received. The system shall be permitted to be used for other announcements, provided that the fire alarm use takes precedence over any other use.
Exception: Any other occupant notification means permitted by 9.6.3 shall be permitted in lieu of live voice public address system announcements.

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

Findings:

On a hospital tour with engineering staff from 1/11/10 to 1/15/10, the hyperbaric facility was observed, and records for maintenance and testing of the fire alarm system were requested.

During the tour of the Wound Care Center, the hyperbaric chamber room corridor wall was observed from both sides.

1-13/10
At 1640 hours, there was an approximately 2 x 1 inch penetration around two grey wires, above Door 1, to the hyperbaric room. There was an approximately 1/2 x 1/2 inch penetration around a flex conduit and a copper pipe and an approximately 3/4 inch round penetration above the door. The penetrations were observed from the corridor outside of the hyperbaric room.

At 1645 hours, there were two approximately 5 inch by 6 inch penetrations around two oxygen pipes, observed in the corridor wall outside the hyperbaric room. The penetrations were located on the wall opposite the changing room and Door 1 to the hyperbaric room.

At 1646 hours, there was an approximately 12 inch by 12 inch penetration and an approximately 9 inch by 11 inch penetration observed in the corridor wall from inside the hyperbaric room. The penetrations were located around two oxygen pipes.

At 1650 hours, there were two approximately 1/4 inch penetrations in the back wall of the exterior oxygen storage closet. There was an approximately 1 by 2 inch penetration around a copper pipe and an approximately 1/8 inch penetration along one side of the sprinkler pipe, around two wires, in the back wall.

1/14/10
At 0841 hours, there was an approximately 4 1/2 inch penetration around a one inch copper pipe and an approximately 1 1/2 inch by 3 1/4 inch penetration around wires on one side of a copper pipe. There was an approximately 1/4 - 1/2 inch penetration around a 2 inch copper pipe, in the left wall of the office adjacent to the hyperbaric room. The penetrations were observed in the walls above the ceiling tiles.

At 0843 hours, there were two approximately three inch penetrations around two flexible conduits in the back wall, above the ceiling, in the employee break room. There was an approximately 2 inch penetration around a copper pipe and an approximately 2 1/2 inch by 5 inch penetration around a four inch pipe in the same back wall. There was an approximately two inch by four inch penetration around a pipe in the left wall of the break room. The penetrations were observed in the walls above the ceiling tiles.

During an interview at 0846 hours, Staff E101 reported no one had inspected the corridor walls of the hyperbaric room after installation of the two new chambers in 3/09.

During interviews on 1/14/10, Wound Care Center staff were interviewed about fire drill procedures. Specifications were requested for the hyperbaric chamber room.

At 0810 hours, Staff E104 reported there had been no fire drills that staff remembered since 2004.
Staff E101 stated four staff work in the Center and are available to evacuate patients in an emergency. Staff reported there are usually five to six patients in the facility at one time. The Center is located on the bottom floor of a three story building. The evacuation route requires non-ambulatory patients to be carried up two flights of stairs to the ground level. A backboard is the only equipment available on site to transport the patients.

At 0817 hours, Staff E103 reported remembering the last fire drill was 2-3 years ago. Staff E103 stated evacuation time with potential patient injury, due to the speed of decompression, would be 1 1/2 minutes. During that time staff would have to stay with the decompressing patient and would not be available to assist with other patient evacuations. Staff stated that the safe patient evacuation time was approximately four to five minutes.

During an interview at 0830 hours, Staff E21 reported remembering a fire drill approximately 8 months ago. No other staff confirmed a fire drill during that time.

Staff E101 indicated no fire drill records were available. No records were provided by the hospital indicating fire drills or evacuation drills were held in the Wound Care Center.

At 0845 hours, during an interview, Staff AS8 was asked about the mock surveys conducted in the hospital. Staff AS8 reported the hospital had conducted mock surveys to ensure compliance with federal regulations at both campuses but the Wound Care Center was not included. The hospital was unaware that the federal regulations applied to the Wound Care Center.

At 0930 hours, Staff E101 reported there has not been any inspection and maintenance at the Wound Care Center because they don't own the building.

1/15/10
During sprinkler alarm testing the monitoring company and building management company were contacted to ensure the alarm signal is received and to determine what actions are taken after alarm notification.

At 1205 hours, staff (BMC1) from the building management company was interviewed. BMC1 reported the monitoring company notifies them by cell phone in the event the sprinkler alarm is activated.
They were asked what would happen after they were notified and if they would notify anyone. Staff stated they would ensure notification of the fire department. After prompting, the building management staff stated they would get a list of tenants and notify them of the possible fire.

The monitoring company is required to notify the fire department initially after receiving the signal that a sprinkler has been activated, before notifying the building management company. There was no procedure to ensure tenants of the building would be notified in the event of a fire.


18995

Wound Center-1/14/10
During sprinkler testing, record review and interview, the ITV (Inspector's Test Valve) was tested and specifications for the hyperbaric chambers were provided.

At 0904 hours, the manufacturer's specifications, page 2-2, number 1, for two hyperbaric chambers recommended that the minimum measurements for the room be 16 feet wide, and 21 feet long. The hyperbaric room was approximately nine feet wide and approximately 38 feet long.

The manufacturer's specifications, page 2-2, number 11, indicated "All electrical equipment in the treatment facility must be properly grounded and in optimum working condition.

At 0909 hours, there was a DVD player connected to the wall outlet near each hyperbaric chamber. The DVD players were not grounded.
At 0911 hours there was a surgical clipper that was not grounded, plugged into an outlet on the wall behind a wooden cabinet.

1/15/10
During the facility tour, the fire sprinkler alarm system was observed.

At 1153 hours, there was no smoke detector observed in the closet where the fire alarm control panel was located. The closet was located in the building corridor, opposite the entrance doors to the Wound Care Center.

At 1203 hours, the ITV was tested. There was no audible alarm at the fire alarm control panel, located in the corridor outside the entrance to the Wound Care Center. In an interview with Staff E104, staff stated that they did not hear the alarm from inside the suite during the testing.

At 1215 hours, there were no complete records of testing and maintenance of the fire alarm system provided for review. The record "Inspection and Testing Form" dated 11/2/09 was for an annual test of the fire alarm system. No records of monthly testing of the fire alarm system, confirmed to the central station, were provided for review.

Based on record review and interview, This affected the entire campus at Inland Valley and could result in a potential generator failure during a power outage.

NFPA 110 1999 edition
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During record review and interview with facility staff on 1/12/10, the generator records were requested for Inland Valley and Rancho Springs. The generator logs documented the generator was tested under load for 30 minutes every month. There were no records for weekly inspections since August 2009 for Inland Valley.

During an interview, E101 reported he thought the weekly inspections were no longer required.

Based on observation, record review and interview, the hospital failed to ensure that electrical wiring and equipment are maintained in accordance with NFPA 70 and NFPA 99. This was evidenced by failing to provide complete records of testing electrical receptacles and failing to maintain the integrity of the electrical wiring and connections. This affected two of 13 smoke compartments at Inland Valley, two of eleven smoke compartments at Rancho Springs, and two of two smoke compartments in the Wound Care Center. This could result in an increased risk of an electrical fire.

NFPA 99 1999 Edition
Electrical Systems
3-3.2.1.2 All Patient Areas
(d) Receptacles. 3. Polarity of Receptacles. Each receptacle shall be wired in accordance with NFPA 70, National Electrical Code, to ensure correct polarity.

3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Section 400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the 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, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On a hospital tour with engineering staff from 1/11/10 to 1/15/10, the electrical outlets and connections were observed, and the records for maintenance and testing were reviewed.

Inland Valley- 1/11/10
At 1114 hours, there was a microwave plugged into a surge protector in the Doctor's lounge.

At 1327 hours, there was a refrigerator and a microwave plugged into a surge protector in the employee lounge in the intensive care unit.

At 1346 hours, there was a refrigerator and a microwave plugged into a surge protector in the patient nourishment room in the Operating Room (OR) area.

Rancho Springs- 1/12/10

At 1106 hours, there were incomplete records of receptacle outlet testing provided for review for Inland Valley and Rancho Springs. The record "Annual tension testing" invoice # 5170, dated 9/8/09, did not include a complete record for the testing conducted. There was no complete list of the outlet locations and results of the testing for each outlet.

In an interview with Staff M46, staff stated that they did not have any additional records of electrical outlet testing and maintenance. There was no record for semi annual testing of the receptacles in wet locations.

At 1502 hours, there was an uncovered square electrical box with red wires exposed, in the attic above the smoke barrier doors between the OR and labor and delivery.

At 1514 hours, there was a Computer on Wheels (COW) in the corridor outside the OR changing room. The COW was plugged into an electrical outlet inside the OR changing room. The cord passed through the doorway, on the floor to connect to the outlet.

1/13/10
At 1149 hours, the light switch was missing the cover plate, on the left wall inside the materials management room.
At 1210 hours, there was a microwave plugged into a surge protector inside the employee lounge.
At 1218 hours, there was an uncovered square electrical box to the right of the west exterior doors in the mechanical room.


21026

Inland Valley - 1/11/10
At 0945 hours, there was a surge protector plugged into a surge protector in the office of the EVS (environmental services) supervisor.
At 0950 hours, there was a refrigerator plugged into a surge protector and a surge protector plugged into a surge protector in the House Supervisor office.
At 1010 hours, the outlet cover plate was missing in the EVS closet, near the lobby. A transformer and wire were connected to the outlet.
At 1135 hours, there was biohazard refrigerator plugged into a surge protector, in the lab next to the blood bank.
During an interview at 1136 hours, Staff E101 reported the surge protector was used to connect the refrigerator to a red outlet.
At 1343 hours, there was an endoscopy lab monitor plugged into a surge protector, plugged into a red outlet.
At 1345 hours, there was a surge protector plugged into a surge protector in the "fast track area" nurses' station.
At 1450 hours, there was a broken outlet cover on the right wall in the outpatient restroom and vending machine area.

Rancho Springs - 1/12/10
At 1210 hours, there was a surge protector plugged into a surge protector in the storage room near the east nurses' station.

Based on observation, the hospital failed to maintain the integrity of the occupancy separation walls, as evidenced by unsealed penetrations in one wall in the Wound Care Center. This could result in the spread of smoke and fire in the event of a fire affecting four staff and 5-6 patients on any treatment day.

Findings:

On a hospital tour with engineering staff from 1/13/10 to 1/14/10, the occupancy separation walls were observed at the Wound Care Center.

1/13/10 -
At 1624 hours, there was an approximately 1/8 inch penetration around a three inch sprinkler pipe and an approximately 1/4 to 1/2 inch penetration around a three inch sprinkler pipe in the wall above the entry doors to the Wound Care Center. There was an approximately 1/8 inch penetration around a pipe sleeve, an approximately 1/4 inch penetration around wires inside a 3/4 inch pipe sleeve and an approximately 1/8 to 1/4 inch penetration around a three inch pipe. There was an approximately 4 inch by 5 inch penetration in the occupancy separation wall to the right of the entry doors. All penetrations were observed above the drop ceiling from the building corridor.

1/15/10
At 1145 hours, there was an approximately 1 inch x 2 inch penetration around a two inch pipe next to the light fixture. The wall was observed by removing a ceiling tile above the entrance doors to the suite.

Based on observation, the hospital failed to maintain the integrity of the building construction, as evidenced by the failure to seal penetrations in the walls and ceilings. This affected three of three buildings and five smoke compartments, and could result in the spread of smoke from one compartment to another in the event of a fire.

Findings:

On a hospital tour with staff from 1/11/10 to 1/14/10, the ceilings and walls in the facility were observed.

Inland Valley-1/11/10
First Floor
At 0958 hours, there was an approximately 1/4 - 1/2 inch penetration in the ceiling, around the stall support, in the women's bathroom.
At 1005 hours, there was an approximately 2 x 1 1/2 inch penetration around a condensate pipe in the left wall in the environmental services closet, near the lobby.
At 1325 hours, there was an approximately 2 inch round penetration in a ceiling tile in the ICU waiting room.
At 1430 hours, there was an approximately 3/4 - 1 inch penetration around a copper pipe in the right wall of the alcove, adjacent to the dishwashing area, in the kitchen. The O ring was loose and was not flush to the wall.
At 1437 hours, there were two approximately 1/4 inch penetrations in the back wall in Purchasing.

Rancho Springs - 1/12/10
At 1506 hours, there was an approximately 1/2 - 3/4 inch penetration around blue data wires, inside a pipe sleeve, in the data closet out side of the ED (emergency department) waiting room.
At 1511 hours, there were two ceiling tiles with broken corners above the admitting desk in the ED waiting room.
There was an approximately 1/8 inch penetration in the left wall and an approximately 1/4 x 2 inch gap at the top of the outlet cover plate, behind the copier, in the PAS office area.

1/13/10
At 1205 hours, there were three 1/8 - 1/4 inch penetrations in the back wall of the Admissions office. There were four approximately 1/8 - 1/4 inch penetrations in the front wall above the couch.
At 1235 hours, there was an approximately 1 x 1/2 inch penetration behind the door in Room C2, the Pyxis machine room.
There was an approximately 1 1/2 inch penetration around a communication wire and five approximately 1/8 inch penetrations in the wall, to the right of the magnetic hold open device for the door.

Wound Care Center - 1/13/10
At 1640 hours, there was an approximately 2 x 1 inch penetration around two grey wires, above Door 1, to the hyperbaric room. There was an approximately 1/2 x 1/2 inch penetration around a flex conduit and a copper pipe and an approximately 3/4 inch round penetration above the door. The penetrations were observed from the corridor outside of the hyperbaric room.

At 1645 hours, there were two approximately 5 inch by 6 inch penetrations around two oxygen pipes, observed in the corridor wall outside the hyperbaric room. The penetrations were located on the wall opposite the changing room.

At 1646 hours, there was an approximately 12 inch by 12 inch penetration and an approximately 9 inch by 11 inch penetration observed in the corridor wall from inside the hyperbaric room. The penetrations were located around two oxygen pipes.

At 1650 hours, there were two approximately 1/4 inch penetrations in the back wall of the exterior oxygen storage closet. There was an approximately 1 by 2 inch penetration around a copper pipe and an approximately 1/8 inch penetration along one side of the sprinkler pipe, around two wires, in the back wall.

1/14/10
At 0841 hours, there was an approximately 4 1/2 inch penetration around a one inch copper pipe and an approximately 1 1/2 inch by 3 1/4 inch penetration around wires on one side of a copper pipe. There was an approximately 1/4 - 1/2 inch penetration around a 2 inch copper pipe, in the left wall of the office adjacent to the hyperbaric room. The penetrations were observed in the wall above the ceiling tiles.

At 0843 hours, there were two approximately three inch penetrations around two flexible conduits in the back wall, above the ceiling, in the employee break room. There was an approximately 2 inch penetration around a copper pipe and an approximately 2 1/2 inch by 5 inch penetration around a four inch pipe in the same back wall. There was an approximately two inch by four inch penetration around a pipe in the left wall of the break room. The penetrations were observed in the walls above the ceiling tiles.


18995

Inland Valley - 1/11/10
At 1021 hours, there was an approximately 1/4 inch ceiling penetration around a 1/2 inch conduit, an approximately three inch by four inch ceiling penetration around a cable bundle, and an approximately two inch by three inch metal channel ceiling penetration, in the telemetry room to the right of the central nursing station.

Based on observation, the hospital failed to ensure corridor walls are constructed to resist the passage of smoke, as evidenced by penetrations located in corridor walls in two areas of the hospital. This could result in a delay in evacuation and the spread of smoke in the event of a fire, affecting one smoke compartment at Inland Valley and the Administration building at Rancho Springs.

Findings:

During the observation tour, with staff from 1/11/10 - 1/14/10, the corridor walls in the hospital were observed.

Inland Valley - 1/11/10
At 1148 hours, there was an approximately 3/4 inch penetration around blue wires inside a pipe sleeve on the left wall at Radiology.
There was an approximately 1/8 - 1/4 inch penetration around wires inside a pipe sleeve approximately ten feet north of Radiology. The penetrations were observed in the wall above the drop down ceiling.

Administration building Lab-1/14/10
At 1508 hours, there was an approximately 1/2 inch penetration around a conduit, and an approximately 3 1/2 inch wall penetration, in the occupancy separation wall to the right of the entrance doors to the Lab.

At 1512 hours, there was an approximately 1/2 inch by 3/4 inch penetration around a copper pipe, two approximately 1 1/2 inch by 1 1/2 inch penetrations around a copper pipe, and an approximately 3/4 inch penetration around a metal cross bar, to the left of the entrance doors to the Lab. The penetrations were observed in the wall above the drop down ceiling, from the corridor.

Based on observation and interview, the hospital failed to ensure that doors protecting corridor openings shall be provided with a means suitable for keeping the doors closed, and that there are no impediments to closing the doors. This was evidenced by doors that were obstructed from closing. This affected two of four smoke compartments in the Inland Valley facility and one of eleven smoke compartments in the Rancho Springs facility. This could result in the passage of smoke and flames in the event of a fire.

Findings:

On a hospital tour with staff from 1/11/10 to 1/15/10, the corridor doors in the facility were observed.

Inland Valley-1/11/10
Second floor
At 1030 hours, the door to Room 253 was obstructed by a soiled linen container inside the room.

At 1034 hours, the door to Room 267 was obstructed by a trash container inside the room.

Rancho Springs- 1/12/10
At 1515 hours, the self-closing device on the emergency department changing room door was obstructed from automatic closing by an electrical cord for a Computer on Wheels (COW), which was plugged into an electrical outlet inside the room.


21026

Inland Valley - 1/11/10
First floor
At 1325 hours, 1405 hours and 1445 hours, the self-closing door to the ICU waiting room was observed. The door was obstructed from closing by a trash can. During and interview, at 1325 hours, staff removed the trash can. Staff E101 reported visitors for ICU patients prop the door open because the room is small.
At 1405 hours and 1445 hours, the self-closing door to the ICU waiting room was obstructed by the trash can.

Based on observation, the hospital failed to ensure that smoke barrier walls maintain a 1/2 hour fire resistance rating and are constructed in accordance with 8.3. This was evidenced by smoke barrier walls that had unsealed penetrations around pipes or wires.
This affected 4 of 13 smoke compartments at Inland Valley and 3 of 3 smoke compartments in the emergency department (ED) area at Rancho Springs. This could result in the spread of smoke from one compartment to another and in a delay in evacuation to a safe area, in the event of a fire.

8.3.2 - Continuity. Smoke barriers required by this Code shall be continuous from an outside wall to an outside wall, from floor to a floor, or from a smoke barrier to a smoke barrier or a combination thereof. Such barriers shall be continuous throughout all concealed spaces, such as those found above a ceiling, including interstitial spaces.

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 with facility staff from 1/11/10 - 1/13/10, the smoke barrier walls were observed in the main hospital and at the Inland Valley campus.

Inland Valley, First floor - 1/11/10
At 1025 hours, there was an approximately 3 inch penetration around a 1/2 inch cable, inside of a pipe sleeve, in the ceiling of the C hallway telephone closet.
At 1128 hours, there was an approximately 1/4 - 1/2 inch penetration around cables and a pipe sleeve above the door in the smoke barrier wall at the lab.

Rancho Springs - 1/12/10
At 1600 hours, there was an approximately 5/8 inch penetration inside a pipe sleeve in the smoke barrier wall at the entrance to the ED. There was an approximately 1 inch penetration around a grey wire and an approximately 2 x 1 3/4 inch penetration around a wire in the same smoke barrier wall.


18995

Inland Valley - 1/11/10
First floor
At 1131 hours, there were three approximately 1/4 to 1/2 inch penetrations above a copper pipe, through the smoke barrier wall above the Manager of Emergency Services office.
At 1147 hours, there was an approximately one inch by two inch penetration around a sprinkler pipe through the smoke barrier wall above Room 138.

Second floor
At 1053 hours, there was an approximately 1/2 inch penetration around a six inch water pipe in the smoke barrier wall at the 2 West telemetry room.

Rancho Springs - 1/12/10
At 1550 hours, there were two penetrations in the smoke barrier wall at the entrance to the radiology corridor. There was an approximately 3 x 3 inch square penetration around two blue wires and an approximately 1/4 - 1/2 inch penetration around an orange flexible conduit. The smoke barrier separates the emergency department suite from the radiology department.

Based on observation and interview, the hospital failed to maintain hazardous areas with 1 hour rated construction and failed to ensure hazardous areas are separated from other spaces by smoke resisting partitions and self closing doors. This was evidenced by one hazardous area with penetrations and two hazardous areas with doors that failed to self close and latch. This affected two of 13 smoke compartments at Inland Valley and one smoke compartment at the Wound Care Center. This could result in the spread of fire from a hazardous area to other areas of the hospital or could result in fire in an unprotected area.

7.2.1.8.1
A door normally required to be kept closed shall not be secured in the open position at any time and shall be self-closing or automatic-closing in accordance with 7.2.1.8.2.

Findings:

During the hospital tour with staff on 1/11/10 and 1/13/10, hazardous areas were observed at Inland Valley and at the Wound Care Center.
Inland Valley - 1/11/10
At 1330 hours, there were two approximately 1/8 inch penetrations in the ICU soiled linen room.
At 1433 hours, the kitchen dry storage room was equipped with a self-closing device. The door was obstructed from closing by a coat rack.

The room is greater than 50 square feet in size and contained cardboard boxes and paper packages of food and supplies. The door is required to self close and latch.

Wound Care Center - 1/13/10
At 1645 hours, the changing room at the Wound Care Center was observed. There was an approximately 60 gallon container for soiled linen stored in the room. The container was filled past the top. The gowns in the container were worn in the hyperbaric chamber. The door was not equipped with a self-closing device.

During an interview at 1648 hours, Staff E104 reported that the linen cart was kept in the changing room during the day and was picked up at night.

Soiled linen and trash receptacles greater than 32 gallons in size, when not attended, shall be located in a room protected as a hazardous area. Hazardous areas are required to have self-closing doors.

Based on observation and interview, the hospital failed to maintain the exit access so that exits were readily accessible at all times. This was evidenced by two of two exit corridors that were not fully accessible from the Emergency Department (ED). This could result in a delay in exiting the hospital from the ED in the event of a fire or other emergency affecting 19 ED patients, radiological patients, visitors and staff.

Findings:

During the hospital tour with facility engineering staff from 1/11/10 to 1/14/10, the exit corridors were observed.

Rancho Springs - 1/12/10

1. At 1516 hours, there were six hospital beds lined up along the right side of the corridor from the ED towards the Radiology Department. The corridor was approximately eight feet wide. The hospital gurneys are approximately 32 inches wide. Hospital beds are approximately 39 inches wide. Chairs are approximately 18 inches wide. There was a tri-fold privacy screen, a bedside table, a chair, and a metal table on the right side of the corridor between Bed #15 and Bed #16. At 1517 hours, there was a chair, two blood pressure machines, and a bedside table on the right side of the corridor near Bed #17. At 1519 hours, there were two blood pressure machines, and two chairs on the right side of the corridor near Radiology Room 2. These items combined to obstruct the exit access width to less than four feet.

2. At 1517 hours, there were three hospital beds, three blood pressure machines, two chairs and a tri-fold privacy screen along the left side of the exit corridor from the radiology department towards the East courtyard corridor. The corridor was approximately eight feet wide. The hospital beds were approximately thirty nine inches wide. Gurneys are approximately 32 inches wide. Chairs are approximately 18 inches wide. These items combined to obstruct the exit access width to less than four feet.

3. At 1529 hours, there was a blood draw station with a chair, a chair, a table, and two biohazard containers on the right side of the corridor to the right of the X-ray Room and Bed # 13. The furniture was just outside of the smoke barrier doors protecting the ED. The doorway width was obstructed approximately 34 inches.

4. In an interview at 1533 hours, Staff E15 stated that the hospital maintains eight beds or gurneys in the corridor even if they are not in use or needed.

At 1516 hours, the numbers 13 through 18 were painted on the corridor wall from the Emergency Department towards the Radiology Department. The numbers 11 and 12 were painted on the corridor wall from the Emergency Department towards the East courtyard corridor.
In an interview at 1530 hours, Staff AS8 stated that the numbers had been painted on the walls for approximately fifteen years. Staff AS8 indicated the hospital has used the corridor as an overflow area for the ED on a on-going basis.

In an interview with hospital staff E16 at 1553 hours, staff stated that the beds in the corridor are typically occupied 100 percent of the time during the shift from 7 a.m. to 7 p.m.



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5. At 1525 hours, a computer on wheels (COW) was located in the ambulance entry way into the ED. An Atlas heat pump was located on left wall. The heat pump extended 32 inches into the exit access. There was a chair against the right wall of the ambulance entry. These items partially obstructed the exit access out of the ED into the ambulance entry/exit.

During interviews on 1/12/10, hospital staff were asked about fire drill procedures.

At 1545 hours, Staff E17 reported the corridor was usually congested with beds, chairs and equipment daily from 1200 to 0300 hours. The blood draw station is always in the corridor. Sometimes the visitor chairs are cleared out but the beds or gurneys remain at all times. In the event of a fire, Staff E17 would evacuate patients through the corridor but would have to work a pathway through the congestion if the patients were on a bed or gurney.

At 1550 hours, Staff M47 reported patients could be evacuated in the corridor going towards the OR (operating room) or out through the courtyard. Staff M47 reported it can take from 5-7 minutes to get a bed or gurney out of radiology and through the corridor.

Based on record review and interview the hospital failed to ensure fire drills are held at least quarterly on each shift and staff are familiar with fire procedures. This was evidenced by missing fire drills on one shift in 4 of 4 quarters at the Wound Center, and by interviews with other hospital staff. This could result in a delayed response to a fire emergency if hospital staff are unfamiliar with the proper fire emergency procedures and the failure to protect residents in the event of a fire.

19.7.1.2 - Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.2.3 All health care occupancy personnel shall be instructed in the use of and response to fire alarms. In addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions:
(1) When the individual who discovers a fire must immediately go to the aid of an endangered person
(2) During a malfunction of the building fire alarm system

Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual fire alarm box and then shall execute immediately their duties as outlined in the fire safety plan.

Findings:

During record review with hospital staff on 1/12/10, 1/13/10 and 1/14/10, the reports for fire drills were reviewed. During fire alarm testing and the observation tour, hospital staff were interviewed regarding responses to a fire.

On 1/12/10 at 1525 hours, during an interview, a financial staff person in the ED was asked what they would do in a fire. They were unable to remember the actions required using RACE, (rescue, alarm, contain and extinguish or evacuate). The RACE procedure is provided on the back of the card attached to the staff ID badge.

At 1550, during an interview, Staff M47 was asked about fire drill procedures. Staff reported when a fire alarm is activated staff respond with fire extinguishers as if there is a fire. Then there is a 10-15 minute in-service of what to do in the event of a fire. Staff reported there was no actual drill where staff activate the alarm and evacuate the corridors or plan how to move patients in the radiology corridor.

During an interview at 1612 hours, Staff E6 did not know where the closest pull station was located. The pull station was approximately 10 feet away obstructed by a computer on wheels.

On 1/13/10, fire drill reports were requested for the Wound Care Center. Staff E101 indicated a fire drill had been conducted and the hospital would provide a copy of the drill.

During interviews on 1/14/10, Wound Care Center staff were interviewed about fire drill procedures.

At 0810 hours, Staff E104 reported there had been no fire drills that staff remembered since 2004. Staff E104 reported that many patients in the Wound Care Center are not ambulatory. Staff reported that during a previous incident, when the elevator was disabled, paramedics were called to evacuate the patients.

Staff E101 stated four staff are available on site, to evacuate five or six patients in an emergency. The Center is located on the bottom floor of a three story building. The evacuation route requires non-ambulatory patients to be carried up two flights of stairs to the ground level. A backboard is the only equipment available on site to transport the patients.

At 0817 hours, Staff E103 reported remembering the last fire drill was 2-3 years ago. Staff E103 stated evacuation time with potential patient injury, due to the speed of decompression, would be 1 1/2 minutes. During that time staff would have to stay with the decompressing patient and would not be available to assist with other patient evacuations.

During an interview at 0830 hours, Staff E21 reported remembering a fire drill approximately 8 months ago. No other staff confirmed a fire drill during that time.

Staff E101 indicated no fire drill records could be located. No records were provided by the hospital indicating fire drills or evacuation drills were held in the Wound Care Center.

Based on observation and interview, the hospital failed to ensure the fire alarm system is in accordance with NFPA 101 and NFPA 72. This was evidenced by no fire alarm system devices or smoke detection devices in required areas in the Wound Care Center. This affected the entire facility, and could result in a delay in notification, or a delay in evacuation, in the event of a fire or other emergency.

NFPA 101, 2000 edition
21.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

39.3.4.3 Occupant Notification
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions.
(a) It shall activate a general alarm in accordance with 9.6.3 throughout the building.
(b) It shall activate an alarm signal in a continuously attended location for the purpose of initiating emergency action by personnel trained to respond to emergencies. Emergency action shall be initiated by means of live voice public address system announcements originating from the attended location where the alarm signal is received. The system shall be permitted to be used for other announcements, provided that the fire alarm use takes precedence over any other use.
Exception: Any other occupant notification means permitted by 9.6.3 shall be permitted in lieu of live voice public address system announcements.

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

Findings:

On a hospital tour and record review with engineering staff from 1/11/10 to 1/15/10, the fire alarm system was observed, and records for maintenance and testing of the fire alarm system were requested.

Wound Care Center - 1/14/10
During the tour at 0815 hours, there were no smoke detectors located in the Wound Care Center. There was no pull station located in the building. There were two smoke detectors located on the first floor around the pharmacy. There were no annunciation devices located inside the Wound Care Center or the building it occupies. There was no notification device in any area that would notify occupants of a fire.

During an interview at 0815 hours, Staff E21 confirmed there were no fire alarm pull stations inside the Wound Care Center or on the first floor of the building. Staff stated there are no annunciators located within the building.


18995

Wound Care Center- 1/15/10
At 1153 hours, there was no smoke detector observed in the closet where the fire alarm control panel was located. The closet was located in the building corridor, opposite the entrance doors to the Wound Care Center.

Based on observation, record review and interview, the hospital failed to ensure inspection, maintenance and testing of the fire alarm system in accordance with NFPA 72 and NFPA 101. This was evidenced by fire alarm pull stations that were obstructed from use in the emergency department (ED), and by no audible alarm to notify occupants, no smoke detector at the fire alarm panel, and no records of monthly activation of the fire sprinkler alarm system, in the Wound Care Center. This affected two of twenty six fire alarm pull stations in the main hospital building and the entire Wound Care Center. This could result in a delay in activation of the fire alarm system in the event of a fire, and in a delay in notification and evacuation of the patients in the ED and the Wound Care Center.

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

2-8.2.1 Location and Spacing
Manual fire alarm boxes shall be located throughout the protected area so that they are unobstructed and accessible.

7-2.2 Testing Methods
16. Supervising Station Fire Alarm Systems- Transmission Equipment
a. All Equipment
Tests shall be performed on all system functions and features in accordance with the equipment manufacturer's instructions for correct operation in conformance with the applicable sections of Chapter 5.

Initiating devices shall be actuated. Receipt of the correct initiating device signal at the supervising station within 90 seconds shall be verified. Upon completion of the test, the system shall be restored to its functional operating condition.

Table 7-3.2 Testing Frequencies
Component Frequency
23. Supervising Station Fire Alarm Systems
Receivers Monthly

NFPA 101, 21.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

Findings:

During the hospital tour with staff, on 1/12/10, the emergency department was observed.

Rancho Springs - 1/12/10
1. At 1525 hours, there was a computer on wheels (COW) completely obstructing the pull station at the ambulance entrance to the ED.

At 1610 hours, during an interview, Staff E6 was asked what the procedure was in the event of a fire. Staff E6 stated they were trained to call for help. Staff E6 was asked where the closest fire alarm, pull station was located. Staff was unable to locate the pull station which was completely obstructed by the COW.

Wound Care Center - 1/14/10
2. During the tour at 0815 hours, there were no smoke detectors located in the Wound Care Center. There was no pull station located in the building. There were two smoke detectors located on the first floor around the pharmacy. There were no annunciation devices located inside the Wound Care Center or the building it occupies. There was no notification device in any area that would notify occupants of a fire.

During an interview at 0815 hours, Staff E21 confirmed there were no fire alarm devices inside the Wound Care Center or on the first floor of the building.

During the tour at Wound Care Center, on 1/15/10, the sprinkler alarm system was observed and tested.

During an interview on 1/15/10, at 1105 hours, E104 reported there had never been any audible alarms during sprinkler testing and inspection, by an outside vendor.

During a phone interview at 1205 hours, building management staff reported they are notified, by the monitoring company, in the event of activation of a sprinkler alarm. They were asked what would happen after they were notified and if they would notify anyone. Staff stated they would ensure notification of the fire department. The monitoring company is required to notify the fire department initially after receiving the signal that a sprinkler has been activated, before notifying the building management company. After prompting, the building management staff stated they would get a list of tenants and notify them of the possible fire. There was no procedure to ensure tenants of the building would be notified in the event of a fire.



18995

Rancho Springs - 1/12/10
1. At 1612 hours, the COW was obstructing the fire alarm device located to the left of the ambulance entrance to the ED.

In an interview with hospital staff E31 at 1613 hours, staff stated that the COW and chair had been in that location since early December, 2009.

At 1619 hours, there were two hospital beds obstructing the fire alarm pull station located in the radiology corridor between Radiology Room 3 and the Control room.

During the hospital tour at Southwest Healthcare System Wound Care Center, on 1/15/10, the sprinkler alarm system was observed and tested.

2. At 1153 hours, there was no smoke detector provided in the closet where the fire alarm control panel was located.

At 1203 hours, the Inspector's Test Valve (ITV) was tested. There was no audible alarm at the fire alarm control panel, located in the corridor outside the entrance to the Wound Care Center. In an interview with Staff E104, staff stated that they did not hear the alarm from inside the suite during testing.

During record review at 1215 hours, there were no complete records of testing and maintenance of the fire alarm system provided for the Wound Care Center. The record "Inspection and Testing Form" dated 11/2/09 was for an annual test of the fire alarm system. No records of monthly testing of the fire alarm system or quarterly sprinkler testing were provided.

Based on observation, interview and record review, the hospital failed to maintain the integrity of the automatic sprinkler system in accordance with NFPA 13 and NFPA 25. This was evidenced by no records for quarterly inspection and testing of the automatic sprinkler system at the Wound Care Center, for three of four quarters, and by obstructions under the sprinkler heads in one of 13 smoke compartments at Inland Valley and one of 11 smoke compartments at Rancho Springs. This could result in a failure of the sprinkler system or obstruction of the sprinkler spray pattern in the event of a fire.

Findings:

During the hospital tour and record review with engineering staff, from 1/11/10 to 1/15/10, the automatic sprinkler system was observed and records for maintenance and testing of the automatic sprinkler system devices were requested.

Inland Valley-1/11/10
First Floor
At 1121 hours, there was storage within approximately ten inches of the sprinkler head in the storage closet to the left of Room 12.

Rancho Springs - 1/12/10
At 1508 hours, there was computer equipment on a shelf approximately 10 inch below the sprinkler deflector, in the data closet outside of the ED waiting room.


18995

Wound Center-1/14/10
At 0750 hours, there were no records of quarterly testing of the automatic sprinkler system provided for review. The record "Inspection and Testing Form" dated 11/2/09 stated an annual inspection of the sprinkler system had been conducted.

In an interview with Staff E101 at 0755 hours, staff stated that the quarterly sprinkler testing had not been conducted during the first, second and third quarters of 2009.

Wound Center- 1/15/10

At 1203 hours, the Inspector's Test Valve (ITV) was tested. There was no audible alarm at the fire alarm control panel, located in the corridor outside the entrance to the Wound Center suite. In an interview with staff E104, staff stated that they did not hear the alarm from inside the suite during the testing.

Based on observation, the hospital failed to maintain the portable fire extinguishers in the facility in accordance with NFPA 10. This was evidenced by portable fire extinguishers that were stored unsecured, fire extinguisher cabinets that were obstructed, and by a fire extinguisher that was missing monthly checks. This affected one of thirteen smoke compartments at Inland Valley, one of eleven smoke compartments at Rancho Springs, and one of one smoke compartments in the Lab. This could result in a delay in extinguishing a fire.

NFPA 10, 1998 edition
1-6.7 Portable fire extinguishers other than wheeled types shall be securely installed on the hanger or in the bracket supplied or placed in cabinets or wall recesses. The hanger or bracket shall be securely and properly anchored to the mounting surface in accordance with the manufacturers's instructions.

4-3.1* Frequency. Fire extinguishers shall be inspected when initially placed in service and thereafter at approximately 30-day intervals. Fire extinguishers shall be inspected at more frequent intervals when circumstances require.

4-3.2* Procedures. Periodic inspection of fire extinguishers shall include a check of at least the following items:
(a) Location in designated place
(b) No obstruction to access or visibility
(c) Operating instructions on nameplate legible and facing outward
(d) *Safety seals and tamper indicators not broken or missing
(e) Fullness determined by weighing or "hefting"
(f) Examination for obvious physical damage, corrosion, leakage, or clogged nozzle
(g) Pressure gauge reading or indicator in the operable range or position
(h) Condition of tires, wheels, carriage, hose, and nozzle checked (for wheeled units)
(i) HMIS label in place

Findings:

On a hospital tour with engineering staff from 1/11/10 to 1/15/10, the portable fire extinguishers in the facility were observed.

Inland Valley 1/11/10
At 1541 hours, there were nine portable fire extinguishers stored unsecured on the floor in the plant operations shop.

Rancho Springs-1/12/10
At 1454 hours, the portable fire extinguisher cabinet in the Operating Room sterile corridor was obstructed by a clothing rack.

Administration Building- Lab- 1/14/10
At 1456 hours, the portable fire extinguisher cabinet was obstructed by a lab machine.

At 1457 hours, the portable fire extinguisher was missing the monthly inspection checks from October, 2009 to January, 2010. The certification tag was dated 9/11/09.

Based on observation, the hospital failed to maintain the integrity of the building service equipment by permitting the use of a portable space heating device. This was evidenced by a portable space heating device observed in the entryway into the emergency room. This affected one of eleven smoke compartments, and could result in an increased risk of fire.

Findings:

On a hospital tour with engineering staff on 1/12/15, the hospital patient and treatment rooms were observed at Rancho Springs.

At 1134 hours, there was a portable space heating device observed on one side of the ambulance entrance to the emergency department. The Atlas heater was connected to the wall outlet and vented into the open area above the ceiling tiles.

Based on observation and interview, the facility failed to maintain means of egress continuously free of all obstructions or impediments to full instant use in the case of a fire or other emergency. This was evidenced by chairs and tables placed in two of six exit corridors. This failure could lead to an obstruction of the corridor and the exit path during a fire or other emergency, resulting in harm to patients who would be delayed in exiting. This affected two of five smoke compartments.

Findings:

On a hospital tour with hospital engineering staff from 1/11/10 to 1/13/10, the exit corridors were observed.

Inland Valley- 1/11/10
At 1114, 1505 and at 1610 hours, there were four wheelchairs stored in the temporary exit path outside the ambulance entrance to the emergency department. The exit path was six feet wide.

Rancho Springs - 1/12/10
At 1153 hours, there were ten chairs, one round table and one square table in the east corridor across from the emergency department.
At 1154 hours, there were five chairs in the corridor outside of labor and delivery.


21026

Rancho Springs - 1/12/10
At 0935, 1245, and 1505 hours, there were 9 chairs and two tables in the corridor outside of nuclear medicine, across from the emergency department.

At 0935, 1245, and 1505 hours, there were two chairs in the corridor across from the clinical lab. There were five chairs in the corridor across from labor and delivery (L&D).

During an interview at 1506 hours, Staff M46 reported the areas with chairs were used as waiting rooms.

Rancho Springs - 1/13/10
At 0953 hours, there were 20 chairs and two tables in the labor and delivery exit corridor, opposite the corridor entrance to the emergency department (ED).

At 0953 hours there were four chairs in the corridor across from the clinical lab. There were three chairs in the corridor across from labor and delivery.

During an interview at 0955 hours, Staff M46 reported some chairs had been moved into the corridor to make more space in the new triage area.
At 1004 hours, a triage area was observed in the ED waiting room. By using the waiting room as a triage area the patient waiting room seating for the emergency department was reduced.

Based on observation, the hospital failed to maintain the integrity of the storage of medical gas in accordance with NFPA 99. This was evidenced by failing to secure two "E" type oxygen cylinders. This affected two of thirteen smoke compartments, and could result in an increased risk or acceleration of a fire.

NFPA 99
4-3.1.1.1 Cylinder and Container Management.
Cylinders in service and in storage shall be individually secured and located to prevent falling or being knocked over.

4-3.1.1.2 Storage Requirements (Location, Construction, Arrangement).
3. Provisions shall be made for racks or fastenings to protect cylinders from accidental damage or dislocations.

Findings:

On a hospital tour with engineering staff on 1/11/10, the oxygen cylinders were observed at Inland Valley.

At 1033 hours, there was one "E" type oxygen cylinder stored in a wheeled cart inside Room 259. The corridor door could not be pulled closed from the corridor without striking the wheeled cart.

At 1542 hours, there was an "E" type oxygen cylinder stored unsecured on the floor in the plant operations shop.

Based on observation, record review and interview, the hospital failed to maintain the integrity of the hyperbaric facility in accordance with NFPA 99 and NFPA 101. This was evidenced by failing to maintain the building construction and the occupancy separation walls, by failing to ensure fire alarm notification, by failing to provide smoke detection devices in required areas, by failing to conduct fire evacuation drills, and by failing to maintain the integrity of the electrical wiring and connections. This could result in an increased risk of fire, delay in notification, delay in evacuation, and possible patient injury or death, in the event of a fire or other emergency.

NFPA 99, 1999 edition
19-3.1.4.6 Fire training drills shall be carried out at regular intervals.

NFPA 101, 2000 edition
21.3.4.3 Occupant Notification
Occupant notification shall be accomplished automatically, without delay, upon operation of any fire alarm activating device by means of an internal audible alarm in accordance with 9.6.3.

39.3.2.2 High Hazard contents areas, as classified in Section 6.2, shall meet the following criteria:
(1) The area shall be separated from other parts of the building by fire barriers having a fire resistance rating of not less than 1 hour, with all openings therein protected by 3/4-hour fire protection-rated self-closing doors.
(2) The area shall be protected by an automatic extinguishing system in accordance with Section 9.7

39.3.4.3 Occupant Notification
During all times that the building is occupied (see 7.2.1.1.3), the required fire alarm system, once initiated, shall perform one of the following functions.
(a) It shall activate a general alarm in accordance with 9.6.3 throughout the building.
(b) It shall activate an alarm signal in a continuously attended location for the purpose of initiating emergency action by personnel trained to respond to emergencies. Emergency action shall be initiated by means of live voice public address system announcements originating from the attended location where the alarm signal is received. The system shall be permitted to be used for other announcements, provided that the fire alarm use takes precedence over any other use.
Exception: Any other occupant notification means permitted by 9.6.3 shall be permitted in lieu of live voice public address system announcements.

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

Findings:

On a hospital tour with engineering staff from 1/11/10 to 1/15/10, the hyperbaric facility was observed, and records for maintenance and testing of the fire alarm system were requested.

During the tour of the Wound Care Center, the hyperbaric chamber room corridor wall was observed from both sides.

1-13/10
At 1640 hours, there was an approximately 2 x 1 inch penetration around two grey wires, above Door 1, to the hyperbaric room. There was an approximately 1/2 x 1/2 inch penetration around a flex conduit and a copper pipe and an approximately 3/4 inch round penetration above the door. The penetrations were observed from the corridor outside of the hyperbaric room.

At 1645 hours, there were two approximately 5 inch by 6 inch penetrations around two oxygen pipes, observed in the corridor wall outside the hyperbaric room. The penetrations were located on the wall opposite the changing room and Door 1 to the hyperbaric room.

At 1646 hours, there was an approximately 12 inch by 12 inch penetration and an approximately 9 inch by 11 inch penetration observed in the corridor wall from inside the hyperbaric room. The penetrations were located around two oxygen pipes.

At 1650 hours, there were two approximately 1/4 inch penetrations in the back wall of the exterior oxygen storage closet. There was an approximately 1 by 2 inch penetration around a copper pipe and an approximately 1/8 inch penetration along one side of the sprinkler pipe, around two wires, in the back wall.

1/14/10
At 0841 hours, there was an approximately 4 1/2 inch penetration around a one inch copper pipe and an approximately 1 1/2 inch by 3 1/4 inch penetration around wires on one side of a copper pipe. There was an approximately 1/4 - 1/2 inch penetration around a 2 inch copper pipe, in the left wall of the office adjacent to the hyperbaric room. The penetrations were observed in the walls above the ceiling tiles.

At 0843 hours, there were two approximately three inch penetrations around two flexible conduits in the back wall, above the ceiling, in the employee break room. There was an approximately 2 inch penetration around a copper pipe and an approximately 2 1/2 inch by 5 inch penetration around a four inch pipe in the same back wall. There was an approximately two inch by four inch penetration around a pipe in the left wall of the break room. The penetrations were observed in the walls above the ceiling tiles.

During an interview at 0846 hours, Staff E101 reported no one had inspected the corridor walls of the hyperbaric room after installation of the two new chambers in 3/09.

During interviews on 1/14/10, Wound Care Center staff were interviewed about fire drill procedures. Specifications were requested for the hyperbaric chamber room.

At 0810 hours, Staff E104 reported there had been no fire drills that staff remembered since 2004.
Staff E101 stated four staff work in the Center and are available to evacuate patients in an emergency. Staff reported there are usually five to six patients in the facility at one time. The Center is located on the bottom floor of a three story building. The evacuation route requires non-ambulatory patients to be carried up two flights of stairs to the ground level. A backboard is the only equipment available on site to transport the patients.

At 0817 hours, Staff E103 reported remembering the last fire drill was 2-3 years ago. Staff E103 stated evacuation time with potential patient injury, due to the speed of decompression, would be 1 1/2 minutes. During that time staff would have to stay with the decompressing patient and would not be available to assist with other patient evacuations. Staff stated that the safe patient evacuation time was approximately four to five minutes.

During an interview at 0830 hours, Staff E21 reported remembering a fire drill approximately 8 months ago. No other staff confirmed a fire drill during that time.

Staff E101 indicated no fire drill records were available. No records were provided by the hospital indicating fire drills or evacuation drills were held in the Wound Care Center.

At 0845 hours, during an interview, Staff AS8 was asked about the mock surveys conducted in the hospital. Staff AS8 reported the hospital had conducted mock surveys to ensure compliance with federal regulations at both campuses but the Wound Care Center was not included. The hospital was unaware that the federal regulations applied to the Wound Care Center.

At 0930 hours, Staff E101 reported there has not been any inspection and maintenance at the Wound Care Center because they don't own the building.

1/15/10
During sprinkler alarm testing the monitoring company and building management company were contacted to ensure the alarm signal is received and to determine what actions are taken after alarm notification.

At 1205 hours, staff (BMC1) from the building management company was interviewed. BMC1 reported the monitoring company notifies them by cell phone in the event the sprinkler alarm is activated.
They were asked what would happen after they were notified and if they would notify anyone. Staff stated they would ensure notification of the fire department. After prompting, the building management staff stated they would get a list of tenants and notify them of the possible fire.

The monitoring company is required to notify the fire department initially after receiving the signal that a sprinkler has been activated, before notifying the building management company. There was no procedure to ensure tenants of the building would be notified in the event of a fire.


18995

Wound Center-1/14/10
During sprinkler testing, record review and interview, the ITV (Inspector's Test Valve) was tested and specifications for the hyperbaric chambers were provided.

At 0904 hours, the manufacturer's specifications, page 2-2, number 1, for two hyperbaric chambers recommended that the minimum measurements for the room be 16 feet wide, and 21 feet long. The hyperbaric room was approximately nine feet wide and approximately 38 feet long.

The manufacturer's specifications, page 2-2, number 11, indicated "All electrical equipment in the treatment facility must be properly grounded and in optimum working condition.

At 0909 hours, there was a DVD player connected to the wall outlet near each hyperbaric chamber. The DVD players were not grounded.
At 0911 hours there was a surgical clipper that was not grounded, plugged into an outlet on the wall behind a wooden cabinet.

1/15/10
During the facility tour, the fire sprinkler alarm system was observed.

At 1153 hours, there was no smoke detector observed in the closet where the fire alarm control panel was located. The closet was located in the building corridor, opposite the entrance doors to the Wound Care Center.

At 1203 hours, the ITV was tested. There was no audible alarm at the fire alarm control panel, located in the corridor outside the entrance to the Wound Care Center. In an interview with Staff E104, staff stated that they did not hear the alarm from inside the suite during the testing.

At 1215 hours, there were no complete records of testing and maintenance of the fire alarm system provided for review. The record "Inspection and Testing Form" dated 11/2/09 was for an annual test of the fire alarm system. No records of monthly testing of the fire alarm system, confirmed to the central station, were provided for review.

Based on record review and interview, This affected the entire campus at Inland Valley and could result in a potential generator failure during a power outage.

NFPA 110 1999 edition
6-4.1* Level 1 and Level 2 EPSSs, including all appurtenant components, shall be inspected weekly and shall be exercised under load at least monthly.

Findings:

During record review and interview with facility staff on 1/12/10, the generator records were requested for Inland Valley and Rancho Springs. The generator logs documented the generator was tested under load for 30 minutes every month. There were no records for weekly inspections since August 2009 for Inland Valley.

During an interview, E101 reported he thought the weekly inspections were no longer required.

Based on observation, record review and interview, the hospital failed to ensure that electrical wiring and equipment are maintained in accordance with NFPA 70 and NFPA 99. This was evidenced by failing to provide complete records of testing electrical receptacles and failing to maintain the integrity of the electrical wiring and connections. This affected two of 13 smoke compartments at Inland Valley, two of eleven smoke compartments at Rancho Springs, and two of two smoke compartments in the Wound Care Center. This could result in an increased risk of an electrical fire.

NFPA 99 1999 Edition
Electrical Systems
3-3.2.1.2 All Patient Areas
(d) Receptacles. 3. Polarity of Receptacles. Each receptacle shall be wired in accordance with NFPA 70, National Electrical Code, to ensure correct polarity.

3-3.3.3 Receptacle Testing in Patient Care Areas.
(a) The physical integrity of each receptacle shall be confirmed by visual inspection.
(b) The continuity of the grounding circuit in each electrical receptacle shall be verified.
(c) Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
(d) The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

Section 400-8 Unless specifically permitted in Section 400-7, flexible cord and cables shall not be used for the following:
(1) As a substitute for the 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, dropped ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this Code.

Findings:

On a hospital tour with engineering staff from 1/11/10 to 1/15/10, the electrical outlets and connections were observed, and the records for maintenance and testing were reviewed.

Inland Valley- 1/11/10
At 1114 hours, there was a microwave plugged into a surge protector in the Doctor's lounge.

At 1327 hours, there was a refrigerator and a microwave plugged into a surge protector in the employee lounge in the intensive care unit.

At 1346 hours, there was a refrigerator and a microwave plugged into a surge protector in the patient nourishment room in the Operating Room (OR) area.

Rancho Springs- 1/12/10

At 1106 hours, there were incomplete records of receptacle outlet testing provided for review for Inland Valley and Rancho Springs. The record "Annual tension testing" invoice # 5170, dated 9/8/09, did not include a complete record for the testing conducted. There was no complete list of the outlet locations and results of the testing for each outlet.

In an interview with Staff M46, staff stated that they did not have any additional records of electrical outlet testing and maintenance. There was no record for semi annual testing of the receptacles in wet locations.

At 1502 hours, there was an uncovered square electrical box with red wires exposed, in the attic above the smoke barrier doors between the OR and labor and delivery.

At 1514 hours, there was a Computer on Wheels (COW) in the corridor outside the OR changing room. The COW was plugged into an electrical outlet inside the OR changing room. The cord passed through the doorway, on the floor to connect to the outlet.

1/13/10
At 1149 hours, the light switch was missing the cover plate, on the left wall inside the materials management room.
At 1210 hours, there was a microwave plugged into a surge protector inside the employee lounge.
At 1218 hours, there was an uncovered square electrical box to the right of the west exterior doors in the mechanical room.


21026

Inland Valley - 1/11/10
At 0945 hours, there was a surge protector plugged into a surge protector in the office of the EVS (environmental services) supervisor.
At 0950 hours, there was a refrigerator plugged into a surge protector and a surge protector plugged into a surge protector in the House Supervisor office.
At 1010 hours, the outlet cover plate was missing in the EVS closet, near the lobby. A transformer and wire were connected to the outlet.
At 1135 hours, there was biohazard refrigerator plugged into a surge protector, in the lab next to the blood bank.
During an interview at 1136 hours, Staff E101 reported the surge protector was used to connect the refrigerator to a red outlet.
At 1343 hours, there was an endoscopy lab monitor plugged into a surge protector, plugged into a red outlet.
At 1345 hours, there was a surge protector plugged into a surge protector in the "fast track area" nurses' station.
At 1450 hours, there was a broken outlet cover on the right wall in the outpatient restroom and vending machine area.

Rancho Springs - 1/12/10
At 1210 hours, there was a surge protector plugged into a surge protector in the storage room near the east nurses' station.