HospitalInspections.org
Bringing transparency to federal inspections
COLUMBIA BASIN HOSPITAL
Doors with Self-Closing Devices
Tag No.: K0223
Based upon observations and staff interviews on 07/05/2022 between approximately 1130 to 1330 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:
Cross-Corridor doors leading in and out of the Emergency Department failed to close and latch when tested.
NFPA 101 (2012) 19.2.2.2.7
The above was discussed and acknowledged by the maintenance director who stated that he was unaware of these doors being self-closing.
Fire Drills
Tag No.: K0712
Based on record review and staff interview on 07/05/2022 between approximately 0930 to 1130 hours the facility has failed to provide fire drill records reflecting drills being conducted on all shifts for each quarter for the past 12 months. This could potentially result in the staff not responding in a coordinated manner in the event of a fire or other emergency and endangering patients, staff and/or visitors.
The findings include:
There is no documentation of the completion of the third quarter 2021 - all shifts.
There is no documentation of the completion of the first quarter 2022 - day and swing shifts.
The above was discussed and acknowledged by the maintenance director in the presence of the administrator.
NFPA 101 (2012 ed) 19.1.1.1.1, 19.7.1.6
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on observation and staff interview on July 5, 2022 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 are:
1. The facility is unable to provide documentation of monthly load testing for April, May and June of 2022.
2. The facility is unable to provide documentation of a weekly inspection for 04/04/2022.
The administrator and the maintenance manager acknowledged that there is no documentation of the above.
NFPA 99 (2012 ed) 6.4.4.1.1.3, 2.1, NFPA 110 (2010 ed)1.1, 6.4.4.1.1.4, 8.3.1
NFPA 99 (2012 ed) 6.4.4.1.1.3, 2.1, NFPA 110 (2010 ed)1.1, 8.4.1.1