HospitalInspections.org

Based upon observations and staff interviews along with record review on 7/18/17 during the inspection of the facility between 1200 and 1615 hours the facility has failed to maintain the laboratory fire protection plan in accordance with NFPA 45. This could result in a failure to for staff to respond appropriately in the event of a lab fire, resulting in potential harm to staff, patients and visitors.


The findings include, but are not limited to:

-The Lab does not have procedures for extinguishing a clothing fire in their lab-specific emergency plan as required by NFPA 45-6.6.3.2.


The above was discussed and acknowledged by the Maintenance Staff member #1 who said that they were unaware the requirements.

Based upon observation and staff interviews on 7/18/17 during the physical inspection of the campus between approximately 1245 and 1615 hours, the facility has failed to maintain and install the fire sprinkler system as required by NFPA 13. 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:



-There was no Automatic Sprinkler protection observed under the exterior wood canopy that extends over four feet from the building at the Housekeeping exterior breezeway. Per NFPA 13-8.15.7.1 sprinklers shall be installed under exterior roofs, canopies, porte-cocheres, balconies, decks, or similar projections exceeding 4 ft (1.2 m) in width.




The above was discussed and acknowledged by the Facility Maintenance staff who said they were not aware of the sprinkler head requirements for the breezeway.

Based upon document review and staff interviews as well as observation during they physical tour of the facility on 7/18/17 between approximately 1200 and 1615 hours the facility has failed to maintain and test the fire sprinkler system as required by NFPA 13 and NFPA 25. 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:

Visual Inspection at approximately 1245 hours on 7/18 determined the majority of the basement and main levels were equipped with Quick Response Pendent sprinkler heads dated 1994. (Approximately 300+ heads) These heads were due for replacement or UL testing in 2015.

Document review was conducted at approximately 1200 to 1245 hours on 7/18/17 and the 7/20/16 Annual Sprinkler Inspection report did not indicate any of the facility's heads were past due. The maintenance staff member #1 called the Sprinkler Contractor who had no record of any UL testing conducted and was unaware of the expired heads.

The Maintenance Staff member #1 stated he was unaware of the Quick Response sprinkler head 20 year testing / replacement requirements and that the sprinkler contractor had not informed him that there were any sprinkler heads due for replacement.


After consultation with Olympia Headquarters, the Facility was instructed to enter into 24/7 fire watch at 1325 hours on 7/18 until the heads are replaced or laboratory testing results indicate the heads are operational. The facility was instructed that they cannot terminate firewatch until authorization is given by the SFMO.

Based upon record review and staff interviews on 7/18/17 during the review of facility documentation between approximately 1200 and 1245 hours the facility has failed to maintain and test fire and smoke dampers in accordance with NFPA 80 and NFPA 105. This could result in failure of the dampers to operate and close in the event of a fire, allowing the spread of the products of combustion from one compartment to another, endangering the patients, staff and/or visitors.

The findings include, but are not limited to:


The facility could not provide any documentation indicating their fire and smoke dampers have been inspected and tested within the last four years.
Per NFPA 80-19.4.1 Each damper shall be tested and inspected 1 year after installation and 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.


The above was discussed and acknowledged by the Maintenance Staff member #1 who said they were unaware of the damper testing requirements.

Based upon observations and staff interviews on 7/18/17 during the physical tour of the facility between 1245 and 1615 hours the facility has failed to maintain generator equipment locations in accordance with NFPA 110. This could result in a failure to contain or restrict the passage of the products of combustion in the event of a fire in the generator room, resulting in potential harm to staff, patients and visitors.


The findings include, but are not limited to:

-The interior Generator room in the basement has one door to the corridor that is rated at 3/4 hour (45 minutes) fire resistance. Per NFPA 110-7.2.1.1 The room shall have a minimum 2-hour fire rating or be located in an adequate enclosure located outside the building capable of resisting the entrance of snow or rain at a maximum wind velocity required by local building codes. Per NFPA 101-Table 8.3.4.2, 2 hour fire barriers shall have doors with a minimum 1 and 1/2 hour rating.


The above was discussed and acknowledged by the Maintenance Staff member #1 who said that they were unaware the door to the generator room did not meet the requirements.

Based upon observations and staff interviews on 7/18/17 during the physical tour of the facility between approximately 1245 and 1615 hours, the facility has failed to properly maintain the Type 1 Medical Gas Piped System in the facility. This could result in gas supply or delivery malfunction which could potentially endanger patients in the OR or Acute Care within the facility.

The findings include, but are not limited to:

There is no exterior Emergency Oxygen Supply Connection as required by 2012 NFPA 99-5.1.3.5.13 and 1999 NFPA 99-4-3.1.1.8 (h) .

The above was discussed and acknowledged by the Maintenance Staff member #1 who said they were unaware of any installed emergency connection and that he was unaware of the requirement.

Based upon observations and staff interviews on 7/18/17 during the physical tour of the campus between approximately 1245 and 1615 hours, the facility has failed to ensure all electrical wiring is in accordance with NFPA 70. This could result in a delay to access electrical panels in the event of an emergency, endangering the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:

-There was a desk blocking access to electrical panels J1 and 2C in the kitchen. Per NFPA 70-110.26(3)(1), the panels shall have a minimum of 36 inches clear working space in front of them.



The above was discussed and acknowledged by the Maintenance Staff member who said kitchen staff had been previously instructed on the clear space requirements in front of the panels, but that he was unaware the panels were currently blocked.

Based upon observations and staff interviews on 7/18/17 during the physical tour of the facility between approximately 1245 and 1615 hours, the facility has failed to properly maintain the Type 1 EES in the facility. This could result in electrical malfunction or misidentification of emergency circuits which could potentially endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

The Automatic Transfer Switches in the basement that serve the Life Safety, Critical and Equipment branches are not labeled to indicate which branch they serve.

Per NFPA 70 (National Electrical Code):
700.10 Wiring, Emergency System.
(A) Identification. All boxes and enclosures (including transfer switches, generators, and power panels) for emergency circuits shall be permanently marked so they will be readily identified as a component of an emergency circuit or system.

The above was discussed and acknowledged by the Maintenance Staff member #1 who said they were unaware of the electrical system labeling requirements for the transfer switches.

Based upon observations and staff interviews on 7/18/17 during the physical tour of the campus between approximately 1245 and 1615, the facility has failed to restrict the use of powerstrips to providing power to permitted electrical equipment, using extension cords and on a temporary basis and from ensuring all electrical wiring is in accordance with NFPA 70. This could result in a fire from overheating of the extension cord due to the prolonged power draw or result in an electrical hazard due to misuse, endangering the residents, staff and/or visitors within the facility.



The findings include, but are not limited to:

-There was a non-UL1363A powerstrip in use with a crash cart in the 2nd floor Operating Room.

-There was a powerstrip plugged into another powerstrip in the IT server room.



The above was discussed and acknowledged by the Facility maintenance staff who said they had not previously observed the unapproved powerstrip in the OR or the daisy-chained powerstrips in the IT room.