HospitalInspections.org

Based upon staff interviews and observations made during the survey tour, the facility has failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially cause the quick spread of smoke, heat and fire, and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the survey tour on February 09, 2016, between the hours of 11:00am and 3:00pm, I observed the following deficiencies in corridor fire separation doors:

1. At 11:02am, I observed that fire separation door to the Sanctuary entrance when tested and closed had a large gap between the two doors that would allow smoke, heat, and fire to penetrate to the other smoke compartment.
2. At 2:16pm, I observed that the fire separation door by Robins Nest #202 when tested and closed had a large gap between the two doors that would allow smoke, heat, and fire to penetrate to the other smoke compartment.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that the The Type I EES generator is divided into the critical branch, life safety branch and the emergency system in accordance with 3-4.2.2.2, 3-5.2.2. NFPA 99. This could potentially endanger patients, staff and/or visitors within the facility during a power outage.
The findings include, but are not limited to:
Based upon observation of the generator room on February 09, 2016 at approximately 1:45pm, the following deficiencies were observed:
1. Interview with Maintenance Director revealed that the generator does not have the 3 separate branches as required. The maintenance Director showed me a written schematic of the generator and it did not include the 3 separate branches.- Removed see below
2. Observation of the generator room revealed that there was not an Emergency Stop Button outside of the generator room as required.
These findings were observed and discussed with the Maintenance Director.


The Washington State Office of the State Fire Marshal's Office reviewed documentation submitted by the hospital. The documentation stated that the facility did not require the three electrical branches.

Based upon staff interviews and observations made during the survey tour, the facility has failed to assure that door openings closed to resist the passage of smoke to corridors. This potentially cause the quick spread of smoke, heat and fire, and thus expose patients, visitors, and staff to the threat of fire.

The findings include, but are not limited to:

During the survey tour on February 09, 2016, between the hours of 11:00am and 3:00pm, I observed the following deficiencies in corridor fire separation doors:

1. At 11:02am, I observed that fire separation door to the Sanctuary entrance when tested and closed had a large gap between the two doors that would allow smoke, heat, and fire to penetrate to the other smoke compartment.
2. At 2:16pm, I observed that the fire separation door by Robins Nest #202 when tested and closed had a large gap between the two doors that would allow smoke, heat, and fire to penetrate to the other smoke compartment.

These findings were observed and discussed with the Maintenance Director.

The facility has failed to ensure that the The Type I EES generator is divided into the critical branch, life safety branch and the emergency system in accordance with 3-4.2.2.2, 3-5.2.2. NFPA 99. This could potentially endanger patients, staff and/or visitors within the facility during a power outage.
The findings include, but are not limited to:
Based upon observation of the generator room on February 09, 2016 at approximately 1:45pm, the following deficiencies were observed:
1. Interview with Maintenance Director revealed that the generator does not have the 3 separate branches as required. The maintenance Director showed me a written schematic of the generator and it did not include the 3 separate branches.- Removed see below
2. Observation of the generator room revealed that there was not an Emergency Stop Button outside of the generator room as required.
These findings were observed and discussed with the Maintenance Director.


The Washington State Office of the State Fire Marshal's Office reviewed documentation submitted by the hospital. The documentation stated that the facility did not require the three electrical branches.