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Based on interviews and observation, the facility failed to take precautions for, and supervision of, repair work on 10/02/14 that involved welding that resulted in the combustion of a large amount of combustible material leading to heat hot enough to melt aluminum and enough smoke to enter the facility's heating, ventilation and cooling system which resulted in eight staff members being treated for smoke inhalation, one patient having his/her procedure postponed, one patient having a colonoscopy in a "less than thorough manner," a diversion of ambulances from the emergency department for nearly three hours, and the cafeteria/kitchen being closed for approximately eight hours. As of 10/08/14, the facility failed to ensure a system was in place in which repairs to facility equipment are made in order to provide a safe physical environment for the patients when repairs are being done. There are currently 20 construction projects underway, including one project involving welding. The facility's census is 489 patients.

Findings include:

See A701.

Based on observation, interview, and record review, the facility failed to take steps to protect its building from fire. There are currently 20 construction projects underway, including one project involving welding. The facility's census is 489 patients.


Findings include:

1. On 10/06/14 at 11:00 A.M. an interview was conducted with Staff Q, R, B, and D. They confirmed the facility had sustained a fire on 10/02/14 as a result of welding work on an air handler.

2. The air handling unit was observed during tour on 10/06/14 at 3:58 P.M with Staff Q and R. The aluminum framework was observed to hold numerous (50 plus) air filters approximately four feet from where welding would be.

3. On 10/06/14 at 3:58 P.M. in an interview, Staff Q and R stated they did not know how the air filters caught fire and did not know why the combustible air filters were not protected from the welding. Staff Q and R did say the fire was hot enough to melt the aluminum framing that held the filters as well as the handle of the door that leads into room that held the air handler. Staff Q and R said the investigation on how it began would begin on 10/09/14.

On 10/08/14 at 11:56 A.M. in an interview Staff R stated the contractors in question are working at another building (a cancer center that is part of the hospital) and are doing welding there. Staff R confirmed the facility has not yet met with either the contracting company in general or the people involved in the fire from the contractor.

On 10/08/14 at 12:10 P.M. in an interview, Staff R stated permits for welding, cutting and hot work are issued to the contractors before they begin work.

4. On 10/08/14 a review of a blank permit was completed. The review revealed in the instructions a safeguard checklist is to be completed along with the rest of the form, then the top form is kept by the facility, and the bottom form is to be hung by the contractor at the work site. The safeguard checklist includes removal of combustible material from within 35 feet of the work and fire resistive covers and metal shield provided as needed.

Interview of Staff R on 10/08/14 at 12:10 P.M. revealed both copies were given to the contractor (and not just the bottom one) and both copies burned in the fire. Staff R said he/she did not have any other documentation to show a permit was issued.

Review of the facility's Hot Work Permits and Firewatch policy as originated on July 1998 and revised in October 2014, was completed on 10/08/14. The review revealed the policy reiterated that within 35 feet of hot work, if combustibles are not removed, they shall be protected with fire resistive tarpaulins or metal sheets. The policy stated "Emergency Maintenance will survey the area and contact the Safety Officer or designee who will issue a permit if the area has the necessary precautions. "

Staff Q stated on 10/07/14 at 9:00 A.M. in an interview, the contractors weren't necessarily escorted to the work site, and no one from the hospital evaluated the work site before work began. The facility was unable to provide evidence whether the precautions and safeguard checklist was followed by the contractors.

Staff Q stated there is an "informal knowledge" of what contractors can do what kind of repairs. Staff Q could not show a policy that describes how each contractor's performance is evaluated.

5. On 10/07/14 at 3:15 P.M. in an interview, Staff C stated while standing in the corridor between the surgeon's lounge and the heart catheterization laboratory he/she observed enough smoke to fill approximately 20 yards of the corridor and that it was thick enough that one could not see through it.

6. On 10/06/14 at 11:30 A.M. in an interview Staff A stated eight staff members were treated and released from the emergency department. The clinical record review of Patient #6 (a staff member) was completed on 10/08/14. The review revealed a physician assistant's note dated 10/02/14 at 11:59 A.M. that stated the patient was covered in black smoke including his/her face, hands, and shirt. The note stated he/she had black soot noted in the nostril passages.

7. Review of Patient #5's clinical record , a staff member, was completed on 10/08/14. The review revealed the patient also had soot noted on head, face, shirt, arms and hands.

Review of staff member, Patient #8's clinical record was completed on 10/09/14. The review revealed the patient complained of coughing up black soot.

8. On 10/07/14 at 2:55 P.M. in an interview, Staff C stated 65 people were evacuated from the cafeteria.

On 10/07/14 at 11:30 A.M. in an interview, Staff A stated the cafeteria was closed for approximately 8 hours. (He/she stated the facility's food needs were met in that time by bringing food in from three other area hospitals).

On 10/07/14 at 2:05 P.M. in an interview, Staff E stated the emergency department diverted ambulances (except for trauma cases) for nearly three hours on the morning of 10/02/14.

9. On 10/07/14 at 2:15 P.M. in an interview, Staff C confirmed two patients were directly affected. Patient #3 was in the cardiac catheter laboratory at the time the fire occurred, but his/her procedure had not yet begun, and Patient #3 was subsequently taken from the area.

The clinical record review for Patient #3 revealed the patient was undergoing an elective catheterization as part of preparing for a kidney transplant.

Staff C stated Patient #2, an outpatient, was in endoscopy, and was evacuated after the colonoscopy was complete per interview on 10/07/14 at 2:15 P.M.

The clinical record review for the other patient directly affected, Patient #2, was completed on 10/08/14. The review revealed Patient #2 was having an elective colonoscopy for intermittent rectal bleeding. The review revealed a physician's note dated 10/02/14 at 10:07 A.M. that stated, "During the procedure a code red was called and partial evacuation of the building ordered-including the 2nd floor, endoscopy suite. As such the procedure was completed in a less than thorough manner than would normally be done. "

10. On 10/06/14 at 11:00 A.M. in an interview, Staff Q stated he/she could not be sure if all the smoke dampers in the heating, ventilation and cooling system that should have closed, did close. He/she said they have not been retested since the fire.

Staff Q explained the air handler that was being worked on had been shut down prior to work beginning, and that it serviced the second, first, and ground floor of the building. Staff Q said a stacking effect brought most of the smoke to the highest floor serviced by the air handler, the second floor.

A review of the facility's life safety code documentation revealed from 07/05/12 to 01/11/13 the building's smoke dampers were inspected. As a result of the inspection, 16 percent were inaccessible out of a total of 491 dampers. This included 10 dampers on the ground floor with three near the radiology department.

On 10/07/14 at 2:15 P.M. in an interview Staff C stated the radiology department waiting area was closed due to damage from the fire on 10/02/14 and not reopened until 10/08/14, six days later.

On 10/09/14 at 4:00 P.M. in an interview Staff G stated he/she didn't know whether the inaccessible dampers worked or not.

11. On 10/07/14 at 2:52 P.M. a tour was taken of the second floor of the building with Staff Q and R. The tour revealed two penetrations in the smoke barrier, and three penetrations in the fire barrier.

On 10/08/14 at 8:45 A.M. a tour was taken of the ground floor with Staff Q and R. The tour revealed six penetrations in the fire barrier and one in a smoke barrier.