HospitalInspections.org

Based upon observations and staff interviews on 06/12-06/13/2017 between approximately 0800 and 1600 hours the facility has failed to maintain the ability of delayed egress exit doors to open. This could cause an inability or delay in the evacuation of residents in the event of a non-fire related emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

The delayed egress door 22-294X had a 30 second delayed egress but no sign.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on 06/12-06/13 between approximately 0800 and 1600 hours the facility has failed to maintain the exit discharge free of obstructions. This could cause an inability or delay in the evacuation of residents in the event of an emergency which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

The psych building S1-220 leads to the grass area which is locked on the outside and is not 50 feet from the building. There was also a large bush in the way.

S1-220 door is locked with a bolt lock and does not unlatch with the fire alarm and staff did not have a key.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 06/12-06/13/2017 between approximately 0800 and 1600 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a problem and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Fire alarm panel CKT LHW-8 was in trouble and the facility was unaware of the issue or that it was in trouble.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on June 12, 2017 between approximately 1300 and 1600 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility failed to have fire watch policies that meet the intent of the 2012 Life Safety Code. Upon review of the fire watch policies and interview with the staff it was determined that the facility security staff were completing the fire watch. However, the people assigned to complete the watch had their normal security duties and would leave their watch if called in for security measures.

A.9.6.1.6 A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guard(s) to walk the areas affected. Such individuals should be specially trained in fire prevention and in occupant and fire department notification techniques, and they should understand the particular fire safety situation for public education purposes. (Also see NFPA601, Standard for Security Services in Fire Loss Prevention.)

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on June 12-13, 2017 between approximately 0530 and 1600 hours the facility has failed to provide fire sprinkler protection to all required areas of the facility. This could result in a fire not being contained to the area of origin and could endanger residents, staff and/or visitors.

The findings include, but are not limited to:

The day surgery sterile processing and back corridor has intermixed heads in one area (quick response, standard, and intermediate temperature rating.)

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on June 12-13, 2017 between approximately 0530 and 1600 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure of notification to staff of a water supply problem to the fire sprinkler system and endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The following areas had storage to close to the sprinkler heads, obstructing the spray of water:

NFPA 13 2010 8.5.5.3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or non-continuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8.5.5.3.

00-165

S1-193

Dirty heads:

NFPA 25 2011 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).

Labor and delivery nurses station
Sprinkler head fifth floor outside room 504 Dirty
Sprinkler head fourth floor outside of room 413 Dirty
Sprinkler head in lab break room dirty


Missing escutcheon ring:

NFPA 13, 2010 6.2.7.1 Plates, escutcheons, or other devices used to cover the annular space around a sprinkler shall be metallic or shall be listed for use around a sprinkler.

Copy room by desk

Emile Gramlin dining room skylights

00-119

QR Sprinkler heads:

NFPA 25, 2011 5.3.1.1.1.3* Sprinklers manufactured using fast-response elements that have been in service for 20 years shall be replaced, or representative samples shall be tested and then retested at 10-year intervals.

Interview with facility staff stated that the Emile Gramlin building heads were over 20 years old and have not been tested or replaced.

The sprinkler heads in the walk-in coolers and freezers in the main kitchen were over 10 years old.
NFPA 25 5.3.1.1.1.6* Dry sprinklers that have been in service for 10 years shall be replaced or representative samples shall be tested and then retested at 10-year intervals.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on June 12, 2017 between approximately 1300 and 1600 hours the facility has failed to have a written procedure for instituting as approved fire watch in the event of a failure of the sprinkler system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility failed to have fire watch policies that meet the intent of the 2012 Life Safety Code. Upon review of the fire watch policies and interview with the staff it was determined that the facility security staff were completing the fire watch. However, the people assigned to complete the watch had their normal security duties and would leave their watch if called in for security measures.

A.9.6.1.6 A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional
security guard(s) to walk the areas affected. Such individuals should be specially trained in fire prevention and in occupant
and fire department notification techniques, and they should understand the particular fire safety situation for public education
purposes. (Also see NFPA601, Standard for Security Services in Fire Loss Prevention.)

The above was discussed and acknowledged by the facility staff.

Based upon record review and observation on June 12-13, 2017 between approximately 0530 and 1700 hours the facility has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The following areas were missing fire extinguishers every 75 feet as required by NFPA 10 6.2.1.1:

Lower level under 1 South missing fire extinguishers every 75 feet for several hundred feet.

The bed repair area had one fire extinguisher, but not another within 75 feet. 2 would be required for the area.

By 00-403A


The following areas had fire extinguishers over 40 lbs and the top of the extinguisher over 5 ft:

Bed repair area
Sterile processing
Fire extinguisher in LLOR1
Kitchen fire extinguisher 02-301
Room 02-0135 extinguisher
Day surgery back hallway

The following areas had the incorrect type of fire extinguisher:

SIM lab conference room has a CO extinguisher when it should be an ABC.
Hybrid OR room fire extinguisher wrong type

XWY32607 extinguisher is missing the label.

Elevator room 14 fire extinguisher not signed off

The above was discussed and acknowledged by the facility maintenance.

Based upon observations and staff interviews on June 12-13, 2017 between approximately 0530 and 1600 hours 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 residents, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

The following doors were missing their smoke seals:

01-414

22-201

The following have their labels painted:

23-323
22-201
01-424

The following cross-corridor doors failed to close and latch:

02-045
S1-137
Eyewash by clean laundry
23-301X
23-339
01-750

The following cross-corridor doors had penetrations, missing parts, or other issues:

01-239
01-568
S1-137
S1-140
S1-213
S0-091
01-244
01-243
01-236
01-239
01-245-plans called for a 1 hour rated door
01-733
All doors in the psych building-piano hinges were added and holes were in the door that you could see through

The following have had their hinges modified:

23-354

S1-162 soiled utility room has rated walls, needs a rated door
S1-200 electrical room with tranformers has rated walls, but not a rated door

The fire curtain connected to the fire alarm system between the CCU wings was left 70% closed as a rule. The facility could not state if the wall would close the rest of the way on activation of the fire alarm.

The facility could not provide testing records on any fire curtains or roll down shutters.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 06/12-06/13/201 7 between approximately 0800 and 1600 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger people in the building by risk of fire, electrocution, or other harm.

The findings include, but are not limited to:

NFPA 70 (C) Warning Signs. Entrances to rooms and other guarded locations that contain exposed live parts shall be marked with conspicuous warning signs forbidding unqualified persons to enter. The marking shall meet the requirements in 110.21(B).

The following electrical rooms are not marked as such:
01-454A
01-204A
01-585B
SO-096

The above was discussed and acknowledged by the facility staff.

This requirement is not met as evidenced by:

The facility was unable to provide recall testing on their elevators. During the time of the survey, one of the two elevators in the main lobby was not working. Staff members stated that the elevator has not worked properly for at least a week.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on June 12-13, 2017 between approximately 1300 and 1600 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering residents, staff and/or visitors.

The findings include, but are not limited to:
The facility was unable to provide adequate documentation that fire drills have been done in accordance with the 2012 LSC and WAC 212-12.
Interview with the head of security who ran the drills stated that all drills are pre-announced by giving out a worksheet for all staff members to fill out. Attendance was also voluntary, if one floor or department decided to opt out, that would be acceptable. The security personal would tell that one person that there was a "fire" somewhere and ask them to run through the steps involved.
The security department would randomly chose one person in a department and ask them to answer the questions and run through the steps involved in a drill, not the entire floor or department.
Approximately 1/2 of the floors or departments had not had security come to them in the past two years.
Interviews of staff differed, some had no idea what to do in a fire and other did know.
No person was able to show that they pulled the fire alarm during the drill. Interviews differed on the second day that the surveyors were on site.
The short stay unit was unable to provide what to do in event of a fire when asked.
The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on 06/12-06/13 between approximately 0800 and 1600 hours the facility has failed to prohibit the use of portable electric heaters within the facility. This could result in a fire due to the ignition of combustible materials that would place residents, staff and/or visitors in danger.

The findings include, but are not limited to:
Unapproved heater room 11-137 fixed at time of inspection
Unapproved heater room 00-238B no tip over device

The above was discussed and acknowledged by the facility staff.

The facility was unable to produce a risk assessment in accordance with NFPA 101, NFPA 99, and NFPA 551.

Based upon observations and staff interviews on June 12-13, 2017 between approximately 0530- 16:00 hours the facility has failed to properly maintain the gas and vacuum piped systems in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility staff stated that they do not have a policy for testing and maintenance nor has any been completed.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on June 12-13, 2017 between approximately 0530- 16:00 hours the facility has failed to properly maintain the electrical outlets in the facility. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

During an interview with the facility staff they stated that they have not done nor have documented testing of the hospital grade receptacles. The facility stated that they do not have a policy for electrical receptacle testing.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on June 12-13, 2017 between approximately 0530- 16:00 hours the facility has failed to restrict the use of multi-plug outlets (power strips) and extension cords to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw
endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

Appliances plugged into powerstrips:

D1 Cath lab had a microwave plugged into a powerstrip.
3rd floor staff lounge in Emile Gramlin had four refrigerators plugged into one powerstrip
Center core blanket heater cabinet plugged into power strip
PACU break room microwave coffeemaker plugged in the power strip fixed at time of inspection
Room 03-308 coffee pot plugged in the power strip
Room 02-524 refrigerator plugged in the power strip
Second-floor Old human resources area refrigerator plugged into power strip Pyxis station
Room 02-339 toaster and microwave plug in the power strip
Room 02-118 microwave and refrigerator plugged into a power strip
Room 02-136 microwave and refrigerator plugged in the power strip fixed at time of inspection
Room 02-120 microwave and refrigerator plugged in the power strip fixed at time of inspection
Pathology break room refrigerator plugged in the power strip
Office next to pathology break room daisy-chained power strips
Room 00-457C refrigerator plugged into power strip
Room 00-420 microwave refrigerator coffee maker plugged in the power strip times two
Room 00-432E UPS to power strip with power strip plug into UPS
Room 00-406 microwave refrigerator plugged in the power strip
Foundation office microwave coffeemaker refrigerator plugged in the power strip
Case management office space microwave refrigerator plugged in the power strip
Telecom room 00-457 microwave plugged into power strip fixed daytime inspection
Room 02-013 refrigerator plugged in the power strip

Extension cords being used as a permanent source of power:

Bed repair area had 10 extension cords hanging from the ceiling.
Extension cord in years in room 02-335 fixed at time of inspection
Extension cord in use in room 02-338A fixed at time of inspection
Extension cords in all operating rooms

The findings include, but are not limited to:

The facility does not have a policy on the installation and testing of medical gas equipment.