HospitalInspections.org

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility 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:

Penetrations were observed in the ceiling in Sleep Wellness Center - Storage/Sprinkler Riser Room (no ceiling tiles)

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility 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:

Penetrations were observed in the wall or ceiling in the following locations:
1) Environmental Services Storage Room
2) Electrical Room in Cafeteria Hall
3) Environmental Services - Clean Room
4) Environmental Services - Director's Office
5) Materials Management Office
6) Respiratory Therapy Lab
7) Respiratory Therapy Breakroom

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 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:

Fire Doors failed to close and latch in the following areas:
1) Administration Hallway
2) Administration/Engineering Hallway
3) Birthing Center

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 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:

Anacortes Family Medicine - Exit not clear to the public way due to staff bike on exit ramp. The deficiency was corrected during the inspection.

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 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:

Missing sprinkler head(s) were noted in the following locations:

1) Anacortes Family Medicine - alcove in the reception area
2) Dietary Office off main entrance corridor
3) Men's Restroom off main entrance corridor
4) Portions of the Engineering Shop
5) Patient/Visitor Lactation Room (closet sprinklered - room not sprinklered)
6) Coffee Shop - storage area

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours The facility has failed to conduct testing and maintenance of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility was unable to provide documentation of a five year internal pipe inspection. Facility has a pipe inspection scheduled for April 12-14, 2016.

Dirt, grease or other particulate was observed on sprinkler heads in the following locations:
1) Computed Tomography (CT) /Magnetic Resonance Imaging (MRI) Prep Room
2) Computed Tomography (CT) Scan Room

An escutcheon ring was observed to be missing on a sprinkler head in the Sleep Wellness Center - Continuous Positive Airway Pressure (CPAP) Storage Room

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours The facility has failed to conduct testing and maintenance of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility was unable to provide documentation of a five year internal pipe inspection. Facility has a pipe inspection scheduled for April 12-14, 2016.

Dirt, grease or other particulate was observed on sprinkler heads in the following locations:
1) Volunteer Room
2) Scope Room
3) Kitchen - Café grilling area

Escutcheon rings were observed to be missing on sprinkler heads in the following locations:
1) Medical Office Building - Pain Clinic Clean Room
2) Anacortes Family Medicine - Break Room
3) Engineering Shop
4) Fidalgo Medical Associates - Break Room

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to posted signs that read NO SMOKING or with the international symbol for no smoking. This could result residents, staff and/or visitors smoking in prohibited areas and the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

No smoking signing were absent at the entrance of the Medical Arts Pavilion

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to posted signs that read NO SMOKING or with the international symbol for no smoking. This could result residents, staff and/or visitors smoking in prohibited areas and the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

No smoking signs were absent at the entrance of the following:
1) Medical Office Building
2) Anacortes Family Medical

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility 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:

There is no emergency shut off remote from the generator

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. Additionally, electrical wiring failed to meet the requirements of NFPA 70. 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:

Power strips attached to another power strip in the following locations:
1) Central Registration
2) Medical Records - Reception/Copy Machine area

An appliance was plugged into a power strip in the Emergency Department - Soiled Room (refrigerator)

An electrical cover plates was missing in X-Ray 1 - Room 1074

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. Additionally, electrical wiring failed to meet the requirements of NFPA 70. 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:

Power strips attached to another power strip in the following locations:
1) Medical Office Building - Electrical Room
2) Respiratory Therapy Storage
3) Doctors' Sleeping Room
4) Operating Room - Director of Surgical Services
5) Environmental Services - Breakroom
6) Lab - under desk to the right of the entrance

Appliances were plugged into power strips in the following locations:
1) Medical Office Building - Massage & Injectable Room (massage table)
2) Medical Office Building - Pain Clinic (microwave)
3) Engineering Conference Room (microwave)
4) Painter's Office (refrigerator)
5) Environmental Services - Breakroom (heater)
6) Volunteer Room (refrigerator)
7) Respiratory Therapy Breakroom (microwave)
8) Surgery Recovery - Clean Utility Room (appliance)
9) Coffee Shop (freezer/cooler)
10) Sterile Room (refrigerator and microwave)

Electrical cover plates were missing in the following locations:
1) Communications Room by Environmental Services
2) Respiratory Therapy Director's Office

A junction box was partially protruding out of wall in the Respiratory Therapy Director's Office

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility 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:

Penetrations were observed in the ceiling in Sleep Wellness Center - Storage/Sprinkler Riser Room (no ceiling tiles)

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility 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:

Penetrations were observed in the wall or ceiling in the following locations:
1) Environmental Services Storage Room
2) Electrical Room in Cafeteria Hall
3) Environmental Services - Clean Room
4) Environmental Services - Director's Office
5) Materials Management Office
6) Respiratory Therapy Lab
7) Respiratory Therapy Breakroom

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 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:

Fire Doors failed to close and latch in the following areas:
1) Administration Hallway
2) Administration/Engineering Hallway
3) Birthing Center

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 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:

Anacortes Family Medicine - Exit not clear to the public way due to staff bike on exit ramp. The deficiency was corrected during the inspection.

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 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:

Missing sprinkler head(s) were noted in the following locations:

1) Anacortes Family Medicine - alcove in the reception area
2) Dietary Office off main entrance corridor
3) Men's Restroom off main entrance corridor
4) Portions of the Engineering Shop
5) Patient/Visitor Lactation Room (closet sprinklered - room not sprinklered)
6) Coffee Shop - storage area

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours The facility has failed to conduct testing and maintenance of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility was unable to provide documentation of a five year internal pipe inspection. Facility has a pipe inspection scheduled for April 12-14, 2016.

Dirt, grease or other particulate was observed on sprinkler heads in the following locations:
1) Computed Tomography (CT) /Magnetic Resonance Imaging (MRI) Prep Room
2) Computed Tomography (CT) Scan Room

An escutcheon ring was observed to be missing on a sprinkler head in the Sleep Wellness Center - Continuous Positive Airway Pressure (CPAP) Storage Room

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours The facility has failed to conduct testing and maintenance of the fire sprinkler system as required. This could result in the failure of the fire sprinkler system to operate properly in the event of a fire which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The facility was unable to provide documentation of a five year internal pipe inspection. Facility has a pipe inspection scheduled for April 12-14, 2016.

Dirt, grease or other particulate was observed on sprinkler heads in the following locations:
1) Volunteer Room
2) Scope Room
3) Kitchen - Café grilling area

Escutcheon rings were observed to be missing on sprinkler heads in the following locations:
1) Medical Office Building - Pain Clinic Clean Room
2) Anacortes Family Medicine - Break Room
3) Engineering Shop
4) Fidalgo Medical Associates - Break Room

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to posted signs that read NO SMOKING or with the international symbol for no smoking. This could result residents, staff and/or visitors smoking in prohibited areas and the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

No smoking signing were absent at the entrance of the Medical Arts Pavilion

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to posted signs that read NO SMOKING or with the international symbol for no smoking. This could result residents, staff and/or visitors smoking in prohibited areas and the ignition of the combustible materials adjacent to the staff smoking area which would endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

No smoking signs were absent at the entrance of the following:
1) Medical Office Building
2) Anacortes Family Medical

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility 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:

There is no emergency shut off remote from the generator

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. Additionally, electrical wiring failed to meet the requirements of NFPA 70. 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:

Power strips attached to another power strip in the following locations:
1) Central Registration
2) Medical Records - Reception/Copy Machine area

An appliance was plugged into a power strip in the Emergency Department - Soiled Room (refrigerator)

An electrical cover plates was missing in X-Ray 1 - Room 1074

The above was discussed and acknowledged by the Director of Plant Operations.

Based upon observations and staff interviews on 02/23/2016 between approximately 0830 and 1815 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. Additionally, electrical wiring failed to meet the requirements of NFPA 70. 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:

Power strips attached to another power strip in the following locations:
1) Medical Office Building - Electrical Room
2) Respiratory Therapy Storage
3) Doctors' Sleeping Room
4) Operating Room - Director of Surgical Services
5) Environmental Services - Breakroom
6) Lab - under desk to the right of the entrance

Appliances were plugged into power strips in the following locations:
1) Medical Office Building - Massage & Injectable Room (massage table)
2) Medical Office Building - Pain Clinic (microwave)
3) Engineering Conference Room (microwave)
4) Painter's Office (refrigerator)
5) Environmental Services - Breakroom (heater)
6) Volunteer Room (refrigerator)
7) Respiratory Therapy Breakroom (microwave)
8) Surgery Recovery - Clean Utility Room (appliance)
9) Coffee Shop (freezer/cooler)
10) Sterile Room (refrigerator and microwave)

Electrical cover plates were missing in the following locations:
1) Communications Room by Environmental Services
2) Respiratory Therapy Director's Office

A junction box was partially protruding out of wall in the Respiratory Therapy Director's Office

The above was discussed and acknowledged by the Director of Plant Operations.