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Based on records review and interview, the critical access hospital failed to meet emergency preparedness rules as outlined in Appendix Z.

Finding:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator, director of maintenance and director of education present, during records review and interviews found the following:

1. The facility failed to provide documentation that their emergency preparedness plan included strategies for addressing emergency events identified by the risk assessment. Their plan only had plans/policies for some of the events identified on the hazard assessment.


The surveyors confirmed these findings with the facility administrator, maintenance director and director of education at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet emergency preparedness rules as outlined in Appendix Z.

Finding:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator, director of maintenance and director of education present, during records review and interviews found the following:

1. The facility failed to provide documentation that their emergency preparedness plan that address patient/client population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency.


The surveyors confirmed these findings with the facility administrator, maintenance director and director of education at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet emergency preparedness rules as outlined in Appendix Z

Finding:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator, director of maintenance and director of education present, during records review and interview found the following:

1. The facility failed to provide up to date documentation in their emergency preparedness plan that would have included, Memorandums of Understanding (MOU) that should been reviewed/updated within the last 12 months.


The surveyors confirmed these findings with the facility administrator, maintenance director and director of education at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet emergency preparedness rules as outlined in Appendix Z.

Findings:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator, director of maintenance and director of education present, during records review and interviews found the following:

1. The facility failed to provide documentation that they performed the following within the last 12 months

a. Participate in a full-scale exercise that is community-based or when a community-based exercise is not accessible, an individual, facility-based. If the hospital experiences an actual natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in a community-based or individual, facility-based full-scale exercise for 1 year following the onset of the actual event.

b. Conduct an additional exercise that may include, but is not limited to the following:
1b. A second full-scale exercise that is community-based or individual, facility-based.

2b. A tabletop exercise that includes a group discussion led by a facilitator, using a narrated,
clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.


The surveyors confirmed these findings with the facility administrator, maintenance director and director of education at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet installation requirements per NFPA 99 ( 5.1.4.8.5) (5.1.9.3.1)

Finding:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, during records review and interview, surveyors in the presence of facility administrator and director of maintenance

1. The last documented fire alarm test report that was provided by the facility was completed in July 2018. The facility failed to provide any documentation that they had performed fire alarm testing within the last 12 months as required by NFPA 72.


The surveyors confirmed these findings with the facility administrator and maintenance director at the time of the records review.

Based on observations and interview, the Critical Access Hospital failed to ensure the corridor smoke barrier walls would resist the passage of smoke.

Findings:

On 8/12/19 between 12:15 pm and 12:57 pm, a surveyor, with a Maintenance Worker present, observed the following:

1. Directly above door marked M0000099, a sprinkler pipe and data cables penetrated the smoke barrier wall, spaces around the wires and piping and where not properly sealed.

2. Directly above the consultation office located next to the Emergency Department entrance, a 4" square penetration was found in the corridor wall that would allow the passage of smoke to enter the corridor.


The surveyor confirmed these findings with the Maintenance Worker at the time of the observation.

Based on records review and interview, thecritical access hospital failed to meet the NFPA 19.7.1.4 through 19.7.1.7 requirements for fire drills.

Finding:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm during records review and interview surveyors with the facility administrator and director of maintenance present found the following:

1. The facility failed to provide documentation that they had conducted a fire drill on the second shift of the fourth quarter for drills conducted 2018 and 2019.

Surveyors confirmed these findings with the facility administrator at the time of the records review.

Based on observations and interview, the Critical Care Hospital failed to ensure mops and rags were not dried in clothes dryers per manufacturer recommendation.

Finding:

On 8/12/19 at 12:25 pm, a surveyor, with a Maintenance Worker present, observed the following:

During interview it was stated that it was a regular practice to dry mop heads and micro-fiber rags from housekeeping on high heat in the dryers.

Even after rags or mop heads have been laundered, they can still hold enough contaminated traces of oil to add fuel to the oxidation process that causes spontaneous ignition per NFPA 921, Guide for Fire and Explosion Investigations 2008, 5.7.4.1.3.4

The surveyor confirmed this finding with the Maintenance Worker at the time of the observation.

Based on records review and interview, the critical access hospital failed to meet installation requirement per NFPA 99 ( 5.1.4.8.5) (5.1.9.3.1)

Findings:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator and director of maintenance present, during records review and interviews found the following:

1. The facility failed to provide documentation that they had corrected the following deficiencies that were identified on the Medical gas testing and evaluation report for 2018. Some of the same deficiencies cited in the 2018 inspection report were also identified as deficiencies in 2017 and are noted in parenthesis below.

Physical Therapy
a. Zone valves located left of patient area nurse's station are installed behind a normally open or normally closed door (2017).

Radiology
a. Zone valves located across from lab area are installed behind a normally open or normally closed door (2017).

LDRP
a. Zone valves located left of the nurse's station are installed behind a normally open or normally closed door (2017).


The surveyors confirmed these findings with the facility administrator and maintenance director at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet the requirements per NFPA 99.

Findings:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator and director of maintenance present, during records review and interviews found the following:

1. The facility failed to provide documentation that they had corrected the following deficiencies that were identified on the Medical gas testing and evaluation report for 2018. Some of the deficiencies were also identified in 2017 Medical Gas inspection report and are noted to the right in parenthesis.

Master Alarms and Sources
a. Bulk oxygen system-source valve has threaded connections on each side of the valve and not factory brazed extensions.
b. The outdoor bulk cryogenic liquid system needs to be provided with a minimum of two entries/exits. (2017)
c. Oxygen check valve located on the main line piping has threaded connections. (2017)
d. The auxiliary source connection does not have a removable cap.
e. Emergency oxygen supply connection-oxygen check valve located on the EOSC piping has threaded connections. (2017)


The surveyors confirmed these findings with the facility administrator and maintenance director at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet maintenance requirements for medical gas/vacuum systems per NFPA 99.

Findings:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator and director of maintenance present, during records review and interviews found the following:

1. The facility failed to provide documentation that they had corrected the following deficiencies that were identified on the Medical gas testing and evaluation report for 2018. Some of the deficiencies were also identified in 2017 Medical Gas Inspection Report and are noted to the right in parenthesis.

Critical Care 1
a. Emergency room- 1st vacuum inlet has low flow (2017)
b. Emergency room- 2nd vacuum inlet has low flow (2017)
c. Emergency room- 3rd vacuum inlet has low flow (2017)
d. Emergency room- 1st oxygen outlet on slide rail has defective latch

Critical Care 2
a. Emergency room- 1st vacuum inlet has low flow (2017).
b. Emergency room- 2nd vacuum inlet has low flow (2017).
c. Emergency room- 3rd vacuum inlet has low flow (2017).

LDRP
a. Nursery- The moisture analysis was +42.7 degrees Fahrenheit, which is above NFPA 99 criteria (2017 was +39.7).

Patient Area
a. Room 106-oxygen outlet leaks with adapter attached.

Sources
a. Emergency oxygen supply connection-check valve on the emergency line leaks at the threaded connection on the main-line side. (2017)

Operating Rooms
a. Operating room 1-2nd vacuum inlet on ceiling 1 leaks at the ceiling..
b. Operating room 2-1st vacuum inlet on ceiling 1 leaks at ceiling.
c. Operating room 2-2nd vacuum inlet on ceiling 1 leaks at ceiling.
d. Operating room 2-1st vacuum inlet on ceiling 2 leaks at ceiling.
e. Operating room 2-2nd vacuum inlet on ceiling 2 leaks at ceiling.

The surveyors confirmed these findings with the facility administrator and maintenance director at the time of the records review.

Based on records review and interview, the critical access hospital failed to meet maintenance requirements for medical gas/vacuum systems per NFPA 99.

Findings:

On 08/13/2019 between the hours of 10:30 am and 4:30 pm, surveyors with the facility administrator and director of maintenance present, during records review and interviews found the following:

1. The facility failed to provide documentation that they had corrected the following deficiencies that were identified on the Medical gas testing and evaluation report for 2018.

Emergency

a. Zone valve located right of exam 3 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

b. Zone valve located across from critical care 1 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

c. Zone valve located across from critical care 2 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

Physical Therapy

a. Zone valve located left of patient area nurse's station needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly

Surgical Services
a. Area alarm panel located at LDRP nurse's station for the operating rooms is not located in an area for appropriate surveillance and is not labeled

b. Zone valves located right of operating room 1 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

c. Zone valves located left of operating room 2 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

PACU
a. Area alarm panel located at LDRP nurse's station for endoscopy is not located in an area for appropriate
surveillance (2017)

b. Zone valve located right of the endoscopy room needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

LDRP
a. Zone valves located left of the nurse's station needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

b. Zone valves located left of LDRP room 1 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.

Patient area
a. Zone valves located left of room 109 needs to be relabeled, so that the label is not affixed to the removable cover and is visible from outside the zone valve assembly.


The surveyors confirmed these findings with the facility administrator and maintenance director at the time of the records review.

Based on observation and interview the critical access hospital failed to ensure power strips are used with general precautions and are not used as a substitute for fixed wiring of a structure in 1 of 5 smoke compartments .


Finding:

1. At 11:52 a.m., an electrical power strip was located in the staff lounge of the operating room. The power strip was supplying power to two different coffee makers and no documentation could be provided to indicate that the multi outlet device was designed/approved to power such appliances without exceeding the capacity/capabilities of the device .


This was found and confirmed with the maintenance employee.