HospitalInspections.org

Based on record review and interview the hospital failed to ensure the emergency preparedness policies and procedures addressed the facility's role in emergencies where the President declares a major disaster.

Findings:

Record review showed the facility did not develop and maintain an 1135 policy and procedure in the emergency preparedness plan as required.

On 11/11/21 at 2:14pm the surveyor asked staff B for the facility's 1135 waiver policy and procedure. Staff B stated the facility had not developed the policy but will to be in compliance.

Based on observation and interview the facility failed to ensure doors could be opened with one action as required.

Findings:

On 11/10/21 at 4:17pm the surveyor observed deadbolt locks on four patient room doors and several other emergency egress corridor doors in addition to barrel latches on the bathroom doors of the patient rooms.

On 11/10/21 at 4:17pm the surveyor asked staff B why there were deadbolts on the corridor doors and slide latches on the patient room bathroom doors which would take two actions to open. Staff B stated the deadbolts and slide latches were on the doors within the facility since he started working there and he did not know they were not allowed. Staff B stated they would have them changed with a lock that will only take one action to open the door to be in compliance.