HospitalInspections.org

Based on observation, the critical access hospital failed to ensure that a common wall with a nonconforming building was protected by a two-hour fire resistance-rated barrier.

Failure to ensure that the critical access hospital is adequately protected from a nonconforming building risks spread of smoke and fire into the critical access hospital from an occupancy with lower levels of fire protection.

Findings include:

During a tour of the critical access hospital on 09/11/2012, it was observed that the rated occupancy separation in the basement between the critical access hospital and the adjacent business occupancy was penetrated by several unsealed conduits above the rated door assembly in the corridor near the engineering director's office.

The observation was confirmed by the critical access hospital director of engineering.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain corridor walls so that they will resist the passage of smoke. This could result in the toxic products of combustion moving from one room into the corridor.

The findings include:

At approximately 1051 on 09-11-12 observed in the upper level tele com room near elevator 2 unsealed conduit passing through the wall.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain smoke barrier doors so the they would close and resist the passage of smoke. This could result in smoke from a fire in one smoke compartment moving into the second smoke compartment place all the patients in the two smoke compartment in peril.

The findings include:

At approximately 1059 hours observed that the smoke barrier doors located next to patient room 2105 failed to close and latch.

Based on observation and plan review, the critical access hospital failed to protect a hazardous areas with a one hour fire-rated barrier.

Failure to protect hazardous areas with a one hour fire-rated barrier risks spread of fire and smoke into other areas of the hospital.

Findings include:

1. During a tour of the critical access hospital on 09/11/2012, it was observed that a boiler room in the "SDS" building basement communicated with a vertical shaft that extended several floors up to the building roof. The shaft had an unprotected opening into the boiler room and a breach in the concrete shaft wall at the building 1st floor. This breach was filled with metal studs and wallboard on the opposite side from the shaft space. Review of construction drawings confirmed that this wallboard opening was adjacent to an exit passageway on the hospital 1st floor. The wallboard did not protect the metal studs on the hazardous side of the opening, potentially permitting fire from the boiler room to destroy the infill and enter the hospital corridor.

2. During deputy state fire marshal survey rounds it was observed that several room had been converted into storage rooms throughout the hospital. The storage rooms were larger than 50 square feet. The room door had not been equipped with self-closing devices or automatic closing devices. The following rooms were observed without closing devices: Room 2059, Room 1070 and room 105.

3. Deputy state fire marshal also observed that the Clean Utility room door failed to close and
latch.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain exit access so that it is readily accessible to all occupants of the building. This could result in non staff members believing that they can not use the exit and excessive delay in being able to access a means of egress.

The findings include:

1. All of the doors opening into the exit stair towers have the following words on the door. 'STAFF STAIRWELL ONLY SECURITY BADGE NECESSARY FOR EXIT" This could give the impression that people other than hospital personnel would not be able to exit from the second floor through the door into the stairway.

2. Observations and interviews revealed that the exit door would open and you could actually exit the building. The doors are locked from the stairway side and re-entry is not possible without a security badge.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain the automatic fire sprinkler system so as to ensure proper operation in the event of a fire. This could result in the failure of the fire sprinkler system to operate properly which could
allow for a fire to intensify.

The findings include,

Based upon the document review and interviews with the Plant Services Director, quarterly tests of the fire sprinkler system have not been conducted as required.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain corridors free of obstructions and storage. This could result in the inability to use the corridor in a timely manner in the event of a fire or other emergency.

The findings include:

At approximately 1148 hours on Tuesday September 11, 2012 several items stored in the exit access corridor of the Emergency Department. Items included a Computer on Wheels, Wheel chair and other items. They were observed to remain in the corridor during the entire survey time which concluded at 1700 hours.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain trash and waste storage in a room protected as a hazardous area. This could result in waste material being ignited and resulting in the exit access corridor being unusable due to smoke and the toxic products of combustion filling the corridor.

The findings include:

Observed during the entire survey on 09-11-12 broken down cardboard boxes and other waste material in an alcove in the corridor near the kitchen.

Based on record review and interview, the critical access hospital failed to ensure that relative humidity in anesthetizing locations was maintained equal to or greater than 35%.

Failure to maintain minimum levels of humidity in anesthetizing locations increases the risk of fire in a surgical suite, potentially causing great harm or death to a patient.

Findings include:

During a tour of the surgery department on 09/11/2012, it was stated that surgery personnel monitored the humidity levels in the operating rooms. Review of humidity level documentation found that humidity was recorded below 35% in all three operating rooms at least 21 times in January 2012, at least 16 times in February 2012, at least 15 times in March, 2012, at least 10 times in April, 2012, and at least 5 times in the period of May - September, 2012.

The critical access hospital policy "Monitoring of humidity levels in the operating room" (Policy Surgery H-4.0, effective 07/2006) states, in part: 'III. If humidity level is below 35% or above 60%, the maintenance department will be notified, and adjustments will be made according to the maintenance policy.'"

In an interview on 09/12/2012, the critical access hospital director of engineering stated that notifications had not been made to his department to adjust the humidity as often as it was recorded out of range by surgery personnel.

Based on observation, the critical access hospital failed to ensure that a common wall with a nonconforming building was protected by a two-hour fire resistance-rated barrier.

Failure to ensure that the critical access hospital is adequately protected from a nonconforming building risks spread of smoke and fire into the critical access hospital from an occupancy with lower levels of fire protection.

Findings include:

During a tour of the critical access hospital on 09/11/2012, it was observed that the rated occupancy separation in the basement between the critical access hospital and the adjacent business occupancy was penetrated by several unsealed conduits above the rated door assembly in the corridor near the engineering director's office.

The observation was confirmed by the critical access hospital director of engineering.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain corridor walls so that they will resist the passage of smoke. This could result in the toxic products of combustion moving from one room into the corridor.

The findings include:

At approximately 1051 on 09-11-12 observed in the upper level tele com room near elevator 2 unsealed conduit passing through the wall.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain smoke barrier doors so the they would close and resist the passage of smoke. This could result in smoke from a fire in one smoke compartment moving into the second smoke compartment place all the patients in the two smoke compartment in peril.

The findings include:

At approximately 1059 hours observed that the smoke barrier doors located next to patient room 2105 failed to close and latch.

Based on observation and plan review, the critical access hospital failed to protect a hazardous areas with a one hour fire-rated barrier.

Failure to protect hazardous areas with a one hour fire-rated barrier risks spread of fire and smoke into other areas of the hospital.

Findings include:

1. During a tour of the critical access hospital on 09/11/2012, it was observed that a boiler room in the "SDS" building basement communicated with a vertical shaft that extended several floors up to the building roof. The shaft had an unprotected opening into the boiler room and a breach in the concrete shaft wall at the building 1st floor. This breach was filled with metal studs and wallboard on the opposite side from the shaft space. Review of construction drawings confirmed that this wallboard opening was adjacent to an exit passageway on the hospital 1st floor. The wallboard did not protect the metal studs on the hazardous side of the opening, potentially permitting fire from the boiler room to destroy the infill and enter the hospital corridor.

2. During deputy state fire marshal survey rounds it was observed that several room had been converted into storage rooms throughout the hospital. The storage rooms were larger than 50 square feet. The room door had not been equipped with self-closing devices or automatic closing devices. The following rooms were observed without closing devices: Room 2059, Room 1070 and room 105.

3. Deputy state fire marshal also observed that the Clean Utility room door failed to close and
latch.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain exit access so that it is readily accessible to all occupants of the building. This could result in non staff members believing that they can not use the exit and excessive delay in being able to access a means of egress.

The findings include:

1. All of the doors opening into the exit stair towers have the following words on the door. 'STAFF STAIRWELL ONLY SECURITY BADGE NECESSARY FOR EXIT" This could give the impression that people other than hospital personnel would not be able to exit from the second floor through the door into the stairway.

2. Observations and interviews revealed that the exit door would open and you could actually exit the building. The doors are locked from the stairway side and re-entry is not possible without a security badge.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain the automatic fire sprinkler system so as to ensure proper operation in the event of a fire. This could result in the failure of the fire sprinkler system to operate properly which could
allow for a fire to intensify.

The findings include,

Based upon the document review and interviews with the Plant Services Director, quarterly tests of the fire sprinkler system have not been conducted as required.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain corridors free of obstructions and storage. This could result in the inability to use the corridor in a timely manner in the event of a fire or other emergency.

The findings include:

At approximately 1148 hours on Tuesday September 11, 2012 several items stored in the exit access corridor of the Emergency Department. Items included a Computer on Wheels, Wheel chair and other items. They were observed to remain in the corridor during the entire survey time which concluded at 1700 hours.

Based upon deputy state fire marshal observations and staff interviews with the Director of Plant Services during survey rounds on 09-11-12 Whitman Hospital and Health Center has failed to maintain trash and waste storage in a room protected as a hazardous area. This could result in waste material being ignited and resulting in the exit access corridor being unusable due to smoke and the toxic products of combustion filling the corridor.

The findings include:

Observed during the entire survey on 09-11-12 broken down cardboard boxes and other waste material in an alcove in the corridor near the kitchen.

Based on record review and interview, the critical access hospital failed to ensure that relative humidity in anesthetizing locations was maintained equal to or greater than 35%.

Failure to maintain minimum levels of humidity in anesthetizing locations increases the risk of fire in a surgical suite, potentially causing great harm or death to a patient.

Findings include:

During a tour of the surgery department on 09/11/2012, it was stated that surgery personnel monitored the humidity levels in the operating rooms. Review of humidity level documentation found that humidity was recorded below 35% in all three operating rooms at least 21 times in January 2012, at least 16 times in February 2012, at least 15 times in March, 2012, at least 10 times in April, 2012, and at least 5 times in the period of May - September, 2012.

The critical access hospital policy "Monitoring of humidity levels in the operating room" (Policy Surgery H-4.0, effective 07/2006) states, in part: 'III. If humidity level is below 35% or above 60%, the maintenance department will be notified, and adjustments will be made according to the maintenance policy.'"

In an interview on 09/12/2012, the critical access hospital director of engineering stated that notifications had not been made to his department to adjust the humidity as often as it was recorded out of range by surgery personnel.