HospitalInspections.org

Based upon observations and staff interviews during survey rounds between 0900 and 1600 on October 09, 2012 Kittitas Valley Community Hospital has failed to maintain corridor walls that separate the corridor from use areas in a condition that will resist the passage of smoke. This could allow for the toxic products of combustion to move from use areas into the exit access corridor making the exit access corridor unsafe for evacuation either a partial or complete evacuation.


The findings include:

1. At approximately 0938 on October 09, 2012 observed unsealed penetrations above the ceiling tiles in the one hour fire resistive rated wall separating the Engineering office and the exit access corridor for the passage of wires. These penetrations were sealed prior to the conclusion of the inspection.

Based upon observations and interviews with the Director of Maintenance. during survey rounds between 0800 and 1200 on October 10, 2012 Kittitas Valley Community Hospital has failed to maintain the separation of hazardous locations from the remaining facility with doors that self close or automatically close and latch. This could result in the toxic products of combustion moving from the hazardous location into other areas of the hospital.

The findings include:

1. Observed that the door to the Laundry failed to close and latch.

2. Observed that the door to the soiled linen room from the corridor next to the commercial laundry failed to close and latch.

The specific standard found at Section 7.9.3 of NFPA 10 Life Safety Code 2000 edition states:

7.9.3 Periodic Testing of Emergency Lighting Equipment. A
functional test shall be conducted on every required emergency
lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required
battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having
jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.




Based upon a record review on October 10, 2012 at 1120 hours and staff interviews with the Director of Maintenance Kittitas Valley Community Hospital has failed to conduct the testing of Emergency Battery Back-up Lighting. This could result in the failure of the emergency lighting to operate in the event of a power failure which could leave vital areas without illumination.


The findings include:

1. Based upon a record review at 1120 hours on October 10, 2012 and interviews with the Director of Maintenance at that time there were no records to verify that the required testing of emergency lighting for 30 seconds once per month and a minimum of 90 minutes once per year.

2. Interviews with the Director of Maintenance revealed that the maintenance staff was not aware of this requirement. The maintenance staff tested the lamps for illumination for a few seconds every month but not for 30 seconds and did not conduct the 90 minute annual tests.

Based upon observations and staff interviews during survey rounds between 0900 and 1600 on October 09, 2012 Kittitas Valley Community Hospital has failed to maintain Exit Directional Signs in a manner to indicated the direction of egress. This might result in a delay in egress in the event of an emergency due to a lack of information as to the direction that must be taken to reach the exit.


The findings include:

1. Observed on 10-09-12 that the illuminated EXIT sign located at the T intersection from the Birthing Center did not display a directional arrow to indicate the direction to take to access the exit. This was acknowledged by the Director of Maintenance at the time of the observation.

Based upon a record review and interviews with the Director of Maintenance Kittitas Valley Community Hospital has failed to maintain the automatic fire sprinkler system in accordance with the requirements of National Fire Protection Association (NFPA) 25 Standard for the inspection, testing and maintenance of water based fire protection systems. This could result in the failure of the fire sprinkler system to function as designed and not be able to suppress a fire.


The findings include:

1. During a record review on October 10, 2012 at approximately 1050 hours the dry sprinkler system number 4 installed in 2009 for the protection of the canopy to the MRI area has not had a full trip test. Records at the hospital indicate that the system was installed and completed in February of 2009 and there was no trip test due to cold weather. In 2010 a partial trip test was conducted. In 2011 a partial trip was conducted. In 2012 a partial trip test was conducted.

2. Based upon the record review and interviews with the Director of Maintenance the required full trip test every three years which includes the timed water reaches the test outlet has not been conducted.

Based upon a record review on October 10, 2012 at 1050 hours and staff interviews with the Director of Maintenance Kittitas Valley Community Hospital has failed to maintain the automatic fire sprinkler system in a reliable operating condition due to the failure of required testing. This could result in the fire sprinkler system operating properly in the event of a fire allowing the fire to grow in size and potentially place all of the patients, staff and visitors in danger.


The findings include:

1. During the record review at 1050 hours on October 10, 2012 and interviews with the Director of Maintenance records of the required quarterly testing of the fire sprinkler system could not be located.

2. Interviews with the Director of Maintenance indicated that quarterly testing of the fire sprinkler system had not been done.

1. During a record review on October 10, 2012 at approximately 1050 hours the dry sprinkler system number 3 has not had a full trip test during the past three (3) years as required In 2009 there was only a partial trip test conducted In 2010 a partial trip test was conducted. In 2011 a partial trip was conducted. In 2012 a partial trip test was conducted.

2. Based upon the record review and interviews with the Director of Maintenance the required full trip test every three years which includes the timed water reaches the test outlet has not been conducted.

Based upon observations and staff interviews during survey rounds between 0800 and 1600 on October 09, 2012 Kittitas Valley Community Hospital has failed to maintain the egress corridors free of obstructions. This could result in a delay in being able to evacuate to another smoke compartment or to conduct an entire building evacuation due to the obstructions in the corridor.


The findings include:

1. Observed at the time of entry into the hospital two (2) computer on wheels plugged into wall outlets in the medical /surgical wing of the hospital. The units were still in place upon the start of the survey at approximately 0915.

2. Observed a cart with a coffee pot, cups and condiments for patients, family, visitors and staff in the exit access corridor which passes through the emergency department at approximately 1000 hours. This cart was removed and relocated prior to the end of the survey.

3. Observed several material bins and boxes stored in the back corridor to the surgical wing. This material was close to central supply.


The above findings were discussed with and acknowledged by the Director of Maintenance.

Based upon a record review on October 10, 2012 and staff interviews with the Director of Maintenance and the Director of Surgical Services Kittitas Valley Community Hospital has failed to maintain a Humidity Level above 35% in the Anesthetizing Locations. This could result in a greater chance of a static electrical discharge which could cause an ignition of material in these areas.


The findings include:

1. Interviews with the Director of Surgical Services at approximately 1400 hours on October 09, 2012 it is common to have humidity levels below 35 %

2. Interviews with the Director of Surgical Services indicated that they measured humidity levels with hand held meters at several times during the day beginning at 0600 hours.

3, Interviews with the Director of Surgical Services the hospital would suspend surgical procedures when the humidity level was above 60% however they would continue with surgical procedures if the humidity was below or at any level below 35%.

4. A review of the written procedures on October 09, 2012 at approximately 1400 indicated that the humidity range was to be between 30% and 60%

5. Interviews with the Director of Maintenance indicated that the hospital does not have the ability to control humidity.

6. Interviews with the Director of Maintenance indicated that the hand held monitors used by the surgical staff are not calibrated on a regular basis.

7. A record review conducted at approximately 0900 hours on October 10, 2012 indicated the following:

a. During the twenty one (21) surgical days in January 2012 the humidity level was at 35.1% one (1) day. All other days were below 35% with the lowest level being 17.6%
b. During the nineteen (19) surgical days in February 2012 two days (2) had a humidity level at or above 35%. The other seventeen (17) days had a humidity level below 35% with the lowest being 19.1%
c. During the twenty two (22) surgical days in March 2012 five (5) days had a humidity level at or above 35% The other seventeen (17) days had a humidity level below 35% with the lowest being 22.8%
d. During the twenty one (21) surgical days in April 2012 eight (8) days had a humidity level at or above 35% The other thirteen (13) days had a humidity level below 35% with the lowest being 27%
e. During the twenty two (22) surgical days in May 2012 fourteen (14) days had a humidity level at or above 35% The other eight (8) days had a humidity level below 35% with the lowest being 25.1%
f. During the twenty one (21) surgical days in June 2012 twenty (20) days had a humidity level at or above 35% One (1) day had a humidity level below 35% with a humidity level of 34.2%.
g. During the twenty (20) surgical days in July 2012 The humidity level was above 35% on all twenty (20) days
h. During the twenty three (23) surgical days in August 2012 twenty one (21) days had a humidity level at or above 35% Two days had a humidity level below 35% with the lowest being 29.1%
i. During the nineteen (19) surgical days in September 2012 fifteen (15) days had a humidity level at or above 35% The other four (4) days had a humidity level below 35% with the lowest being 26.1%
j. During the first seven (7) surgical days in October 2012 one (1) day had a humidity level at or above 35% The other six (6) days had a humidity level below 35% with the lowest being 19.1%

The actual standard from NFPA 99 states:

(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equip me
1. Illumination of means of egress as required in NFPA 101, Life Safety Code
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, ' ' Gas and Vacuum Systems ' '
4.* Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.

No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
r Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

(c)* Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.

1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas-task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing area
. d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaries)
4. Additional specialized patient care task illumination and where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7.* Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based upon observations and staff interviews with the Director of Maintenance on October 10,2012 at approximately 1100 hours Kittitas Valley Community Hospital has failed to restrict the circuits that are allowed on the Life Safety Branch of the Essential Electrical System. This could result in a failure of the Essential Electrical System.

The findings include:

1. Observed that that following circuits were located in the electrical panel for the Life Safety Branch:
a. Sump Pumps
b. Heli pad lighting.
c. Radio system

This observation was acknowledged by the Director of Maintenance.

Based upon observations and staff interviews Kittitas Valley Community Hospital has failed to maintain Alcohol Based Hand Rub (ABHR) clear of ignition sources. This could result in the flammable fluid from the ABHR being ignited by an electrical arc.


The findings include:

1. Observed at 0900 on October 09,2012 a ABHR dispenser located directly above the electrical thermostat located in the second floor large conference room.

Based upon observations and staff interviews during survey rounds between 0900 and 1600 on October 09, 2012 Kittitas Valley Community Hospital has failed to maintain corridor walls that separate the corridor from use areas in a condition that will resist the passage of smoke. This could allow for the toxic products of combustion to move from use areas into the exit access corridor making the exit access corridor unsafe for evacuation either a partial or complete evacuation.


The findings include:

1. At approximately 0938 on October 09, 2012 observed unsealed penetrations above the ceiling tiles in the one hour fire resistive rated wall separating the Engineering office and the exit access corridor for the passage of wires. These penetrations were sealed prior to the conclusion of the inspection.

Based upon observations and interviews with the Director of Maintenance. during survey rounds between 0800 and 1200 on October 10, 2012 Kittitas Valley Community Hospital has failed to maintain the separation of hazardous locations from the remaining facility with doors that self close or automatically close and latch. This could result in the toxic products of combustion moving from the hazardous location into other areas of the hospital.

The findings include:

1. Observed that the door to the Laundry failed to close and latch.

2. Observed that the door to the soiled linen room from the corridor next to the commercial laundry failed to close and latch.

The specific standard found at Section 7.9.3 of NFPA 10 Life Safety Code 2000 edition states:

7.9.3 Periodic Testing of Emergency Lighting Equipment. A
functional test shall be conducted on every required emergency
lighting system at 30-day intervals for not less than 30
seconds. An annual test shall be conducted on every required
battery-powered emergency lighting system for not less than
11/2 hours. Equipment shall be fully operational for the duration
of the test. Written records of visual inspections and tests
shall be kept by the owner for inspection by the authority having
jurisdiction.
Exception: Self-testing/self-diagnostic, battery-operated emergency
lighting equipment that automatically performs a test for not less than
30 seconds and diagnostic routine not less than once every 30 days
and indicates failures by a status indicator shall be exempt from the
30-day functional test, provided that a visual inspection is performed
at 30-day intervals.




Based upon a record review on October 10, 2012 at 1120 hours and staff interviews with the Director of Maintenance Kittitas Valley Community Hospital has failed to conduct the testing of Emergency Battery Back-up Lighting. This could result in the failure of the emergency lighting to operate in the event of a power failure which could leave vital areas without illumination.


The findings include:

1. Based upon a record review at 1120 hours on October 10, 2012 and interviews with the Director of Maintenance at that time there were no records to verify that the required testing of emergency lighting for 30 seconds once per month and a minimum of 90 minutes once per year.

2. Interviews with the Director of Maintenance revealed that the maintenance staff was not aware of this requirement. The maintenance staff tested the lamps for illumination for a few seconds every month but not for 30 seconds and did not conduct the 90 minute annual tests.

Based upon observations and staff interviews during survey rounds between 0900 and 1600 on October 09, 2012 Kittitas Valley Community Hospital has failed to maintain Exit Directional Signs in a manner to indicated the direction of egress. This might result in a delay in egress in the event of an emergency due to a lack of information as to the direction that must be taken to reach the exit.


The findings include:

1. Observed on 10-09-12 that the illuminated EXIT sign located at the T intersection from the Birthing Center did not display a directional arrow to indicate the direction to take to access the exit. This was acknowledged by the Director of Maintenance at the time of the observation.

Based upon a record review and interviews with the Director of Maintenance Kittitas Valley Community Hospital has failed to maintain the automatic fire sprinkler system in accordance with the requirements of National Fire Protection Association (NFPA) 25 Standard for the inspection, testing and maintenance of water based fire protection systems. This could result in the failure of the fire sprinkler system to function as designed and not be able to suppress a fire.


The findings include:

1. During a record review on October 10, 2012 at approximately 1050 hours the dry sprinkler system number 4 installed in 2009 for the protection of the canopy to the MRI area has not had a full trip test. Records at the hospital indicate that the system was installed and completed in February of 2009 and there was no trip test due to cold weather. In 2010 a partial trip test was conducted. In 2011 a partial trip was conducted. In 2012 a partial trip test was conducted.

2. Based upon the record review and interviews with the Director of Maintenance the required full trip test every three years which includes the timed water reaches the test outlet has not been conducted.

Based upon a record review on October 10, 2012 at 1050 hours and staff interviews with the Director of Maintenance Kittitas Valley Community Hospital has failed to maintain the automatic fire sprinkler system in a reliable operating condition due to the failure of required testing. This could result in the fire sprinkler system operating properly in the event of a fire allowing the fire to grow in size and potentially place all of the patients, staff and visitors in danger.


The findings include:

1. During the record review at 1050 hours on October 10, 2012 and interviews with the Director of Maintenance records of the required quarterly testing of the fire sprinkler system could not be located.

2. Interviews with the Director of Maintenance indicated that quarterly testing of the fire sprinkler system had not been done.

1. During a record review on October 10, 2012 at approximately 1050 hours the dry sprinkler system number 3 has not had a full trip test during the past three (3) years as required In 2009 there was only a partial trip test conducted In 2010 a partial trip test was conducted. In 2011 a partial trip was conducted. In 2012 a partial trip test was conducted.

2. Based upon the record review and interviews with the Director of Maintenance the required full trip test every three years which includes the timed water reaches the test outlet has not been conducted.

Based upon observations and staff interviews during survey rounds between 0800 and 1600 on October 09, 2012 Kittitas Valley Community Hospital has failed to maintain the egress corridors free of obstructions. This could result in a delay in being able to evacuate to another smoke compartment or to conduct an entire building evacuation due to the obstructions in the corridor.


The findings include:

1. Observed at the time of entry into the hospital two (2) computer on wheels plugged into wall outlets in the medical /surgical wing of the hospital. The units were still in place upon the start of the survey at approximately 0915.

2. Observed a cart with a coffee pot, cups and condiments for patients, family, visitors and staff in the exit access corridor which passes through the emergency department at approximately 1000 hours. This cart was removed and relocated prior to the end of the survey.

3. Observed several material bins and boxes stored in the back corridor to the surgical wing. This material was close to central supply.


The above findings were discussed with and acknowledged by the Director of Maintenance.

Based upon a record review on October 10, 2012 and staff interviews with the Director of Maintenance and the Director of Surgical Services Kittitas Valley Community Hospital has failed to maintain a Humidity Level above 35% in the Anesthetizing Locations. This could result in a greater chance of a static electrical discharge which could cause an ignition of material in these areas.


The findings include:

1. Interviews with the Director of Surgical Services at approximately 1400 hours on October 09, 2012 it is common to have humidity levels below 35 %

2. Interviews with the Director of Surgical Services indicated that they measured humidity levels with hand held meters at several times during the day beginning at 0600 hours.

3, Interviews with the Director of Surgical Services the hospital would suspend surgical procedures when the humidity level was above 60% however they would continue with surgical procedures if the humidity was below or at any level below 35%.

4. A review of the written procedures on October 09, 2012 at approximately 1400 indicated that the humidity range was to be between 30% and 60%

5. Interviews with the Director of Maintenance indicated that the hospital does not have the ability to control humidity.

6. Interviews with the Director of Maintenance indicated that the hand held monitors used by the surgical staff are not calibrated on a regular basis.

7. A record review conducted at approximately 0900 hours on October 10, 2012 indicated the following:

a. During the twenty one (21) surgical days in January 2012 the humidity level was at 35.1% one (1) day. All other days were below 35% with the lowest level being 17.6%
b. During the nineteen (19) surgical days in February 2012 two days (2) had a humidity level at or above 35%. The other seventeen (17) days had a humidity level below 35% with the lowest being 19.1%
c. During the twenty two (22) surgical days in March 2012 five (5) days had a humidity level at or above 35% The other seventeen (17) days had a humidity level below 35% with the lowest being 22.8%
d. During the twenty one (21) surgical days in April 2012 eight (8) days had a humidity level at or above 35% The other thirteen (13) days had a humidity level below 35% with the lowest being 27%
e. During the twenty two (22) surgical days in May 2012 fourteen (14) days had a humidity level at or above 35% The other eight (8) days had a humidity level below 35% with the lowest being 25.1%
f. During the twenty one (21) surgical days in June 2012 twenty (20) days had a humidity level at or above 35% One (1) day had a humidity level below 35% with a humidity level of 34.2%.
g. During the twenty (20) surgical days in July 2012 The humidity level was above 35% on all twenty (20) days
h. During the twenty three (23) surgical days in August 2012 twenty one (21) days had a humidity level at or above 35% Two days had a humidity level below 35% with the lowest being 29.1%
i. During the nineteen (19) surgical days in September 2012 fifteen (15) days had a humidity level at or above 35% The other four (4) days had a humidity level below 35% with the lowest being 26.1%
j. During the first seven (7) surgical days in October 2012 one (1) day had a humidity level at or above 35% The other six (6) days had a humidity level below 35% with the lowest being 19.1%

The actual standard from NFPA 99 states:

(b) Life Safety Branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equip me
1. Illumination of means of egress as required in NFPA 101, Life Safety Code
2. Exit signs and exit direction signs required in NFPA 101, Life Safety Code
3. Alarm and alerting systems including the following:
a. Fire alarms
b. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, ' ' Gas and Vacuum Systems ' '
4.* Hospital communication systems, where used for issuing instruction during emergency conditions
5. Task illumination, battery charger for emergency battery powered lighting unit(s), and selected receptacles at the generator set location
6. Elevator cab lighting, control, communication, and signal systems
7. Automatically operated doors used for building egress.

No function other than those listed above in items 1 through 7 shall be connected to the life safety branch.
r Exception: The auxiliary functions of fire alarm combination systems complying with NFPA 72, National Fire Alarm Code, shall be permitted to be connected to the life safety branch.

(c)* Critical Branch. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and selected power circuits serving the following areas and functions related to patient care. It shall be permitted to subdivide the critical branch into two or more branches.

1. Critical care areas that utilize anesthetizing gases, task illumination, selected receptacles, and fixed equipment
2. The isolated power systems in special environments
3. Patient care areas-task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing area
. d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaries)
4. Additional specialized patient care task illumination and where needed
5. Nurse call systems
6. Blood, bone, and tissue banks
7.* Telephone equipment rooms and closets
8. Task illumination, selected receptacles, and selected circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
9. Additional task illumination, receptacles, and selected power circuits needed for effective facility operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch.

Based upon observations and staff interviews with the Director of Maintenance on October 10,2012 at approximately 1100 hours Kittitas Valley Community Hospital has failed to restrict the circuits that are allowed on the Life Safety Branch of the Essential Electrical System. This could result in a failure of the Essential Electrical System.

The findings include:

1. Observed that that following circuits were located in the electrical panel for the Life Safety Branch:
a. Sump Pumps
b. Heli pad lighting.
c. Radio system

This observation was acknowledged by the Director of Maintenance.