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Based on record review and interview the facility failed to ensure policy and procedures were
established to address the use of volunteers in an emergency.

Findings:

On 02/07/18 at 1:38 pm the surveyor requested documentation to verify volunteers at the facility had been trained for disasters. The plant operations manager stated the facility did not have a policy in place to address the volunteers roles and responsibilities. The policy did not exist.

Based on record review and interview the facility failed to ensure the development of written transfer agreements or contracted agreements with other facilities identified in their emergency procedure manual to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

Findings:

On 02/07/18 at 1:17 pm the surveyor asked the plant operations manager for documentation of transfer agreement or contracted arrangements to receive patients in the event of an disaster and the facility would not be able to shelter in place. The facility emergency preparedness manual stated their patients would be transferred to the Allen family practice, Redbud Physical Therapy or Wagoner High School activity center. The facility manager stated the written transfer agreement did not exist.

Based on record review and interview the facility failed to ensure training for new staff, individuals providing services under arrangement, and volunteers on the emergency preparedness plan.

Findings:

Record review of the facility emergency preparedness training documentation
did not contain the in-service training for new staff, volunteers and
individuals providing services under arrangement.

On 02/06/18 at 1:47 pm the surveyor asked the facility administrator and plant operations manager for documentation of training in-service for volunteers and individuals providing services under arrangement. The human resource administrator stated they were unaware this was required for facility volunteers and individuals providing services under arrangement.
The in-service training did not exist.

On 02/06/18 at 3:10 pm the surveyor reviewed 29 employee files for emergency
preparedness training. One out of the 29 files (Staff 1, Staff 2, Staff 3, Staff 4, Staff 5, Staff 6, Staff 7, Staff 8, Staff 9, Staff 10, Staff 11, Staff 12, Staff 13, Staff 14, Staff 15, Staff 16, Staff 17, Staff 18, Staff 19, Staff 20, Staff 21, Staff 22, Staff 23, Staff 24, Staff 25, Staff 26, Staff 27, Staff 28, Staff 29) revealed Staff 21 who worked as an ER tech with the date of hire as 12/27/17 had not received in-service training on the facility emergency preparedness plan. The document did not exist.

Based on record review and interview the facility failed to ensure the inclusion of the off-site campus in the development of their unified and integrated emergency preparedness program.

Findings:

Record review of the facility's emergency preparedness program showed the facility did not include the off-site wound care clinic with the same CCN as the main facility. The document showing the inclusion of the wound care clinic located in Muskogee, OK in the Wagoner Community Hospital Emergency Preparedness Program did not exist.

On 02/06/18 at 2:12 pm the surveyor asked the plant operations manager if the wound care clinic located in Muskogee Oklahoma is considered a part of Wagoner Hospital and if they use the same CCN number as the main hospital located in Wagoner. The plant operations manager stated the wound care clinic is considered a part of the hospital and uses the same CCN number as the main hospital.

Based on observation and interview the facility failed to ensure a required means of egress was not equipped with a deadbolt lock that requires two actions to open from the egress side.

Findings:

On 02/07/18 at 3:17 pm 11 patient rooms were observed to be repurposed into staff offices, and two housekeeping rooms. The repurposed rooms were also observed to have deadbolt's installed on each of the doors which would require two actions to open instead of the required one action.

On 02/07/18 at 3:31 pm the plant operations manager was asked why the deadbolt's were installed on the wing with the repurposed patient rooms and he stated to secure each of the rooms. He stated he would remove the deadbolt's from the doors in order to comply with fire code requirement for them to be opened with one action.

Based on observation and interview the facility failed to ensure emergency powered back up lighting was installed at each exit discharge.

Findings:

On 02/07/18 at 2:00 pm each of the facility exit discharges were observed to not have identifiable emergency powered back up lighting.

On 02/07/18 at 2:13 pm the plant operations manager was asked to identify where the emergency powered back up exit discharge lighting was at each facility exit discharge or to identify each exit discharge emergency powered light which was on emergency generator power. He stated he could not positively identify the lighting which may be on emergency generator power or be on emergency battery backed up power at each exit discharge.

Based on record review and interview the facility failed to maintain relative humidity (RH) levels equal to or greater than 30% in anesthetizing locations.

Findings:

The facility relative humidity policy showed the facility policy for the low range starting point for RH was 20% instead of the required 30%. The facility's operating rooms relative humidity and temperature logs for April 2016 through January 2018 showed humidity levels for April 2016 through January 2018 were below 20% and a range of 11-20%. Temperature logs for April 2016 through January 2018 showed recorded temperatures below 68 degrees Fahrenheit recorded on multiple days and showed a range of 60-70 degrees Fahrenheit. Operating room scheduling documentation dated January 16-18, 2018 showed the facility cancelled operating room procedures due to low relative humidity readings in the range of 20%.

On 02/07/18 at 2:23 pm the plant operations manager explained the cancellation of surgical procedures for the dates January 16th-18th, 2018. He stated the cancellations were due to low relative humidity readings and they would not resume until the relative humidity level read 20%. The plant operations manager stated the humidity was adjusted on the air handler to get the relative humidity to 20% and that surgical operations did resume as scheduled after January 19th, 2018. The surveyor asked the plant operations manager why the facility's starting range number for relative humidity was 20%. He stated it was because they are using CMS's categorical waiver to lower relative humidity to 20%. The surveyor informed the plant operations manager the categorical waiver does allow states to go to 20%RH when more stringent RH levels are required by State or local laws and regulations. The surveyor explained Oklahoma by state statute has the range of 30-60%RH and 68-75 degrees Fahrenheit for temperature for operating rooms. The plant operations manager stated the facility would follow-up on that information.

Based on observation and interview the facility failed to ensure alcohol based hand rub dispensers (ABHR) were not installed over ignition sources as required.

Findings:

On 02/07/18 at 2:59 pm the surveyor observed two ABHR dispensers installed over a light switch in surgical suites one and two.

On 02/07/18 at 3:02 pm the surveyor observed one ABHR dispenser installed over a light switch located in the sterile instrument room.

Based on record review and interview the facility failed to ensure procedures to cover out-of-service procedures during a fire alarm system outage.

Findings:

Record review showed no written out-of-service procedures that cover a fire alarm system system outage.

On 02/06/18 at 11:14 am the surveyor asked the plant operations manager for documentation for procedures the facility developed for when the required fire alarm system is out of service for more than four hours in a 24-hour period or an approved fire watch for the facility. The plant operations manager stated a written policy and procedure did not exist.

Based on record review and interview the facility failed to ensure procedures to cover out-of-service procedures during a sprinkler system outage.

Findings:

Record review showed no written fire alarm system out-of-service procedures covering a sprinkler system outage.

On 02/06/18 at 11:12 am the surveyor asked the plant operations manager for documentation for procedures the facility developed for when the sprinkler system is out of service for more than 10 hours in a 24-hour period or an approved fire watch for the facility. The plant operations manager stated a written policy and procedure did not exist.

Based on observation and interview the facility failed to provide smoke barriers constructed to provide at least one-half hour fire resistance rating as required.

Findings:

On 02/07/18 at 4:03 pm the surveyor observed four penetrations of the smoke barrier wall located outside of the pharmacy and classroom area on the first floor.

On 02/07/18 at 4:03 pm the plant operations manager stated he would get the penetration fixed.

Based on observation and interview the facility failed to ensure a required means of egress was not equipped with a barrel latch that requires two actions to open from the egress side.

Findings:

On 02/07/18 at 2:33 pm a barrel latch was observed on the door of the special procedure room in surgical suite.

On 02/07/18 at 2:35 pm the surgical manager was asked why the barrel latch was on the door. She stated she did not know why and did not know it was a violation. She stated she will ask maintenance to have it removed.

Based on observation and interview the facility failed to ensure facility electrical
wiring and equipment was in accordance with the National Electrical Code.

Findings:

On 02/07/18 at 3:02 pm an endoscopic tube washing machine was observed in the decontamination room without a current inspection label.

On 02/07/18 at 3:02 pm the plant operations manager was asked if the endoscopic tube washing machine was currently inspected. He stated he would check with the biomedical staff and did not get back with the surveyor with the requested inspection dates for the machine.

On 02/07/18 at 3:07 pm an endoscopic tube processing machine in the clean processing room within the surgical suite was observed to not have a current inspection label.

On 02/07/18 at 3:07 pm the plant operations manager was asked if the endoscopic tube processing machine was currently inspected. He stated he would check with the biomedical staff and did not get back with the surveyor with the requested inspection dates for the machine.

On 02/07/18 at 3:08 pm a Steris sterilizer in the clean processing room of the surgical suite was observed to not have a current inspection label.

On 02/07/18 at 3:08 pm the plant operations manager was asked if the Steris sterilizer was currently inspected. He stated he would check with the biomedical staff and did not get back with the surveyor with the requested inspection dates for the machine.

On 02/07/18 at 3:20 pm a microwave oven located in respiratory therapy was observed to be plugged into a power strip.

On 02/07/18 at 3:20 pm the plant operations manager was asked for the manufacturer's documentation recommending the microwave to be plugged into a power strip. The plant operations manager stated he would get the manufacturer's documentation but failed to provide it as it does not exist.

Based on record review and interview the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for 2016 and 2017 did not document transmission of a fire alarm signal. The documentation of verification of a fire alarm signal for each fire drill did not exist.

On 02/08/18 at approximately 11:17 am the surveyor stated to the plant operations manager the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. The plant operations manager stated ok.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 were not completed. The documentation did not exist.

On 02/07/18 at 3:35 pm the surveyor asked the plant operations manager for the annual fire rated door assembly inspections. The plant operations manager stated the inspection was not completed for 2017 and the documentation did not exist.

Based on record review and interview the facility failed to ensure the medical gas building system risk assessments were completed.

Findings:

Record review showed the facility medical gas building system risk assessments were not completed. The documentation did not exist.

On 02/07/18 at 1:17 pm the surveyor asked the plant operations manager for the medical gas building system risk assessments, the plant operations manager stated the assessment was not conducted. The documentation did not exist.

Based on record review and interview the facility failed to ensure electrical receptacles in patient care areas were tested annually as required.

Findings:

Record review showed the facility did not test patient care electrical receptacles for 2015, 2016 and 2017.

On 02/07/18 at 3:33 pm the plant operations manager was asked for the patient care area electrical receptacle testing for 2015, 2016 and 2017. The plant operations manager failed to provide the impedance testing documentation for the facility. The electrical receptacle testing documentation does not exist for 2015, 2016 and 2017.

Based on record review and interview the facility failed to ensure line isolation monitor (LIM) inspection and testing was completed for the surgical suite.

Finding:

Record review showed the facility did not complete LIM inspection and testing for 2015, 2016 and 2017. The LIM inspection and testing documentation does not exist for 2015, 2016 and 2017.

On 02/07/18 at 1:12 pm the plant operation manager was asked for documentation for the inspection and testing for the surgical suite LIM system. The plant operations manager stated the LIM annual inspections were not completed for 2015, 2016 and 2017 and the documentation did not exist.

Based on record review and interview the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the EES building system risk assessments were not completed. The documentation did not exist.

On 02/07/18 at 1:23 pm during record review the surveyor asked the plant operations manager for the EES building system risk assessments, the plant operations manager stated the assessment was not conducted. The document did not exist.

Based on record review and interview the facility failed to ensure the annual emergency generator fuel quality testing was completed.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016 and 2017, as the documents do not exist.

On 02/07/18 at 1:52 pm the plant operations manager was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016 and 2017. The plant operations manager stated the annual emergency generator fuel quality tests have never been done and the documents do not exist.