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Based upon observations, documentation review and staff interviews on November 2, 2021 between approximately 0800 hours and 1615 hours the facility failed to maintain the facility in accordance with NFPA 101 (2012) 19.1. Failure to maintain in accordance with 2012 NFPA 101 may place patients, staff, and visitors at a greater risk of exposure to heat, fire, and smoke.

Findings include:

The facility failed to notify the Washington State Department of Health of the fire sprinkler activation and generator failure which occurred on June 30, 2021.

NFPA 101 (2012) 19.1.1.1.3, 4.6.1.2
WAC 246-320-151 Reportable operational or maintenance events.
(1) Hospitals must notify the department within forty-eight hours whenever any of the following events have occurred:
(a) A failure or facility system malfunction such as the heating, ventilation, fire alarm, fire sprinkler, electrical, electronic information management, or water supply affecting patient diagnosis, treatment, or care within the facility


Facility staff replaced sprinkler head after discharge activation on June 30, 2021.

NFPA 101 (2012) 19.1.1.1.3, 4.6.1.2
WAC 212-80-018 License and certification requirements.
2) Fire protection sprinkler system certification - Only a certificate holder may prepare layout drawings or install, inspect, test, maintain, or repair a fire protection sprinkler system or any part of such a system based on his or her design certification level.

Based upon documentation and staff interviews on November 2, 2021 between approximately 0800 to 1615 hours the facility has failed to maintain records of testing for the emergency battery backup lighting. This could result in the failure of the battery powered backup lighting in the event of a power outage and render the means of egress dark. This could result delayed egress and in tripping and fall injuries to patients, staff and/or visitors.

The findings include:

The facility was unable to provide documentation of monthly 30 second testing of emergency lighting since July 27, 2021.

NFPA 101 (2012 ed)19.1.1.1.1, 19.2.9, 7.9, 7.9.3.1.1

The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based upon documentation review and staff interviews on November 2, 2021 between approximately 0800 to 1615 hours the facility has failed to maintain proper exit signage. This could potentially misdirect patients, staff, and/or visitors during an emergency.

The findings include:

The facility was unable to provide documentation of 30 second testing of the emergency exit signs since June 2, 2021.

NFPA 101 (2012 ed)19.1.1.1.1, 19.2.9, 7.9, 7.9.3.1.1

The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based on documentation review and staff interviews on November 2, 2021 between approximately 0800 to 1615 hours the facility has failed to have appropriate testing of the fire alarm system which result in the failure to notify staff of a problem with the fire alarm system. This could lead to the system not functioning as intended and lead patients, staff, and visitors within the building not being notified of a fire.

The findings include:

The facility was unable to provide documentation of smoke detector sensitivity testing within the past five years.

NFPA 101 (2012) 19.1.1.1.1, 19.3.4.1, 9.6.1.3, 2.1, NFPA 72 (2010) 1.1.1, 14.4.5.3

The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based on documentation review and staff interviews on November 2, 2021 between approximately 0800 to 1615 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire alarm system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, potentially endangering patients, staff, and/or visitors within the facility.

The findings include:

The facility was unable to provide a fire watch policy in the event of the fire alarm system is out of service greater than four hours.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.1, 9.6.1.6

The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based on documentation review and staff interview on November 2, 2021 between approximately 0800 to 1615 hours the facility has failed to have a written procedure for instituting an approved fire watch in the event of a failure of the fire sprinkler system. This could result in an inadequate fire watch which may result in a delay of fire detection and suppression, endangering patients, staff, and/or visitors within the facility.

The findings include:

The facility had a sprinkler head activation due to excessive heat in the generator room at approximately 2215 hours on June 30, 2021. A licensed fire sprinkler contractor's service on the system was not complete until approximately 1730 hours on July 2, 2021. The facility failed to perform fire watch between July 1, 2021 at 0815 hours, 10 hours following the initial sprinkler system impairment as fire watch policy states, and July 2, 2021 at 1730 hours when work was complete.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 15.5.2
The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager

Based on observation, documentation review and staff interview on November 2, 2021 between approximately 0800 to 1615 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:

Emergency Department - fire extinguisher obstructed. Corrected during inspection.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 6.1.3.3.1

Monthly fire extinguisher inspections were not maintained on the following extinguishers:
Helipad - last performed 7/2021
Operating Room - last performed 8/2021
Kitchen - last performed 8/2021
Elevator Room - last performed 9/2021

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.4.12, 9.7.4.1, 2.1, NFPA 10 (2010 ed) 1.1, 7.3.3.1.3

The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based on observation and staff interview on November 2, 2021 between approximately 0800 to 1615 hours the facility has failed to maintain electric and gas equipment in a safe manner and in accordance with NFPA 54 and NFPA 70. This could endanger patients, staff, and visitors in the building by risk of fire, electrocution, or other harm.

The findings include:

Exposed wires were observed in the following locations:
Traction Storage - heater cover removed
Break Room - heater cover removed

NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A), 424.12.(A)

Traction Storage - electrical junction box was knocked off the wall
Old Big Emergency Room - several open electrical boxes

NFPA 101 (2012 ed) 19.1.1.1.1, 19.5.1.1, 9.1.2, 2.1, NFPA 70 (2011 ed) 90.2 (A), 314.28




The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based on observation and staff interview on November 2, 2021 between approximately 0800 to 1615 hours the facility failed to maintain their medical gas identification and labeling in accordance with NFPA 99. Failure to maintain medical gas identification as required could place patients, staff, and visitors to the threat of misused gases or using open flames around gases.

The findings include:

The medical gas storage room containing positive pressure gases other than just oxygen and medical air did not have the following signage:

Positive Pressure Gases
NO Smoking or Open Flame
Room May Have Insufficient Oxygen
Open Door and Allow Room to
Ventilate Before Entering

NFPA 99 (2012) 5.1.3.1.8

The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.

Based on observation and staff interview on November 2, 2021 the facility failed to maintain a maintenance program for their medical gas equipment. This could lead to the equipment malfunctioning endangering patients and staff.

The findings include:

1) The facility was unable to provide documentation of credentialing for staff performing inspections to the approved ASSE level(s) as required by NFPA 99 5.1.14.2.2.5.

2) The facility was unable to provide a risk assessment for the establishment of inspection procedure(s) and testing methods of the medical gas and vacuum system as required by NFPA 99 5.1.14.2.2.3.


The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interview on November 2, 2021 between approximately 0800 to 1615 hours the facility failed to maintain their medical gas equipment through testing and inspection possible leading to a problem not being detected, and thus place patients, staff, and visitors to the threat of an accelerated fire.

The findings include:

1) The facility was unable to provide documentation of periodic inspections of medical gas and vacuum system components as required by NFPA 99 5.1.14.2.3.

All reports must be free of deviancies.



The above was discussed and acknowledged by the Facilities Engineer/Maintenance Manager.