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Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to maintain exit corridor doors resist the passage of smoke into the means of egress in the event of a hostile fire event (LSC 19.2.3.5, Table 19.3.2.1, 19.3.6.3, Exception 2; A19.3.6.3.3) affecting the entire facility. Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility did not have documentation of the required fire and smoke door inspection and testing in accordance with NFPA 80 1999 edition, the facility staff responsible for testing the fire and smoke doors did not have access to the adopted standards, the inspection staff indicated that they were using the 2007 NFPA 80. Per the Facilities Manager in charge of the inspection staff "staff only inspect fire doors twice a year and do not inspect any of the smoke doors". The checklists were reviewed and found to not match the adopted standards.


2. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the 1 hour double doors by room 25 had a large gap between the meeting edges and was a new door per staff. The main entrance doors adjacent to 09411 had a large gap at the bottom of the doors and at the meeting edges. Door 54-09126 was not latching closed. Door 54-09115 was not latching and had a large gap.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide a one-hour separation between hazardous areas and the corridor/ hallway. This resulted in the potential for patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the door to storage room 09169 was not closing and latching on multiple attempts.

Based on observations and interviews it was determined through on-going dialog with the Director of Facility Services that the facility failed to install/ maintain exit access throughout the means of egress including the exterior to the public way or 50' from the building. (LSC 7.1, 7.2.1.5, 19/18.2.1, 19/18.2.5.10). Surveyor was accompanied by the Maintenance Supervisor who acknowledged the existence of the following conditions. Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there was an exterior exit stairway from the main stair tower for Doernbecher that was not traversable. The stairs were made of railroad ties that were not back filled to create steps. This stairway started outside 7 th floor and passed by door 54-09103.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide adequate exit illumination to the public way with bulbs arranged so that if one bulb burned out there would still be adequate exit lighting. This resulted in the potential for confusion and panic by patients & staff during emergency evacuation conditions (LSC 19/18.2.8). Findings include, but are not limited to:



1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there was not two bulb exterior illumination on emergency power at the exterior stair from the 7th floor that passed by door 54-09103.

Based on interviews, observations, and record review during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide fire drills and in-service training for all staff. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 19.7.1.2, A.19.7.1.2). Findings include, but are not limited to:



1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility had documentation of conducting (initiating) a fire drill on 9 North one time on one shift in 2012. The day shift was not observed for fire drills in any quarter of 2012. Swing shift was not observed for fire drills on second and fourth quarters of 2012, Night shift was not observed for fire drills on first quarter 2012. Facility was not ensuring an adequate number of drills were conducted in each unit to ensure staff participation and competency in responding to actual fire events. Facility was not tracking attendance of staff at fire drills. Per Director of Nursing at Doernbecher on 2/22/2013 at 11:25 a.m., "staff could work at the hospital 20 years and not attend a drill if not working when drills occurred". It was determined that only 3 of the 15 staff that were working on 2/2/2013 when the fire occurred had attended a fire drill within the previous 12 months. The fire drill forms were found to be incomplete and did not include who participated, location of fire, type of fire simulated, weather, time to simulate evacuation of the smoke compartment of the fire, and staff performance comments.



Staff interview RN #1 3/4/2013 at 1:00 p.m., indicated that the RN that was on duty when the fire occurred on 2/2/2013 had been with OHSU for over 26 years and they indicated that were unsure of the R.A.C.E. acronym used by OHSU for responding to fires, and PASS for fire extinguisher use. They indicated that they would focus on a patient and not call code red or activate a fire alarm pull station. They indicated they were not sure when the last fire drill was conducted in their unit.



Staff interview RN #2 3/4/2013 at 1:05 p.m., indicated that the RN that was on duty when the fire occurred on 2/2/2013 had been with OHSU for over 5 years. They indicated that the last fire drill they attended was 5 years ago when they were first hired. They were unfamiliar with RACE and PASS. They indicated that they did not activate the fire alarm when the fire occurred and that they could have with Code Red, or by pulling a pull station, or by activating their voicera on the lanyard but that they were only focused on the patient on fire and not any other patients or occupants of the smoke compartment of the fire.



2. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility had not enforced the annual inservice training requirements for all staff. Of the 15 staff that were working on 2/2/2013 when the fire occurred, six staff were found to have not completed any fire and life safety training in 2012.



3. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility conducted a fire drill on 3/8/2013 at 9:00 a.m. which was observed by surveyors. The facility did not properly conduct or respond to the fire drill. The following deficiencies were noted during the drill: nearest pull station was not immediately pulled, code red not initiated by staff discovering the "fire", corridors not cleared of housekeeping and other carts and chairs, rooms not checked or simulated evacuated, doors not marked as evacuated, doors were not closed to isolate the "fire", fire extinguishers were not brought to the "fire", maintenance staff reset pull station and paged all clear prior to any response by unit staff. Facility did not track attendance of participating staff. Facility did not document staff performance. Fire Code Specialist responsible for conducting drills coached the staff within the unit during the drill and provided training to the staff immediately prior to the drill. Staff did not communicate with each other during the drill and all staff on the unit were found to be complacent. Several staff walked through the "fire" unit during the drill and continued on with normal operations instead of assisting. Dispatch was given the specific location of the "fire" (room 39) and did not page the specific location overhead. Dispatch only paged the location of the fire alarm pull station that was initiated that was located at the opposite end of the unit from the fire as the staff were not familiar with pull station locations within the unit and nearest the fire. One maintenance staff member on the adjacent unit was observed changing a light bulb during the entire drill with a ladder in the corridor.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to install fire alarm system in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.6). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility fire alarm system was found to be inaudible for "Code Red" paging at several locations including the 9 North nurse station. The fire alarm panels did not indicate the location and breaker number of the main shutoff for the alarm system at each panel, there was no set screw lock on breaker EL-7LA#12, and other fire alarm breakers including EL10 #10.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure that there was a complete sprinkler system installed in accordance with NFPA 13. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5.1, NFPA 13 5-6.3.3, .4, NFPA 25). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the doors to the sprinkler riser rooms were not labeled, including at 54-01101 and water service door inside 54-01101. There was a shutoff switch installed on the dry sprinkler system air compressor located in room 096908.

Based on observations, records review and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure the sprinkler system is continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 4.6.12.1, NFPA 13 3-2.91, .2, .3, NFPA 25 9.6.2.1, .2 & 8.17.4.6). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility did not have documentation of the required fire sprinkler testing in accordance with NFPA 25 1998 edition, the facility staff responsible for testing the fire sprinkler system did not have access to the adopted standards, the inspection staff indicated that they were using the 2002 NFPA 25. Per the Senior Programmer/ Analyst in charge of the inspection staff "staff do not reference the standards when doing inspections, they use a checklist that was based on the standards". The checklists were reviewed and found to not match the adopted standards.


2. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility did not have documentation of the required 5 year testing of the fire sprinkler systems.


3. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility provided an annual inspection report of the sprinkler system dated 7/20/2012 and did not have documentation that any of the deficiencies had been corrected since the inspection. The report indicated that sprinkler gauges were out dated, that there was no 5 year inspection recorded for obstructions in piping and 5 year inspection for alarm valves and check valves internally.


4. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility provided an in-house annual visual inspection report of the sprinkler heads dated 2/19/2013 indicating all sprinklers were free of paint, corrosion, and obstruction. On the survey 2/22/2013, numerous sprinkler heads were found with paint, corrosion, or obstructions that had not been noted on 2/19/2013. Including but not limited to a painted sprinkler head in stair 3 Doernbecher 9 th floor, coated sprinkler head above consult room 09201 and it was obstructed, there was a missing escutcheon ring in 09132 RN Manager office, missing escutcheon in restroom 09151 room 38, debris on sprinkler head above 09246, missing escutcheon ring in restroom of 09429, corroded and painted sprinkler head in restroom of 09421, sprinkler head obstructed by ceiling tile in 09672.


5. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility had sprinkler water and air pressure gauges on numerous sprinkler risers that were dated 1996 and were past due for the 5 year calibration or replacement since 2001. Including but not limited to stairwells and main risers. There were 1997 gauges on the riser in room 096908 and there were not and adequate supply of spare sprinkler heads or a wrench at that location.

Based on observations, records review, and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to maintain fire extinguishers in accordance with adopted standards. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.6, 4.6.12.1, 9.7.4.1, NFPA 10). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 the facility did not have documentation of the required fire extinguisher testing in accordance with NFPA 10 1998 edition, the facility staff responsible for testing the fire extinguisher did not have access to the adopted standards, the inspection staff indicated that they were using the 2002 NFPA 10. Per the Senior Programmer/Analyst in charge of the inspection staff "staff do not reference the standards when doing inspections, they use a checklist that was based on the standards". The checklists were reviewed and found to not match the adopted standards. The staff responsible for inspecting fire extinguishers was found to be checking extinguishers by scanning the affixed barcode only and not completing the required visible inspection of each unit. Per interview on 3/4/2013 at 12:57 p.m. of the staff responsible for inspecting extinguishers, it was determined that they were not removing extinguishers from the cabinet to verify units were not discharged, obstructed, missing seals or labels. They indicated that they did not perform a visual inspection of nozzles to verify no obstructions existed and stated that they stick their finger in the hose to check them. They indicated that all fire extinguishers were installed less than 5' above the floor to the top of the handle, though several were found over 5' above the floor during the survey. There was an obstructed fire extinguisher in room C09690B.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Maintenance Director that the facility failed to ensure safe smoking practices at the facility in accordance with facility policies and life safety regulations. This resulted in the potential for exposing staff, visitors, and patients to a fire and/or smoke environment (LSC 18.7.4). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there were improperly discarded cigarette butts in the landscaping outside 54-09103, and a smoker in a wheelchair at the main entrance to the 9th floor lobby on the non-smoking campus.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections exceeding 6" from 40" up to 80" above the floor and no projections exceeding 4 1/2" below 40" from the floor. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 7.1.10, S&C). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there was a blanket warmer in the corridor across from room 09245 (rm 36) that was obstructing the 8' clear corridor width.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure that no storage of highly flammable character existed in the corridors. This resulted in the potential for excessive fire spread (LSC 19.7.5.5, Exhibit 19.23). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there was soiled linen containers exceeding 32 gallons open to the corridor at 09541.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to provide safe storage for compressed gas cylinders. This resulted in the potential for injury to staff and patients from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, 4.3.1.1.2). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there was oxygen storage in room 09442 and the electrical was not 60" above the floor minimum. There were unsecured oxygen cylinders in C09690B and there was electrical within 60" of the floor within the room.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Facility Services that the facility failed to ensure that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to patients & staff (NFPA 70 550.13 (B), 9.1.2, NEC 110-3.8). Findings include, but are not limited to:


1. During the complaint investigation conducted February 3, 2013 through March 8, 2013 there was a relocatable power tap on the floor at room 09291, 6 relocatable power taps on the floor in room 09289, a non-patient area listed power tap zip tied to a cart in room 09177 (rm 43), two non-patient area listed power taps at the nurse station by room 09171, a refrigerator plugged into a power tap that was also on the floor at 09136 (RN Manager Office), a household use only microwave in room 09163, a non-GFCI protected outlet at the sink in room 9LB-5, 6 power taps on floor in 09161, non-patient area power taps at the nurse station by room 09235 (rm 33) and two were on the floor, a non-GFCI protected outlet at the sink in the playroom 09327, a household use only microwave in lounge 09320, a non-patient area power tap in alcove by 09223 (rm 29), three non-patient power tap at main nurse station by 09127 (rm 27), daisy-chained UPS into power tap at nurse charting station by 09127, a household microwave and toaster in 09244, a non-GFCI protected outlet at the sink in 09244, there were improperly sized and discolored transformer plugs overheating in room 09246 that were plugged into permanently installed power taps. There was a non-patient area power tap in 09238 procedure room, an EPIC cart plugged into a non-patient area listed power tap in 09211 (rm 25), a non-patient power tap at nurse station adjacent to 09571, a non-patient power tap on a Child Life cart in room 09571 and throughout the floor on all Child Life carts, a non-patient area power tap at the television in room 09526, a household use only microwave and coffee maker in staff lounge 09673, three power taps on the floor in 09669, a missing outlet trim plate in 09577, non-patient area power taps at nurse station adjacent to 09435, non-GFCI at sink in room 09405, household microwave in 09404, exposed electrical wires on child life cart in rooms 09427 and 09423. Two non-patient power taps at main nurse station on 9 South, household microwave in 09344, three power taps on the floor and a household microwave in 09668, six power taps on floor with two daisy chained and a household coffee maker in room 09666, two power taps on floor in 09664, household microwave and toaster in 09683, power tap on floor in EVS office 09685, household microwave and toaster oven in 09601A, three power taps on floor of 09601A, power tap on floor 09601B, household microwave at 09604, and a power tap on the floor in 09610.