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723 MEMORIAL STREET

PROSSER, WA 99350

No Description Available

Tag No.: K0018

Based on observation, the hospital failed to maintain doors protecting corridor openings able to be closed to prevent the passage of smoke into the corridor. Failure to maintain these door able to be closed to prevent the passage of smoke places all building occupants at risk from the spread of smoke and toxic combustion products into the corridor.

Findings:

During a tour of the hospital on 11/30/10, obstructions preventing corridors doors from closing were found on the Acute Care Unit rooms 12, 13, and 32.

No Description Available

Tag No.: K0051

Based on review of smoke detector installation instructions and observation, the hospital failed to maintain all components of the fire alarm system in accordance with manufacturer specifications and NFPA 72, 2-3.5.1 by positioning smoke detectors where forced air ventilation may dilute the smoke before it reaches the detector [Not closer than 3 feet from an air supply diffuser] (reference NFPA 101 19.3.4.2, 9.6.2.10).

Failure to locate smoke detectors where they are not subject to air currents which may cause smoke to bypass the detector risks failure of smoke detectors in the event of a fire, and subsequent failure to alert patients, staff and other building occupants.

Findings:

Simplex photoelectric/ionization smoke detector installation instructions [PER-21-007 (575-285) Ed 2 93] states "Do not install detectors where forced air ventilation may dilute the smoke before it reaches the detector."

During a tour of the hospital on 11/30/10 a smoke detector was found in the basement exit corridor placed approximately 18 inches from the center of an air supply diffuser. On this same tour, a smoke detector was placed approximately 14 inches from an air supply diffuser on the main level in the lobby area.

During a tour of the hospital on 12/1/10 two smoke detectors were found in the exit corridor on the upper level near the hospitalist office approximately 12 inches and 18 inches from air supply diffusers.

No Description Available

Tag No.: K0072

Based on observation and staff interview, the hospital failed to maintain the means of egress continuously free of all obstructions. Failure to maintain a clear unobstructed exit risks the ability of building occupants to exit during a fire emergency.

Findings:

During a tour of the PACU on 11/30/10, an emergency code response cart and blanket warming cart were found in front of an exit door equipped with panic hardware and designed to swing in the direction of egress. The electronically controlled door on the other side of the corridor opened into the PACU.

Hospital nursing staff confirmed that the emergency code cart was usually found in this location and the blanket warmer were permanently placed in front of the door.

No Description Available

Tag No.: K0078

Based on review of hospital records and interview with hospital staff, the hospital failed to maintain relative humidity in each operating room equal to or greater than 35%.

Failure to ensure relative humidity is at least 35% in each operating room increases the risk of electrostatic spark discharges which may ignite a fire and endanger patients and others. :

Findings

Review of relative humidity monitoring records for 2010 showed relative humidity for OR #1 below 35% 2 days during October, 5 days during May, 16 days during April, 17 days in March, 5 days in February, and 14 days in January. Relative humidity records OR #2 during 2010 showed below 35% 4 days in January.

Hospital Surgery Director (Staff Member #MS 3) stated that when relative humidity measures below 35% the maintenance department and the surgeon are notified. When asked if surgery is rescheduled, s/he replied that it is at the surgeon's discretion.