HospitalInspections.org

Based on observation, the facility failed to:
Maintain the integrity of their fire barrier walls on horizontal corridor connections by providing at least a 2- hour fire barrier wall and a door with at least a 1-1/2 hour fire protection rating. This was evidenced by penetrations in fire barrier walls and a door not installed within this separation in the 1st Level Floor of the Main Hospital Building. This affected 4 of 4 buildings with 2-hour fire barrier compartments in the Main Hospital Building;
Maintain the integrity of common wall separations in POB1, Suite 308 by providing at least a 1-hour fire barrier wall as evidenced by penetrations and openings on walls that have been separated from other business occupancies which affected 1 of 3 suites;
In POB 2, Suites 219 & 309, the facility failed to maintain the integrity of common wall separations by providing at least a 1-hour fire barrier wall as evidenced by penetrations on walls that have been separated from other business occupancies affecting 2 of 3 suites. This had the potential to allow the spread of smoke and fire from one building to another building, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire barrier walls were observed.

SURVEYOR 29626
Main Hospital @ 4445 Magnolia Ave. (Buildings A, B, C, & D)
On 04/18/2011, at 10:40 a.m., the fire barrier wall, located on the 1st Floor between Building A and Building B by the financial services department, had three penetrations above the drop down ceilings and above the fire doors. Two penetrations were located underneath electrical conduits, measuring approximately 1/4-inch each. The third penetration was surrounding a pipe that measured approximately 2-inches in diameter with green material that was used but did not completely seal penetrations, exposing an approximately ?-inch hole.

On 04/18/2011, at 10:43 a.m., the fire barrier wall, located on the 1st Floor between Building A and Building B by the PBX (Private Branch Exchange) Office, had a penetration above the drop down ceiling. The penetration surrounded an electrical conduit that measured approximately 3-inches.

On 04/18/2011, at 1:38 p.m., the fire barrier wall, located on the 1st Floor between Building B and Building D by the Outpatient Pre-Operation/Observation Unit, had a fire rated door frame with no door installed. This left an opening that measured approximately 32-inches x 80-inches.

On 04/18/2011, at 2:12 p.m., the fire barrier wall, located on the 1st Floor between Building B and Building C by the Emergency Departments 1 & 2, had a penetration above the drop down ceiling. The unsealed penetration was within a piped sleeve with cables running through it.

Community Professional Building @ 4000 14th Street (POB 1, Ste. 308)
On 04/19/2011, at 3:57 p.m., the fire barrier wall separating the corridor and Suite 308, located on the 3rd Floor, had a penetration that measured approximately 1-foot by 4-inches. This was located above the drop down ceiling on the corner of the corridor by the entrance of the Suite.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This affected the Riverside Community Main Hospital, Community Professional Building (POB1) and Evans Park Medical Arts Building (POB2).

Findings:

During a tour of the facility with Hospital Staff On April 18, 2011 through April 21, 2011, the facility walls and ceilings were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, Basement level:
At 10:53 a.m., in the Engineering Office on the Basement level there was a 1 inch round penetration in the wall behind the printer.

At 11:40 a.m., the Linen Room had a 3 inch x 4 inch penetration in the wall.

At 11:45 a.m., the door to the Laundry Room was missing the door handle creating a 2 inch x 2 inch round penetration in the door that leads into the Laundry Room.

At 11:46 a.m., in the Laundry Room Storage area there was a 5 inch x 5 inch penetration in the right wall by the towels and blankets.

At 1:28 p.m., in the Electrical Room next to Room B-0213, there was a 4 inch x 2 inch penetration around the electrical pipe in the right wall.

At 1:35 p.m., in the Bench Room in the IT area there were 11 penetrations approximately ? inch round each in the wall and 4 penetrations approximately ? inch round each in the wall of the IT main area.

At 1:53 p.m., in the Janitor closet next to the elevators there were three, 1 inch round penetrations in the wall.

At 1:55 p.m., in the Information Systems room there were five, 1 inch round penetrations in the wall.

At 2:15 p.m., in the Respiratory Storage Room there were 4 penetrations approximately 1 inch round each in the wall above the ultrasonic cleaner machine.

At 2:16 p.m., in the Storage Room used by IT there were 4 penetrations approximately 1 inch round each in the wall.

At 3:50 p.m., there was a 1 inch x 1 inch square penetration in the overhang in the exit access from the Heart Care Institute to the outside.

On 4/19/11, 2nd floor of Building C:
At 8:45 a.m., in the Frozen Section Lab C224 there was a penetration approximately 2 inch x 2 inch due to a missing electrical box cover on the left wall.

At 8:50 a.m., there was a 5 inch x 5 inch penetration in the crawl space above the ceiling tiles viewed through the access panel labeled " D.D 10 + 11 "by Room C224.1 Janitors Closet" .

At 8:55 a.m., in the Business Office, there were 8 penetrations approximately ? inch round each in the wall where a board had been removed per the PACU Manager.

At 8:56 a.m., in the Education Room by the ORs there were 2 penetrations approximately 2 inches x 2 inches square by the clock. One penetration did not have a metal electrical box and you could see the back side of the sheet rock of the corridor wall.

At 9:00 a.m., when looking through the access panel by OR 9, there was a 6 inch x 6 inch penetration in the corridor wall above the ceiling tiles.

On 4/19/11, 4th floor of Building C:
At 9:43 a.m., there were 2 penetrations approximately ? inch each in the wall next to Room C403.

At 9:48 a.m., there were 2 penetrations approximately ? inch each in the wall next to room C415.

On 4/19/11, Evans Park Medical Arts Bldg. (POB2) @ 4500 Brockton, Ste. 101, 219 and 309
At 1:52 p.m., there was a 2 inch x 2 inch round penetration in the wall above the door in the room where the fire alarm panel is located on the 1st floor.

On 4/19/11, Community Professional Bldg. (POB1) @ 4000 14th Street, Ste. 102, 109, 308
At 3:50 p.m., in Suite 308 there was one penetration in the wall and one penetration in the ceiling of the Storage Closet off of the new Xerox room approximately 1 inch x 1 inch round each.

On 4/20/11, Building C, 2nd floor Operating Rooms 1-9 areas:
At 1:25 p.m., there was a 12 inch x 5 inch penetration in the right wall of the Soiled Linen & Utility Room C238.

At 1:35 p.m., there were two, 1 inch round penetration in the Store room back wall.

On 4/20/11, Building C, 4th floor:
At 2:23 p.m., there was a 3 inch x 3 inch round penetration in the MIC corridor wall behind the left smoke barrier door.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, "A" Building - First Floor:
At 10:41 a.m., in the Financial Services Break Room there was a ? inch penetration in the back wall.

At 10:48 a.m., in the Marketing Office there was a ? inch penetration in the ceiling around a conduit.

At 10:53 a.m., in the Cashier Office there was a 4 inch by 4 inch penetration in the wall above the file cabinet.

At 11:20 a.m., the Case Management Office printer room had a ? inch penetration in the left wall around wires and conduits.

On 4/18/11, "B" Building - Fourth Floor:
At 3:55 p.m., the Electrical Room that is located in the Nurse Charting room had a 1 inch penetration in the ceiling around a conduit.

On 4/19/11, "B" Building-Fifth Floor:
At 9:10 a.m., in the Conference Room there was a 2 inch penetration in the wall below the light switch.

On 4/19/11, "C" Building-Fourth Floor:
At 9:58 a.m., in Patient room C426 there was a 4 inch penetration in the wall behind the bed.

On 4/20/11, "C" Building -3rd floor:
At 1:22 p.m. in the Visitors Break Area there was a 4 inch by 6 inch penetration and a 4 inch in diameter penetration behind the vending machine.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue
On 04/18/2011, at 3:22 p.m., there were 4 penetrations on the wall in Room B362, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:24 p.m., there was a penetration on the wall in Room B359 that measured approximately 1/2-inch.

On 04/18/2011, at 3:27 p.m., there were 4 penetrations on the wall in Room B356, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:29 p.m., there were 8 penetrations on the wall in Room B353, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:31 p.m., there were 4 penetrations on the wall in Room B351, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:32 p.m., there were 4 penetrations on the wall in Room B352, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:33 p.m., there were 3 penetrations on the wall in Room B350, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 4:26 p.m., there was a penetration on the wall in Room B261 that measured approximately 1/2-inch.

On 04/18/2011, at 4:28 p.m., there was a penetration on the wall in Room B259 that measured approximately 1/2-inch.

On 04/19/2011, at 9:09 a.m., there were 2 penetrations on the wall above a sharps dispenser in Room B660, with each one measuring approximately 1/4-inch.

On 04/19/2011, at 9:12 a.m., there was penetration on the wall behind Bed B in Room B658 that measured approximately 4-inches by 12-inches.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor walls as evidenced by unsealed penetrations in the facility's corridor walls that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2001 through April 21, 2011, the corridor walls and were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Ave.
On 4/18/11, Basement level:
At 1:25 p.m., in the corridor wall next to the Soiled Utility Room B-023.14, the old pull station had been removed and a cover plate had been added. The cover plate failed to cover the entire hole and there was a 1 inch x 3 inch long penetration down the side of the cover plate.

At 2:40 p.m., in the corridor wall next to the Diabetes Solutions office there were two, 1 inch round penetrations by the sink.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave. (Buildings A, B, & D)
On 04/18/2011, at 12:06 p.m., there were 3 penetrations on the corridor wall on the 1st Floor in Building A by the cafeteria. The penetrations were located above the drop down ceiling. The first penetration measured approximately 8-inches by 2-inches, the second penetration measured approximately 8-inches by 1/2-inch, and the third penetration measured approximately 8-inches by 1-1/2 inches.

On 04/18/2011, at 1:17 p.m., there was a penetration on the corridor wall on the 1st Floor in Building D by the Medical Records Office. The penetration measured approximately 1/2-inch.

On 04/18/2011, at 1:50 p.m., there was a penetration on the corridor wall on the 1st Floor in Building B by CT Room 1. The penetration was above the drop down ceiling that measured approximately 1/2-inch and surrounded an electrical conduit.

On 04/18/2011, at 3:56 p.m., there was a penetration on the corridor wall on the 4th Floor in Building B, North, by the Computer Room. The penetration was surrounded by a red colored compound material that did not completely seal a hole that measured approximately 1-inch by 2-inches.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Ave.
On 4/19/11, "C" Building-Fourth Floor:
At 9:55 a.m., the corridor wall across Patient room C438 had a 6 inch by 6 inch penetration in the wall.

At 10:09 a.m., the corridor wall entering the C432 Unit had a 3 inch by 4 inch penetration in the wall.

On 4/20/11, "B" Building-Fourth Floor:
At 2:19 p.m., the corridor wall across Patient room B480, had a 1/4 inches by penetration above the manual pull station where the old pull station was removed.

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to positive latch and/or were blocked from closing. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the facilities corridor doors were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 1:40 p.m., the door to the " Hospitalist RPN Case Management " office had a door that failed to positive latch due to a door wedge that prevented it from closing.

On April 18, 2011 in Building C, 2nd floor:
At 4:40 p.m., the door to the Break Room C250.4 had a door that failed to positive latch due to two chairs pushed up against the door preventing it from closing.

On April 20, 2011, Building B, 2nd floor:
At 11:45 a.m., the door to C-Section Supply Room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, "A" Building-First Floor:
At 10:58 a.m., in the Medical Staff Library, the copy room door that is equipped with a self-closure was held open by a wedge.

At 11:05 a.m., the COP door is equipped with a self-closure and was held open by a floor fan.

At 11:40 a.m., the Laboratory Storage Room with a self-closure was held open by boxes.

On 4/18/11, "D" Building, 2nd Floor:
At 2:31 p.m., Room 205.1 Janitor's closet door closure was disassembled.

On 4/18/11 "D" Building, 3rd Floor:
At 3:05 p.m., the door to Patient room D301 failed to latch when closed.

Community Professional Building @ 4000 14th Street (POB 1, Ste. 109)
On 4/19/11:
At 3:38 p.m., the MRI/Computer Room 1 failed to latch upon self-closure.

On 4/20/11, Riverside Community Hospital @ 4445 Magnolia Avenue
"C" Building Second Floor:
At 1:15 p.m., the double doors next to the Pre Op entrance failed to latch upon self-closure, the self-closure was broken.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue
On 04/18/2011, at 2:00 p.m., the door leading into the corridor from CT Room 2, located on the 1st Floor in Building B, had tape on the latching mechanism that prevented the door from positively latching.

On 04/18/2011, at 3:33 p.m., the door leading into the corridor from Room B350, located on the 3rd Floor in Building B, did not positively latch upon closing.

On 04/18/2011, at 3:38 p.m., the door leading into the corridor from the Nourishment Room by the South Nursing Station, located on the 3rd Floor in Building B, did not positive latch upon closing by the self-closing mechanism.

On 04/20/2011, at 10:55 a.m., the roll down door between the Emergency Department Treatment/Triage Area and Waiting Room, located on the 1st Floor in Building C, was blocked from fully closing by medical records and binders upon the activation of a smoke detector.

Based on observation, the facility failed to maintain the integrity of the walls in the stairwells by providing at least a 1-hour fire barrier wall. This was evidenced by penetrations on walls to a stairwell, affecting 1 of 3 suites in POB1, Ste. 308. This had the potential to allow the spread of smoke and fire into the stairwell exit, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire barrier walls in the stairwells were observed.

SURVEYOR 29626
Community Professional Building @ 4000 14th Street (POB 1, Ste. 308)
On 04/19/2011, at 3:47 p.m., the wall in the stairwell on the 1st Floor, located by the Main Lobby, had two penetrations that measured approximately ?-inches each.

On 04/19/2011, at 3:48 p.m., the wall in the stairwell on the 2nd Floor, located by Suite 214, had a penetration that measured approximately 1/2-inch.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by smoke barrier doors that failed to release from the magnet. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients and the staff in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the facility doors were observed.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue, (Bldg. B & D)
On 4/20/11, "B" Building-Third Floor:
At 2:10 p.m., the fire doors in Pediatrics 3 North, the leaf next to the Managers Office failed to release from its hold open device during the testing of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls and provide at least a one-half hour fire resistance rating. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of fire, resulting in burns and/or smoke inhalation.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the smoke barrier walls were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Ave.
On 4/18/11, Basement level:
At 2:48 p.m., above the smoke barrier doors and the drop down ceiling tiles leading to Building C, there was a 1 foot x 6 inch penetration around 3 metal pipes in the wall.

At 3:10 p.m., above the smoke barrier doors and the drop down ceiling tiles leading to the Heart Care Institute, there was a 1 inch x 1 inch penetration around the pipe.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs. B & D)
On 04/18/2011, at 2:29 p.m., the smoke barrier wall by Room 208, located on the 2nd Floor in Building D, had three penetrations above the drop down ceiling. The first two penetrations measured approximately 1/4 inch each and the third penetrations measured approximately 1/2 inch.

On 04/18/2011, at 3:07 p.m., the smoke barrier wall by Room B352, located on the 3rd Floor in Building B, had two penetrations above the drop down ceiling. The penetrations measured approximately 2 inches each.

On 04/18/2011, at 3:48 p.m., the smoke barrier wall by Room B3474, located on the 4th Floor in Building B, had a penetration above the drop down ceiling. The penetration was surrounded by a red colored compound material that did not completely seal a hole that measured approximately 1/2 inch by 1 inch.

On 04/19/2011, at 8:40 a.m., the smoke barrier wall by Elevator 6R, located on the 6th Floor in Building B, had a penetration above the drop down ceiling. The penetration was above electrical conduits and had a cable running through it, measuring approximately 3 inches.

On 04/19/2011, at 8:46 a.m., the smoke barrier wall by Room B670, located on the 6th Floor in Building B, had a penetration above the double doors and above the drop down ceiling. The penetration had a wire mesh that did not completely seal, measuring approximately 3 inches by 4 inches.

SURVEYOR 21101
On 4/19/11, "C" Building-Fourth Floor:
At 10:10 a.m., the smoke barrier wall entering C432 Unit had two penetrations; a ? inch penetration around a conduit in the right side of the wall and a ? inch penetration next to the cable tray on the left side of the wall.

Based on observation, the facility failed to maintain the integrity of the walls and doors in hazardous areas by providing at least a one hour fire resistance rating as evidenced by penetrations in rooms considered hazardous. This had the potential to allow the rapid spread of smoke and fire, resulting in injury to patients and staff.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, hazardous areas were observed.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs A & B)
On 04/18/2011, at 11:14 a.m., there were penetrations on the wall to the Employment Office, located on the 1st Floor in Building A. The office was considered a hazardous area because the size of the room was greater than 50 square feet and the room contained combustible paper documents that covered approximately a quarter of the room. The penetration was approximately ? inch that surrounded a pipe sleeve. Within the pipe sleeve, there was a network cable running through it that was unsealed.

On 04/18/2011, at 3:36 p.m., there were over 20 penetrations on the wall to the Clean Linen Room by the South Nursing Station, located on the 3rd Floor in Building B. The storage room was considered a hazardous area because the room size was greater than 50 square feet and the room contained combustible materials. The penetrations were approximately 1/4 inch each. Also, the door to the room did not positively latch upon closing by the self-closing mechanism.

On 04/19/2011, at 9:24 a.m., there were two penetrations on the wall to the Soiled Utility Room by the South Nursing Station, located on the 6th Floor in Building B. The room was considered a hazardous area because the size of the room was greater than 50 square feet and the room contained combustible materials. The penetrations were approximately 1/4-inch each.

Based on observation, the facility failed to maintain the doors in stairways used as exits as evidenced by stairwell doors that failed to positively latch. This had the potential for fire and smoke to spread, rendering the stairway non-usable for patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the stairwell egresses were observed.

SURVERYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs B & C)
On 04/19/2011, at 9:44 a.m., the latching mechanism to the door in Stairwell 1, located on the Basement Floor in Building B, failed to positively latch.

On 04/19/2011, at 9:55 a.m., the latching mechanism to the door in Stairwell 3, located on the 3rd Floor in Building C, failed to positively latch.

On 04/20/2011, at 2:36 p.m., the latching mechanism to the door in Stairwell 3, located on the 5th Floor in Building C, failed to positively latch.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by medical equipment, blue laundry tubs, metal racks and other equipment and/or supplies in the exit access corridors that lead to the exit discharge. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire.

Findings:

During the tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the exits were observed.

SURVERYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 11:28 a.m., the exit path of egress outside the Emergency Room was blocked by 3 laundry carts approximately 5ft wide by 6ft tall, boxes, wooden pallets, metal racks, recycling boxes, trash containers and a shopping cart.

At 11:50 a.m., there were 20 laundry bins approximately 5ft wide by 6ft tall in the exit path of egress outside the Laundry on the loading dock.

At 2:20 p.m., there were two wooden boxes approximately 8 ft long x 3 ft wide x 4ft tall each stacked one on top of the other and, a wooden pallet approximately 6ft x 5ft high in the corridor next to the " Director of Rehab Services " office in the Rehab/Speech therapy area.

On April 18, 2011, Building C 1st floor:
At 3:50 p.m., there was a large stack approximately 10 feet wide x 5 ft tall of cardboard boxes that had been broken down in the exit path to the outside from the Heart Institute. The path was marked by red paint to be kept clear.

At 4:30 p.m., there were boxes, a shredder, patient bed and chairs in the corridor across from C131.

At 4:31 p.m., there were chairs with patients sitting in them on both sides of the corridor approximately 1 foot from the smoke barrier doors.

On April 18, 2011, Building C 2nd floor:
At 4:40 p.m., there were 5 patient beds in the corridor leading to the Operating Rooms.

On April 19, 2011, Building C 2nd floor:
At 8:30 a.m., there was a Davinici Machine, two Flouroscan machines, 1 Orthopedic machine and one Exposcop 700 machine in the corridor by Room "C240 Anesthesia".

SURVERYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs. A & B)
On 04/18/2011, at 11:01 a.m., the exit door to the overflow cafeteria, located on the 1st Floor in Building A, was obstructed by items that prevented the door from fully opening. The items observed along the pathway of the exit discharge included a rubber floor mat and boxes. The door was marked with an exit sign.

On 04/18/2011, at 11:36 a.m., the exit discharge to the Microbiology Area, located on the 1st Floor in Building A and along the loading dock, had items obstructing its pathway. The items observed along the pathway included 7 palettes, 2 carts, and a trash can. The door to this exit discharge was marked with an exit sign.

On 04/19/2011, at 10:17 a.m., the exit discharge from Stairwell 1, located on the 1st Floor in Building B, had a metal platform obstructing its pathway. The platform was approximately 3-inches in vertical height, 8-inches horizontal width, and extended within the pathways length. The door to this exit discharge was marked with an exit sign. There was no markings and no lighting on the platform.

Based on observation, the facility failed to maintain illumination throughout means of egress. This was evidenced by lighting units that failed to illuminate and no lighting unit present in an exit discharge. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff, the illumination throughout egress paths were observed.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldg. B)
On 4/19/11,
At 9:20 a.m., the Exit Sign next to the Social Services was not illuminated and when tested did not illuminate

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldg. B)
On 04/18/2011, at 11:01 a.m., the lighting units on the 4th Floor in Stairwell 4 failed to illuminate 2 of 2 units.

On 04/19/2011, at 10:17 a.m., the exit discharge from Stairwell 1, located on the 1st Floor in Building B, had no lighting unit in the area.

Based on observation, the facility failed to maintain exit signs and directional signs as evidenced by missing signs and non-illuminating exit signs. This could have the potential for delaying evacuation of patients and incorrectly directing evacuees into a non-exit area during an emergency.

NFPA 101 Life Safety Code, 2000 Edition
7.2.2.5.4 Stair Identification Signs. Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

Findings:

During a tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the exits, exit signs and their illumination were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 3:15 p.m., there was no " Exit " sign over the doors leading to the parking structure from the Heart Institute area.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave (Bldgs. A, B, & C)
On 04/18/2011, at 11:03 a.m., the exit sign above the door in the overflow cafeteria, located on the 1st Floor in Building A, did not illuminate. The radioactive exit sign was marked with a replacement date of October 2008.

On 04/18/2011, at 11:21 a.m., the door leading to an exit discharge by the Employment Office, located on the 1st Floor in Building A, did not have an exit sign.

On 04/18/2011, at 2:03 p.m., the exit sign above the door to CT Room 2, located on the 1st Floor in Building B, did not illuminate.

On 04/18/2011, at 2:08 p.m., the exit sign above the door that leads into Stairwell 3, located on the 1st Floor in Building C, did not illuminate. The radioactive exit sign was marked with a replacement date of October 2008.

On 04/19/2011, at 9:58 a.m., 2 of 2 doors inside Stairwell 3, located on the 1st Floor in Building C, did not display sign/s to identify if each door was an exit or not an exit.

On 04/19/2011, between 10:00 a.m. and 10:15 a.m., the outside stairwell in Building B did not have a sign displaying the required stair identification on the 6th Floor, 5th Floor, 4th Floor, 3rd Floor, 2nd Floor, and 1st Floor.

Based on records review, the facility failed to ensure that all staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a fire drill report that did not include names of staff members who participated in a drill. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to patients and staff.

Findings:

During document review with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire drill records were reviewed.

SURVEYOR 29626
Community Professional Building @ 4000 14th Street (POB 1: Suite 102, 109, & 308)
The fire drill records were requested for review from the Director of Facilities Management on 04/18/2011 at 10:30 a.m. The records received, when reviewed on 04/21/2011 at 1:30 p.m., did not contain any names of staff members who had participated in a fire drill conducted on 03/29/2011 at 10:00 a.m. for POB I - Suites 102, 109 , and 308.

Evans Park medical Arts Building @ 4500 Brockton Ave (POB 2: Suite 101)
The fire drill records were requested for review from the Director of Facilities Management on 04/18/2011 at 10:30 a.m. The records received, when reviewed on 04/21/2011 at 1:35 p.m., did not contain any names of staff members who had participated in a fire drill conducted on 03/29/2011 at 10:30 a.m. for POB II - Suite 101.

Based on observation and interview, the facility failed to provide protection if their fire alarm control unit as evidenced by the fire alarm control panel with no smoke detector or heat detector installed, affecting 3 of 3 suites in the POB 2 and, the facility failed to maintain the fire alarm system as evidenced by failing to provide effective warning of fire as evidenced by strobes and chimes that failed to alarm and/or could not be heard. This could result in fire alarm system failure and delay in notifying visitors and staff of a fire in the facility, causing potential injury.

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

NFPA 72 National Fire Alarm Code, 1999 Edition
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
4-3.2.2 To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.

NFPA 101, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire alarm control panel, strobes and chimes were observed.

SURVEYOR 29626
Evans Park medical Arts Building @ 4500 Brockton Ave (POB 2: entire building)
On 02/23/2011, at 2:00 p.m. the fire alarm system control panel, located on the 1st Floor, did not have a smoke detector or heat detector installed. The room, where the fire alarm control panel was installed, was not continuously occupied.

Riverside Community Hospital @ 4445 Magnolia Avenue
On 04/20/2011, at 10:00 a.m., the fire alarm was activated in the Basement in Building D. The alarm sound was not audible and no visual signal was visible in the Woodshop Suite.

SURVEYOR 27961
Community Professional Building (POB1) @ 4000 14th Street, Suite 102, 109, 308
On April 19, 2011,
At 3:35 p.m., in Suite 109, the fire alarm notification devices were activated and the alarms were not heard by surveyor or staff. When interviewed on April 19, 2011 at 3:35 p.m., Hospital Staff was asked if they could hear the alarms and they stated that they could not.

At 3:50 p.m., in Suite 308, the strobe/chime device was pushed up through the ceiling tiles.

Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/20/11, Basement level:
At 9:23 a.m., in the Sterile Processing C006 OR/SPD area, the fire alarm notification devices were activated and the alarms were not heard by surveyor or staff. When interviewed on April 20, 2011 at 9:23 a.m., Hospital Staff stated that they could not hear the fire alarm.

At 9:23 a.m., in the OR/SPD area the bell on the wall failed to activate.

At 9:45 a.m., the strobe by the Director of EVS office failed to activate after testing of the smoke detector.

At 10:34 a.m., in the Pharmacy on the 1st floor there was a chime that was covered with clear packing tape which prevented it from being heard when the smoke detector and pull station was activated.

On 4/20/11, Building B, 2nd floor:
At 11:35 a.m., the strobes failed on the right and left wall by OR11.

Based on observation, the facility failed to maintain their fire alarm system as evidenced by the batteries past the 4 year replacement date according to NFPA 72. This could cause harm to patients and staff in the event of a fire.

NFPA 72, 1999 Edition
Table 7-3.2 Testing Frequencies (Continued)
7-2.2
Initial/ Table
Component Reacceptance Monthly Quarterly Semiannually Annually Reference
6. Batteries - Fire Alarm Systems
a. Lead-Acid Type - - - - - 6b
1. Charger Test (Replace battery as needed.) X - - - X -
2. Discharge Test (30 minutes) X - - X - -
3. Load Voltage Test X - - X - -
4. Specific Gravity X - - X - -
b. Nickel-Cadmium Type - - - - - 6c
1. Charger Test (Replace battery as needed.) X - - - X -
2. Discharge Test (30 minutes) X - - - X -
3. Load Voltage Test X - - X - -
c. Primary Type (Dry Cell) - - - - - 6a
1. Load Voltage Test X X - - - -
d. Sealed Lead-Acid Type - - - - - 6d
1. Charger Test (Replace battery every 4 years.) X - - - X -
2. Discharge Test (30 minutes) X - - - X -
3. Load Voltage Test X - - X - -

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the batteries in the fire alarm panel were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
At 3:00 p.m., the batteries in the fire alarm panel were dated 1/2/04 and the panel stated "Low Battery".

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers with escutcheon rings that were not flush to the ceiling and sprinklers that were not free of debris. These could result in the fire sprinkler system not functioning as designed and increased risk of injury to residents and staff.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the sprinkler system was observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 11:28 a.m., in the Oxygen Storage area outside the building there were 2 of 2 sprinklers covered in dust/debris.

At 2:42 p.m., in the Storage Closet in the Rehab area there was a sprinkler blocked by boxes, supplies, brochures and files approximately 3 inches from the sprinkler.

Evans Park medical Arts Building (POB2) @ 4500 Brockton, Ste. 101, 219 & 309
On April 19, 2011, At 1:58 p.m., in Suite 101, there was a sprinkler missing an escutcheon ring in the Storage area next to the Nurses office.

SURVEYOR 21101
On 4/18/11, "A" Building-First Floor:
At 11:00 a.m., in the Conference Room 1 of 6 sprinkler escutcheon rings was missing.

At 11:03 a.m., in the Medical Staff Library room 1 of 6 sprinkler escutcheon rings were missing.

At 11:32 a.m., in the Microbiology Department 2 of 4 sprinkler escutcheon rings were missing.

On 4/18/11, "D" Building-First Floor:
1:10 p.m., in the EEG Office 1 of 8 sprinkler escutcheon rings was missing .

On 4/18/11, "D" Building-Third Floor:
At 3:05 p.m., the sprinkler escutcheon rings in Patient room D326 had gaps and were not flush with the ceiling.

On 4/18/11, "B" Building-Fourth Floor:
At 3:50 p.m., the sprinkler escutcheon ring in the Clean Linen Room had a gap and was not flush with the ceiling.

At 3:58 p.m., the sprinkler escutcheon ring in Patient room B452 (bathroom) was missing.

On 4/19/20, "B" Building-Fifth Floor:
At 8:49 a.m., the sprinkler escutcheon ring in Patient room B551 (bathroom) was missing.

At 9:05 a.m., the sprinkler escutcheon ring in Patient room B575 (bathroom) had a ? inch gap and was not flush with the ceiling.

At 9:06 a.m., the sprinkler escutcheon ring in Patient room B573 (bathroom) was missing.

Community Professional Building (POB 1) @ 4000 14th Street - Suite 109
On 4/19/11, At 3:44 p.m., the sprinkler escutcheon ring in the MRI/Computer Room II was missing.

Based on observation, the facility failed to ensure that their portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by fire extinguishers that were mounted over 5ft from the ground to the top of the pin and fire extinguishers that had an incorrect date on the tag. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire.

Findings:

During the facility tour with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire extinguishers were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 3:20 p.m., there was a fire extinguisher in the Sterile Supply to OR area that was mounted approximately 5 ft 8 inches above the ground.

On April 18, 2011, Building C, 1st floor:
At 4:10 p.m., there was a fire extinguisher in the Emergency Department by Room C18 that had a date hole punched the 1st and the 27th, no month indicated and the year was hole punched 2013.

Based on observation and interview, the facility failed to ensure that their heating and air conditioning vents were maintained as evidenced by dust and debris discharging from the heating and air conditioning vents during alarm testing. This could result in potential harm to patients and staff.

NFPA 101, 2000 Edition
SECTION 19.5 BUILDING SERVICES
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.
19.5.2 Heating, Ventilating, and Air Conditioning.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, 1999 Edition
2-3.6 Air Outlets.
2-3.6.1 General. Air supplied to any space shall not contain flammable vapors, flyings, or dust in quantities and concentrations that would introduce a hazardous condition.

Findings:

During alarm testing with the Hospital Staff on April 20, 2011, the smoke detector was tested and a vent in the Exam Room discharged dust and debris.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/20/11, "C" Building
At 10:42 a.m., while testing the fire alarm system in the Emergency Department, dust and debris discharged from the vent in the ceiling in Exam Room C186. Four patients came out of the Exam Room wiping dust and debris from their clothes. The vent was observed to be covered in dust and debris as well as the floor, chair and exam bed. When interviewed on April 20, 2011 at 10:42 a.m., the patients stated that dust and debris had fallen on them while sitting in the Exam Room.

Based on observation, the facility failed to ensure that the oxygen cylinders were properly secured as evidenced by unsecured oxygen tanks, and, the facility failed to ensure oxygen cylinders were not stored with combustible items. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner.

NFPA 99 Health Care Facilities, 1999 Edition
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.

NFPA 99 4-3.1.1.2(a) 7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the facilities oxygen storage areas and tanks were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 3:20 p.m., there was one unsecured oxygen "E" cylinder tank lying on top of the gurney in the parking structure outside the Sterile Supply /Heart Institute.

At 3:45 p.m., there was one unsecured oxygen "E" cylinder tank and one D cylinder tank laying on the ground in C031 Clean Utility room.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, "B" Building-First Floor:
At 1:52 p.m., there were 6 "E" oxygen tanks stored in Soiled Linen room B102.11. Staff was interviewed and stated the room is used for oxygen storage.

On 4/19/11, " C " Building-Fourth Floor:
At 9:48 a.m., there were 13 "E" oxygen tanks stored in Clean Linen room C430.4 within 1 foot of linen and boxes filled with supplies.

Based on document review and interview, the facility failed to provide a written policy and procedure ensuring the Humidity levels were maintained at 35% or greater for 11 of 11 operating rooms and, the facility failed to provide documentation of corrective actions that were taken to correct the humidity levels when they were out of range. This failure affected the entire surgery suite and could increase the risk of a fire hazard, resulting in potential harm to patients during surgery.

NFPA 101, Life Safety Code 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Health Care Facilities 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During records review and interview with the Manager of Facilities Operations on April 20, 2011 and April 21, 2011, the humidity logs were reviewed.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
The facility provided the Policy and Procedure for Temperature and Humidity Control in Operating Suites. Under Procedure: " B " states Room humidity will be maintained between 30% - 60%. There was a hand written note of 20% - 60% noted above the 30-60 percent. During an interview, the Manager of Facilities Operations stated the facility was in the process of changing the humidity level range to 20%-60%. The Manager of Facilities Operations was asked for documentation for the corrective actions taken when the humidity levels were below the acceptable range. The Manager of Facilities Operations stated they did not document the corrective actions taken when the humidity levels were low for the following dates.

Humidity Levels documented for April 15, 2011:
OR1- 27.55, OR3- 29.74, OR5- 26.80, OR6- 27.10, OR7- 27.08, OR8- 25.71, OR9- 25.35, OR11 -23.45.
Humidity Levels documented for April 4, 2011:
OR1- 28.34, OR4- 28.52, OR5- 28.46, OR7- 27.30, OR8- 27.11, OR9- 27.76, OR11- 22.94.
Humidity Levels documented for February 10, 2011:
OR3- 22.60, OR7- 28.53, OR10- 26.04, OR11- 13.36.
Humidity Levels documented for February 3, 2011:
OR3- 18.11, OR4- 23.67, OR5- 21.26, OR6- 21.18, OR7- 21.08, OR10- 22.78, OR11- 10.17.
Humidity Levels documented for January 23, 2011:
OR3- 24.16, OR6- 25.41, OR7- 24.75, OR11- 15.98.

Based on document review and interview, the facility failed to maintain the Emergency Power Supply System (EPSS) in accordance with NFPA 110, affecting all of the facilities buildings. This was evidenced by failing to maintain weekly maintenance schedules on the EPSS from 2010 through April 2011. This had the potential for generator failure during a power outage, resulting in injury to patients, visitors, and staff.

NFPA 110, Standard for Emergency and Standby Power System, 1999 Edition
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. (see figure Figure A-6-3.1(a) in NFPA 110 for suggested maintenance schedule)

Findings:

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave (Bldgs A, B, C, D)
The generator's maintenance records were requested for review from the Director of Facilities Management on 04/18/2011 at 10:30 a.m. The records received, when reviewed on 04/19/2011 at 11:10 a.m., did not contain a written schedule of weekly visual inspections from January 2010 through April 2011. The records were requested once again on 04/21/2011 at 2:30 p.m. from the Manager of Facilities Operation. The Manager of Facilities Operation stated that the person responsible for maintaining the generator was on vacation and unavailable for an interview. The facility was given the opportunity to fax over records if found, but none were received as of 04/29/2011.

Based on observation, the facility failed to maintain electrical safety as evidenced by electrical appliances plugged into extension cords and multi-plug power strips and not directly into electrical outlets, and, as evidenced by broken electrical components and exposed energized parts. This could result in an increased risk of electrical fire and potential injury to patients and staff.

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

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

Findings:

During a tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the electrical system was observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, on the Basement level:
At 10:53 a.m., in the Engineering Office, there was a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall.

At 10:56 a.m., there was an electrical panel missing the latch creating a 1 inch x 1 inch round hole through the metal panel door. The panel door was held closed by a screw. When interviewed on April 18, 2011 at 10:56 a.m., the Director of Facilities Management stated that they had a work order issued on April 13, 2011 requesting the new replacement latch.

At 11:12 a.m., in the Engineering Break Room there was a microwave plugged into a multi-outlet adapter and not directly into the wall.

At 11:35 a.m., in the Materials Management office there was a microwave plugged into a multi-outlet adapter and a refrigerator plugged into an extension cord.

On April 18, 2011, in Building C, 1st floor:
At 4:03 p.m., in the Soiled Utility Room C1, there was an electrical box missing the cover plate.

At 4:15 p.m., in the Med Room in the Emergency Department there was a refrigerator plugged into a multi-outlet adapter and not directly into the wall.

On April 19, 2011, in Building C, 2nd floor:
At 9:00 a.m., in the OR Staff Lounge, there was a refrigerator plugged into an extension box and not directly into the wall.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, " A " Building-First Floor:
At 10:40 a.m., in the Financial Services break room the refrigerator and microwave was plugged into a black extension cord and not directly into the wall receptacle.

At 10:45 a.m., in the Marketing office, the refrigerator and microwave oven was plugged into a power strip not directly into the wall receptacle.

At 10:55 a.m., Information desk had a white extension cords plugged into a power strip.

At 10:56 a.m., in the Chief Nursing office there was a power strip plugged into a power strip.

At 11:08 a.m., in the Best Upon Request office there was a white extension cord in use.

At 11:12 a.m., in the Nutrition Clinical Manager office the refrigerator and microwave were plugged into a power strip and not directly into the wall receptacle.

At 11:27 a.m., in the Risk Management office there were three extension cords in use.

On 4/18/11, "D" Building-First Floor:
At 1:23 p.m., in the EEG office there was a power strip plugged into a power strip.

At 1:32 p.m., in the Medical Records work room there was a brown extension cord in use.

On 4/18/11, "B" Building-First floor:
At 1:58 p.m., in the GI Lab Managers offices there was a broken electrical outlet located next to the shredder.

On 4/18/11, "B" Building-Third Floor:
At 3:15 p.m., the electrical faceplate located across bed "B" in room B372 was broken.

On 4/19/11, "B" Building-Fifth Floor:
At 9:13 a.m., in the Nurses Lounge the microwave was plugged into a power strip and not directly into the wall receptacle.

On 4/19/11, "C" Building-fourth Floor:
At 9:49 a.m., in Clean Linen room C430.4 the two red emergency outlets were missing the face plate.

On 4/19/11, Evans Park Medical Arts Building (POB 2), Suite 219:
At 2:30 p.m., there was a broken ground port in the Technician work area.
At 2:45 p.m., the microwave was plugged into a power strip and not directly into the wall receptacle.

On 4/19/11, Community Professional Building (POB 1), Suite 308:
At 3:55 p.m., there was a 3 outlet adapter in use and plugged into the wall receptacle that had no overcurrent protection.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave., (Bldgs. A, B, C, & D)
On 04/18/2011, at 11:19 a.m., the multi-outlet in the Office used by the Trauma Clinical Care Specialist, located on the 1st Floor in Building A, had a broken receptacle that exposed its energized parts.

On 04/18/2011, at 11:42 a.m., the wall to the " Gross Room " in the Pathology Laboratory, located on the 1st Floor in Building A, had exposed electrical parts by the working area.

On 04/18/2011, at 3:15 p.m., a receptacle wall outlet in the South Shower Room, located on the 3rd Floor in Building B, was not completely covering its energized parts.

On 04/18/2011, at 3:17 p.m., the lighting unit in the hallway of the South Shower Room, located on the 3rd Floor in Building B, did not have a cover to its energized components.

On 04/18/2011, at 3:19 p.m., the receptacle wall outlet between patients' beds in Room 366, located on the 3rd Floor in Building B, had a broken cover.

On 04/18/2011, at 3:24 p.m., the receptacle wall outlet in Room B362, located on the 3rd Floor in Building B, was not securely flushed to the wall.

On 04/18/2011, at 3:25 p.m., the receptacle wall outlet between patients' beds in Room B357, located on the 3rd Floor in Building B, did not have a cover.

On 04/19/2011, at 9:22 a.m., the storage room by the South Nursing Station, located on the 6th Floor in Building B, had multiple cables and exposed energized parts.

On 04/19/2011, at 9:31 a.m., the receptacle wall outlet behind Bed A in Room B674, located on the 6th Floor in Building B, had a broken cover.

On 04/20/2011, at 1:22 p.m., the lighting unit in the corridor above the door to Operating Room 5, located on the 2nd Floor in Building C, did not have a cover to its energized components.

On 04/20/2011, at 1:24 p.m., the lighting unit in the corridor above the door to Operating Room 8, located on the 2nd Floor in Building C, did not have a cover to its energized components.

Based on observation, the facility failed to:
Maintain the integrity of their fire barrier walls on horizontal corridor connections by providing at least a 2- hour fire barrier wall and a door with at least a 1-1/2 hour fire protection rating. This was evidenced by penetrations in fire barrier walls and a door not installed within this separation in the 1st Level Floor of the Main Hospital Building. This affected 4 of 4 buildings with 2-hour fire barrier compartments in the Main Hospital Building;
Maintain the integrity of common wall separations in POB1, Suite 308 by providing at least a 1-hour fire barrier wall as evidenced by penetrations and openings on walls that have been separated from other business occupancies which affected 1 of 3 suites;
In POB 2, Suites 219 & 309, the facility failed to maintain the integrity of common wall separations by providing at least a 1-hour fire barrier wall as evidenced by penetrations on walls that have been separated from other business occupancies affecting 2 of 3 suites. This had the potential to allow the spread of smoke and fire from one building to another building, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire barrier walls were observed.

SURVEYOR 29626
Main Hospital @ 4445 Magnolia Ave. (Buildings A, B, C, & D)
On 04/18/2011, at 10:40 a.m., the fire barrier wall, located on the 1st Floor between Building A and Building B by the financial services department, had three penetrations above the drop down ceilings and above the fire doors. Two penetrations were located underneath electrical conduits, measuring approximately 1/4-inch each. The third penetration was surrounding a pipe that measured approximately 2-inches in diameter with green material that was used but did not completely seal penetrations, exposing an approximately ?-inch hole.

On 04/18/2011, at 10:43 a.m., the fire barrier wall, located on the 1st Floor between Building A and Building B by the PBX (Private Branch Exchange) Office, had a penetration above the drop down ceiling. The penetration surrounded an electrical conduit that measured approximately 3-inches.

On 04/18/2011, at 1:38 p.m., the fire barrier wall, located on the 1st Floor between Building B and Building D by the Outpatient Pre-Operation/Observation Unit, had a fire rated door frame with no door installed. This left an opening that measured approximately 32-inches x 80-inches.

On 04/18/2011, at 2:12 p.m., the fire barrier wall, located on the 1st Floor between Building B and Building C by the Emergency Departments 1 & 2, had a penetration above the drop down ceiling. The unsealed penetration was within a piped sleeve with cables running through it.

Community Professional Building @ 4000 14th Street (POB 1, Ste. 308)
On 04/19/2011, at 3:57 p.m., the fire barrier wall separating the corridor and Suite 308, located on the 3rd Floor, had a penetration that measured approximately 1-foot by 4-inches. This was located above the drop down ceiling on the corner of the corridor by the entrance of the Suite.

Based on observation, the facility failed to maintain the integrity of the building construction as evidenced by unsealed penetrations in the walls and ceilings. This could result in faster spread of fire and smoke through compartments causing potential harm to patients and staff in the event of a fire. This affected the Riverside Community Main Hospital, Community Professional Building (POB1) and Evans Park Medical Arts Building (POB2).

Findings:

During a tour of the facility with Hospital Staff On April 18, 2011 through April 21, 2011, the facility walls and ceilings were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, Basement level:
At 10:53 a.m., in the Engineering Office on the Basement level there was a 1 inch round penetration in the wall behind the printer.

At 11:40 a.m., the Linen Room had a 3 inch x 4 inch penetration in the wall.

At 11:45 a.m., the door to the Laundry Room was missing the door handle creating a 2 inch x 2 inch round penetration in the door that leads into the Laundry Room.

At 11:46 a.m., in the Laundry Room Storage area there was a 5 inch x 5 inch penetration in the right wall by the towels and blankets.

At 1:28 p.m., in the Electrical Room next to Room B-0213, there was a 4 inch x 2 inch penetration around the electrical pipe in the right wall.

At 1:35 p.m., in the Bench Room in the IT area there were 11 penetrations approximately ? inch round each in the wall and 4 penetrations approximately ? inch round each in the wall of the IT main area.

At 1:53 p.m., in the Janitor closet next to the elevators there were three, 1 inch round penetrations in the wall.

At 1:55 p.m., in the Information Systems room there were five, 1 inch round penetrations in the wall.

At 2:15 p.m., in the Respiratory Storage Room there were 4 penetrations approximately 1 inch round each in the wall above the ultrasonic cleaner machine.

At 2:16 p.m., in the Storage Room used by IT there were 4 penetrations approximately 1 inch round each in the wall.

At 3:50 p.m., there was a 1 inch x 1 inch square penetration in the overhang in the exit access from the Heart Care Institute to the outside.

On 4/19/11, 2nd floor of Building C:
At 8:45 a.m., in the Frozen Section Lab C224 there was a penetration approximately 2 inch x 2 inch due to a missing electrical box cover on the left wall.

At 8:50 a.m., there was a 5 inch x 5 inch penetration in the crawl space above the ceiling tiles viewed through the access panel labeled " D.D 10 + 11 "by Room C224.1 Janitors Closet" .

At 8:55 a.m., in the Business Office, there were 8 penetrations approximately ? inch round each in the wall where a board had been removed per the PACU Manager.

At 8:56 a.m., in the Education Room by the ORs there were 2 penetrations approximately 2 inches x 2 inches square by the clock. One penetration did not have a metal electrical box and you could see the back side of the sheet rock of the corridor wall.

At 9:00 a.m., when looking through the access panel by OR 9, there was a 6 inch x 6 inch penetration in the corridor wall above the ceiling tiles.

On 4/19/11, 4th floor of Building C:
At 9:43 a.m., there were 2 penetrations approximately ? inch each in the wall next to Room C403.

At 9:48 a.m., there were 2 penetrations approximately ? inch each in the wall next to room C415.

On 4/19/11, Evans Park Medical Arts Bldg. (POB2) @ 4500 Brockton, Ste. 101, 219 and 309
At 1:52 p.m., there was a 2 inch x 2 inch round penetration in the wall above the door in the room where the fire alarm panel is located on the 1st floor.

On 4/19/11, Community Professional Bldg. (POB1) @ 4000 14th Street, Ste. 102, 109, 308
At 3:50 p.m., in Suite 308 there was one penetration in the wall and one penetration in the ceiling of the Storage Closet off of the new Xerox room approximately 1 inch x 1 inch round each.

On 4/20/11, Building C, 2nd floor Operating Rooms 1-9 areas:
At 1:25 p.m., there was a 12 inch x 5 inch penetration in the right wall of the Soiled Linen & Utility Room C238.

At 1:35 p.m., there were two, 1 inch round penetration in the Store room back wall.

On 4/20/11, Building C, 4th floor:
At 2:23 p.m., there was a 3 inch x 3 inch round penetration in the MIC corridor wall behind the left smoke barrier door.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, "A" Building - First Floor:
At 10:41 a.m., in the Financial Services Break Room there was a ? inch penetration in the back wall.

At 10:48 a.m., in the Marketing Office there was a ? inch penetration in the ceiling around a conduit.

At 10:53 a.m., in the Cashier Office there was a 4 inch by 4 inch penetration in the wall above the file cabinet.

At 11:20 a.m., the Case Management Office printer room had a ? inch penetration in the left wall around wires and conduits.

On 4/18/11, "B" Building - Fourth Floor:
At 3:55 p.m., the Electrical Room that is located in the Nurse Charting room had a 1 inch penetration in the ceiling around a conduit.

On 4/19/11, "B" Building-Fifth Floor:
At 9:10 a.m., in the Conference Room there was a 2 inch penetration in the wall below the light switch.

On 4/19/11, "C" Building-Fourth Floor:
At 9:58 a.m., in Patient room C426 there was a 4 inch penetration in the wall behind the bed.

On 4/20/11, "C" Building -3rd floor:
At 1:22 p.m. in the Visitors Break Area there was a 4 inch by 6 inch penetration and a 4 inch in diameter penetration behind the vending machine.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue
On 04/18/2011, at 3:22 p.m., there were 4 penetrations on the wall in Room B362, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:24 p.m., there was a penetration on the wall in Room B359 that measured approximately 1/2-inch.

On 04/18/2011, at 3:27 p.m., there were 4 penetrations on the wall in Room B356, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:29 p.m., there were 8 penetrations on the wall in Room B353, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:31 p.m., there were 4 penetrations on the wall in Room B351, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:32 p.m., there were 4 penetrations on the wall in Room B352, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 3:33 p.m., there were 3 penetrations on the wall in Room B350, with each one measuring approximately 1/4-inch.

On 04/18/2011, at 4:26 p.m., there was a penetration on the wall in Room B261 that measured approximately 1/2-inch.

On 04/18/2011, at 4:28 p.m., there was a penetration on the wall in Room B259 that measured approximately 1/2-inch.

On 04/19/2011, at 9:09 a.m., there were 2 penetrations on the wall above a sharps dispenser in Room B660, with each one measuring approximately 1/4-inch.

On 04/19/2011, at 9:12 a.m., there was penetration on the wall behind Bed B in Room B658 that measured approximately 4-inches by 12-inches.

Based on observation, the facility failed to maintain the integrity of the building construction of the corridor walls as evidenced by unsealed penetrations in the facility's corridor walls that could result in the spread of fire and smoke. This had the potential of harming patients and staff with burns and/or smoke inhalation in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2001 through April 21, 2011, the corridor walls and were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Ave.
On 4/18/11, Basement level:
At 1:25 p.m., in the corridor wall next to the Soiled Utility Room B-023.14, the old pull station had been removed and a cover plate had been added. The cover plate failed to cover the entire hole and there was a 1 inch x 3 inch long penetration down the side of the cover plate.

At 2:40 p.m., in the corridor wall next to the Diabetes Solutions office there were two, 1 inch round penetrations by the sink.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave. (Buildings A, B, & D)
On 04/18/2011, at 12:06 p.m., there were 3 penetrations on the corridor wall on the 1st Floor in Building A by the cafeteria. The penetrations were located above the drop down ceiling. The first penetration measured approximately 8-inches by 2-inches, the second penetration measured approximately 8-inches by 1/2-inch, and the third penetration measured approximately 8-inches by 1-1/2 inches.

On 04/18/2011, at 1:17 p.m., there was a penetration on the corridor wall on the 1st Floor in Building D by the Medical Records Office. The penetration measured approximately 1/2-inch.

On 04/18/2011, at 1:50 p.m., there was a penetration on the corridor wall on the 1st Floor in Building B by CT Room 1. The penetration was above the drop down ceiling that measured approximately 1/2-inch and surrounded an electrical conduit.

On 04/18/2011, at 3:56 p.m., there was a penetration on the corridor wall on the 4th Floor in Building B, North, by the Computer Room. The penetration was surrounded by a red colored compound material that did not completely seal a hole that measured approximately 1-inch by 2-inches.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Ave.
On 4/19/11, "C" Building-Fourth Floor:
At 9:55 a.m., the corridor wall across Patient room C438 had a 6 inch by 6 inch penetration in the wall.

At 10:09 a.m., the corridor wall entering the C432 Unit had a 3 inch by 4 inch penetration in the wall.

On 4/20/11, "B" Building-Fourth Floor:
At 2:19 p.m., the corridor wall across Patient room B480, had a 1/4 inches by penetration above the manual pull station where the old pull station was removed.

Based on observation, the facility failed to maintain corridor doors as evidenced by corridor doors that failed to positive latch and/or were blocked from closing. This would allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients, staff and visitors in the event of a fire.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the facilities corridor doors were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 1:40 p.m., the door to the " Hospitalist RPN Case Management " office had a door that failed to positive latch due to a door wedge that prevented it from closing.

On April 18, 2011 in Building C, 2nd floor:
At 4:40 p.m., the door to the Break Room C250.4 had a door that failed to positive latch due to two chairs pushed up against the door preventing it from closing.

On April 20, 2011, Building B, 2nd floor:
At 11:45 a.m., the door to C-Section Supply Room was equipped with a self closing device. The door was held open to the fullest extent and allowed to close but, failed to positive latch upon closure.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, "A" Building-First Floor:
At 10:58 a.m., in the Medical Staff Library, the copy room door that is equipped with a self-closure was held open by a wedge.

At 11:05 a.m., the COP door is equipped with a self-closure and was held open by a floor fan.

At 11:40 a.m., the Laboratory Storage Room with a self-closure was held open by boxes.

On 4/18/11, "D" Building, 2nd Floor:
At 2:31 p.m., Room 205.1 Janitor's closet door closure was disassembled.

On 4/18/11 "D" Building, 3rd Floor:
At 3:05 p.m., the door to Patient room D301 failed to latch when closed.

Community Professional Building @ 4000 14th Street (POB 1, Ste. 109)
On 4/19/11:
At 3:38 p.m., the MRI/Computer Room 1 failed to latch upon self-closure.

On 4/20/11, Riverside Community Hospital @ 4445 Magnolia Avenue
"C" Building Second Floor:
At 1:15 p.m., the double doors next to the Pre Op entrance failed to latch upon self-closure, the self-closure was broken.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue
On 04/18/2011, at 2:00 p.m., the door leading into the corridor from CT Room 2, located on the 1st Floor in Building B, had tape on the latching mechanism that prevented the door from positively latching.

On 04/18/2011, at 3:33 p.m., the door leading into the corridor from Room B350, located on the 3rd Floor in Building B, did not positively latch upon closing.

On 04/18/2011, at 3:38 p.m., the door leading into the corridor from the Nourishment Room by the South Nursing Station, located on the 3rd Floor in Building B, did not positive latch upon closing by the self-closing mechanism.

On 04/20/2011, at 10:55 a.m., the roll down door between the Emergency Department Treatment/Triage Area and Waiting Room, located on the 1st Floor in Building C, was blocked from fully closing by medical records and binders upon the activation of a smoke detector.

Based on observation, the facility failed to maintain the integrity of the walls in the stairwells by providing at least a 1-hour fire barrier wall. This was evidenced by penetrations on walls to a stairwell, affecting 1 of 3 suites in POB1, Ste. 308. This had the potential to allow the spread of smoke and fire into the stairwell exit, resulting in injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire barrier walls in the stairwells were observed.

SURVEYOR 29626
Community Professional Building @ 4000 14th Street (POB 1, Ste. 308)
On 04/19/2011, at 3:47 p.m., the wall in the stairwell on the 1st Floor, located by the Main Lobby, had two penetrations that measured approximately ?-inches each.

On 04/19/2011, at 3:48 p.m., the wall in the stairwell on the 2nd Floor, located by Suite 214, had a penetration that measured approximately 1/2-inch.

Based on observation, the facility failed to ensure that the smoke barrier doors could protect against fire as evidenced by smoke barrier doors that failed to release from the magnet. This could allow smoke and fire to travel throughout the facility and increase the risk of harm to the patients and the staff in the event of a fire.

Findings:

During a tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the facility doors were observed.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue, (Bldg. B & D)
On 4/20/11, "B" Building-Third Floor:
At 2:10 p.m., the fire doors in Pediatrics 3 North, the leaf next to the Managers Office failed to release from its hold open device during the testing of the fire alarm system.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls and provide at least a one-half hour fire resistance rating. This was evidenced by penetrations in smoke barrier walls. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of fire, resulting in burns and/or smoke inhalation.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the smoke barrier walls were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Ave.
On 4/18/11, Basement level:
At 2:48 p.m., above the smoke barrier doors and the drop down ceiling tiles leading to Building C, there was a 1 foot x 6 inch penetration around 3 metal pipes in the wall.

At 3:10 p.m., above the smoke barrier doors and the drop down ceiling tiles leading to the Heart Care Institute, there was a 1 inch x 1 inch penetration around the pipe.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs. B & D)
On 04/18/2011, at 2:29 p.m., the smoke barrier wall by Room 208, located on the 2nd Floor in Building D, had three penetrations above the drop down ceiling. The first two penetrations measured approximately 1/4 inch each and the third penetrations measured approximately 1/2 inch.

On 04/18/2011, at 3:07 p.m., the smoke barrier wall by Room B352, located on the 3rd Floor in Building B, had two penetrations above the drop down ceiling. The penetrations measured approximately 2 inches each.

On 04/18/2011, at 3:48 p.m., the smoke barrier wall by Room B3474, located on the 4th Floor in Building B, had a penetration above the drop down ceiling. The penetration was surrounded by a red colored compound material that did not completely seal a hole that measured approximately 1/2 inch by 1 inch.

On 04/19/2011, at 8:40 a.m., the smoke barrier wall by Elevator 6R, located on the 6th Floor in Building B, had a penetration above the drop down ceiling. The penetration was above electrical conduits and had a cable running through it, measuring approximately 3 inches.

On 04/19/2011, at 8:46 a.m., the smoke barrier wall by Room B670, located on the 6th Floor in Building B, had a penetration above the double doors and above the drop down ceiling. The penetration had a wire mesh that did not completely seal, measuring approximately 3 inches by 4 inches.

SURVEYOR 21101
On 4/19/11, "C" Building-Fourth Floor:
At 10:10 a.m., the smoke barrier wall entering C432 Unit had two penetrations; a ? inch penetration around a conduit in the right side of the wall and a ? inch penetration next to the cable tray on the left side of the wall.

Based on observation, the facility failed to maintain the integrity of the walls and doors in hazardous areas by providing at least a one hour fire resistance rating as evidenced by penetrations in rooms considered hazardous. This had the potential to allow the rapid spread of smoke and fire, resulting in injury to patients and staff.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, hazardous areas were observed.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs A & B)
On 04/18/2011, at 11:14 a.m., there were penetrations on the wall to the Employment Office, located on the 1st Floor in Building A. The office was considered a hazardous area because the size of the room was greater than 50 square feet and the room contained combustible paper documents that covered approximately a quarter of the room. The penetration was approximately ? inch that surrounded a pipe sleeve. Within the pipe sleeve, there was a network cable running through it that was unsealed.

On 04/18/2011, at 3:36 p.m., there were over 20 penetrations on the wall to the Clean Linen Room by the South Nursing Station, located on the 3rd Floor in Building B. The storage room was considered a hazardous area because the room size was greater than 50 square feet and the room contained combustible materials. The penetrations were approximately 1/4 inch each. Also, the door to the room did not positively latch upon closing by the self-closing mechanism.

On 04/19/2011, at 9:24 a.m., there were two penetrations on the wall to the Soiled Utility Room by the South Nursing Station, located on the 6th Floor in Building B. The room was considered a hazardous area because the size of the room was greater than 50 square feet and the room contained combustible materials. The penetrations were approximately 1/4-inch each.

Based on observation, the facility failed to maintain the doors in stairways used as exits as evidenced by stairwell doors that failed to positively latch. This had the potential for fire and smoke to spread, rendering the stairway non-usable for patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the stairwell egresses were observed.

SURVERYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs B & C)
On 04/19/2011, at 9:44 a.m., the latching mechanism to the door in Stairwell 1, located on the Basement Floor in Building B, failed to positively latch.

On 04/19/2011, at 9:55 a.m., the latching mechanism to the door in Stairwell 3, located on the 3rd Floor in Building C, failed to positively latch.

On 04/20/2011, at 2:36 p.m., the latching mechanism to the door in Stairwell 3, located on the 5th Floor in Building C, failed to positively latch.

Based on observation, the facility failed to maintain their exit access so that exits were readily accessible at all times. This was evidenced by medical equipment, blue laundry tubs, metal racks and other equipment and/or supplies in the exit access corridors that lead to the exit discharge. This has the potential to cause harm to patients and staff in the event of an evacuation due to a fire.

Findings:

During the tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the exits were observed.

SURVERYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 11:28 a.m., the exit path of egress outside the Emergency Room was blocked by 3 laundry carts approximately 5ft wide by 6ft tall, boxes, wooden pallets, metal racks, recycling boxes, trash containers and a shopping cart.

At 11:50 a.m., there were 20 laundry bins approximately 5ft wide by 6ft tall in the exit path of egress outside the Laundry on the loading dock.

At 2:20 p.m., there were two wooden boxes approximately 8 ft long x 3 ft wide x 4ft tall each stacked one on top of the other and, a wooden pallet approximately 6ft x 5ft high in the corridor next to the " Director of Rehab Services " office in the Rehab/Speech therapy area.

On April 18, 2011, Building C 1st floor:
At 3:50 p.m., there was a large stack approximately 10 feet wide x 5 ft tall of cardboard boxes that had been broken down in the exit path to the outside from the Heart Institute. The path was marked by red paint to be kept clear.

At 4:30 p.m., there were boxes, a shredder, patient bed and chairs in the corridor across from C131.

At 4:31 p.m., there were chairs with patients sitting in them on both sides of the corridor approximately 1 foot from the smoke barrier doors.

On April 18, 2011, Building C 2nd floor:
At 4:40 p.m., there were 5 patient beds in the corridor leading to the Operating Rooms.

On April 19, 2011, Building C 2nd floor:
At 8:30 a.m., there was a Davinici Machine, two Flouroscan machines, 1 Orthopedic machine and one Exposcop 700 machine in the corridor by Room "C240 Anesthesia".

SURVERYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldgs. A & B)
On 04/18/2011, at 11:01 a.m., the exit door to the overflow cafeteria, located on the 1st Floor in Building A, was obstructed by items that prevented the door from fully opening. The items observed along the pathway of the exit discharge included a rubber floor mat and boxes. The door was marked with an exit sign.

On 04/18/2011, at 11:36 a.m., the exit discharge to the Microbiology Area, located on the 1st Floor in Building A and along the loading dock, had items obstructing its pathway. The items observed along the pathway included 7 palettes, 2 carts, and a trash can. The door to this exit discharge was marked with an exit sign.

On 04/19/2011, at 10:17 a.m., the exit discharge from Stairwell 1, located on the 1st Floor in Building B, had a metal platform obstructing its pathway. The platform was approximately 3-inches in vertical height, 8-inches horizontal width, and extended within the pathways length. The door to this exit discharge was marked with an exit sign. There was no markings and no lighting on the platform.

Based on observation, the facility failed to maintain illumination throughout means of egress. This was evidenced by lighting units that failed to illuminate and no lighting unit present in an exit discharge. This had the potential for delaying evacuation and causing injury to patients, staff, and visitors.

Findings:

During a tour of the facility with the Hospital Staff, the illumination throughout egress paths were observed.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldg. B)
On 4/19/11,
At 9:20 a.m., the Exit Sign next to the Social Services was not illuminated and when tested did not illuminate

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Avenue (Bldg. B)
On 04/18/2011, at 11:01 a.m., the lighting units on the 4th Floor in Stairwell 4 failed to illuminate 2 of 2 units.

On 04/19/2011, at 10:17 a.m., the exit discharge from Stairwell 1, located on the 1st Floor in Building B, had no lighting unit in the area.

Based on observation, the facility failed to maintain exit signs and directional signs as evidenced by missing signs and non-illuminating exit signs. This could have the potential for delaying evacuation of patients and incorrectly directing evacuees into a non-exit area during an emergency.

NFPA 101 Life Safety Code, 2000 Edition
7.2.2.5.4 Stair Identification Signs. Stairs serving five or more stories shall be provided with signage within the enclosure at each floor landing. The signage shall indicate the story, the terminus of the top and bottom of the stair enclosure, and the identification of the stair enclosure. The signage also shall state the story of, and the direction to, exit discharge. The signage shall be inside the enclosure located approximately 5 ft (1.5 m) above the floor landing in a position that is readily visible when the door is in the open or closed position.

Findings:

During a tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the exits, exit signs and their illumination were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 3:15 p.m., there was no " Exit " sign over the doors leading to the parking structure from the Heart Institute area.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave (Bldgs. A, B, & C)
On 04/18/2011, at 11:03 a.m., the exit sign above the door in the overflow cafeteria, located on the 1st Floor in Building A, did not illuminate. The radioactive exit sign was marked with a replacement date of October 2008.

On 04/18/2011, at 11:21 a.m., the door leading to an exit discharge by the Employment Office, located on the 1st Floor in Building A, did not have an exit sign.

On 04/18/2011, at 2:03 p.m., the exit sign above the door to CT Room 2, located on the 1st Floor in Building B, did not illuminate.

On 04/18/2011, at 2:08 p.m., the exit sign above the door that leads into Stairwell 3, located on the 1st Floor in Building C, did not illuminate. The radioactive exit sign was marked with a replacement date of October 2008.

On 04/19/2011, at 9:58 a.m., 2 of 2 doors inside Stairwell 3, located on the 1st Floor in Building C, did not display sign/s to identify if each door was an exit or not an exit.

On 04/19/2011, between 10:00 a.m. and 10:15 a.m., the outside stairwell in Building B did not have a sign displaying the required stair identification on the 6th Floor, 5th Floor, 4th Floor, 3rd Floor, 2nd Floor, and 1st Floor.

Based on records review, the facility failed to ensure that all staff members were aware of their duties to protect patients in the event of a fire. This was evidenced by a fire drill report that did not include names of staff members who participated in a drill. This had the potential for staff members to not properly respond to an emergency situation, such as a fire, that could result in harm to patients and staff.

Findings:

During document review with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire drill records were reviewed.

SURVEYOR 29626
Community Professional Building @ 4000 14th Street (POB 1: Suite 102, 109, & 308)
The fire drill records were requested for review from the Director of Facilities Management on 04/18/2011 at 10:30 a.m. The records received, when reviewed on 04/21/2011 at 1:30 p.m., did not contain any names of staff members who had participated in a fire drill conducted on 03/29/2011 at 10:00 a.m. for POB I - Suites 102, 109 , and 308.

Evans Park medical Arts Building @ 4500 Brockton Ave (POB 2: Suite 101)
The fire drill records were requested for review from the Director of Facilities Management on 04/18/2011 at 10:30 a.m. The records received, when reviewed on 04/21/2011 at 1:35 p.m., did not contain any names of staff members who had participated in a fire drill conducted on 03/29/2011 at 10:30 a.m. for POB II - Suite 101.

Based on observation and interview, the facility failed to provide protection if their fire alarm control unit as evidenced by the fire alarm control panel with no smoke detector or heat detector installed, affecting 3 of 3 suites in the POB 2 and, the facility failed to maintain the fire alarm system as evidenced by failing to provide effective warning of fire as evidenced by strobes and chimes that failed to alarm and/or could not be heard. This could result in fire alarm system failure and delay in notifying visitors and staff of a fire in the facility, causing potential injury.

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

NFPA 72 National Fire Alarm Code, 1999 Edition
4-3.2.1 Audible notification appliances intended for operation in the public mode shall have a sound level of not less than 75 dBA at 10 ft (3 m) or more than 120 dBA at the minimum hearing distance from the audible appliance.
4-3.2.2 To ensure that audible public mode signals are clearly heard, they shall have a sound level at least 15 dBA above the average ambient sound level or 5 dBA above the maximum sound level having a duration of at least 60 seconds, whichever is greater, measured 5 ft (1.5 m) above the floor in the occupiable area.

NFPA 101, 2000 Edition
9.6.3.6 Notification signals for occupants to evacuate shall be by audible and visible signals in accordance with NFPA 72, National Fire Alarm Code, and CABO/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities, or other means of notification acceptable to the authority having jurisdiction shall be provided.
9.6.3.8 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level occurring under normal conditions of occupancy.
9.6.3.9 Audible alarm notification appliances shall produce signals that are distinctive from audible signals used for other purposes in the same building.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire alarm control panel, strobes and chimes were observed.

SURVEYOR 29626
Evans Park medical Arts Building @ 4500 Brockton Ave (POB 2: entire building)
On 02/23/2011, at 2:00 p.m. the fire alarm system control panel, located on the 1st Floor, did not have a smoke detector or heat detector installed. The room, where the fire alarm control panel was installed, was not continuously occupied.

Riverside Community Hospital @ 4445 Magnolia Avenue
On 04/20/2011, at 10:00 a.m., the fire alarm was activated in the Basement in Building D. The alarm sound was not audible and no visual signal was visible in the Woodshop Suite.

SURVEYOR 27961
Community Professional Building (POB1) @ 4000 14th Street, Suite 102, 109, 308
On April 19, 2011,
At 3:35 p.m., in Suite 109, the fire alarm notification devices were activated and the alarms were not heard by surveyor or staff. When interviewed on April 19, 2011 at 3:35 p.m., Hospital Staff was asked if they could hear the alarms and they stated that they could not.

At 3:50 p.m., in Suite 308, the strobe/chime device was pushed up through the ceiling tiles.

Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/20/11, Basement level:
At 9:23 a.m., in the Sterile Processing C006 OR/SPD area, the fire alarm notification devices were activated and the alarms were not heard by surveyor or staff. When interviewed on April 20, 2011 at 9:23 a.m., Hospital Staff stated that they could not hear the fire alarm.

At 9:23 a.m., in the OR/SPD area the bell on the wall failed to activate.

At 9:45 a.m., the strobe by the Director of EVS office failed to activate after testing of the smoke detector.

At 10:34 a.m., in the Pharmacy on the 1st floor there was a chime that was covered with clear packing tape which prevented it from being heard when the smoke detector and pull station was activated.

On 4/20/11, Building B, 2nd floor:
At 11:35 a.m., the strobes failed on the right and left wall by OR11.

Based on observation, the facility failed to maintain their fire alarm system as evidenced by the batteries past the 4 year replacement date according to NFPA 72. This could cause harm to patients and staff in the event of a fire.

NFPA 72, 1999 Edition
Table 7-3.2 Testing Frequencies (Continued)
7-2.2
Initial/ Table
Component Reacceptance Monthly Quarterly Semiannually Annually Reference
6. Batteries - Fire Alarm Systems
a. Lead-Acid Type - - - - - 6b
1. Charger Test (Replace battery as needed.) X - - - X -
2. Discharge Test (30 minutes) X - - X - -
3. Load Voltage Test X - - X - -
4. Specific Gravity X - - X - -
b. Nickel-Cadmium Type - - - - - 6c
1. Charger Test (Replace battery as needed.) X - - - X -
2. Discharge Test (30 minutes) X - - - X -
3. Load Voltage Test X - - X - -
c. Primary Type (Dry Cell) - - - - - 6a
1. Load Voltage Test X X - - - -
d. Sealed Lead-Acid Type - - - - - 6d
1. Charger Test (Replace battery every 4 years.) X - - - X -
2. Discharge Test (30 minutes) X - - - X -
3. Load Voltage Test X - - X - -

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the batteries in the fire alarm panel were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
At 3:00 p.m., the batteries in the fire alarm panel were dated 1/2/04 and the panel stated "Low Battery".

Based on observation, the facility failed to maintain their automatic sprinkler system as evidenced by sprinklers with escutcheon rings that were not flush to the ceiling and sprinklers that were not free of debris. These could result in the fire sprinkler system not functioning as designed and increased risk of injury to residents and staff.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the sprinkler system was observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 11:28 a.m., in the Oxygen Storage area outside the building there were 2 of 2 sprinklers covered in dust/debris.

At 2:42 p.m., in the Storage Closet in the Rehab area there was a sprinkler blocked by boxes, supplies, brochures and files approximately 3 inches from the sprinkler.

Evans Park medical Arts Building (POB2) @ 4500 Brockton, Ste. 101, 219 & 309
On April 19, 2011, At 1:58 p.m., in Suite 101, there was a sprinkler missing an escutcheon ring in the Storage area next to the Nurses office.

SURVEYOR 21101
On 4/18/11, "A" Building-First Floor:
At 11:00 a.m., in the Conference Room 1 of 6 sprinkler escutcheon rings was missing.

At 11:03 a.m., in the Medical Staff Library room 1 of 6 sprinkler escutcheon rings were missing.

At 11:32 a.m., in the Microbiology Department 2 of 4 sprinkler escutcheon rings were missing.

On 4/18/11, "D" Building-First Floor:
1:10 p.m., in the EEG Office 1 of 8 sprinkler escutcheon rings was missing .

On 4/18/11, "D" Building-Third Floor:
At 3:05 p.m., the sprinkler escutcheon rings in Patient room D326 had gaps and were not flush with the ceiling.

On 4/18/11, "B" Building-Fourth Floor:
At 3:50 p.m., the sprinkler escutcheon ring in the Clean Linen Room had a gap and was not flush with the ceiling.

At 3:58 p.m., the sprinkler escutcheon ring in Patient room B452 (bathroom) was missing.

On 4/19/20, "B" Building-Fifth Floor:
At 8:49 a.m., the sprinkler escutcheon ring in Patient room B551 (bathroom) was missing.

At 9:05 a.m., the sprinkler escutcheon ring in Patient room B575 (bathroom) had a ? inch gap and was not flush with the ceiling.

At 9:06 a.m., the sprinkler escutcheon ring in Patient room B573 (bathroom) was missing.

Community Professional Building (POB 1) @ 4000 14th Street - Suite 109
On 4/19/11, At 3:44 p.m., the sprinkler escutcheon ring in the MRI/Computer Room II was missing.

Based on observation, the facility failed to ensure that their portable fire extinguishers were easily accessible to allow quick response to fire. This was evidenced by fire extinguishers that were mounted over 5ft from the ground to the top of the pin and fire extinguishers that had an incorrect date on the tag. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff due to fire.

Findings:

During the facility tour with the Hospital Staff on April 18, 2011 through April 21, 2011, the fire extinguishers were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 3:20 p.m., there was a fire extinguisher in the Sterile Supply to OR area that was mounted approximately 5 ft 8 inches above the ground.

On April 18, 2011, Building C, 1st floor:
At 4:10 p.m., there was a fire extinguisher in the Emergency Department by Room C18 that had a date hole punched the 1st and the 27th, no month indicated and the year was hole punched 2013.

Based on observation and interview, the facility failed to ensure that their heating and air conditioning vents were maintained as evidenced by dust and debris discharging from the heating and air conditioning vents during alarm testing. This could result in potential harm to patients and staff.

NFPA 101, 2000 Edition
SECTION 19.5 BUILDING SERVICES
19.5.1 Utilities. Utilities shall comply with the provisions of Section 9.1.
Exception: Existing installations shall be permitted to be continued in service, provided that the systems do not present a serious hazard to life.
19.5.2 Heating, Ventilating, and Air Conditioning.
19.5.2.1 Heating, ventilating, and air conditioning shall comply with the provisions of Section 9.2 and shall be installed in accordance with the manufacturer ' s specifications.

9.2.1 Air Conditioning, Heating, Ventilating Ductwork, and Related Equipment. Air conditioning, heating, ventilating ductwork, and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, or NFPA 90B, Standard for the Installation of Warm Air Heating and Air-Conditioning Systems, as applicable, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction.

NFPA 90A, 1999 Edition
2-3.6 Air Outlets.
2-3.6.1 General. Air supplied to any space shall not contain flammable vapors, flyings, or dust in quantities and concentrations that would introduce a hazardous condition.

Findings:

During alarm testing with the Hospital Staff on April 20, 2011, the smoke detector was tested and a vent in the Exam Room discharged dust and debris.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/20/11, "C" Building
At 10:42 a.m., while testing the fire alarm system in the Emergency Department, dust and debris discharged from the vent in the ceiling in Exam Room C186. Four patients came out of the Exam Room wiping dust and debris from their clothes. The vent was observed to be covered in dust and debris as well as the floor, chair and exam bed. When interviewed on April 20, 2011 at 10:42 a.m., the patients stated that dust and debris had fallen on them while sitting in the Exam Room.

Based on observation, the facility failed to ensure that the oxygen cylinders were properly secured as evidenced by unsecured oxygen tanks, and, the facility failed to ensure oxygen cylinders were not stored with combustible items. This could cause harm to patients and staff in the event the cylinder fell on something or someone and/or the high pressure valve was damaged and caused the cylinder to move about in an uncontrolled manner.

NFPA 99 Health Care Facilities, 1999 Edition
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.

NFPA 99 4-3.1.1.2(a) 7. Combustible materials, such as paper, cardboard, plastics, and fabrics shall not be stored or kept near supply system cylinders or manifolds containing oxygen or nitrous oxide. Racks for cylinder storage shall be permitted to be of wooden construction. Wrappers shall be removed prior to storage.

Findings:

During a tour of the facility with the Hospital Staff on April 18, 2011 through April 21, 2011, the facilities oxygen storage areas and tanks were observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, Basement level:
At 3:20 p.m., there was one unsecured oxygen "E" cylinder tank lying on top of the gurney in the parking structure outside the Sterile Supply /Heart Institute.

At 3:45 p.m., there was one unsecured oxygen "E" cylinder tank and one D cylinder tank laying on the ground in C031 Clean Utility room.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, "B" Building-First Floor:
At 1:52 p.m., there were 6 "E" oxygen tanks stored in Soiled Linen room B102.11. Staff was interviewed and stated the room is used for oxygen storage.

On 4/19/11, " C " Building-Fourth Floor:
At 9:48 a.m., there were 13 "E" oxygen tanks stored in Clean Linen room C430.4 within 1 foot of linen and boxes filled with supplies.

Based on document review and interview, the facility failed to provide a written policy and procedure ensuring the Humidity levels were maintained at 35% or greater for 11 of 11 operating rooms and, the facility failed to provide documentation of corrective actions that were taken to correct the humidity levels when they were out of range. This failure affected the entire surgery suite and could increase the risk of a fire hazard, resulting in potential harm to patients during surgery.

NFPA 101, Life Safety Code 2000 Edition
20.3.2 Protection from Hazards.
20.3.2.2 Anesthetizing locations shall be protected in accordance with NFPA 99, Standards for Health Care Facilities.

NFPA 99, Health Care Facilities 1999 Edition
5-4.1 Ventilation - Anesthetizing Locations.
5-4.1.1 The mechanical ventilation system supplying anesthetizing locations shall have the capability of controlling the relative humidity at a level of 35 percent or greater.

Findings:

During records review and interview with the Manager of Facilities Operations on April 20, 2011 and April 21, 2011, the humidity logs were reviewed.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
The facility provided the Policy and Procedure for Temperature and Humidity Control in Operating Suites. Under Procedure: " B " states Room humidity will be maintained between 30% - 60%. There was a hand written note of 20% - 60% noted above the 30-60 percent. During an interview, the Manager of Facilities Operations stated the facility was in the process of changing the humidity level range to 20%-60%. The Manager of Facilities Operations was asked for documentation for the corrective actions taken when the humidity levels were below the acceptable range. The Manager of Facilities Operations stated they did not document the corrective actions taken when the humidity levels were low for the following dates.

Humidity Levels documented for April 15, 2011:
OR1- 27.55, OR3- 29.74, OR5- 26.80, OR6- 27.10, OR7- 27.08, OR8- 25.71, OR9- 25.35, OR11 -23.45.
Humidity Levels documented for April 4, 2011:
OR1- 28.34, OR4- 28.52, OR5- 28.46, OR7- 27.30, OR8- 27.11, OR9- 27.76, OR11- 22.94.
Humidity Levels documented for February 10, 2011:
OR3- 22.60, OR7- 28.53, OR10- 26.04, OR11- 13.36.
Humidity Levels documented for February 3, 2011:
OR3- 18.11, OR4- 23.67, OR5- 21.26, OR6- 21.18, OR7- 21.08, OR10- 22.78, OR11- 10.17.
Humidity Levels documented for January 23, 2011:
OR3- 24.16, OR6- 25.41, OR7- 24.75, OR11- 15.98.

Based on document review and interview, the facility failed to maintain the Emergency Power Supply System (EPSS) in accordance with NFPA 110, affecting all of the facilities buildings. This was evidenced by failing to maintain weekly maintenance schedules on the EPSS from 2010 through April 2011. This had the potential for generator failure during a power outage, resulting in injury to patients, visitors, and staff.

NFPA 110, Standard for Emergency and Standby Power System, 1999 Edition
6-3.3 A written schedule for routine maintenance and operational testing of the EPSS shall be established. (see figure Figure A-6-3.1(a) in NFPA 110 for suggested maintenance schedule)

Findings:

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave (Bldgs A, B, C, D)
The generator's maintenance records were requested for review from the Director of Facilities Management on 04/18/2011 at 10:30 a.m. The records received, when reviewed on 04/19/2011 at 11:10 a.m., did not contain a written schedule of weekly visual inspections from January 2010 through April 2011. The records were requested once again on 04/21/2011 at 2:30 p.m. from the Manager of Facilities Operation. The Manager of Facilities Operation stated that the person responsible for maintaining the generator was on vacation and unavailable for an interview. The facility was given the opportunity to fax over records if found, but none were received as of 04/29/2011.

Based on observation, the facility failed to maintain electrical safety as evidenced by electrical appliances plugged into extension cords and multi-plug power strips and not directly into electrical outlets, and, as evidenced by broken electrical components and exposed energized parts. This could result in an increased risk of electrical fire and potential injury to patients and staff.

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

NFPA 70 Section 400-8 1999 Ed. Uses not permitted. Unless specifically permitted in section 400-7, flexible cords and cables shall not be used for the following:
(1) As a substitute for a fixed wiring of a structure
(2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors.
(3) Where run through doorways, windows, or similar openings
(4) Where attached to building surfaces
(5) Where concealed behind building walls, structural ceilings, suspended ceilings, or floors
(6) Where installed in raceways, except as otherwise permitted in this code

NFPA 70, National Electrical Code, 1999 Edition
110-12. Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (a) Unused Openings. Unused openings in boxes, raceways, auxiliary gutters, cabinets, equipment cases, or housings shall be effectively closed to afford protection substantially equivalent to the wall of the equipment.
110-56. Energized Parts. Bare terminals of transformers, switches, motor controllers, and other equipment shall be enclosed to prevent accidental contact with energized parts.

Findings:

During a tour of the facility with Hospital Staff on April 18, 2011 through April 21, 2011, the electrical system was observed.

SURVEYOR 27961
Riverside Community Hospital @ 4445 Magnolia Avenue
On April 18, 2011, on the Basement level:
At 10:53 a.m., in the Engineering Office, there was a microwave and refrigerator plugged into a multi-outlet adapter and not directly into the wall.

At 10:56 a.m., there was an electrical panel missing the latch creating a 1 inch x 1 inch round hole through the metal panel door. The panel door was held closed by a screw. When interviewed on April 18, 2011 at 10:56 a.m., the Director of Facilities Management stated that they had a work order issued on April 13, 2011 requesting the new replacement latch.

At 11:12 a.m., in the Engineering Break Room there was a microwave plugged into a multi-outlet adapter and not directly into the wall.

At 11:35 a.m., in the Materials Management office there was a microwave plugged into a multi-outlet adapter and a refrigerator plugged into an extension cord.

On April 18, 2011, in Building C, 1st floor:
At 4:03 p.m., in the Soiled Utility Room C1, there was an electrical box missing the cover plate.

At 4:15 p.m., in the Med Room in the Emergency Department there was a refrigerator plugged into a multi-outlet adapter and not directly into the wall.

On April 19, 2011, in Building C, 2nd floor:
At 9:00 a.m., in the OR Staff Lounge, there was a refrigerator plugged into an extension box and not directly into the wall.

SURVEYOR 21101
Riverside Community Hospital @ 4445 Magnolia Avenue
On 4/18/11, " A " Building-First Floor:
At 10:40 a.m., in the Financial Services break room the refrigerator and microwave was plugged into a black extension cord and not directly into the wall receptacle.

At 10:45 a.m., in the Marketing office, the refrigerator and microwave oven was plugged into a power strip not directly into the wall receptacle.

At 10:55 a.m., Information desk had a white extension cords plugged into a power strip.

At 10:56 a.m., in the Chief Nursing office there was a power strip plugged into a power strip.

At 11:08 a.m., in the Best Upon Request office there was a white extension cord in use.

At 11:12 a.m., in the Nutrition Clinical Manager office the refrigerator and microwave were plugged into a power strip and not directly into the wall receptacle.

At 11:27 a.m., in the Risk Management office there were three extension cords in use.

On 4/18/11, "D" Building-First Floor:
At 1:23 p.m., in the EEG office there was a power strip plugged into a power strip.

At 1:32 p.m., in the Medical Records work room there was a brown extension cord in use.

On 4/18/11, "B" Building-First floor:
At 1:58 p.m., in the GI Lab Managers offices there was a broken electrical outlet located next to the shredder.

On 4/18/11, "B" Building-Third Floor:
At 3:15 p.m., the electrical faceplate located across bed "B" in room B372 was broken.

On 4/19/11, "B" Building-Fifth Floor:
At 9:13 a.m., in the Nurses Lounge the microwave was plugged into a power strip and not directly into the wall receptacle.

On 4/19/11, "C" Building-fourth Floor:
At 9:49 a.m., in Clean Linen room C430.4 the two red emergency outlets were missing the face plate.

On 4/19/11, Evans Park Medical Arts Building (POB 2), Suite 219:
At 2:30 p.m., there was a broken ground port in the Technician work area.
At 2:45 p.m., the microwave was plugged into a power strip and not directly into the wall receptacle.

On 4/19/11, Community Professional Building (POB 1), Suite 308:
At 3:55 p.m., there was a 3 outlet adapter in use and plugged into the wall receptacle that had no overcurrent protection.

SURVEYOR 29626
Riverside Community Hospital @ 4445 Magnolia Ave., (Bldgs. A, B, C, & D)
On 04/18/2011, at 11:19 a.m., the multi-outlet in the Office used by the Trauma Clinical Care Specialist, located on the 1st Floor in Building A, had a broken receptacle that exposed its energized parts.

On 04/18/2011, at 11:42 a.m., the wall to the " Gross Room " in the Pathology Laboratory, located on the 1st Floor in Building A, had exposed electrical parts by the working area.

On 04/18/2011, at 3:15 p.m., a receptacle wall outlet in the South Shower Room, located on the 3rd Floor in Building B, was not completely covering its energized parts.

On 04/18/2011, at 3:17 p.m., the lighting unit in the hallway of the South Shower Room, located on the 3rd Floor in Building B, did not have a cover to its energized components.

On 04/18/2011, at 3:19 p.m., the receptacle wall outlet between patients' beds in Room 366, located on the 3rd Floor in Building B, had a broken cover.

On 04/18/2011, at 3:24 p.m., the receptacle wall outlet in Room B362, located on the 3rd Floor in Building B, was not securely flushed to the wall.

On 04/18/2011, at 3:25 p.m., the receptacle wall outlet between patients' beds in Room B357, located on the 3rd Floor in Building B, did not have a cover.

On 04/19/2011, at 9:22 a.m., the storage room by the South Nursing Station, located on the 6th Floor in Building B, had multiple cables and exposed energized parts.

On 04/19/2011, at 9:31 a.m., the receptacle wall outlet behind Bed A in Room B674, located on the 6th Floor in Building B, had a broken cover.

On 04/20/2011, at 1:22 p.m., the lighting unit in the corridor above the door to Operating Room 5, located on the 2nd Floor in Building C, did not have a cover to its energized components.

On 04/20/2011, at 1:24 p.m., the lighting unit in the corridor above the door to Operating Room 8, located on the 2nd Floor in Building C, did not have a cover to its energized components.