HospitalInspections.org

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital 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 residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The IT phone room was observed to have an unsealed penetration along the wall ceiling line.

The boiler room had unsealed pipe penetrations observed from the boiler room to the concealed ceiling spaces with in the hospital.

The above was discussed and acknowledged by the Facilities Manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital has failed to properly maintain the medical gas 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 oxygen shut-off valve to the old emergency room was observed to be in place, the facilities manager stated the oxygen piping was no longer useable.

The oxygen shut-off to the bone density room was observed to have room 202, 208 and 210 on the label. The facilities manager stated the numbers were construction numbers and the room names have changed.

The medical air secondary supply was observed to have a sign stating "Reserve side does not work even when showing full! Do not use reserve side!!!" When question about the sign the maintenance worker stated that the valve or regulator does not work and they are trying to find a replacement valve or regulator. The respiratory therapist dept head was then interviewed, she knew about the problem and had plans to respond if the secondary air was not available.
NFPA 99 1999 edition 4-3.1.1.5
4-3.1.1.5* Cylinder Systems without Reserve Supply. (See Figure 4-3.1.1.5.)
(a) A cylinder manifold shall have two banks (or units) of cylinders that alternately supply the piping system, each bank having a pressure regulator and cylinders connected to a common header. Each bank shall contain a minimum of two cylinders or at least an average day ' s supply unless normal delivery schedules require a greater supply. When the content of the primary bank is unable to supply the system, the secondary bank shall automatically operate to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover to the secondary bank occurs.



The above was discussed and acknowledged by the facilities manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.
The findings include, but are not limited to:

The generator was observed to not have a remote stop switch. When asked the facilities manager state they were not aware of the requirement.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

The above was discussed and acknowledged by the facilities manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital has failed to restrict the use of multi-plug outlets (power strips) 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:

In the nurse breakroom a microwave oven was observed to be plugged into a power strip. Removed while surveyor was on site.

The above was discussed and acknowledged by the facilities manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital 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 residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The IT phone room was observed to have an unsealed penetration along the wall ceiling line.

The boiler room had unsealed pipe penetrations observed from the boiler room to the concealed ceiling spaces with in the hospital.

The above was discussed and acknowledged by the Facilities Manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital has failed to properly maintain the medical gas 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 oxygen shut-off valve to the old emergency room was observed to be in place, the facilities manager stated the oxygen piping was no longer useable.

The oxygen shut-off to the bone density room was observed to have room 202, 208 and 210 on the label. The facilities manager stated the numbers were construction numbers and the room names have changed.

The medical air secondary supply was observed to have a sign stating "Reserve side does not work even when showing full! Do not use reserve side!!!" When question about the sign the maintenance worker stated that the valve or regulator does not work and they are trying to find a replacement valve or regulator. The respiratory therapist dept head was then interviewed, she knew about the problem and had plans to respond if the secondary air was not available.
NFPA 99 1999 edition 4-3.1.1.5
4-3.1.1.5* Cylinder Systems without Reserve Supply. (See Figure 4-3.1.1.5.)
(a) A cylinder manifold shall have two banks (or units) of cylinders that alternately supply the piping system, each bank having a pressure regulator and cylinders connected to a common header. Each bank shall contain a minimum of two cylinders or at least an average day ' s supply unless normal delivery schedules require a greater supply. When the content of the primary bank is unable to supply the system, the secondary bank shall automatically operate to supply the system. An actuating switch shall be connected to the master signal panels to indicate when, or just before, the changeover to the secondary bank occurs.



The above was discussed and acknowledged by the facilities manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.
The findings include, but are not limited to:

The generator was observed to not have a remote stop switch. When asked the facilities manager state they were not aware of the requirement.

NFPA 110 1999 Edition 3-5.6 All level 1 and 2 installations shall have a remote manual stop station of a similar type to a break-glass station located outside the room housing the prime mover, where so installed or located elsewhere on the premises where the prime mover is located outside the building.

A-3-5.5.6 For level 1 and level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.

The above was discussed and acknowledged by the facilities manager.

Based upon observations and staff interviews on 2/17/2015 between approximately 1000 and 1530 hours Willapa Harbor Hospital has failed to restrict the use of multi-plug outlets (power strips) 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:

In the nurse breakroom a microwave oven was observed to be plugged into a power strip. Removed while surveyor was on site.

The above was discussed and acknowledged by the facilities manager.