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715 RICHLAND MALL

ONTARIO, OH 44906

Roles Under a Waiver Declared by Secretary

Tag No.: E0026

Based on interview and record review, the hospital facility failed to include policies and procedures to address the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials, in accordance with 42 CFR §483.73(b)(8). This finding had the potential to affect all 14 patients in the facility.

Findings include:

On 02/12/2020 at 3:35 P.M., during a review of the facility's emergency preparedness program with the Emergency Management Director #11, the facility failed to provide a policy or procedure addressing the role of the hospital facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Interview with the Emergency Management Director #11 verified this finding at the time of discovery.

Interior Nonbearing Wall Construction

Tag No.: K0163

Based on record review, observation and interview the facility failed to ensure the approved building construction type was maintained in accordance with NFPA 101-2012 Edition, Sections 18.1.6.4; 18.1.6.5. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 12:45 P.M. of the life safety schematics and the building department certificate of occupancy discovered the building construction type was Type 2(222) non-combustible construction.

Observation on 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility of the second floor shelled space, revealed the installation of 784 square feet room partition constructed of non-load bearing combustible vertical wall studs and combustible oriented strand board (OSB) vertical plywood sheeting, approximately 12 feet in height, located on the second floor shelled space, and used for combustible storage.

Interview with Plant Operations Director #1 (POD#1) stated the area was designed for temporary secure storage. POD#1 and Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Egress Doors

Tag No.: K0222

Based on observation and interview the facility failed to ensure emergency exit doors were readily maintained in accordance with NFPA 101-2012 Edition, Sections 7.1.10.1*; 7.2.1.4.5.1; 7.2.1.9.1*; 7.2.1.9.1.2 7.2.1.9.1.3. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M, during tour of the facility, noted the emergency exit doors throughout the facility. Further examination of the power operated slide doors located at the first floor emergency department ambulance entrance, suite F exit, and the Avita Heart exit, revealed the sliding doors were equipped with a breakaway function to open the doors, in the event of a power failure, however the doors lacked a sign to instruct an occupant to egress. In addition, the Avita Heart sliding door break away function, failed to open the door completely, when tested. Furthermore, the exit door to the exterior, located inside the first floor emergency department water equipment room, failed to open freely once pressure was applied to hardware.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Aisle, Corridor, or Ramp Width

Tag No.: K0232

Based on observation and staff interview, the facility failed to ensure the exit corridors were free from storage in accordance with NFPA 101-2012 Edition, Section 19.2.3.4. This deficient practice had the potential to affect all 14 patients who in the facility.

Findings include:

Observation on 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility, noted the exit access of the patient sleeping compartment eight foot corridors throughout the facility. Further examination of the third floor surgical suite rear corridor revealed sterile carts, medical equipment, and hospital beds stored inside the eight foot corridor, which decreased the exit pathway to four feet.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Emergency Lighting

Tag No.: K0291

Based on observation, record review and interview the facility failed to ensure battery operated emergency lights were tested and maintained in accordance with NFPA 101-2012 Edition, Sections 18.2.9.1; 7.9. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility, noted the application of battery operated emergency lights throughout the facility. Further examination of the first floor emergency department water equipment room revealed the combination exit sign and battery operated light failed to function when tested. In addition, battery operated emergency lights were discovered in the ceiling inside suites A through F.

Record review on 02/10/2020 at 3:30 P.M. of the facility maintenance inspection and test records noted the battery operated emergency lights located inside the water equipment room and the first floor suites A, B,C, D, E, and F were not tested monthly or annually.

Interview with Plant Operations Director #1 (POD#1) verified the noted sections of the facility were not connected to the emergency generator system. POD#1 verified the findings at the time of discovery.

Hazardous Areas - Enclosure

Tag No.: K0321

Based on record review, observation and interview the facility failed to ensure hazardous area enclosures were maintained in accordance with NFPA 101-2012 Edition, Sections 18.3.2.1; 7.2.1.8; 8.4; 8.7; 9.7. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 2:15 P.M. of the life safety schematics noted the hazardous area enclosures were constructed with a one hour fire separation.

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility noted integrity of the hazardous area enclosures throughout the facility. Further examination of the hazardous rooms revealed the following deficient practices:

1. Observed from the first floor catheterization lab corridor, across from Room #1, discovered a hazardous area storage room, over 50 square feet with combustible storage, and the room was not identified on the life safety schematics has a one hour fire rated enclosure. In addition, observed from the corridor on the rear side of the room, in the above ceiling space, noted a two inch hole saw cut in the drywall with duct tape and second two inch unsealed penetration where two pieces of drywall adjoined.

2. Observed from the first floor catheterization lab corridor, located in the above ceiling space, outside the procedure room, from the corridor looking into the hazardous area storage room, discovered a one inch open void space around 1/2 inch electrical conduit.

3. Observed from the first floor Avita Heart corridor, located in the above ceiling space, behind the catheterization lab hazardous area rooms, revealed a one inch penetration around 1/2 inch electrical conduit.

4. Observed from the first floor cat scan corridor, in the above ceiling space, looking toward the cat scan employee break room, was noted on the life safety schematics as a hazardous area and contained three open void penetrations around electrical conduit.

5. Observed from the second floor shelled space toward the back side of the environmental services storage room discovered one 1/2 inch unsealed penetration around low voltage communication wire. In addition, a one inch electrical conduit was not sealed.

6. Observed from the first floor center corridor at the laboratories entrance, which connected the main front lobby to the mall, near the cross corridor smoke doors, above the suspended ceiling, revealed three unsealed penetrations around electrical conduit.

7. Observed from the first floor corridor, outside the janitorial equipment room between suites A and B, was noted on the life safety schematics as a hazardous area. Located in the above ceiling space, noted a two penetrations to include a 1/2 inch electrical conduit, and a one inch unsealed void around a water pipe.

8. Observed from the first floor suite F corridor, in the above ceiling space, looking toward the employee break room, was noted a hazardous area on the life safety schematics, and discovered a two inch penetration around flexible electrical conduit.

9. Observed from the first floor suite F corridor, near examination room #13, in the above ceiling space, looking toward the storage room, contained a 1/2 electrical conduit penetration.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Fire Alarm - Control Functions

Tag No.: K0344

Based on observation, record review and interview the facility failed to ensure fire alarm interface equipment was tested in accordance with NFPA 101-2012 Edition, Sections 18.3.4.4; 9.5.5; 9.2.1; NFPA 90-A 2012 Edition, Section 5.4.8.1; NFPA 80-2010 Edition, Section 19.4.1.1; 19.4.9. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility, noted the delayed egress door with an electronic lock, at the cross corridor doors, near the first floor emergency department entrance and security office.

Record review of the annual fire alarm inspection report dated 10/28/19 revealed the documentation under the door releases section was marked not applicable. No additional documentation was provided to validate the electronic door released upon activation of the fire alarm system on an annual basis. Additional review of the electronically actuated smoke dampers, with fire alarm control panel interface, located in the facility heating, ventilation, air conditioning (HVAC) ductwork was installed at the time of installation with the building department certificate of occupancy date of 10/02/17. However, the documentation lacked a functional test and location of the smoke dampers within one year after installation.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Smoke Detection

Tag No.: K0347

Based on observation and interview the facility failed to ensure smoke detectors were installed 36 inches away from air-handling systems in accordance with NFPA 101-2012 Edition, Section 9.6.1.3; NFPA 72-2010 Edition, Section 17.7.4.1*. This deficient pratice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility, noted the application of corridor smoke detectors installed throughout the facility. Further examination of the first floor corridor, at the front lobby emergency department entrance and the first floor rear exit door of Suite C, revealed the smoke detectors were installed within the 36 inches of the heating, ventilation, air conditioning (HVAC) ductwork.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Sprinkler System - Installation

Tag No.: K0351

Based on observation and interview the facility failed to ensure sprinkler protection was provided for all coverage areas, as designed in accordance with NFPA 101-2012 Edition, Section 9.7.5; NFPA 25-2010 Edition, Section 4.1.5*. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility, noted the application of the wet sprinkler system installed throughout the facility. Further examination revealed the following rooms lacked sprinkler protection:

1. Second Floor Mail Room (56 square feet).
2. Second Floor- Office across from the Mail Room- (206 square feet).
3. Physicians Surgical Services Office- (108 square feet).

In addition, the third floor surgery decontamination room was equipped with sprinkler protection, however a ceiling tile was missing, which exposed the above ceiling space and was not sprinklered.

Interview with the Plant Operations Director #1 (POD#1) verified the building was designed and approved with total complete sprinkler protection. Interview with POD#1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Sprinkler System - Maintenance and Testing

Tag No.: K0353

Based on observation and interview the facility failed to provide a supply of spare sprinkler heads of all installed types in accordance with NFPA 101-2012 Edition, Section 9.7.5; NFPA 25-2010 Edition, Section 5.4.1.4*. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M.., during tour of the facility, noted the application of the pendent ordinary thermal response sprinkler heads, located inside the kitchen walk in cooler and freezer and a intermediate temperature side wall head, located in the second floor elevator equipment room. Further examination of the spare sprinkler head cabinet, located at the main sprinkler riser lower level pit, revealed the cabinet lacked a supply of the spare sprinkler heads.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Subdivision of Building Spaces - Smoke Barrie

Tag No.: K0372

Based on record review, observation and interview the facility failed to ensure smoke barrier assemblies could resist the passage of smoke in accordance with NFPA 101-2012 Edition, Sections 18.3.7.3; 8.5.6.2. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 8:45 A.M. of the provided life safety schematics noted the application of one hour rated smoke barrier from outside wall to outside wall on the first, second and third floors of the facility.

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility, noted the integrity of the smoke barrier barrier from outside wall to outside wall. Further examination of the above ceiling space revealed the following penetrations:

1. Observed from the third floor public elevator landing, near the front reception desk, above the suspended ceiling, at the hand hygiene station, revealed two sections of missing drywall, which measured two inches in length.

2. Observed from inside the third floor waiting room, across from Patient Room #3768, above the suspended ceiling, noted five unsealed openings at the end of the one inch electrical.

3. Observed from the corridor, outside the security office, at the cross corridor emergency department entrance, in the above ceiling space, discovered five sections of missing drywall around the angular space low voltage data communication wires.

4. Observed from the first floor Avita Heart Suite, above patient exam room #6 revealed a two inch penetration around 1/2 inch electrical conduit.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Fire Drills

Tag No.: K0712

Based on record review of fire drill and staff interview, the facility failed to conduct quarterly fire drills on each shift with documented times in accordance with NFPA 101-2012 Edition, Section 19.7.1.6. This finding had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 2:30 P.M. of the quarterly fire and evacuation drills performed between February 2019 and February 2020 revealed no drills were conducted on second shift; third quarter (April, May, June) or fourth quarter (October, November, December) of 2019. In addition, no drills were completed on third shift; third quarter or fourth quarter of 2019. In addition, no times were record of the fire drills completed on 04/30/19 and 07/31/19.

Second shift fire drills were completed on 02/28/19 9:00 P.M. and 04/30/19 with no documented time.

Third shift fire drills were completed on 03/30/19 and 07/31/19

Interview with the Emergency Management Director #11 verified this finding at the time of discovery.

Maintenance, Inspection and Testing - Doors

Tag No.: K0761

Based on record review and interview the facility failed to ensure fire barrier doors installed in rated assemblies were tested and maintained in accordance with NFPA 101-2012 8.3.3.1; NFPA 80-2010 Edition, Sections 5.2.4.1; 5.2.4.2. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 12:45 P.M. noted the annual function inspection and test of the swinging fire doors was completed on 01/16/2020. Further review revealed the documentation lacked the fire rating of the barriers, fire doors, and the rated door frame assemblies. No additional documentation was provided at the time of survey to validate the rated assemblies were identified within the facility.

Interview with the Plant Operations Director #1, Plant Operations Manager #2, and Accreditation Manager #3 verified the findings at the time of discovery.

Electrical Systems - Maintenance and Testing

Tag No.: K0914

Based on record review and staff interview the facility failed to provide documentation to validate the hospital grade electrical receptacles were tested and maintained in accordance with NFPA 99-2012 Edition, Sections 6.3.4.1.1; 6.3.4.1.2. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 1:55 P.M. of the facility maintenance records dated from February 2019 to February 2020 lacked an initial electrical retention and polarity tests of the hospital grade electrical outlets located throughout the facility. In addition, no performance data documentation was provided to validate the outlets have been tested.

Interview with Plant Operations Director #1 (POD#1) verified the patient care rooms were equipped with hospital grade electrical receptacles and verified the findings at the time of discovery.

Electrical Systems - Essential Electric Syste

Tag No.: K0916

Based on observation and interview the facility failed to provide an remote annunciator for the emergency stand by generator at constantly attended location in accordance with NFPA 99-2012 Edition, Sections 6.4.1.1.17; 6.4.1.1.17.5. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observations on 02/12/2020 between at 3:10 P.M., during tour of the facility, noted the application the 1500 kilowatt (KW) emergency generator, which served the alternate illumination power source for the emergency exit signs, corridor lights, emergency electrical outlets for the first floor emergency department, third floor intensive care and in-patient unit. Further examination revealed the remote annunciator, which monitored the generator for trouble conditions, was located in the plant operations area and not at a constantly attended locations.

Interview with Plant Operations Director #1 verified the plant operations area is not constantly occupied and verified the findings at the time of discovery.

Electrical Systems - Essential Electric Syste

Tag No.: K0918

Based on record review and interview the facility failed to ensure a diesel fuel quality test was performed on the 1500 kilowatt emergency generator in accordance with NFPA 101-2012 Edition, Section 7.9.2.4; NFPA 110-2010 Edition, Sections 8.3.2; 8.3.8. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Record review on 02/10/2020 at 2:30 P.M. of the emergency generator inspection and test records dated 10/03/19 revealed the documentation lacked a diesel fuel quality test.

Interview with Plant Operations Director #1 (POD#1) verified the emergency generator served as the alternate illumination power source for the emergency exit signs, corridor lights, emergency electrical outlets for the first floor emergency department, third floor intensive care and in-patient units. POD#1 verified the findings at the time of discovery.

Electrical Equipment - Power Cords and Extens

Tag No.: K0920

Based on observation and interview the facility failed to ensure electrical equipment was maintained in accordance with NFPA 101-2012 Edition, Section 9.1.2; NFPA 70-2011 Edition, Sections Article 400.14; 400.8; NFPA 99-2012 Edition, Section 10.2.3.6. This deficient practice had the potential to affect all 14 patients in the facility.

Findings include:

Observation on 02/11/2020 and 02/12/2020 between 8:00 A.M. and 3:30 P.M., during tour of the facility noted the integrity of the electrical junction boxes, power strips and flexible cords throughout the facility. Further examination revealed the following deficient practices:

1. First floor emergency department inside the physician sleeping room discovered an extension cord plugged into a fan.
2. First floor emergency department entrance, above the cross corridor doors, at the security office, discovered electrical junction box cover missing cover.
3. First floor radiology at the cat scan employee break room, in the above ceiling space, noted a junction box cover missing.
4. First floor pharmacy noted a microwave, fridge, coffee pot plugged into a power strip.
5. Third Floor Surgery inside the sterile processing department discovered an extension cord plugged into cleaning equipment.

Features of Fire Protection - Fire Loss Preve

Tag No.: K0933

Based on record review and staff interview the facility failed to document the removal of the flammable germicide preps in accordance with NFPA 99-2012 Edition, Section 15.13. This finding had the potential to affect 31 of 31 patients all who received surgical services at the facility.

Findings include:

Record review on 02/11/2020 at 9:00 A.M. revealed no documentation to validate flammable germicidal preps were removed from the patient care area prior to surgical procedures. It was noted that the facility used the following flammable chloraprep and duraprep swabs with a dry time of 3 minutes on hairless skin. There was a total of 31 out of 31 patients whom did not have documented evidence that the chloraprep or duraprep swabs were removed from the operating room (OR).

Interview with Accreditation Manager #3 completed on 02/12/2020 at 1:30 PM revealed the facility does not document the removal after application of flammable germicides in the patient medical records.