HospitalInspections.org

Based on documentation review and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patient, staff and/or visitors to the toxic products of combustion.

The findings include:

Emergency Department storage room/electrical chase room - self closing device was disabled. Corrected during inspection.

NFPA 101 19.3.2.1.3

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review, observation and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result delayed egress and in tripping and fall injuries to patients, staff, and/or visitors.

The findings include:

The facility was unable to provide documentation of all emergency lighting with battery backup versus generator backup as well as 30 second monthly testing of battery backup emergency lighting.

The facility was unable to provide documentation of all emergency lighting with battery backup versus generator backup as well as 90 minute annual testing of battery backup emergency lighting.

Documentation provided reflected annual test of operating room emergency lighting only.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.2.9, 7.9, 7.9.3.1.1

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review, observation and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency.

The findings include:

The facility was unable to provide documentation of exit signs with battery backup versus generator backup as well as 30 second monthly testing of battery backup signage.

The facility was unable to provide documentation of exit signs with battery backup versus generator backup as well as 90 minute annual testing of battery backup signage.

Two exit signs in the emergency department failed to adequately illuminate when tested.

NFPA 101 19.1.1.1.1, 7.10.9.2, 7.9.3 (2012)

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility failed to maintain their laboratories in a safe and fire resistant manner in accordance with the referenced NFPAs. This could lead to the inability of staff or machinery to function as they should in the event of an emergency or exposed chemicals to magnify the effects of a fire and expose patients, staff, and visitors to these fire dangers.

The findings include:

The facility was unable to provide lab specific emergency plan.

NFPA 101 19.3.2.2, 19.1.1.1, 8.7, 8.7.4, NFPA 45 1.1, 6.6.3 (2011)

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to have their fire alarm system installed in accordance with the references NFPAs and in a manner that is approved. This could result in a fire not being detected by the fire alarm system, possible leading to harm and delayed evacuation of patients, staff, and visitors.

The findings include, but are not limited to:

The facility was unable to provide NICET certifications on all contractor technicians who designed, installed and provided service on the fire alarm system.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010 ed) 1.1.1, 10.4.3.1(2)


The panel which houses the circuit to the fire alarm panel was not identified by signage on the panel door. Corrected during inspection.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010 ed) 1.1.1, 10.5.5.2


Emergency Department doctors sleeping room (on plans as "provider work" room) did not have a smoke alarm installed.

NFPA 101 18.1.3, 6.1.14, 28.3.4.5 (2012)

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review, observation and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to maintain the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire and allow the fire to increase in size and intensity which would endanger the patients, staff and/or visitors.

The findings include:

The facility was unable to provide the report for the three year dry system trip. Contractor reports must be free of deficiencies.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 13.4.4.2.2.2


The facility was unable to provide two of the fire sprinkler systems' internal pipe inspections. Contractor reports must be free of deficiencies.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 14.2.1

Basement women's bathroom - missing escutcheon ring.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 5.2.1.1.4

Emergency Department storage room/electrical chase - cords were tied around sprinkler pipe. Corrected during inspection.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 5.2.2.2

The facility was unable to provide the contractor's Washington State fire sprinkler license information.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 4.1.1.2

The above was discussed and acknowledged by facility plant operations staff.

Based on observation and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include:

Fire extinguishers were not secured in the following locations:
Boiler room
Foundation office
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 6.1.3.4



Fire extinguishers tags indicated they had not had annual service performed within the past twelve months in the following locations:
Helipad
CT room
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010) 1.1, 7.3.1.1.1



Fire extinguisher did not have proper pressure in the operating room corridor. Corrected during inspection.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010) 1.1, 7.2.3

The above was discussed and acknowledged by the facility plant operations staff.

Based on observation and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to maintain fire resistive construction of the building capable of resisting the passage of smoke and fire into other compartments. This could allow the toxic product of combustion to move out of a room and into the exit access corridor and the smoke compartment which would endanger the patients, staff and/or visitors within the facility.

The findings include:

Fire caulk had dislodged in the fire rated wall between area 5 and 6. Corrected during inspection.

NFPA 101 8.3.5, 8.4.4.1, 8.5.6.2 2012

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. LSC 9.2.1 requires, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90B.


The findings include:

Human Resources Director's office - heating and air conditioner duct was covered by plastic tape not listed for this use.

NFPA 101, 19.5.2.1, 9.2, (2012) NFPA 90B 4.3.1 (2012)

The above was discussed and acknowledged by the facility plant operations staff.

Based on documentation review and staff interviews on September 27, 2021 between approximately 1330 and 1715 hours and September 28, 2021 between approximately 0645 and 1200 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide documentation of generator diesel fuel testing within the past twelve months. Contractor reports must be free of deficiencies.

NFPA 99 6.4.4.1.1.3, 2.1 2012, NFPA 110 1.1, 8.3.8, 8.1.1 (2010)

The above was discussed and acknowledged by the facility plant operations staff.