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Building construction type and height meets one of the following. 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 10/22/2014 between approximately 0900 and 1600 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 residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

East Tower Floor 1:
1. Emergency Department corridor near Administration Office, hard ceiling has been removed exposing adjacent areas to the passage of smoke and fire.
2. Emergency Department break room, false ceiling panels are missing exposing the interstitial space and holes through wall allowing for the passage of smoke and fire to adjacent areas.
Main Tower
3. There was a missing smoke - resistant ceiling panel in storage closet #W1247.
4. On the sixth floor there is a ceiling tile missing in custodian closet #6-W6023.


The above was discussed and acknowledged by the facility engineers.

One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 10/22/2014 between approximately 0900 and 1600 hours the facility has failed to maintain doors to hazardous areas as self or automatic closing. This could result in the spreading of the toxic products of combustion into the corridor in the event of a fire which would endanger residents, staff and/or visitors.

The findings include, but are not limited to:

1. The Custodian Closet # W1234 did not have enough self-closer force to fully close and latch.
2. There is a trash collection alcove in the Radiology suite that is separated from the rest of the suite / corridor by only a curtain.


The above was discussed and acknowledged by the facility engineers.

Portable fire extinguishers are provided in all health care occupancies in accordance with 9.7.4.1. 19.3.5.6, NFPA 10

This requirement is not met as evidenced by:

Based upon record review and observation on 10/22/2014 between approximately 0900 and 1600 hours the facility has failed to assure proper maintenance of the facilities portable fire extinguishers. This potentially delays a quick response to contain a fire from spreading which could expose and endanger residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. The Operating Suite was only equipped with Water Mist Extinguishers and did not have any B:C extinguishers within 75 feet travel distance.


The above was discussed and acknowledged by the facility engineers.

Non-smoking and no smoking signs in areas where oxygen is used or stored are in accordance with 19.3.2.4, NFPA 99, 8.6.4.2.

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 10/22/2014 between approximately 0900 and 1600 hours the facility has failed to provide signage where oxygen is in use or stored. This could result in the rapid spread of smoke and fire in the event of ignition which could potentially endanger the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:

1. There are no warning signs indicating that oxygen is stored / used in Ultrasound Room #4.


The above was discussed and acknowledged by the facility engineers.

Based upon observations and staff interviews on 10/22/2014 between approximately 0900 and 1600 hours the facility has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.


The findings include, but are not limited to:

Based upon observations and staff interviews on October 22, 2014 between approximately 0900 and 1600 hours Swedish Medical Center Edmonds has failed to have the emergency generator meet the requirements of the Fire Safety Code. This could result in conditions that would result in the failure of the emergency generator that would not be detected by staff in a timely manner which would endanger the residents, staff and/or visitors within the facility.

NFPA 110 (1999) 3-5.5.6 All Level 1 and Level 2 installations shall have a remote manual stop station of a type similar to a break-glass station located outside the room housing the prime mover, where so installed, or located elsewhere on the premises where the prime mover is located outside the building.

Appendix A-3-5.5.6 For Level 1 and Level 2 systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified.
The findings include, but are not limited to:
East Tower Floor 1:
1. Generator #3 does not have the required remote manual shut off switch.

Main Tower:
1. The weekly inspections are missing for June & August 2014.

The above was discussed and acknowledged by the facility engineers.

Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2

This requirement is not met as evidenced by:

Based upon observations and staff interviews on 10/22/2014 between approximately 0900 and 1600 hours the facility has failed to restrict the use of multi-plug outlets (power strips) to providing power to permitted electrical equipment. This could result in a fire from overheating of the plug strip due to the heavy power draw endangering the residents, staff and/or visitors within the facility.

The findings include, but are not limited to:


East Tower floor 3:
1. Electrical closet across from room 328, extension cord being used in place of permanent wiring to power TV amplifier. CORRECTED at time of survey.
2. Wire Closet 3 - Extension cord supplying power to multi-plug outlet.
3. PCU Staff lounge - multi-plug outlet supplying power to microwave. CORRECTED at time of survey.
East Tower Floor 2:
1. PCU Nurses station - Daisy chained multi-plug outlets (two into one) under desk.
East Tower Floor 1:
1. Lab Negative Pressure room - Extension cord supplying power to vent hood. CORRECTED at time of survey.
2. Lab Micro Room - Daisy chained multi-plug outlets, two locations by automated transfer station (center of room).
3. Panel 1LY4 - Both panel doors were found to be unlocked, allowing direct access to the electrical buss within the panel cabinet.
4. There was an extension cord used in place of permanent wiring in the Electrical Closet #W1248.



The above was discussed and acknowledged by the facility engineers.