HospitalInspections.org

Based on observation, the facility failed to maintain their two hour, fire rated separation wall in one of five buildings. This was evidenced by a penetration in the fire rated separation wall in one area. This failure had the potential to allow the spread of smoke and fire from one occupancy to another.

Findings:

During a tour of the facility with Quality Assurance Staff and Maintenance Staff, on November 27, 2012, the two hour fire wall was observed.

Urgent Care Fontana - November 27, 2012

At 1:45 p.m., there was an approximately five inch penetration in the common wall between the urgent care and the other building tenants. The penetration was located in the wall above the staff lounge, approximately two inches above a conduit. Maintenance Staff observed and confirmed the penetration.

Based on observation, the facility failed to maintain the integrity of their building construction, as evidenced by wall penetrations in the Main Hospital and in the Urgent Care Center. This affected one of six floors of the main hospital (Towers) and the Urgent Care Center, and could result in the spread of smoke and fire to other locations in the facility.

Findings:

During a tour of the facility with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, from November 27, 2012, through November 29, 2012, the building construction was observed.

Urgent Care Center-Highland - November 27, 2012

At 10:40 a.m., there was an approximately five inch round penetration in the one hour fire rated wall in the sprinkler riser room. The penetration was located in the abutting wall at the lower right of the sprinkler riser.


26387

Ancillary - November 29, 2012

At 9:50 a.m., there was an approximately 2 inch by 3 inch penetration in the north wall of the Revenue Out Office in Central Supply.

Surveyor: Leggett, Jerry
Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridor doors with roller latches, by corridor doors that were obstructed from closing, and by corridor doors that failed to latch. This affected five of six floors and could result in the spread of smoke and fire in the event of a fire. This affected 167 patients (census during the survey) and one of two smoke compartments in the Outpatient Surgery Clinic.

Findings:

During a tour of the facility with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, from November 26, 2012 through November 30, 2012, the corridor doors in the facility were observed.

Central Tower - November 26, 2012
1. At 2:46 p.m., the corridor door to Room 501 was impeded from closing by a trash can in front of the door. The trash can was between the frame of the door and the door.

North Tower - November 27, 2012
2. At 8:27 a.m., the west corridor door to the Electrical Room, near Room 678, was equipped with a self closing device. The door did not close and latch when released. The latching mechanism was stuck in the closed position in the latching hardware.

3. At 9:29 a.m., the corridor door to Room 640 did not latch when closed.

4. At 9:34 a.m., the self-closing corridor door to the Supply Room, near Room 636, did not latch when closed.

5. At 9:37 a.m., the self-closing corridor door to Room 636 did not latch when closed.

South Tower - November 27, 2012
6. At 10:06 a.m., the corridor door to Room 601 was impeded from closing by a large box fan, on a stand, in front of the door.

7. At 10:44 a.m., the south corridor door to the Charting Room, near Room 521, did not latch when closed. The latching mechanism was stuck in the latching hardware.

8. At 2:50 p.m., the self-closing corridor door to the Soiled Utility Room, near the Lactation Room on the third floor, did not latch when closed.

Ancillary - November 28, 2012
9. At 2:04 p.m., the corridor door to the holding room in the Operating Room area did not latch when closed. There was a roller latching mechanism on this door.

10. At 2:10 p.m., the front desk corridor door, in the Operating Room area, required two actions to open and unlock the door. The door was equipped with two dead bolt type locks. Both locks had to be unlocked before the door could be opened.

11. At 2:30 p.m., the self-closing corridor to the Operating Room Pharmacy did not latch when closed.

12. At 2:35 p.m., the corridor doors to Operating Rooms 4, 7, 8, and the East and West doors to PACU (Post-Anesthesia Care Unit), did not latch when closed. There was a roller latch mechanism on each of these doors.

13. At 2:46 p.m., the corridor door to the Lounge in the Operating Room area did not latch when closed.

Emergency Room - November 28, 2012
14. At 3:34 p.m., the self-closing corridor door to the Registration Room, in the Emergency Room, did not latch when closed. The latching mechanism was stuck in the closed position, in the latching hardware.

15. At 3:41 p.m., the door to the copy room, in the Emergency Department, was impeded from closing by a brown rubber wedge under the door and by a trash can in the door's path.

Ancillary - November 29, 2012
16. At 9:19 p.m., the East self-closing corridor door, to X-ray Room 3, did not latch when closed. The door was missing the arm to the self- closing device.

17. At 10:18 a.m., the self-closing corridor doors (both) to the main kitchen entrance did not latch when closed.


Surveyor: Bailey, Jeffrey
Out Patient Surgery Clinic - November 26, 2012

18. At 2:30 p.m., the door leading into the surgery center was labeled PACU. The door closed but failed to positive latch when tested.




29751

Based on observation, the facility failed to display exits signs in all egress corridors, as evidenced by no sign displayed at 2 exits. This could delay evacuation on two of six floors in the main hospital, resulting in potential harm to patients in the event of a fire emergency.

Findings:

During a tour of the facility, with the Director of Facility Maintenance and the Service Area Vice President, on November 26, 2012 the exits and exit signs were observed.

Central Tower - November 26, 2012
1. At 3:05 p.m., there was no exit sign displayed in the South exit corridor, from Room 446.

2. At 3:24 p.m., there was no exit sign displayed in the East exit corridor, from the second floor PACU.

Based on observation, the facility failed to maintain its smoke barrier doors to prevent the spread of smoke and fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch. This affected two of six floors in the Towers and one of three floors in the Ancillary Building and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 28, 2012, the smoke barrier doors were observed.

Tower E/W 1990 - November 28, 2012
1. At 9:09 a.m., the East smoke barrier door did not latch when tested, at the main entrance to the 1990 Tower.

Tower N/S 1972
2. At 9:26 a.m., the North smoke barrier door, near the Nursing Station, did not latch when tested.

Ancillary
3. At 2:24 p.m., two smoke barrier doors, near the Operating Room Pharmacy, did not latch when tested.

4. At 3:31 p.m., the North smoke barrier door to the Emergency Room, near the registration room, did not latch when tested.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage, that posed a degree of hazard greater than that normal to the general occupancy, without operational self-closing doors. This deficient practice affected one of six floors within the facility, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 29, 2012, the hazardous areas were observed.

Ancillary - November 29, 2012

At 9:05 a.m., the door to the Radiology Film Library did not close and latch when tested. There was an approximately two foot gap between the door frame and the door. The door dragged on the floor and was obstructed from closing.

During an interview at 9:07 a.m., the X-Ray manager stated that he noticed that the door has not closed and latched for the past 7 days.

Based on observation, document review, and interview, the facility failed to maintain their exit signs. This was evidenced by the failure to document and perform monthly tests on the exit signs equipped with an internal emergency power supply source, by exit signs that were partially illuminated, and by exit signs that failed to illuminate when tested. This affected three of six floors and could result in a delay in evacuation.

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

Findings:

During a tour of the facility with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, from November 26, 2012, through November 29, 2012, the exit signs were observed and testing documents were requested.

Central Tower - November 26, 2012
1. At 2:48 p.m., the exit sign near Room 475 was not fully illuminated. The "E" on the exit sign was not lit.

2. At 2:52 p.m., the exit sign near Room 474 was not fully illuminated. The "I" on the exit sign was not lit.

3. At 2:54 p.m., the exit sign near Room 467 was not fully illuminated. The "IT" on the exit sign was not lit.

4. At 2:57 p.m., the exit sign near Room 459 was not fully illuminated. The "E" on the exit sign was not lit.

5. At 2:58 p.m., the exit sign near Room 456 was not fully illuminated. The "EX" on the exit sign was not lit.

6. At 2:59 p.m., the exit sign near Room 452 was not fully illuminated. The "IT" on the exit sign was not lit.

7. At 3 p.m., the exit sign near Stairwell 8, fourth floor, was not fully illuminated. The "E" on the exit sign was not lit.

8. At 3:07 p.m., the exit sign near Room 338 was not fully illuminated. The "E" on the exit sign was not lit.

Tower N/S - November 27, 2012

9. At 2:01 p.m., the exit sign equipped with an internal battery source did not illuminate when the test button was pressed. The exit sign was near Room 423.

10. At 2:59 p.m., the exit sign, equipped with an internal battery source, did not illuminate when the test button was pressed. The exit sign was in the west side of the Nursing Station near post-partum.

Penthouse - Tower - November 28, 2012
12. At 9 a.m., the East exit sign, equipped with an internal battery source, did not illuminate when the test button was pressed. The exit sign was in the penthouse.

During an interview at 3:15 p.m., Engineering Staff 1A stated that the last two months the signs were visually checked. There was no functional test completed on the exit signs, as required.

During document review, at 3:47 p.m., there was no documentation to indicate the length of time the exit signs were functionally tested and which signs were tested. The exit sign testing document indicated the floor the signs were on. No other information was provided.


29751


November 29, 2012
During document review at 9:30 a.m., the facility failed to provide documentation for monthly 30 second testing of the back up battery powered emergency lights and exits signs for the following locations:
There were no records for testing at the Urgent Care Center- Fontana or the Urgent Care Center - Highland.
There were no records for testing at the Wound Care Center.
There were no records for testing at the Out Patient Surgery/ Rehabilitation.
There were no records for testing at the Heart Care Center.
There were no records for testing at the Towers N/S, E/W.
There were no records for testing at the Ancillary.

During an interview at 9:35 a.m., Maintenance Staff 9a stated that the emergency lights were checked when the generator is tested every month. There was no documentation for annual 90 minute emergency light and exit sign testing.

Based on interview and record review, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by staff members that did not know how to open a locked bathroom door, by a staff person could not locate a fire extinguisher and a manual fire alarm pull station, and by no alarm initiation during one fire drill at the Urgent Care Center in Fontana. This affected two of six floors, and the Urgent Care Center and could result in a delay in staff response during a fire or other emergency.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility and document review with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, on November 27, 2012, and November 29, 2012, staff members were interviewed and fire drill documents were reviewed.

Tower E/W - November 27, 2012
1. At 9:42 a.m., RN staff members 1a through 5a were interviewed and asked to open a locked bathroom door, to evacuate a patient, if a fire was in the far end of the room. Two of five staff could not open the locked door in the event of an emergency. The door can be unlocked with a small key or a small coin.

Tower N/S - November 29, 2012
2. During an interview at 1:06 p.m., Volunteer 1a in the Gift Shop stated that she could not locate a fire extinguisher or a manual fire alarm pull station. The fire extinguisher was approximately 25 feet away and a manual fire alarm pull station was approximately 30 feet away.


29751

Urgent Care Center-Fontana - November 27, 2012
3. At 1:15 p.m., there was no documentation that an initiating device (Fire Alarm device) was activated during the fire drill conducted on September 27, 2012, during the day. During an interview, the facility manager stated they did not activate the alarm system during the drill.

Based on observation, interview, and record review, the facility failed to maintain the integrity of their fire alarm system. This was evidenced by no audible devices in three locations and by alarm devices that failed to activate. This could result in the potential failure to notify the occupants during a fire emergency, or a delay in closing automatic release doors. This affected two of six floors in the building.

NFPA 101 Life Safety Code 2000 Edition
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

Findings:

During fire alarm testing with the Director of Facility Maintenance and the Service Area Vice President, from November 27, 2012, through November 29, 2012, the fire alarm system system was inspected and tested.

Ancillary - November 28, 2012
At 11:59 a.m., the fire alarm system was not audible in the North side of the Clinical Lab and near the System Manager Office (near the Refrigerators). The fire alarm system could not be heard while the alarm was sounding.

At 2:40 p.m., the fire system was not audible in the PACU, near the nursing station, while the doors were closed.

Ancillary - November 29, 2012
At 9:54 a.m., the fire alarm system could not be heard in the Central Supply Storage and Decontamination Rooms while the fire alarm was sounding.

During an interview at 10:07 a.m., Central Supply Staff 7a said that she could not hear the fire alarm system at all, in the area near the machines.

During record review at 10:08 a.m., there was a remark on the fire alarm drill for Central Supply, dated March 29, 2012, that said that the fire alarm system could not be heard in the Central Supply area and the paging system was also hard to hear.

At 11:19 a.m., the emergency release to one won door did not release the door and open it to allow patients to exit.

At 11:20 a.m., the Director of Facility Maintenance reported that the won door appeared to be missing a rivet in the release button.

Based on observation, the facility failed to ensure smoke detectors are installed and maintained according to NFPA 72. This was evidenced by smoke detectors that failed to activate the fire alarm system and by no smoke detectors in one compartment. The smoke detectors could fail and cause a delay in notification, in the event of a fire emergency. This affected two of six floors in the main hospital tower.

Findings:

During a tour of the facility with the Director of Facility Maintenance and Service Area Vice President, on November 28, 2012, the smoke detectors were tested with canned smoke.

Tower E/W - November 28, 2012

1. At 11:01 a.m., the smoke detector 116-106 near Room 338 did not activate the fire alarm system and send a signal to the monitoring staff, when tested with canned smoke. Five attempts were made without activating the fire alarm system.

2. At 11:29 a.m., there were no smoke detectors in the smoke compartment CCU, Side 7. The CCU census was six during the survey.

3. At 3:48 p.m., the smoke detector 201-108-1 in the Fast Track Emergency Room, did not activate the fire alarm system and send a signal to the monitoring staff when tested with canned smoke. Five attempts were made without activating the fire alarm system.

Based on observation, the facility failed to maintain the automatic sprinkler system, as evidenced by no identification label on their automatic sprinkler test valves and by a missing escutcheon ring. This could result in a delay in identifying the Inspector's Test Valve and could allow the spread of heat and smoke around a sprinkler head. This affected six of six floors in the main hospital.

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

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 29, 2012, the sprinkler system components were examined. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly.

Tower N/S and E/W - November 29, 2012

At 9:42 a.m., there were no signs on 6 of 6 inspector test valves in the Towers. There was no way to identify which valves should be used during sprinkler system testing.

At 10:12 a.m., 1 of 8 sprinklers in the Decontamination Room, in Central Supply, was missing an escutcheon ring. The sprinkler was on the north side of the room.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by extinguishers that were not inspected, and by one extinguisher with the gauge in the red. Red indicates that the fire extinguisher needs to be recharged or replaced. This affected two of six floors of the main hospital and could result in the failure of a fire extinguisher or a delay extinguishing a fire.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition),
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.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 28, 2012, and November 29, 2012, the fire extinguishers were examined.

Ancillary - November 28, 2012
1. At 2:51 p.m., the two fire extinguishers in the Medical Library (extinguishers 66 and 66A) were not inspected during the month of October 2012.

2. At 4:12 p.m., the tag for Fire Extinguisher 15 was not signed and inspected for the months of July, August, and September 2012. The extinguisher was in the air handler room, near the Respiratory Care report room.

During an interview at 4:15 p.m., the Security Manager 8a confirmed that these fire extinguishers were not inspected, dated and initialed.

Tower E/W - November 29, 2012
3. At 10:25 a.m., the gauge on the K-class fire extinguisher, in the kitchen, was out of the green zone (safe zone). The gauge arrow was in the red zone, indicating that the fire extinguisher needed to be replaced or recharged.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by appliances and medical equipment plugged into multi-outlet extension cords, by a broken outlet cover, and by two electrical panels that had medical equipment stored in front of the panel doors. This affected two of six floors, and 1 of 5 Out Patient Surgery Clinics. This could increase the risk of an electrical fire and had the potential to delay access to the panel in the event of an emergency.

NFPA 70, National Electrical Code, 1999 edition
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

110-26. Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Findings:

During a tour of the facility, with the Director of Facility Maintenance, the Service Area Vice President, Quality Assurance Staff 1 and Maintenance Staff, on November 26, 2012 and November 29, 2012, the electrical equipment and wiring were observed.

Sixth Floor Tower N/S - November 27, 2012
1. At 9:22 a.m., there was an electrical outlet with more that 50 percent of the cover missing, behind the Omni Cell Machine in the Medication Room.

Tower E/W - November 27, 2012
2. At 2:30 p.m., there was a small refrigerator plugged into a multi-outlet extension cord at the Labor and Delivery Nursing Station.

Ancillary - November 28, 2012
3. At 1:30 p.m., an intravenous pump and a monitor were plugged into a multi-outlet extension cord in Cath Lab 3.


29751

Out Patient Surgery Clinic - November 26, 2012
4. At 2:48 p.m., medical equipment was stored in front of electric panel 2NLB and panel 2ECLD. There was a printed sign in the same area on electrical panel 2EELA that stated that nothing should be placed in front of the Electrical Panels.

Based on observation, the facility failed to maintain their installation of alcohol based hand rub dispensers (ABHR). This was evidenced by the mounting of alcohol based hand rub dispensers over ignition sources. This affected three of six floors, and could result in an alcohol based hand rub ignited fire.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, from November 26, 2012, through November 28, 2012, the alcohol based hand rub dispensers in the facility were observed.

Tower N/S - November 26, 2012
1. At 3:12 p.m., there was an ABHR mounted over an electrical outlet in the north Tower near Room 4 in ICU.

Ancillary - November 26, 2012
2. At 3:42 p.m., there was an ABHR mounted over an electrical outlet in the Emergency Room near Room 9.

Tower E/W - November 27, 2012
3. At 9:08 a.m., there was an ABHR mounted over an electrical switch in the soiled utility room near Room 650.

Ancillary - November 28, 2012
4. At 3:37 p.m., there was an ABHR mounted over an electrical outlet in the Registration Room in the Emergency Room.

Based on observation, the facility failed to maintain their two hour, fire rated separation wall in one of five buildings. This was evidenced by a penetration in the fire rated separation wall in one area. This failure had the potential to allow the spread of smoke and fire from one occupancy to another.

Findings:

During a tour of the facility with Quality Assurance Staff and Maintenance Staff, on November 27, 2012, the two hour fire wall was observed.

Urgent Care Fontana - November 27, 2012

At 1:45 p.m., there was an approximately five inch penetration in the common wall between the urgent care and the other building tenants. The penetration was located in the wall above the staff lounge, approximately two inches above a conduit. Maintenance Staff observed and confirmed the penetration.

Based on observation, the facility failed to maintain the integrity of their building construction, as evidenced by wall penetrations in the Main Hospital and in the Urgent Care Center. This affected one of six floors of the main hospital (Towers) and the Urgent Care Center, and could result in the spread of smoke and fire to other locations in the facility.

Findings:

During a tour of the facility with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, from November 27, 2012, through November 29, 2012, the building construction was observed.

Urgent Care Center-Highland - November 27, 2012

At 10:40 a.m., there was an approximately five inch round penetration in the one hour fire rated wall in the sprinkler riser room. The penetration was located in the abutting wall at the lower right of the sprinkler riser.


26387

Ancillary - November 29, 2012

At 9:50 a.m., there was an approximately 2 inch by 3 inch penetration in the north wall of the Revenue Out Office in Central Supply.

Surveyor: Leggett, Jerry
Based on observation, the facility failed to maintain their corridor doors. This was evidenced by corridor doors with roller latches, by corridor doors that were obstructed from closing, and by corridor doors that failed to latch. This affected five of six floors and could result in the spread of smoke and fire in the event of a fire. This affected 167 patients (census during the survey) and one of two smoke compartments in the Outpatient Surgery Clinic.

Findings:

During a tour of the facility with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, from November 26, 2012 through November 30, 2012, the corridor doors in the facility were observed.

Central Tower - November 26, 2012
1. At 2:46 p.m., the corridor door to Room 501 was impeded from closing by a trash can in front of the door. The trash can was between the frame of the door and the door.

North Tower - November 27, 2012
2. At 8:27 a.m., the west corridor door to the Electrical Room, near Room 678, was equipped with a self closing device. The door did not close and latch when released. The latching mechanism was stuck in the closed position in the latching hardware.

3. At 9:29 a.m., the corridor door to Room 640 did not latch when closed.

4. At 9:34 a.m., the self-closing corridor door to the Supply Room, near Room 636, did not latch when closed.

5. At 9:37 a.m., the self-closing corridor door to Room 636 did not latch when closed.

South Tower - November 27, 2012
6. At 10:06 a.m., the corridor door to Room 601 was impeded from closing by a large box fan, on a stand, in front of the door.

7. At 10:44 a.m., the south corridor door to the Charting Room, near Room 521, did not latch when closed. The latching mechanism was stuck in the latching hardware.

8. At 2:50 p.m., the self-closing corridor door to the Soiled Utility Room, near the Lactation Room on the third floor, did not latch when closed.

Ancillary - November 28, 2012
9. At 2:04 p.m., the corridor door to the holding room in the Operating Room area did not latch when closed. There was a roller latching mechanism on this door.

10. At 2:10 p.m., the front desk corridor door, in the Operating Room area, required two actions to open and unlock the door. The door was equipped with two dead bolt type locks. Both locks had to be unlocked before the door could be opened.

11. At 2:30 p.m., the self-closing corridor to the Operating Room Pharmacy did not latch when closed.

12. At 2:35 p.m., the corridor doors to Operating Rooms 4, 7, 8, and the East and West doors to PACU (Post-Anesthesia Care Unit), did not latch when closed. There was a roller latch mechanism on each of these doors.

13. At 2:46 p.m., the corridor door to the Lounge in the Operating Room area did not latch when closed.

Emergency Room - November 28, 2012
14. At 3:34 p.m., the self-closing corridor door to the Registration Room, in the Emergency Room, did not latch when closed. The latching mechanism was stuck in the closed position, in the latching hardware.

15. At 3:41 p.m., the door to the copy room, in the Emergency Department, was impeded from closing by a brown rubber wedge under the door and by a trash can in the door's path.

Ancillary - November 29, 2012
16. At 9:19 p.m., the East self-closing corridor door, to X-ray Room 3, did not latch when closed. The door was missing the arm to the self- closing device.

17. At 10:18 a.m., the self-closing corridor doors (both) to the main kitchen entrance did not latch when closed.


Surveyor: Bailey, Jeffrey
Out Patient Surgery Clinic - November 26, 2012

18. At 2:30 p.m., the door leading into the surgery center was labeled PACU. The door closed but failed to positive latch when tested.




29751

Based on observation, the facility failed to display exits signs in all egress corridors, as evidenced by no sign displayed at 2 exits. This could delay evacuation on two of six floors in the main hospital, resulting in potential harm to patients in the event of a fire emergency.

Findings:

During a tour of the facility, with the Director of Facility Maintenance and the Service Area Vice President, on November 26, 2012 the exits and exit signs were observed.

Central Tower - November 26, 2012
1. At 3:05 p.m., there was no exit sign displayed in the South exit corridor, from Room 446.

2. At 3:24 p.m., there was no exit sign displayed in the East exit corridor, from the second floor PACU.

Based on observation, the facility failed to maintain its smoke barrier doors to prevent the spread of smoke and fire. This was evidenced by smoke barrier doors that were equipped with latching hardware that failed to latch. This affected two of six floors in the Towers and one of three floors in the Ancillary Building and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 28, 2012, the smoke barrier doors were observed.

Tower E/W 1990 - November 28, 2012
1. At 9:09 a.m., the East smoke barrier door did not latch when tested, at the main entrance to the 1990 Tower.

Tower N/S 1972
2. At 9:26 a.m., the North smoke barrier door, near the Nursing Station, did not latch when tested.

Ancillary
3. At 2:24 p.m., two smoke barrier doors, near the Operating Room Pharmacy, did not latch when tested.

4. At 3:31 p.m., the North smoke barrier door to the Emergency Room, near the registration room, did not latch when tested.

Based on observation and interview, the facility failed to protect its hazardous area enclosures. This was evidenced by rooms which contained combustible storage, that posed a degree of hazard greater than that normal to the general occupancy, without operational self-closing doors. This deficient practice affected one of six floors within the facility, and could result in the spread of smoke and fire.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 29, 2012, the hazardous areas were observed.

Ancillary - November 29, 2012

At 9:05 a.m., the door to the Radiology Film Library did not close and latch when tested. There was an approximately two foot gap between the door frame and the door. The door dragged on the floor and was obstructed from closing.

During an interview at 9:07 a.m., the X-Ray manager stated that he noticed that the door has not closed and latched for the past 7 days.

Based on observation, document review, and interview, the facility failed to maintain their exit signs. This was evidenced by the failure to document and perform monthly tests on the exit signs equipped with an internal emergency power supply source, by exit signs that were partially illuminated, and by exit signs that failed to illuminate when tested. This affected three of six floors and could result in a delay in evacuation.

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

Findings:

During a tour of the facility with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, from November 26, 2012, through November 29, 2012, the exit signs were observed and testing documents were requested.

Central Tower - November 26, 2012
1. At 2:48 p.m., the exit sign near Room 475 was not fully illuminated. The "E" on the exit sign was not lit.

2. At 2:52 p.m., the exit sign near Room 474 was not fully illuminated. The "I" on the exit sign was not lit.

3. At 2:54 p.m., the exit sign near Room 467 was not fully illuminated. The "IT" on the exit sign was not lit.

4. At 2:57 p.m., the exit sign near Room 459 was not fully illuminated. The "E" on the exit sign was not lit.

5. At 2:58 p.m., the exit sign near Room 456 was not fully illuminated. The "EX" on the exit sign was not lit.

6. At 2:59 p.m., the exit sign near Room 452 was not fully illuminated. The "IT" on the exit sign was not lit.

7. At 3 p.m., the exit sign near Stairwell 8, fourth floor, was not fully illuminated. The "E" on the exit sign was not lit.

8. At 3:07 p.m., the exit sign near Room 338 was not fully illuminated. The "E" on the exit sign was not lit.

Tower N/S - November 27, 2012

9. At 2:01 p.m., the exit sign equipped with an internal battery source did not illuminate when the test button was pressed. The exit sign was near Room 423.

10. At 2:59 p.m., the exit sign, equipped with an internal battery source, did not illuminate when the test button was pressed. The exit sign was in the west side of the Nursing Station near post-partum.

Penthouse - Tower - November 28, 2012
12. At 9 a.m., the East exit sign, equipped with an internal battery source, did not illuminate when the test button was pressed. The exit sign was in the penthouse.

During an interview at 3:15 p.m., Engineering Staff 1A stated that the last two months the signs were visually checked. There was no functional test completed on the exit signs, as required.

During document review, at 3:47 p.m., there was no documentation to indicate the length of time the exit signs were functionally tested and which signs were tested. The exit sign testing document indicated the floor the signs were on. No other information was provided.


29751


November 29, 2012
During document review at 9:30 a.m., the facility failed to provide documentation for monthly 30 second testing of the back up battery powered emergency lights and exits signs for the following locations:
There were no records for testing at the Urgent Care Center- Fontana or the Urgent Care Center - Highland.
There were no records for testing at the Wound Care Center.
There were no records for testing at the Out Patient Surgery/ Rehabilitation.
There were no records for testing at the Heart Care Center.
There were no records for testing at the Towers N/S, E/W.
There were no records for testing at the Ancillary.

During an interview at 9:35 a.m., Maintenance Staff 9a stated that the emergency lights were checked when the generator is tested every month. There was no documentation for annual 90 minute emergency light and exit sign testing.

Based on interview and record review, the facility failed to prepare staff members to respond to emergency situations. This was evidenced by staff members that did not know how to open a locked bathroom door, by a staff person could not locate a fire extinguisher and a manual fire alarm pull station, and by no alarm initiation during one fire drill at the Urgent Care Center in Fontana. This affected two of six floors, and the Urgent Care Center and could result in a delay in staff response during a fire or other emergency.

NFPA 101 Life Safety Code, 2000 edition
19.7.1.3 Employees of health care occupancies shall be instructed in life safety procedures and devices.

Findings:

During a tour of the facility and document review with the Director of Facility Maintenance, the Service Area Vice President, and Quality Assurance Staff, on November 27, 2012, and November 29, 2012, staff members were interviewed and fire drill documents were reviewed.

Tower E/W - November 27, 2012
1. At 9:42 a.m., RN staff members 1a through 5a were interviewed and asked to open a locked bathroom door, to evacuate a patient, if a fire was in the far end of the room. Two of five staff could not open the locked door in the event of an emergency. The door can be unlocked with a small key or a small coin.

Tower N/S - November 29, 2012
2. During an interview at 1:06 p.m., Volunteer 1a in the Gift Shop stated that she could not locate a fire extinguisher or a manual fire alarm pull station. The fire extinguisher was approximately 25 feet away and a manual fire alarm pull station was approximately 30 feet away.


29751

Urgent Care Center-Fontana - November 27, 2012
3. At 1:15 p.m., there was no documentation that an initiating device (Fire Alarm device) was activated during the fire drill conducted on September 27, 2012, during the day. During an interview, the facility manager stated they did not activate the alarm system during the drill.

Based on observation, interview, and record review, the facility failed to maintain the integrity of their fire alarm system. This was evidenced by no audible devices in three locations and by alarm devices that failed to activate. This could result in the potential failure to notify the occupants during a fire emergency, or a delay in closing automatic release doors. This affected two of six floors in the building.

NFPA 101 Life Safety Code 2000 Edition
9.6.3 Occupant Notification.
9.6.3.1 Occupant notification shall provide signal notification to alert occupants of fire or other emergency as required by other sections of this Code.

Findings:

During fire alarm testing with the Director of Facility Maintenance and the Service Area Vice President, from November 27, 2012, through November 29, 2012, the fire alarm system system was inspected and tested.

Ancillary - November 28, 2012
At 11:59 a.m., the fire alarm system was not audible in the North side of the Clinical Lab and near the System Manager Office (near the Refrigerators). The fire alarm system could not be heard while the alarm was sounding.

At 2:40 p.m., the fire system was not audible in the PACU, near the nursing station, while the doors were closed.

Ancillary - November 29, 2012
At 9:54 a.m., the fire alarm system could not be heard in the Central Supply Storage and Decontamination Rooms while the fire alarm was sounding.

During an interview at 10:07 a.m., Central Supply Staff 7a said that she could not hear the fire alarm system at all, in the area near the machines.

During record review at 10:08 a.m., there was a remark on the fire alarm drill for Central Supply, dated March 29, 2012, that said that the fire alarm system could not be heard in the Central Supply area and the paging system was also hard to hear.

At 11:19 a.m., the emergency release to one won door did not release the door and open it to allow patients to exit.

At 11:20 a.m., the Director of Facility Maintenance reported that the won door appeared to be missing a rivet in the release button.

Based on observation, the facility failed to ensure smoke detectors are installed and maintained according to NFPA 72. This was evidenced by smoke detectors that failed to activate the fire alarm system and by no smoke detectors in one compartment. The smoke detectors could fail and cause a delay in notification, in the event of a fire emergency. This affected two of six floors in the main hospital tower.

Findings:

During a tour of the facility with the Director of Facility Maintenance and Service Area Vice President, on November 28, 2012, the smoke detectors were tested with canned smoke.

Tower E/W - November 28, 2012

1. At 11:01 a.m., the smoke detector 116-106 near Room 338 did not activate the fire alarm system and send a signal to the monitoring staff, when tested with canned smoke. Five attempts were made without activating the fire alarm system.

2. At 11:29 a.m., there were no smoke detectors in the smoke compartment CCU, Side 7. The CCU census was six during the survey.

3. At 3:48 p.m., the smoke detector 201-108-1 in the Fast Track Emergency Room, did not activate the fire alarm system and send a signal to the monitoring staff when tested with canned smoke. Five attempts were made without activating the fire alarm system.

Based on observation, the facility failed to maintain the automatic sprinkler system, as evidenced by no identification label on their automatic sprinkler test valves and by a missing escutcheon ring. This could result in a delay in identifying the Inspector's Test Valve and could allow the spread of heat and smoke around a sprinkler head. This affected six of six floors in the main hospital.

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

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 29, 2012, the sprinkler system components were examined. Sprinkler heads are UL listed to respond to a calculated ceiling temperature. Escutcheon rings are part of the UL listing of the sprinkler assembly.

Tower N/S and E/W - November 29, 2012

At 9:42 a.m., there were no signs on 6 of 6 inspector test valves in the Towers. There was no way to identify which valves should be used during sprinkler system testing.

At 10:12 a.m., 1 of 8 sprinklers in the Decontamination Room, in Central Supply, was missing an escutcheon ring. The sprinkler was on the north side of the room.

Based on observation and interview, the facility failed to maintain the portable fire extinguishers in accordance with NFPA 10. This was evidenced by extinguishers that were not inspected, and by one extinguisher with the gauge in the red. Red indicates that the fire extinguisher needs to be recharged or replaced. This affected two of six floors of the main hospital and could result in the failure of a fire extinguisher or a delay extinguishing a fire.

NFPA 10 Standard for Portable Fire Extinguishers (1998 Edition),
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.

Findings:

During a tour of the facility with the Director of Facility Maintenance and the Service Area Vice President, on November 28, 2012, and November 29, 2012, the fire extinguishers were examined.

Ancillary - November 28, 2012
1. At 2:51 p.m., the two fire extinguishers in the Medical Library (extinguishers 66 and 66A) were not inspected during the month of October 2012.

2. At 4:12 p.m., the tag for Fire Extinguisher 15 was not signed and inspected for the months of July, August, and September 2012. The extinguisher was in the air handler room, near the Respiratory Care report room.

During an interview at 4:15 p.m., the Security Manager 8a confirmed that these fire extinguishers were not inspected, dated and initialed.

Tower E/W - November 29, 2012
3. At 10:25 a.m., the gauge on the K-class fire extinguisher, in the kitchen, was out of the green zone (safe zone). The gauge arrow was in the red zone, indicating that the fire extinguisher needed to be replaced or recharged.

Based on observation, the facility failed to maintain their electrical equipment and utilities. This was evidenced by appliances and medical equipment plugged into multi-outlet extension cords, by a broken outlet cover, and by two electrical panels that had medical equipment stored in front of the panel doors. This affected two of six floors, and 1 of 5 Out Patient Surgery Clinics. This could increase the risk of an electrical fire and had the potential to delay access to the panel in the event of an emergency.

NFPA 70, National Electrical Code, 1999 edition
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

110-26. Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.

Findings:

During a tour of the facility, with the Director of Facility Maintenance, the Service Area Vice President, Quality Assurance Staff 1 and Maintenance Staff, on November 26, 2012 and November 29, 2012, the electrical equipment and wiring were observed.

Sixth Floor Tower N/S - November 27, 2012
1. At 9:22 a.m., there was an electrical outlet with more that 50 percent of the cover missing, behind the Omni Cell Machine in the Medication Room.

Tower E/W - November 27, 2012
2. At 2:30 p.m., there was a small refrigerator plugged into a multi-outlet extension cord at the Labor and Delivery Nursing Station.

Ancillary - November 28, 2012
3. At 1:30 p.m., an intravenous pump and a monitor were plugged into a multi-outlet extension cord in Cath Lab 3.


29751

Out Patient Surgery Clinic - November 26, 2012
4. At 2:48 p.m., medical equipment was stored in front of electric panel 2NLB and panel 2ECLD. There was a printed sign in the same area on electrical panel 2EELA that stated that nothing should be placed in front of the Electrical Panels.