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Based on document review, staff interview and observation it was determined the facility failed to proceed in accordance with the Life Safety Code (National Fire Protection Association) NFPA 101 and Tentative Interim Amendments 12-1, 12-2, 12-3 and 12-4. An Immediate Jeopardy (IJ) was called on 8/10/20 at 1:25 p.m. The facility submitted an acceptable Plan of Correction and the IJ was abated 8/10/20 at 5:25 p.m. This failure places all patients, staff and visitors at risk for death from a catastrophic event (explosion or fire) (See Tag C 930).

A. An IJ to Physical Plant and Environment was called on 8/10/20 at 1:25 p.m. because the facility failed to ensure the physical plant and environment were safe for patients, staff and visitors. The facility's Maintenance Director identified an oxygen valve leak inside a closet in the maintenance supply room. He stated a work order had been placed on 9/8/19 for this problem but it had not been fixed.

B. Harm or Potential Harm: The potential for death from a catastrophic event (explosion or fire).

C. Immediacy: There is no evidence the repair work was done. The Maintenance Director indicated an oxygen leak currently existed inside the closet.

D. An immediate Plan of Correction was received and sent to the State Agency Program Manager. It was accepted and the facility abated the IJ on 8/10/20 at 5:25 p.m.

A. Based on observation and staff interview it was determined the facility failed to ensure that electrical wiring and equipment was in accordance with National Fire Protection Association (NFPA) 70. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 9:10 a.m. revealed a missing ceiling tile and a junction box with a missing cover plate in a small room across the hall from the emergency room on the first floor.

2. On 08/11/20 from 8:00 a.m. to 6:00 p.m. an observation revealed ceiling tiles throughout the facility with holes and cracks. The ceiling tiles would not keep a tight smoke barrier compartment.

3. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.



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B. Based on observation and staff interview it was determined the facility failed to check the temperature and maintain temperature logs on one (1) blanket warmer in the Post-Anesthesia Recovery Unit (PACU). This failure has the potential to negatively impact all patients receiving PACU care.

Findings include:

1. An observation was conducted in the PACU on 08/10/20 at 11:40 a.m. A blanket warmer located in the PACU patient area had no log with temperatures recorded.

2. An interview was conducted with the operating room manager on 08/10/12 at 11:40 a.m. She stated, "We haven't been checking the temperatures but I know this is something I should be doing."

A. Based on observation and staff interview it was determined the facility failed to ensure a nonflammable medical gas cylinder and the storage requirements were in accordance with National Fire Protection Association (NFPA) 99. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 2:20 p.m. revealed two (2) oxygen cylinders not being stored in a rack or chained to the wall. The cylinders were free standing in the middle of the soiled utility room on the third floor.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

B. Based on observation and staff interview it was determined the facility failed to ensure that delayed egress locking systems were installed in accordance with NFPA 101. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 10:30 a.m. revealed the exit doors in Dietary Service hallway had a turn knob locking device on the exit doors. This device will not let the egress doors work properly to exit the facility.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

C. Based on document review and staff interview it was determined the facility failed to ensure maintenance was performed on the emergency reserve bank in accordance with NFPA 101. This deficient practice has the potential to affect all patients, staff and visitors in the areas referenced. The facility's census was twelve (12).

Findings include:

1. A facility document review was conducted on 08/10/20 from 9:30 a.m. to 5:30 p.m. The documentation from Medical Gas System Specialists, Inc. (MEGSS) showed they did an inspection on 8/31/19 on the O2 system at the hospital and found a bad check valve for the emergency reserve bank leaking. On 9/3/19 MEGSS did a work order to repair the bad valve but there was no paperwork showing the work had been completed. I found the Director of Maintenance to see if this had been completed and he said that a coupling was leaking and the system needed to be shut down for repairs. As of 8/10/20 the work order was not completed so the maintaining of the O2 system is not in compliance with the requirements of NFPA 101.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

A. Based on observation and staff interview it was determined the facility failed to continuously maintain means of egress to be free of all obstructions for full use. The facility's census was twelve (12).

Findings include:

1. An observation on 08/10/20 at approximately 9:10 a.m. revealed wheelchairs are blocking the egress path to the fire extinguisher on the wall in the hallway of the emergency room on the first floor.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

B. Based on record review and staff interview it was determined the facility failed to ensure that fire drills were held at least quarterly on each shift in accordance with National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was 12.

Findings include:

1. During a facility document review conducted on 08/10/20 from 9:30 a.m. to 5:30 p.m. it was revealed a second quarter, afternoon shift fire drill was conducted on 05/16/20 at 7:30 p.m. and a fourth quarter, afternoon shift fire drill was conducted on 11/22/19 at 8:03 p.m. All fire drills must be one (1) hour apart from each other to be in compliance.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/12/20 at approximately 10:45 a.m. at the time of exit. The Administrator agreed this deficiency needed corrected.

Based on observation and staff interview it was determined the facility failed to ensure a significant amount of mammography radiology films were secure. This failure has the potential to negatively impact all patients who had received mammography services in the past.

Findings:

1. An observation of the basement hallway near the cafeteria on 08/12/20 at 12:05 p.m. revealed one (1) sixty (60) gallon blue, plastic barrel approximately half-full of mammography films identified with the patient's name, date of service and the image.

2. An interview with the Director of Medical Records and a Radiology Technician was conducted on 08/12/20 at 12:20 p.m. They both agreed the films should not be there.

Based on observation, document review and staff interview it was determined the facility failed to ensure infection control was enforced in the Dietary Department. This failure places all patients at risk for a health-care acquired illness resulting in harm or death.

Findings include:

1. A tour was conducted of the Dietary Department on 8/10/20 at 2:17 p.m. with the Dietary Manager (DM). During the tour, the following was observed: a pair of oven mitts, one (1) burnt, in use laying on a food prep table; a fan was running near the ceiling; crumbs and debris were laying on a stove top; an oven had grease build-up on the outside; the ice cream freezer had frost build-up, with a brownish substance on the bottom of the inside; and, Cooler #1 had a heavy frost build-up, partially covering the thermometer.

2. Review of the Dietary Nutrition Manual, last reviewed 2017, revealed it contained a policy titled "Cleaning Schedules," which stated in part: "Cleaning schedules are written and assigned to all dietary staff by RD {Registered Dietician} to ensure sanitation of kitchen and equipment."

3. An interview was conducted with the DM on 8/10/20 during the above noted tour. When she was questioned about the observations, she stated there was no cleaning schedule and did not know when the above noted items had been cleaned. She agreed that since there was no cleaning schedule, it was not possible to know if the equipment is being cleaned routinely. She also agreed failure to ensure equipment is clean places all patients at risk for infection.

Based on document review and staff interview it was determined the facility failed to provide a written notice of transfer or discharge to all patients admitted to the facility in a swing-bed status. This failure has the potential to negatively impact all swing-bed patients in the facility.

Findings include:

1. A review was conducted of policy titled "(Facility name) Critical Access Hospital Swing Beds," no last revision or initiation date listed. It states in part, on page 3, section C-0377: "483.12 (a) (4) Notice before transfer. Before a facility transfers or discharges a resident, the facility must-(i) Notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand."

2. A group interview was conducted with the Director of Nursing, the Utilization Review Nurse, the Social Worker and the Nurse Manager of the Acute Care/Swing Bed Unit on 08/12/20 at 12:30 p.m. They all explained the discharge notice has not been given to the swing-bed patients as per policy since the previous Social Worker had left.