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National Fire Protection Association (NFPA) 101, 6.1.14.2 Life Safety Code 2000 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. NFPA 101, 26.3.3.5 requires smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Based on observation, the critical access hospital failed to ensure smoke detectors were installed in staff sleeping rooms.

Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire.

Findings:

During a tour of the critical access hospital on 02/01/11, state deputy fire marshal observed that the staff call room in the old operating room wing, which was used for on call staff sleeping, did not have a smoke detector installed. Engineering staff confirmed that a smoke detector was not installed in the staff sleeping room.

Based on maintenance record review and interview with hospital staff, the hospital failed to test smoke detectors for sensitivity [reference National Fire Protection Association (NFPA) 72 7-3.2.1].

Failure to ensure smoke detectors are tested for sensitivity in accordance with NFPA 72 requirements risks building occupant life safety due to potentially inadequate smoke detection, subsequent occupant notification and evacuation during a fire event.

Findings:

Review on 02/02/11 of hospital maintenance records for annual servicing of the fire alarm system for 2009 and 2010 did not show evidence of smoke detector sensitivity testing.

Maintenance staff stated during an interview that the smoke detectors were on a zone system, and that smoke detector sensitivity testing had not been performed in accordance with NFPA 72.

Based upon observation, the critical access hospital failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in rooms protected as hazardous areas.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include:

During a tour of the critical access hospital on 02/01/11, it was observed that large wheeled recycle paper bin or garbage cans exceeding 32 gallons capacity were located in the basement egress corridor to the west of the Weyerhauser conference room.

The corridor was not protected as a hazardous area.

Based upon a record review and staff interview, the critical access hospital failed to ensure that the generator fuel supply was tested and maintained in accordance with NFPA 110 (8.3.8).

Failure to test and maintain the generator fuel supply risks failure of the emergency power system, placing patients and staff at risk.

Findings include:

During a tour of the critical access hospital on 02/01/11, the director of facilities stated that the diesel fuel for the emergency generator had not been tested for bacterial contamination. He stated that the fuel dwells in the tank for at least two years without need to add or replace the fuel. The critical access hospital did not have documentation or knowledge of when the diesel fuel was last tested for quality.

National Fire Protection Association (NFPA) 101, 6.1.14.2 Life Safety Code 2000 requires the most restrictive life safety requirement be applied when a lodging occupancy exists within a health care occupancy. NFPA 101, 26.3.3.5 requires smoke alarms be installed in accordance with 9.6.2.1 in staff sleeping rooms.

Based on observation, the critical access hospital failed to ensure smoke detectors were installed in staff sleeping rooms.

Failure to install smoke detectors in staff sleeping rooms risks the ability of occupants to safely evacuated in the event of a smoldering fire.

Findings:

During a tour of the critical access hospital on 02/01/11, state deputy fire marshal observed that the staff call room in the old operating room wing, which was used for on call staff sleeping, did not have a smoke detector installed. Engineering staff confirmed that a smoke detector was not installed in the staff sleeping room.

Based on maintenance record review and interview with hospital staff, the hospital failed to test smoke detectors for sensitivity [reference National Fire Protection Association (NFPA) 72 7-3.2.1].

Failure to ensure smoke detectors are tested for sensitivity in accordance with NFPA 72 requirements risks building occupant life safety due to potentially inadequate smoke detection, subsequent occupant notification and evacuation during a fire event.

Findings:

Review on 02/02/11 of hospital maintenance records for annual servicing of the fire alarm system for 2009 and 2010 did not show evidence of smoke detector sensitivity testing.

Maintenance staff stated during an interview that the smoke detectors were on a zone system, and that smoke detector sensitivity testing had not been performed in accordance with NFPA 72.

Based upon observation, the critical access hospital failed to maintain trash collection or recycling paper bin of a capacity exceeding 32 gallons in rooms protected as hazardous areas.

Failure to keep large trash and paper bins in protected rooms risks spread of fire outside a protected environment, endangering patients, staff and visitors.

Findings include:

During a tour of the critical access hospital on 02/01/11, it was observed that large wheeled recycle paper bin or garbage cans exceeding 32 gallons capacity were located in the basement egress corridor to the west of the Weyerhauser conference room.

The corridor was not protected as a hazardous area.

Based upon a record review and staff interview, the critical access hospital failed to ensure that the generator fuel supply was tested and maintained in accordance with NFPA 110 (8.3.8).

Failure to test and maintain the generator fuel supply risks failure of the emergency power system, placing patients and staff at risk.

Findings include:

During a tour of the critical access hospital on 02/01/11, the director of facilities stated that the diesel fuel for the emergency generator had not been tested for bacterial contamination. He stated that the fuel dwells in the tank for at least two years without need to add or replace the fuel. The critical access hospital did not have documentation or knowledge of when the diesel fuel was last tested for quality.