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Based on observation, the facility failed to ensure a door with a self-closure device resists the passage of smoke as evidenced by a door that failed to latch. This failure could result in the potential spread of smoke and fire in the event of a fire resulting in potential harm to residents in 1 of 4 smoke compartments on the second floor.

Findings:

During a tour of the facility with the Plant Operations Safety Manager and Chief Operating Officer on July 27, 2011, the facility corridor doors were observed.

Inland Valley Medical Center (IVMC)
At 1:55 p.m., the door to Clean Utility Room 2161 on the Medical-Surgical West unit, Second Floor failed to latch upon self-closure.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls. This was evidenced by a penetration in a smoke barrier wall. This affected 2 of 12 smoke compartments at Rancho Springs Main Building. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, resulting in injury to patients, staff, and visitors from smoke inhalation.

Findings:

During a tour of the facility with the Plant Operations Manager, Engineer II, and the Director of Plant Operations on July 26, 2011, the smoke barrier walls were observed.

Rancho Springs Medical Center (RSMC)
At 1:49 p.m., the smoke barrier wall in the corridor by the Operation Rooms had a penetration above fire doors labeled 1082 and 1083. The penetration was located above a pipe and it measured approximately one inch.

Based on observation, the facility failed to maintain hazardous area corridor doors as evidenced by a hazardous area corridor door that was not equipped with a self-closing device. This failure affected one smoke compartment, and could result in the transfer of smoke and or fire resulting in potential harm to patients and staff.

Findings:

During a tour of the facility with the Plant Operations Safety Manager and Chief Operating Officer on July 28, 2011, the hazardous areas were observed.

Out Patient Imagining Center (OIC), First Floor Suite 101
At 9:55 a.m., the door to the room designated as a Hazardous room was not equipped with a self -closure as required for hazardous area rooms. There were two large soiled linen bins in the room during observation.

Surveyor: 29626
Based on observation, the facility failed to maintain its hazardous areas by not providing a self-closing mechanism on doors to hazardous rooms. This affected 1 of 7 smoke compartments at Rancho Springs Women's Center/Emergency Department. This had the potential to allow the rapid spread of smoke and fire, resulting in injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Plant Operations Manager, Engineer II, and the Director of Plant Operations on July 27, 2011, hazardous areas were observed.

Women ' s Center/Emergency Department
At 9:01 a.m., the Manager's Office located on the 1st Floor in the Emergency Department, did not have a self-closing mechanism installed on the door. The room contained combustible products such as paper files and cardboard boxes filled with files that covered approximately fifty percent of the room.

Surveyor: 29626
Based on staff interviews, the facility failed to ensure that staff members were aware of the life safety devices installed in their working areas. This was evidenced by a staff who did not know the primary functions of the fire protection devices in the kitchen at Rancho Springs Main Building. 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 a tour of the facility with the Plant Operations Manager and the Director of Plant Operations on July 27, 2011, the facility staff were interviewed to determine their knowledge of their fire emergency procedures and life safety devices.

RSMC
At 11:08 a.m., a kitchen staff was asked how they would activate the fire alarm system by means of the fire alarm manual pull station. The staff member pointed at the kitchen suppression system activation handle instead of the fire alarm manual pull station. The staff could not explain the purpose of the kitchen suppression system.

Surveyor: 29626
Based on observation, the facility failed to ensure that their fire alarm devices are functional and that their manual fire alarm pull stations were easily accessible to allow for quick activation of the fire alarm. This was evidenced by two fire alarm manual pull stations that failed to send a signal to the central monitoring company, an audio/visual fire alarm device that failed to alarm, and one manual fire alarm pull station that was obstructed from view. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Plant Operations on July 27, 2011, the fire alarm system was tested and observed.

RSMC
1. At 9:35 a.m., there was a manual fire alarm pull station in the Intensive Care Unit (ICU) that was obstructed from view by a scale.
2. At 2:07 p.m. and at 2:11 p.m., smoke detectors in Rooms 135 and 121 were activated respectively. The audio/visual device at the Medical Surgical East Nursing Station failed to alarm upon the testing of both smoke detectors, resulting in 1 out of 5 audio/visual devices failure to activate within the smoke compartment.

MRI Trailer @ Rancho Springs
At 3:16 p.m., the central monitoring company failed to receive a signal upon the activation of the manual fire alarm pull station located inside the MRI Trailer.

CT Trailer @ Rancho Springs
At 3:30 p.m., the central monitoring company failed to receive a signal upon the activation of the manual fire alarm pull station.

Surveyor: 29626
Based on observation, the facility failed to ensure the manual fire alarm pull stations were easily accessible to allow for quick activation of fire alarm. This was evidenced by one manual fire alarm pull station that was obstruced from view on the First Floor Women's Center/Emergency Department. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Plant Operations on July 27, 2011, the fire alarm system was tested and observed.

Women's Center/Emergency Department
At 9:35 a.m., the manual fire alarm pull station in the lobby located on the 1st Floor of the Women's Center/Emergency Department was obstructed from view. A stand that contained a tissue box, two mask boxes, and a hand sanitizer was placed in front of the fire alarm pull station. When the volunteer working at the front desk was interviewed and asked if they could point to the nearest manual pull station, they could not locate the fire alarm pull station that was obstructed.

Based on document review and interview, the facility failed to maintain the fire/smoke dampers in accordance with NFPA 90A as evidenced by the failure to test 37 of 165 fire/smoke dampers at Inland Valley Medical Center (IVMC), and 6 of 265 at Rancho Springs Medical Center (RSMC). This had the potential for the fire/smoke dampers to malfunction and fail to contain smoke in the event of a fire, resulting in injury to patients, staff, and visitors from smoke inhalation.

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

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

Findings:

During document review and interview with the Directors of Plant Operations Safety Manager, Chief Operating Officer and Plant Operation Manager on July 26, 2011, from 8:00 a.m., to 11:00 a.m., the fire/smoke damper inspection records were reviewed.

IVMC
At 9:00 a.m., a damper inspection report dated 10/26/2009 was provided for review. The report noted 37 of 165 smoke/fire dampers were not tested and inspected. The Deficiency note stated "access to damper inaccessible, pipes and wiring blocks access and ceiling grid and tiles need to be removed". During an interview, the Inland Valley Medical Center Plant Operations Safety Manager, stated that they have not tested the 37 smoke/fire dampers that were identified to have no access.

RSMC
At 9:30 a.m., the Plant Operations Manager provided testing records that indicated that 4 smoke dampers and 2 fire dampers had not been tested. The report stated the 6 smoke/fire dampers were not tested because they were not accessible. The Director of Plant Operations stated that they have not tested the 6 smoke/fire dampers that were identified to have no access.

NFPA 101, Life Safety Code 2000 Edition
Based on document review and interview, the facility failed to maintain devices/equipment according to the manufactures specifications to ensure reliability as evidenced by 7 of 7 devices used for the monitoring of temperature and humidity that had not been calibrated since the installation of the devices/equipment. This failure could result in incorrect recordings for humidity and temperature in Operating rooms 1 through 5, in the Special Procedures room and in the Sterile Supply room at Inland Valley Medical Center(IVMC).

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with the applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Findings:

During document review and interview with the Plant Operations Safety Manager on July 27, 2011, the Policy and Procedures for maintaining the Vaisala Temperature and Humidity Sensors in critical areas were reviewed.

IVMC
At 9:20 a.m., the facility provided a copy of the Policy & Procedure Title: TEMPERATURE HUMIDITY MONITORING: PERIOPERATIVE SERVICES, WOMEN'S SERVICES AND CARDIOVASCULAR SERVICES. Under Policy C., (2) States Electronic temperature and humidity gauges are self-calibrating (Vaisalas). The Manufactures specifications for the Vaisalas were reviewed. The Manufacture recommended that the Vaisalas are calibrated annually by a license vendor.

At 9:30 a.m., during an interview, the Plant Operations Safety Manager stated he thought the Vaisalas were self-calibrating. The Plant Operating Safety Manager was asked if the seven Vaisalas that are located in Operating Rooms 1-5, in the Special Procedure Room and in Sterile Processing Departments at Inland Valley Medical Center (IVMC) had been calibrated and he stated they had not been calibrated since installation.

Based on observation, the facility failed to ensure a door with a self-closure device resists the passage of smoke as evidenced by a door that failed to latch. This failure could result in the potential spread of smoke and fire in the event of a fire resulting in potential harm to residents in 1 of 4 smoke compartments on the second floor.

Findings:

During a tour of the facility with the Plant Operations Safety Manager and Chief Operating Officer on July 27, 2011, the facility corridor doors were observed.

Inland Valley Medical Center (IVMC)
At 1:55 p.m., the door to Clean Utility Room 2161 on the Medical-Surgical West unit, Second Floor failed to latch upon self-closure.

Based on observation, the facility failed to maintain the integrity of smoke barrier walls. This was evidenced by a penetration in a smoke barrier wall. This affected 2 of 12 smoke compartments at Rancho Springs Main Building. This had the potential to allow the spread of smoke from one smoke compartment to another smoke compartment in the event of a fire, resulting in injury to patients, staff, and visitors from smoke inhalation.

Findings:

During a tour of the facility with the Plant Operations Manager, Engineer II, and the Director of Plant Operations on July 26, 2011, the smoke barrier walls were observed.

Rancho Springs Medical Center (RSMC)
At 1:49 p.m., the smoke barrier wall in the corridor by the Operation Rooms had a penetration above fire doors labeled 1082 and 1083. The penetration was located above a pipe and it measured approximately one inch.

Based on observation, the facility failed to maintain hazardous area corridor doors as evidenced by a hazardous area corridor door that was not equipped with a self-closing device. This failure affected one smoke compartment, and could result in the transfer of smoke and or fire resulting in potential harm to patients and staff.

Findings:

During a tour of the facility with the Plant Operations Safety Manager and Chief Operating Officer on July 28, 2011, the hazardous areas were observed.

Out Patient Imagining Center (OIC), First Floor Suite 101
At 9:55 a.m., the door to the room designated as a Hazardous room was not equipped with a self -closure as required for hazardous area rooms. There were two large soiled linen bins in the room during observation.

Surveyor: 29626
Based on observation, the facility failed to maintain its hazardous areas by not providing a self-closing mechanism on doors to hazardous rooms. This affected 1 of 7 smoke compartments at Rancho Springs Women's Center/Emergency Department. This had the potential to allow the rapid spread of smoke and fire, resulting in injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Plant Operations Manager, Engineer II, and the Director of Plant Operations on July 27, 2011, hazardous areas were observed.

Women ' s Center/Emergency Department
At 9:01 a.m., the Manager's Office located on the 1st Floor in the Emergency Department, did not have a self-closing mechanism installed on the door. The room contained combustible products such as paper files and cardboard boxes filled with files that covered approximately fifty percent of the room.

Surveyor: 29626
Based on staff interviews, the facility failed to ensure that staff members were aware of the life safety devices installed in their working areas. This was evidenced by a staff who did not know the primary functions of the fire protection devices in the kitchen at Rancho Springs Main Building. 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 a tour of the facility with the Plant Operations Manager and the Director of Plant Operations on July 27, 2011, the facility staff were interviewed to determine their knowledge of their fire emergency procedures and life safety devices.

RSMC
At 11:08 a.m., a kitchen staff was asked how they would activate the fire alarm system by means of the fire alarm manual pull station. The staff member pointed at the kitchen suppression system activation handle instead of the fire alarm manual pull station. The staff could not explain the purpose of the kitchen suppression system.

Surveyor: 29626
Based on observation, the facility failed to ensure that their fire alarm devices are functional and that their manual fire alarm pull stations were easily accessible to allow for quick activation of the fire alarm. This was evidenced by two fire alarm manual pull stations that failed to send a signal to the central monitoring company, an audio/visual fire alarm device that failed to alarm, and one manual fire alarm pull station that was obstructed from view. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Plant Operations on July 27, 2011, the fire alarm system was tested and observed.

RSMC
1. At 9:35 a.m., there was a manual fire alarm pull station in the Intensive Care Unit (ICU) that was obstructed from view by a scale.
2. At 2:07 p.m. and at 2:11 p.m., smoke detectors in Rooms 135 and 121 were activated respectively. The audio/visual device at the Medical Surgical East Nursing Station failed to alarm upon the testing of both smoke detectors, resulting in 1 out of 5 audio/visual devices failure to activate within the smoke compartment.

MRI Trailer @ Rancho Springs
At 3:16 p.m., the central monitoring company failed to receive a signal upon the activation of the manual fire alarm pull station located inside the MRI Trailer.

CT Trailer @ Rancho Springs
At 3:30 p.m., the central monitoring company failed to receive a signal upon the activation of the manual fire alarm pull station.

Surveyor: 29626
Based on observation, the facility failed to ensure the manual fire alarm pull stations were easily accessible to allow for quick activation of fire alarm. This was evidenced by one manual fire alarm pull station that was obstruced from view on the First Floor Women's Center/Emergency Department. This could result in a delayed response to a fire and increase the risk of injury to patients, visitors and staff.

Findings:

During a tour of the facility with the Plant Operations Manager and the Director of Plant Operations on July 27, 2011, the fire alarm system was tested and observed.

Women's Center/Emergency Department
At 9:35 a.m., the manual fire alarm pull station in the lobby located on the 1st Floor of the Women's Center/Emergency Department was obstructed from view. A stand that contained a tissue box, two mask boxes, and a hand sanitizer was placed in front of the fire alarm pull station. When the volunteer working at the front desk was interviewed and asked if they could point to the nearest manual pull station, they could not locate the fire alarm pull station that was obstructed.

Based on document review and interview, the facility failed to maintain the fire/smoke dampers in accordance with NFPA 90A as evidenced by the failure to test 37 of 165 fire/smoke dampers at Inland Valley Medical Center (IVMC), and 6 of 265 at Rancho Springs Medical Center (RSMC). This had the potential for the fire/smoke dampers to malfunction and fail to contain smoke in the event of a fire, resulting in injury to patients, staff, and visitors from smoke inhalation.

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

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

Findings:

During document review and interview with the Directors of Plant Operations Safety Manager, Chief Operating Officer and Plant Operation Manager on July 26, 2011, from 8:00 a.m., to 11:00 a.m., the fire/smoke damper inspection records were reviewed.

IVMC
At 9:00 a.m., a damper inspection report dated 10/26/2009 was provided for review. The report noted 37 of 165 smoke/fire dampers were not tested and inspected. The Deficiency note stated "access to damper inaccessible, pipes and wiring blocks access and ceiling grid and tiles need to be removed". During an interview, the Inland Valley Medical Center Plant Operations Safety Manager, stated that they have not tested the 37 smoke/fire dampers that were identified to have no access.

RSMC
At 9:30 a.m., the Plant Operations Manager provided testing records that indicated that 4 smoke dampers and 2 fire dampers had not been tested. The report stated the 6 smoke/fire dampers were not tested because they were not accessible. The Director of Plant Operations stated that they have not tested the 6 smoke/fire dampers that were identified to have no access.

NFPA 101, Life Safety Code 2000 Edition
Based on document review and interview, the facility failed to maintain devices/equipment according to the manufactures specifications to ensure reliability as evidenced by 7 of 7 devices used for the monitoring of temperature and humidity that had not been calibrated since the installation of the devices/equipment. This failure could result in incorrect recordings for humidity and temperature in Operating rooms 1 through 5, in the Special Procedures room and in the Sterile Supply room at Inland Valley Medical Center(IVMC).

NFPA 101, 2000 Edition
4.6.12 Maintenance and Testing.
4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be continuously maintained in accordance with the applicable NFPA requirements or as directed by the authority having jurisdiction.

4.6.12.3 Equipment requiring periodic testing or operation to ensure its maintenance shall be tested or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

Findings:

During document review and interview with the Plant Operations Safety Manager on July 27, 2011, the Policy and Procedures for maintaining the Vaisala Temperature and Humidity Sensors in critical areas were reviewed.

IVMC
At 9:20 a.m., the facility provided a copy of the Policy & Procedure Title: TEMPERATURE HUMIDITY MONITORING: PERIOPERATIVE SERVICES, WOMEN'S SERVICES AND CARDIOVASCULAR SERVICES. Under Policy C., (2) States Electronic temperature and humidity gauges are self-calibrating (Vaisalas). The Manufactures specifications for the Vaisalas were reviewed. The Manufacture recommended that the Vaisalas are calibrated annually by a license vendor.

At 9:30 a.m., during an interview, the Plant Operations Safety Manager stated he thought the Vaisalas were self-calibrating. The Plant Operating Safety Manager was asked if the seven Vaisalas that are located in Operating Rooms 1-5, in the Special Procedure Room and in Sterile Processing Departments at Inland Valley Medical Center (IVMC) had been calibrated and he stated they had not been calibrated since installation.