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SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORIT
Egress Doors
Tag No.: K0222
Based on observation and interview the facility failed to ensure doors could be opened with one action as required.
Findings:
On 09/09/21 at 1:42pm the surveyor observed deadbolt locks on the medical records office door and several other corridor doors in addition to a barrel latch on the second medical records office.
On 09/09/21 at 1:42pm the surveyor asked staff C why there were deadbolts on the corridor doors which would take two actions to open. Staff C stated the deadbolts were on the doors within the facility since he has started and he did not know they were not allowed. Staff C stated they would have them changed with a lock that will only take one action to open the door to be in compliance.
Electrical Systems - Maintenance and Testing
Tag No.: K0914
Based on record review and interview the facility failed to ensure impedance testing/maintenance to patient care related electrical receptacles per NFPA 99 2012 Edition requirements.
Findings:
Record review showed the facility did not complete impedance testing for patient care related electrical receptacles as required in NFPA 99 2012 Edition.
On 09/09/21 at 11:16am the surveyor asked staff C why the impedance testing has not been completed per the requirements outlined in NFPA 99 2012 Edition. Staff C stated they were not fully familiar with the requirements for life safety code but will get the testing scheduled to be in compliance.
Features of Fire Protection - Fire Loss Preve
Tag No.: K0933
Based on record review and interview the facility failed to ensure operating room staff completed specific training on features of fire protection and fire loss prevention in operating rooms as required.
Findings:
Record review showed no fire drills for operating room staff for emergency procedures which included each of the the following required elements: equipment fires, alarm activation, evacuation, equipment shutdown, and control operations in addition to continuing education specific to operating room fire prevention. The operating room fire drills and emergency procedures training did not include surgeons/doctors as required in NFPA 99, 15.13.
On 09/09/21 at 10:04am the surveyor asked staff C if the operating room staff performed practical fire drills in the operating room which included each of the items as outlined in the CMS 2786R document at K933. Staff C stated they do regular fire drills but will document each of the elements of K933 in the future. The surveyor stated they will have to include each of the outlined items in K933 fire code reference to also include doctors in the operating room fire drills to be in compliance.