HospitalInspections.org

The facility has failed to maintain the construction fire rating of the building. Penetrations in fire rated walls and ceilings would allow for smoke, heat, and fire to spread to other parts of the building. This could expose patients, visitors, and staff to the threat of smoke, heat and fire.

The findings include, but are not limited to:

During the facility tour on December 15, 2015 2:00pm and 6:30pm, I observed unsealed penetrations in the wall or ceiling in the following locations:

1. At 5:46pm, in Operating Room 5, I observed that a cable jack had dislodged from the ceiling creating a penetration where smoke, heat, and fire could spread to other areas of the hospital.
2. At 5:50pm, I observed several holes in the autoclave room behind the autoclaves.

Interview with staff the following day revealed that the above mentioned penetrations had been sealed.

This findings were observed and discussed with the Engineering Lead.

Confluence Health - Moses Lake:
During the survey tour of 12/16/2015, at 1400, 1410 and 1420, while accompanied by the Administrator, through observation and staff interview, it was discovered that the facility has failed to maintain separation from other occupancies with a one hour fire barrier. This could allow for the passage of smoke and flames into or out of the ASC in the event of a fire, placing patients, visitors and staff at risk. This finding was acknowledged by the Administrator.

The findings include but are not limited to:

1. Penetrations through the firewall above the ceiling tiles to the left of the doorway from the ASC Waiting Room into the Clinic Waiting Room - 2" diameter hole with IT cable running through.
2. Penetrations through the firewall above the ceiling tiles to the left side of the main ASC exit door - gaps around conduit x2 and a 2"x2" hole punched out below the conduits.
3. Penetrations through the firewall above the ceiling tiles above Post-Op Bed 4 - 3"x 2" hole.

The Administrator was not aware of the penetrations. It is believed these occurred during overhead work by IT. Administrator to follow-up with IT.

The facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
During the facility tour on December 15, 2015 between the hours of 2:00pm and 6:30pm, I observed doors to not close and latch properly in the following locations:
1. At 2:35pm, I observed that the fire doors protecting the corridor did not close and latch when tested in Pain/Admin/Recovery.
2. At 2:40pm, I observed that the door to the switchboard office did not close and latch when tested due to a coat hanger placed from the top of the door frame. Staff removed the impediment and then the door was able to close and latch.
3. At 2:45pm, I observed a chair blocking and coat hanger on door to Clinical Manager room #341 which restricted the door from closing and latching. Staff removed the impediments and then the door was able to close and latch.
4. At 4:00pm, I observed that the south lobby elevator fire door relay was not working. Staff fixed the relay and it worked. But, I observed that the relay was still sticking.
Interview with staff revealed that Maintenance Staff was not aware of other staff placing impediments in the doors.
These findings were observed and discussed with the Engineering Lead.

The facility has failed to provide adequate records of testing of the battery-powered emergency lighting. This could allow batteries to become inoperable and not provide the 90 minutes of battery power required during a power outage, and thus, could place patients and staff at risk of critical moments of darkness in a power outage.

The findings include, but are not limited to:

During record review on December 15, 2015 at 9:55am of the facilities testing records, I observed that there was not a written record of the annual 90 minute testing of the battery-powered emergency lights.

Interview with Maintenance Staff revealed that the test may have been done, but it was not logged.

The finding above was observed and discussed with the Engineering Lead.

The Confluence Health - Moses Lake:
During the survey tour of the facility on 12/16/2015, at 1430, while accompanied by the Administrator and Maintenance Manager, it was revealed through record review, observation and staff interview that the facility has not been testing the battery-operated emergency lights in the Operating Rooms. This could result in failure of the lights to illuminate in the event of a loss of power (lag time between power outage and emergency power start-up) placing patients and staff at risk during procedures. In addition, this could result in failure of the lights to illuminate in the event of a loss of power (should the EPS fail to function). This finding was acknowledged by the Administrator and the Maintenance Manager.

2000 NFPA 101 - 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The Maintenance Manager stated that he was unaware of the testing requirements and that he will implement a program to test and document same for the emergency lights.

The facility has failed to maintain the automatic sprinkler system as required. This could allow for the sprinkler system inoperable and place patients, visitors, and staff at risk of not having sprinkler protection when needed.

The findings include, but are not limited to:

1. During record review on December 15, 2015 at 9:35am of the facilities maintenance and testing records, I observed that the Sprinkler Company had indicated several deficiencies in the system on the April 2015 report and again on the July 2015 report. There was no written record of all these items having been addressed/corrected. When I conducted the facility tour later that day, I observed that a sprinkler escutcheon that had been written up as missing on the Sprinkler Company report in a housekeeping closet was still missing.

Interview with staff revealed that some items were taken care of as they no longer existed.

2. During the facility tour on December 15, 2015 at 2:09pm, I observed that the construction of a duct covering was obstructing the sprinkler heads on each side of the duct covering.

Interview with Engineering Lead revealed that recent construction had been done in this room and the sprinkler company may not have been made aware.

The above findings were observed and discussed with the Engineering Lead.

The Confluence Health - Moses Lake:
During the facility survey of 12/16/2015, during the record review, at 1315, while accompanied by the Administrator and the Maintenance Director, through staff interview, record review and observation, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients and employees at risk. This finding was acknowledged by the Administrator and the Maintenance Director.

The findings include but are not limited to:

Quarterly inspections of the fire sprinkler system are not being performed.
During the interview the Maintenance Director stated that he was unaware of this requirement. Going forward, he stated that he will work with the main hospital to assure compliance.

The facility has has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.
The findings include, but are not limited to:
During record review on December 15, 2015 at 9:55am of the facilities maintenance and testing records, I observed that the kitchen suppression system had last been serviced in January 2015. There was no record available that the system had been serviced every six months as required.

Interview with Engineering Lead revealed that it was missed and the company came out in October, but the servicing could not be completed as it would interrupt procedures in the Operating Rooms.

This finding was observed and discussed with the Engineering Lead

The facility has failed to ensure that the life safety branch of the the hospital furnished electrical drawings detailing the various branches of the Essential Electrical System (EES). The drawing available did not sufficiently describe that the EES is in compliance with the National Fire Protection Association Standard 99 (NFPA 99). This could allow for the system to have items to be on unapproved branches, and thus expose patients, visitors, and staff to have insufficient emergency power for the required items.

The findings include but are not limited to:

Based upon staff interviews, observations and record reviews, the facility was unable to verify that the type one essential electrical system (EES) is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. The facility could not provide documentation that indicated what items were on each branch.

Interview with the Maintenance Lead indicated that he thought the EES system is correct and would find the documentation and identified panels.

This finding was observed and discussed with the Maintenance Lead.

The facility has failed to maintain the construction fire rating of the building. Penetrations in fire rated walls and ceilings would allow for smoke, heat, and fire to spread to other parts of the building. This could expose patients, visitors, and staff to the threat of smoke, heat and fire.

The findings include, but are not limited to:

During the facility tour on December 15, 2015 2:00pm and 6:30pm, I observed unsealed penetrations in the wall or ceiling in the following locations:

1. At 5:46pm, in Operating Room 5, I observed that a cable jack had dislodged from the ceiling creating a penetration where smoke, heat, and fire could spread to other areas of the hospital.
2. At 5:50pm, I observed several holes in the autoclave room behind the autoclaves.

Interview with staff the following day revealed that the above mentioned penetrations had been sealed.

This findings were observed and discussed with the Engineering Lead.

Confluence Health - Moses Lake:
During the survey tour of 12/16/2015, at 1400, 1410 and 1420, while accompanied by the Administrator, through observation and staff interview, it was discovered that the facility has failed to maintain separation from other occupancies with a one hour fire barrier. This could allow for the passage of smoke and flames into or out of the ASC in the event of a fire, placing patients, visitors and staff at risk. This finding was acknowledged by the Administrator.

The findings include but are not limited to:

1. Penetrations through the firewall above the ceiling tiles to the left of the doorway from the ASC Waiting Room into the Clinic Waiting Room - 2" diameter hole with IT cable running through.
2. Penetrations through the firewall above the ceiling tiles to the left side of the main ASC exit door - gaps around conduit x2 and a 2"x2" hole punched out below the conduits.
3. Penetrations through the firewall above the ceiling tiles above Post-Op Bed 4 - 3"x 2" hole.

The Administrator was not aware of the penetrations. It is believed these occurred during overhead work by IT. Administrator to follow-up with IT.

The facility has failed to maintain doors without impediments to their closing and latching. This could result in a delay in getting the door to the room closed in the event of a fire. This could result in toxic products of combustion getting into the room and into the exit corridor which would endanger the patients, staff and/or visitors within the smoke compartment.
The findings include, but are not limited to:
During the facility tour on December 15, 2015 between the hours of 2:00pm and 6:30pm, I observed doors to not close and latch properly in the following locations:
1. At 2:35pm, I observed that the fire doors protecting the corridor did not close and latch when tested in Pain/Admin/Recovery.
2. At 2:40pm, I observed that the door to the switchboard office did not close and latch when tested due to a coat hanger placed from the top of the door frame. Staff removed the impediment and then the door was able to close and latch.
3. At 2:45pm, I observed a chair blocking and coat hanger on door to Clinical Manager room #341 which restricted the door from closing and latching. Staff removed the impediments and then the door was able to close and latch.
4. At 4:00pm, I observed that the south lobby elevator fire door relay was not working. Staff fixed the relay and it worked. But, I observed that the relay was still sticking.
Interview with staff revealed that Maintenance Staff was not aware of other staff placing impediments in the doors.
These findings were observed and discussed with the Engineering Lead.

The facility has failed to provide adequate records of testing of the battery-powered emergency lighting. This could allow batteries to become inoperable and not provide the 90 minutes of battery power required during a power outage, and thus, could place patients and staff at risk of critical moments of darkness in a power outage.

The findings include, but are not limited to:

During record review on December 15, 2015 at 9:55am of the facilities testing records, I observed that there was not a written record of the annual 90 minute testing of the battery-powered emergency lights.

Interview with Maintenance Staff revealed that the test may have been done, but it was not logged.

The finding above was observed and discussed with the Engineering Lead.

The Confluence Health - Moses Lake:
During the survey tour of the facility on 12/16/2015, at 1430, while accompanied by the Administrator and Maintenance Manager, it was revealed through record review, observation and staff interview that the facility has not been testing the battery-operated emergency lights in the Operating Rooms. This could result in failure of the lights to illuminate in the event of a loss of power (lag time between power outage and emergency power start-up) placing patients and staff at risk during procedures. In addition, this could result in failure of the lights to illuminate in the event of a loss of power (should the EPS fail to function). This finding was acknowledged by the Administrator and the Maintenance Manager.

2000 NFPA 101 - 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 11/2 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

The Maintenance Manager stated that he was unaware of the testing requirements and that he will implement a program to test and document same for the emergency lights.

The facility has failed to maintain the automatic sprinkler system as required. This could allow for the sprinkler system inoperable and place patients, visitors, and staff at risk of not having sprinkler protection when needed.

The findings include, but are not limited to:

1. During record review on December 15, 2015 at 9:35am of the facilities maintenance and testing records, I observed that the Sprinkler Company had indicated several deficiencies in the system on the April 2015 report and again on the July 2015 report. There was no written record of all these items having been addressed/corrected. When I conducted the facility tour later that day, I observed that a sprinkler escutcheon that had been written up as missing on the Sprinkler Company report in a housekeeping closet was still missing.

Interview with staff revealed that some items were taken care of as they no longer existed.

2. During the facility tour on December 15, 2015 at 2:09pm, I observed that the construction of a duct covering was obstructing the sprinkler heads on each side of the duct covering.

Interview with Engineering Lead revealed that recent construction had been done in this room and the sprinkler company may not have been made aware.

The above findings were observed and discussed with the Engineering Lead.

The Confluence Health - Moses Lake:
During the facility survey of 12/16/2015, during the record review, at 1315, while accompanied by the Administrator and the Maintenance Director, through staff interview, record review and observation, it was discovered that the facility has failed to maintain the automatic fire sprinkler system in a reliable operating condition as required by NFPA 25. This could result in a failure of the proper operation of the automatic fire sprinkler system with the potential of fire spreading unchecked, placing patients and employees at risk. This finding was acknowledged by the Administrator and the Maintenance Director.

The findings include but are not limited to:

Quarterly inspections of the fire sprinkler system are not being performed.
During the interview the Maintenance Director stated that he was unaware of this requirement. Going forward, he stated that he will work with the main hospital to assure compliance.

The facility has has failed to conduct testing of the hood and duct fire suppression equipment protecting the commercial cooking equipment in the kitchen. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.
The findings include, but are not limited to:
During record review on December 15, 2015 at 9:55am of the facilities maintenance and testing records, I observed that the kitchen suppression system had last been serviced in January 2015. There was no record available that the system had been serviced every six months as required.

Interview with Engineering Lead revealed that it was missed and the company came out in October, but the servicing could not be completed as it would interrupt procedures in the Operating Rooms.

This finding was observed and discussed with the Engineering Lead

The facility has failed to ensure that the life safety branch of the the hospital furnished electrical drawings detailing the various branches of the Essential Electrical System (EES). The drawing available did not sufficiently describe that the EES is in compliance with the National Fire Protection Association Standard 99 (NFPA 99). This could allow for the system to have items to be on unapproved branches, and thus expose patients, visitors, and staff to have insufficient emergency power for the required items.

The findings include but are not limited to:

Based upon staff interviews, observations and record reviews, the facility was unable to verify that the type one essential electrical system (EES) is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. The facility could not provide documentation that indicated what items were on each branch.

Interview with the Maintenance Lead indicated that he thought the EES system is correct and would find the documentation and identified panels.

This finding was observed and discussed with the Maintenance Lead.