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Based upon observations and staff interviews on August 10, 2021 between approximately 0800 hours and 1315 hours the facility has failed to maintain the facility in accordance with NFPA 101 (2012) 18.1 and 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.

The findings include:

Carbon monoxide detection was not provided in the vicinity of the emergency department, kitchen, and boiler room

NFPA 101 19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

NFPA 101 4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

International Fire Code 1103.9 Carbon monoxide alarms. Existing Group I or Group R occupancies shall be provided with single station carbon monoxide alarms in accordance with Section 915.4.3. An inspection will occur when alterations, repairs or additions requiring a permit occur, or when one or more sleeping rooms are added or created. The carbon monoxide alarms shall be listed as complying with UL 2034 and be installed and maintained in accordance with NFPA 720-2015 and the manufacturer's instructions.
EXCEPTIONS:
1. For other than R-2 occupancies, if the building does not contain a fuel-burning appliance, a fuel-burning fireplace, or an attached garage.
2. Work involving the exterior surfaces of dwellings, such as the replacement of roofing or siding, or the addition or replacement of windows or doors, or the addition of a porch or deck, or electrical permits.
3. Installation, alteration or repairs of non-combustion plumbing or mechanical systems.
4. Sleeping units or dwelling units in I and R-1 occupancies and R-2 college dormitories, hotel, DOC prisons and work releases and assisted living facilities and residential treatment facilities licensed by the state of Washington which do not themselves contain a fuel-burning appliance, a fuel-burning fireplace, or have an attached garage, need not be provided with carbon monoxide alarms provided that:
4.1. The sleeping units or dwelling unit is not adjacent to any room which contains a fuel-burning appliance, a fuel-burning fireplace, or an attached garage; and
4.2. The sleeping units or dwelling unit is not connected by duct work or ventilation shafts with a supply or return register in the same room to any room containing a fuel-burning appliance, a fuel-burning fireplace, or to an attached garage; and
4.3. The building is provided with a common area carbon monoxide detection system.
5. An open parking garage, as defined in the International Building Code, or enclosed parking garage ventilated in accordance with Section 404 of the International Mechanical Code shall not be considered an attached garage.

The above was discussed and acknowledged by facility staff.

Based upon observations and staff interviews on August 10, 2021 between approximately 0800 and 1315 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 patients, staff and/or visitors within the facility.

The findings include:

IT room M130 - a penetration was filled with non-rated caulk.

NFPA 101 19.1.1.1, 19.1.6.5, 8.3.5, 8.4.4.1, 8.5.6.2 2012

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility has failed to maintain all means of egress continuously free of obstructions. This could inhibit the orderly exit of patients, staff, and visitors out of the building during an emergency and may prevent emergency responders from entering.

The findings include:

OR emergency exit door was blocked by a anesthesia cart.
Acute Care east emergency exit pathway is obstructed by garden hose and bark.
Emergency exit through the "bone yard" was obstructed by unused equipment.

NFPA 101 19.1.1.1, 19.2.1, 7.1.10.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based upon observations and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility has failed to maintain the ability of doors to be held open only by devices arranged to automatically close upon activation of the fire alarm. This could result in the passage of smoke or fire from one compartment into another compartment thereby exposing patients, staff and/or visitors to the toxic products of combustion.

The findings include:

Sterile Processing M219 room - door was blocked open inhibiting the ability to close and latch.

NFPA 101 19.1.1.1, 19.2.2.2.7

The above was discussed and acknowledged by facility staff.

Based upon documentation review and staff interviews on August 9, 2021 between approximately 1300 and 1700 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 has not performed annual 90 minute power test of the emergency lighting within the past twelve months.

NFPA 101 19.1.1.1.1, 19.2.9.1, 7.9.3.1.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based upon documentation review, observations and staff interviews on August 9, 2021 between approximately 1300 and 1700 hours and August 10, 2021 between approximately 0800 and 1315 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:

1) The facility has not performed annual 90 minute power test of the exits signs within the past twelve months.

NFPA 101 19.2.9.1, 19.1.1.1.1, 7.10.9.2, 7.9.3 (2012)

2) Exit doors in the following locations have illuminated emergency exit signs above the doors but also have signage on the doors stating, "NOTICE THIS IS NOT A FIRE EXIT" possibly creating confusion and misdirecting occupants.
Conference room
Nursing Administration Office M137

NFPA 101 19.2.10.1, 7.10.1.2.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based upon observation and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility has failed to maintain the safety of hazardous areas. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger patients, staff and/or visitors.

The findings include:

Boiler room - combustible materials were observed in several locations in the room.

NFPA 101 7.13.1.1, 7.13.1.2 (2012)

The above was discussed and acknowledged by the facility staff.

Based on observation, documentation review and staff interviews of August 10, 2021 between 0800 and 1315 hours the facility failed to maintain their laboratories in a safe and fire resistant manner in accordance with the referenced NFPAs. This could lead to the inability of staff or machinery to function as they should in the event of an emergency or exposed chemicals to magnify the effects of a fire and expose patients, staff, and visitors to these fire dangers.

The findings include:

The facility was unable to provide the annual laboratory hood inspection and service report.

NFPA 99 15.4, 2.1 (2012), NFPA 45, 1.1.1, 8.13.1 (2011)

Contractors service report must free of deficiencies.

The above was discussed and acknowledged by the facility staff.

Based upon record review and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility has failed to maintain the safety of cooking appliances that create grease laden vapors. This could result in the failure of the system to operate properly which would endanger the patients, staff and/or visitors within the facility.

The findings includes:

Popcorn machines creating grease laden vapors but not protected by a code compliant kitchen hood were in use in the kitchen and radiology department.

NFPA 101 19.1.1.1.1, 19.3.2.5.1, 9.2.3, 2.1 (2012), NFPA 96 1.1.1, 4.1.1 (2011)

The above was discussed and acknowledged by the facility staff.

Based on documentation review, observation and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility has failed to maintain 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 and allow the fire to increase in size and intensity which would endanger the patients, staff, and/or visitors within the facility.

The findings include:

1) Fire sprinkler heads were loaded in the following locations:
Corridor outside the mail room.
Room M176.
Room M179 (both sprinkler heads)


NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 5.2.1.1.4

2) Director of Support Services office - cable and twine was attached to the fire sprinkler pipe.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.3.5.1, 9.7.5, 2.1, NFPA 25 (2011 ed) 1.1, 5.2.2.2

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 10, 2021 between approximately 0800 and 1315 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:

1) Unsecured fire extinguishers were observed in the following locations:
Shop
Care Coordinators office. 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, 6.1.3.4

2) Administration - fire extinguisher was obstructed by a coat rack. 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

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 10, 2021 between approximately 0800 and 1315 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:

1) Bone Density Room - exposed wires from a missing wall light.

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), 70 90.1(B), 110.12(B)

2) OR Storage - electrical panels were blocked. Corrected during inspection.

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), 110.26(C), 110.33(A)

The above was discussed and acknowledged by the facility staff.

Based on documentation review, observation and staff interview on August 9, 2021 between approximately 1300 and 1700 hours the facility has failed to ensure dampers in the facility were inspected and provided necessary maintenance at least every four years in accordance with NFPA 90A. NFPA 101 9.2.1 requires heating, ventilating and air conditioning (HVAC), ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems.

NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. The test and inspection frequency shall be every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected. This deficient practice could affect all patients/residents, staff, and visitors.

The findings include:

Repairs/corrections to dampers found deficient on the August 29, 2019 damper inspection report have not been completed.

Contractor inspection/service reports must free of deficiencies.

NFPA 101 (2012 ed) 19.1.1.1.1, 19.2.1, 7.2.1.15.2, NFPA 80 (2010 ed) 1.1, 19.5.3

The above was discussed and acknowledged by the facility staff.

Based upon documentation review, observations and staff interviews on August 9, 2021 between approximately 1300 and 1700 hours and August 10, 2021 between approximately 0800 and 1315 hours the facility 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 inside the building.

The findings include:

1) The facility was unable to provide required documentation of annual fire door inspection for each fire doors.

2) Fire door between main entrance and administration area had a penetration at the top of the door and the label had been painted over.

NFPA 101 19.1.1.1.1, 19.2.1, 7.2.1.15.2 (2012), NFPA 80 1.1, 5.2.4.1, 5.1.5.1 (2010)

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on August 9, 2021 between approximately 1300 and 1700 hours the facility did not complete an evaluation including hazards associated with electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment. 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 room if liquids come in contact with the electrical receptacles.

The findings include:

The facility was unable to provide documentation an evaluation of hazards that could be encountered during surgical procedures.

NFPA 99 1.1.1, 6.3.2.2.8.4, 15.13.1 (2012)

The above was discussed and acknowledged by the facility staff.

Based on documentation and staff interviews on August 9, 2021 between approximately 1300 and 1700 hours the facility failed to keep records or conduct maintenance on their hospital grade receptacles and non-hospital grade receptacles. This could cause an increased risk of fire due to the non-maintenance of the electrical system, and place patients, staff, and visitors of electrical shock or harm.

The findings include:

1) The facility was unable to provide documentation of testing hospital grade electrical receptacles in the required testing locations.

NFPA 99 1.1.1, 6.3.4.1.1 (2012)

2) The facility was unable to provide documentation of testing non-hospital grade electrical receptacles in the required testing locations.

NFPA 99 1.1.1, 6.3.4.1.3 (2012)

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interview on August 9, 2021 between approximately 1300 and 1700 hours the facility has failed to maintain and test the emergency generator in accordance with NFPA 110. This could result in a failure of the emergency power system which would leave the facility without egress and task lighting in the event of a power failure which would endanger the patients, staff, and/or visitors within the facility.

The findings includes:

The facility was unable to provide documentation of tri-annual 4 hours load test.

NFPA 99 6.4.4.1.1.3, 2.1 (2012), NFPA 110 1.1, 8.4.9. (2010)

Contractors service report must free of deficiencies.

The above was discussed and acknowledged by the facility staff.

Based on observations and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility failed to restrict the use of extension cords and non-approved power strips in their facility. This could endanger patients, staff, and visitors in the facility due to the increased fire risk.

The findings include:

1) Nursing Office - powerstrip was plugged into another powerstrip in the the back of the office. Corrected during inspection.

NFPA 99 1.1.4.2 (2012), NFPA 70 Scope, 400.7(B) (2011)

2) Concrete Room - extension cord was in use in place of permanent wiring. Corrected during inspection.

NFPA 99 1.1.4.2 (2012), NFPA 70 Scope, 400.8 (2011)

The above was discussed and acknowledged by the facility staff.

Based on observation and staff interviews on August 10, 2021 between approximately 0800 and 1315 hours the facility has failed to maintain oxygen storage areas as being smoke and fire resistant. This could result in the products of combustion traveling from the hazardous area into the exit corridor in the event of a fire which could endanger patients, first-responders, staff, and/or visitors.

The findings include:

Indoor Medical Gas Storage - combustible material was stored in the room without adequate separation. Corrected during inspection.

NFPA 99 1.1.1, 1.1.9, 11.3.2.3 (2012)

The above was discussed and acknowledged by the facility staff.

Based on documentation review and staff interviews on August 9, 2021 between approximately 1300 and 1700 hours the facility has failed to provide documentation of personnel concerned with the application, maintenance, and handling of medical gases and cylinders that are trained on the risk and provide continuing education. Failure to provide training and continuing education on the safe handling and use of gases and cylinders could place patients, visitors, and staff at risk of oxygen malfunctions.

The findings include:

The facility was unable to provide documentation of staff training on the use of medical gas equipment.

NFPA 99 1.1.1, 11.5.2.1, 11.5.2.1.2 (2012)

The above was discussed and acknowledged by the facility staff.