HospitalInspections.org

Based upon observations and staff interviews on March 20, 2018 between approximately 1230 to 1430 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 following locations:

1. Closet room #100
2. Data closet room #200

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on March 20, 2018 between approximately 1530 and 1730 hours at the facility located at 111 S. 11th Avenue, Yakima has failed to test all fire rated doors in accordance with NFPA 80. This could lead to the doors not functioning as required in a fire, endangering patients, visitors, and staff at risk of spread fire, smoke, and heat.

The findings include, but are not limited to:

Document review at the facility revealed that fire doors were in the process of being tested annually, but had not been conducted.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1230 and 1400 hours the facility has failed to have their fire alarm system installed in accordance with the references NFPAs and in a manner that is approved. This could result in a fire not being detected by the fire alarm system, possible leading to harm and delayed evacuation and place patients, visitors, and staff at risk.
The findings include, but are not limited to:
Smoke alarms are required to be in all rooms used for sleeping. Smoke alarms were not present in the following locations:
1. Doctor's sleeping room #118.
2. Both doctor's sleeping rooms in or/surgery area.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1230 to 1430 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 patients, staff and/or visitors.

The findings include, but are not limited to:
Incorrect sprinkler head application was observed in the maintenance storage room by service exit. Both standard and quick response heads were located covering the same area which is in direct violation of the NFPA 13 8.3.3.2.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1230 to 1400 hours the facility failed to maintain their fire extinguishers in accordance with NFPA 10. This potentially delays a quick response to contain a fire from spreading which could expose and endanger patients, staff, and/or visitors within the facility.

The findings include, but are not limited to:
Fire extinguishers throughout were observed to be mounted higher than 5' to the highest point of the fire extinguisher.
The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1230 and 1400 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 patients, staff and/or visitors within the smoke compartment.

The findings include, but are not limited to:

1. Excessive gap between the double doors on fire doors into MRI.
2. Patient room #114 did not close and latch.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1030 and 1230 hours revealed that the facility's operating rooms were considered wet locations. Operation rooms are by default considered wet locations and require either GFCI or isolated power. This could potentially endanger patients and staff in the operating rooms if liquids come in contact with the electrical receptacles.

The findings include, but are not limited to:

The operating rooms do not have either GFCI or isolated power.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1030 to 1200 hours the facility failed to keep records or conduct maintenance on the hospital grade and non-hospital grade receptacles located at patient bed locations and where deep sedation or general anesthesia is administered. This could cause an increased risk of fire due to the non-maintenance of the electrical system and place patients and staff at risk.

The findings include, but are not limited to:

Document review of the facility records revealed that testing of electrical outlets at the above mentioned locations were not being conducted. Interview with staff revealed that they were not aware of this requirement.

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on March 20, 2018 between approximately 1530 and 1730 hours at the Ambulatory Surgical Center (ASC) located at 111 S. 11th Avenue, Yakima failed to keep records or conduct maintenance on the hospital grade and non-hospital grade receptacles located at patient bed locations and where deep sedation or general anesthesia is administered. This could cause an increased risk of fire due to the non-maintenance of the electrical system and place patients and staff at risk.

The findings include, but are not limited to:

Document review of the facility records revealed that testing of electrical outlets at the above mentioned locations were not being conducted. Interview with staff revealed that they were not aware of this requirement.

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on March 20, 2018 between approximately 1000 to 1030 hours the facility failed to maintain their hyperbaric chambers in accordance with the referenced NFPAs. The increased pressure and oxygen of these areas could lead to an increased risk of fire and place patients, visitors, and staff at risk.

The findings include, but are not limited to:

Inspection of the room where the B class hyperbaric chamber is housed did not have a fire alarm activation device in the room for staff to immediately active the fire alarm system.

The above was discussed and acknowledged by the facility staff.