HospitalInspections.org

Based upon observation during a tour of the facility on October 23, 2012, the facility has failed to maintain doors protecting corridor openings. This prevents the doors from resisting the passage of smoke due to doors failingto close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire.

The findings include, but are not limited to:

1. Observed at approximately 1036 hours that the door between the exit access corridor and the clean linen room failed to close and latch.
2. Observed at approximately 1016 hours a wooden door wedge being used to keep the door to the Physical Therapy intake room open.
3. Observed numerous door wedges on the floor near the office doors in the office area. At the time of the observations the wedges were not in use. Interviews with the Director of Plant Engineering indicated that they are typically used while people are in the offices.

The above findings were discussed and acknowledged by the Director of Plant Engineering.

Based upon a record review of the building construction plans, staff interviews with the Director of Plant Engineering and observation between 1045 and 1100 hours Chelan Community Hospital has failed to install or maintain smoke barrier walls as indicated on the construction plans. This could result in no smoke barriers being present on the medical surgical patient care areas.

1. The smoke barrier wall as indicated on the construction plans does not meet the requirements for a smoke barrier wall in that the wall does not extend above the ceiling to the floor above. This indicated wall is located near the quiet room and by the former nursing station.

This finding was observed and acknowledged by the Director of Plant Engineering.

Based upon observations and staff interviews with the Director of Plant Engineering between the survey hours of 0800 and 1600 Chelan Community Hospital has failed to maintain the required separation of hazardous areas from other others in the hospital. This could result in the movement of the toxic products of combustion into other areas of the hospital and thereby jeopardizing patients, staff and visitors.

The findings include, but are not limited to:

1. Observed at approximately 1026 hours several unsealed penetrations in the Mechanical room wall which separated the Central Supply room from the Mechanical room. This was acknowledged by the Director of Plant Engineering who immediately directed his staff to seal the penetrations.
2. Observed at approximately 1036 hours that the Soiled Linen Room on the first floor near the maintenance and security offices a door with a Bio Hazard Label on the door. This door had an unsealed louver cut into the door. This condition would not resist the passage of smoke from the Soiled Linen room into the exit access corridor. This was acknowledged by the Director of Plant Engineering.
3. Observed at approximately 1145 hours the soiled linen room on the second floor near the nursing station had a door without a self closing device and the door failed to close and latch.

The above findings were observed and acknowledged by the Director of Plant Engineering.

Based upon observations during the facility tour on October 23, 2012, the facility failed to ensure that the automatic sprinkler system has been installed and maintained in accordance with NFPA 13. This could result in a system malfunction and could place staff and patients at risk of fire from an indequate system.

The findings include, but are not limited to:

1. At approximately 1003 hours on October 23, 2012 that the elevator mechanical room located on the first floor beneath the stairway did not have automatic fire sprinkler protection. This was acknowledged by the Director of Plant Engineering who stated that was due to the room being of concrete construction.

2. At approximately 1045 hours on October 23, 2012 observed that the closet with the doors located in the board room did not have automatic fire sprinkler protection. This was acknowledged by the Director of Plant Engineering at the time of the observation.

3. At approximately 1118 hours on October 23, 2012, I observed that the closet in the Mamograph room with the nitro tank did not have a sprinkler head. This finding was observed and discussed with the Safety Officer.

The facilityl has failed to maintain the automatic fire sprinkler system in a reliable operating condition due to the failure of required testing. This could result in the fire sprinkler system operating properly in the event of a fire allowing the fire to grow in size and potentially place all of the patients, staff and visitors in danger.

The findings include, but are not limited to:

1. During the record review at 9:00am on October 23, 2012 and interviews with the Safety Officer, sprinkler records for the past 12 months prior to the date of survey revealed that the required quarterly testing of the fire sprinkler system had been done, yet no records could be provided that it had been done.

2. Interviews with the Director of Plant Engineering indicated that quarterly testing of the fire sprinkler system had not been done.

3. During a record review on October 23, 2012 of the sprinkler test reports for the 12 month period prior to the day of survey revealed that the Internal Pipe inspection was last performed on 2006 and was due again on 2011. No reports were availble to indicate that the internal pipe inspection had been done.

These findings were observed and discussed with the Safety Officer.

Based upon observations and staff interviews with the Director of Plant Engineering during survey rounds between approximately 0800 and 1600 hours Chelan Community Hospital has failed to restrict the use of portable electric heaters. This could result in a fire due to the high temperatures of the heater.

The findings include, but are not limited to:

1. At approximately 1033 hours observed a portable electric heater in the office of the OB coordinator. At the time of the observation the heater was not in use and the office was vacant. When the heater was plugged in it became hot enough to cause a burn to the skin. This heater was well above 212 degrees.

This was observed and acknowledged by the Director of Plant Engineering and the heater was removed.

Based upon observations and staff interviews Lake Chelan Community Hospital has failed to maintain the exit access corridors free of obstructions or impediments to allow for the full instant use in the event of a fire or other emergency. This could result in a delay in evacuating a compartment in the event of a fire or other emergency.

The findings include, but are not limited to:

1. At approximately 0830 observed a large linen cart in the exit access corridor immediately across from the nurses' station on the second floor. During the entire length of the survey the cart did not move. Interviews with the hospital staff indicated that is where the cart is kept at all times.
2. At approximately 0830 observed numerous computers on wheels carts in the exit access corridor of the medical surgical area on the second floor. These devices were observed throughout the day of the survey being in the same place. The carts were plugged into wall outlets in the corridor. Staff interviews indicated that is where they were maintained.
3. At approximately 1030 hours observed a large plastic Linen cart in the exit access corridor near the office of the Chief Nursing Officer. This cart is what the facility uses to collect and receive laundry from their off site laundry company.
4. At approximately 1346 hours observed in the exit access corridor from the recovery room and surgical room area a large black container marked " Region #7 ASPR Grant Equipment " , and infant Crib, and numerous 5 gallon water bottles (8) stored in the corridor. There is insufficient room to move a bed between these items and the corridor walls in the event any type of evacuation of the compartment would be needed.
5. At approximately 1130 hours, I observed that the entire length of the exit corridor on the 3rd floor was lined with sofa chairs and tables on one side, restricting the corridor width to maybe 4 feet.
6. At approximately 1300 hours, I observed that the Emergency Room corridors had numerous items stored on both sides of the corridor restricting the exit path.
7. At approximately 1120, I observed that the 3rd floor Sanctuary exit paths were partially obstructed by a food cart and other items. This was observed and acknowledged by the Safety Officer and staff promptly removed all the obstructions at the time of finding.

These findings were observed and acknowledged by the Director of Maintenance and/or the Safety Officer.

Based upon observation during the facility survey on October 23, 2012, the facility has failed to properly store flammable/combustible liquids containers/storage. This could hamper the emergency responders to recognize the contents of the containers and know how to properly extinguish, and thus expose the patients, staff, and visitors to the threat of explosion or fire.

The findings include, but are not limited to:

During the survey tour on October 23, 2012 at approximately 1300 hours, I observed that the propane tank on the north wall of the hospital by first floor kitchen access did not have any identification of content signs or no smoking signs.

This finding was observed and discussed with the Safety Officer.

Based upon a record review and interviews with the director of Maintenance during survey hours from 0800 to 1600 Chelan Community Hospital has failed to properly test and record results of the Battery Backup emergency lighting in the hospital. This could result in the emergency lighting failing to provide immediate illumination in critical areas for the required length of time. This could result in inadvertent injury to a patient during a critical procedure due to the lack of illumination.

The findings include,but are not limited to:

1. Interviews with the Director of Plant Engineering at approximately 1335 indicated that the emergency battery back-up lighting in the Operating rooms is not tested for a minimum of 30 seconds monthly and 90 minutes annually as required. He stated that they pushed the button long enough for the lights to illuminate once a month. He further stated that they were not aware of the requirement for a specific time.

2.. During the record review on Octboer 23, 2012 at 10:45am, of the facility's maintance records for the 12 months prior to the date of survey revealed that there were no logs of battery testing of emergency lighting in the facility. Interview with the Safety Officer indicated that there were no battery lights in the facility.

3. During the facility tour at 11:25am, I observed that there were battery lights in the Specialty Clinic on the 3rd floor. No logs were discovered for these emergency lights.

Based upon observations and staff interviews with the Director of Plant Services during survey rounds between approximately 0800 and 1600 Chelan Community Hospital has failed to restrict the use of extension cords and multi-plug plug strips. This could result in the overheating of the flexible wiring which could cause a fire and expose patients, staff, and visitors to the threat of an electrical fire.

The findings include, but are not limited to:

1. At approximately 1018 hours observed an orange extension cord that had been placed in a small diameter plastic pipe or tube and then extending from a wall outlet, behind file cabinets and along a side wall to an area behind the office desk at which point a multi outlet plug strip was plugged into it. The plug strip had numerous pieces of computer equipment such as printers, computer, and monitor plugged into it. This was acknowledged by the Director of Plant Engineering and it was removed and replaced with an approved plug strip.

2. At approximately 1035 hours, I observed a power strip in the Safety Officer's office on a shelf that was plugged into another power strip. This was observed and discussed with the Safety Officer.

The facility has failed to provide a written plan for fire watch procedures in case of the automatic sprinkler system is out of service for more than 4 hours. This could provide for staff not aware that a fire watch is necessary and thereby allowing the facility to be without protection and place patients and staff at risk of fire.

The findings include, but are not limited to:

1. During the record review of the facility's disaster plan and emergency procedures at 9:00am on October 23, 2012 and interviews with the Safety Officer, records revealed that the facility did not have a plan in place for fire watch implementation when sprinkler system is down for more than 4 hours.

2. During the record review of the facility's disaster plan and emergency procedures at 9:00am on October 23, 2012 and interviews with the Safety Officer, records revealed that the facility did not have an approved fire watch procedure in place. The facility's fire watch procedure was vague and did not have means to ensure that fire watch personnel's sole duty would be to watch for fires.

These findings were observed and discussed with the Safety Officer.

Based upon observation during a tour of the facility on October 23, 2012, the facility has failed to maintain doors protecting corridor openings. This prevents the doors from resisting the passage of smoke due to doors failingto close and latch or being prevented from closing due to impediments being in the doors travel path. This could result in smoke passing into the corridor or into rooms in the event of a fire.

The findings include, but are not limited to:

1. Observed at approximately 1036 hours that the door between the exit access corridor and the clean linen room failed to close and latch.
2. Observed at approximately 1016 hours a wooden door wedge being used to keep the door to the Physical Therapy intake room open.
3. Observed numerous door wedges on the floor near the office doors in the office area. At the time of the observations the wedges were not in use. Interviews with the Director of Plant Engineering indicated that they are typically used while people are in the offices.

The above findings were discussed and acknowledged by the Director of Plant Engineering.

Based upon a record review of the building construction plans, staff interviews with the Director of Plant Engineering and observation between 1045 and 1100 hours Chelan Community Hospital has failed to install or maintain smoke barrier walls as indicated on the construction plans. This could result in no smoke barriers being present on the medical surgical patient care areas.

1. The smoke barrier wall as indicated on the construction plans does not meet the requirements for a smoke barrier wall in that the wall does not extend above the ceiling to the floor above. This indicated wall is located near the quiet room and by the former nursing station.

This finding was observed and acknowledged by the Director of Plant Engineering.

Based upon observations and staff interviews with the Director of Plant Engineering between the survey hours of 0800 and 1600 Chelan Community Hospital has failed to maintain the required separation of hazardous areas from other others in the hospital. This could result in the movement of the toxic products of combustion into other areas of the hospital and thereby jeopardizing patients, staff and visitors.

The findings include, but are not limited to:

1. Observed at approximately 1026 hours several unsealed penetrations in the Mechanical room wall which separated the Central Supply room from the Mechanical room. This was acknowledged by the Director of Plant Engineering who immediately directed his staff to seal the penetrations.
2. Observed at approximately 1036 hours that the Soiled Linen Room on the first floor near the maintenance and security offices a door with a Bio Hazard Label on the door. This door had an unsealed louver cut into the door. This condition would not resist the passage of smoke from the Soiled Linen room into the exit access corridor. This was acknowledged by the Director of Plant Engineering.
3. Observed at approximately 1145 hours the soiled linen room on the second floor near the nursing station had a door without a self closing device and the door failed to close and latch.

The above findings were observed and acknowledged by the Director of Plant Engineering.

Based upon observations during the facility tour on October 23, 2012, the facility failed to ensure that the automatic sprinkler system has been installed and maintained in accordance with NFPA 13. This could result in a system malfunction and could place staff and patients at risk of fire from an indequate system.

The findings include, but are not limited to:

1. At approximately 1003 hours on October 23, 2012 that the elevator mechanical room located on the first floor beneath the stairway did not have automatic fire sprinkler protection. This was acknowledged by the Director of Plant Engineering who stated that was due to the room being of concrete construction.

2. At approximately 1045 hours on October 23, 2012 observed that the closet with the doors located in the board room did not have automatic fire sprinkler protection. This was acknowledged by the Director of Plant Engineering at the time of the observation.

3. At approximately 1118 hours on October 23, 2012, I observed that the closet in the Mamograph room with the nitro tank did not have a sprinkler head. This finding was observed and discussed with the Safety Officer.

The facilityl has failed to maintain the automatic fire sprinkler system in a reliable operating condition due to the failure of required testing. This could result in the fire sprinkler system operating properly in the event of a fire allowing the fire to grow in size and potentially place all of the patients, staff and visitors in danger.

The findings include, but are not limited to:

1. During the record review at 9:00am on October 23, 2012 and interviews with the Safety Officer, sprinkler records for the past 12 months prior to the date of survey revealed that the required quarterly testing of the fire sprinkler system had been done, yet no records could be provided that it had been done.

2. Interviews with the Director of Plant Engineering indicated that quarterly testing of the fire sprinkler system had not been done.

3. During a record review on October 23, 2012 of the sprinkler test reports for the 12 month period prior to the day of survey revealed that the Internal Pipe inspection was last performed on 2006 and was due again on 2011. No reports were availble to indicate that the internal pipe inspection had been done.

These findings were observed and discussed with the Safety Officer.

Based upon observations and staff interviews with the Director of Plant Engineering during survey rounds between approximately 0800 and 1600 hours Chelan Community Hospital has failed to restrict the use of portable electric heaters. This could result in a fire due to the high temperatures of the heater.

The findings include, but are not limited to:

1. At approximately 1033 hours observed a portable electric heater in the office of the OB coordinator. At the time of the observation the heater was not in use and the office was vacant. When the heater was plugged in it became hot enough to cause a burn to the skin. This heater was well above 212 degrees.

This was observed and acknowledged by the Director of Plant Engineering and the heater was removed.

Based upon observations and staff interviews Lake Chelan Community Hospital has failed to maintain the exit access corridors free of obstructions or impediments to allow for the full instant use in the event of a fire or other emergency. This could result in a delay in evacuating a compartment in the event of a fire or other emergency.

The findings include, but are not limited to:

1. At approximately 0830 observed a large linen cart in the exit access corridor immediately across from the nurses' station on the second floor. During the entire length of the survey the cart did not move. Interviews with the hospital staff indicated that is where the cart is kept at all times.
2. At approximately 0830 observed numerous computers on wheels carts in the exit access corridor of the medical surgical area on the second floor. These devices were observed throughout the day of the survey being in the same place. The carts were plugged into wall outlets in the corridor. Staff interviews indicated that is where they were maintained.
3. At approximately 1030 hours observed a large plastic Linen cart in the exit access corridor near the office of the Chief Nursing Officer. This cart is what the facility uses to collect and receive laundry from their off site laundry company.
4. At approximately 1346 hours observed in the exit access corridor from the recovery room and surgical room area a large black container marked " Region #7 ASPR Grant Equipment " , and infant Crib, and numerous 5 gallon water bottles (8) stored in the corridor. There is insufficient room to move a bed between these items and the corridor walls in the event any type of evacuation of the compartment would be needed.
5. At approximately 1130 hours, I observed that the entire length of the exit corridor on the 3rd floor was lined with sofa chairs and tables on one side, restricting the corridor width to maybe 4 feet.
6. At approximately 1300 hours, I observed that the Emergency Room corridors had numerous items stored on both sides of the corridor restricting the exit path.
7. At approximately 1120, I observed that the 3rd floor Sanctuary exit paths were partially obstructed by a food cart and other items. This was observed and acknowledged by the Safety Officer and staff promptly removed all the obstructions at the time of finding.

These findings were observed and acknowledged by the Director of Maintenance and/or the Safety Officer.

Based upon observation during the facility survey on October 23, 2012, the facility has failed to properly store flammable/combustible liquids containers/storage. This could hamper the emergency responders to recognize the contents of the containers and know how to properly extinguish, and thus expose the patients, staff, and visitors to the threat of explosion or fire.

The findings include, but are not limited to:

During the survey tour on October 23, 2012 at approximately 1300 hours, I observed that the propane tank on the north wall of the hospital by first floor kitchen access did not have any identification of content signs or no smoking signs.

This finding was observed and discussed with the Safety Officer.

Based upon a record review and interviews with the director of Maintenance during survey hours from 0800 to 1600 Chelan Community Hospital has failed to properly test and record results of the Battery Backup emergency lighting in the hospital. This could result in the emergency lighting failing to provide immediate illumination in critical areas for the required length of time. This could result in inadvertent injury to a patient during a critical procedure due to the lack of illumination.

The findings include,but are not limited to:

1. Interviews with the Director of Plant Engineering at approximately 1335 indicated that the emergency battery back-up lighting in the Operating rooms is not tested for a minimum of 30 seconds monthly and 90 minutes annually as required. He stated that they pushed the button long enough for the lights to illuminate once a month. He further stated that they were not aware of the requirement for a specific time.

2.. During the record review on Octboer 23, 2012 at 10:45am, of the facility's maintance records for the 12 months prior to the date of survey revealed that there were no logs of battery testing of emergency lighting in the facility. Interview with the Safety Officer indicated that there were no battery lights in the facility.

3. During the facility tour at 11:25am, I observed that there were battery lights in the Specialty Clinic on the 3rd floor. No logs were discovered for these emergency lights.

Based upon observations and staff interviews with the Director of Plant Services during survey rounds between approximately 0800 and 1600 Chelan Community Hospital has failed to restrict the use of extension cords and multi-plug plug strips. This could result in the overheating of the flexible wiring which could cause a fire and expose patients, staff, and visitors to the threat of an electrical fire.

The findings include, but are not limited to:

1. At approximately 1018 hours observed an orange extension cord that had been placed in a small diameter plastic pipe or tube and then extending from a wall outlet, behind file cabinets and along a side wall to an area behind the office desk at which point a multi outlet plug strip was plugged into it. The plug strip had numerous pieces of computer equipment such as printers, computer, and monitor plugged into it. This was acknowledged by the Director of Plant Engineering and it was removed and replaced with an approved plug strip.

2. At approximately 1035 hours, I observed a power strip in the Safety Officer's office on a shelf that was plugged into another power strip. This was observed and discussed with the Safety Officer.

The facility has failed to provide a written plan for fire watch procedures in case of the automatic sprinkler system is out of service for more than 4 hours. This could provide for staff not aware that a fire watch is necessary and thereby allowing the facility to be without protection and place patients and staff at risk of fire.

The findings include, but are not limited to:

1. During the record review of the facility's disaster plan and emergency procedures at 9:00am on October 23, 2012 and interviews with the Safety Officer, records revealed that the facility did not have a plan in place for fire watch implementation when sprinkler system is down for more than 4 hours.

2. During the record review of the facility's disaster plan and emergency procedures at 9:00am on October 23, 2012 and interviews with the Safety Officer, records revealed that the facility did not have an approved fire watch procedure in place. The facility's fire watch procedure was vague and did not have means to ensure that fire watch personnel's sole duty would be to watch for fires.

These findings were observed and discussed with the Safety Officer.