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Based on observation, record review and staff interviews, the Critical Access Hospital failed to provide a safe and secure environment for the provision of patient care.

Due to the scope and severity of the deficiencies identified below, the DOH surveyors and the Deputy Fire Marshal consulted with officials of the Washington State Patrol, Fire Protection Bureau; Washington State Department of Health; and the Centers for Medicare and Medicaid Services, Region 10. A state of Immediate Jeopardy was declared on 7/24/2013. Hospital administration was notified of the finding of Immediate Jeopardy on 7/24/2013 AT 11:15 AM.

The findings below and additional findings found during the fire life safety survey demonstrated that the Condition of Participation for Physical Plant and Environment was NOT MET

Cross Reference: Tags C231, K050, K052, K062, K144, K147, K018

Findings:

Item 1 - Fire Suppression Sprinkler System:

1. There was no evidence that quarterly inspections had been completed
2 An annual report from the contracted sprinkler company included the same deficiencies from 2011 to 2013
3. A 5 year internal pipe inspection had not been done and was noted in the last two annual reports
4. The escutcheon on the sprinklers in the basement Americans with Disabilities Act-compliant (ADA) restrooms had been installed upside down
5. The sprinklers in both ADA-compliant restrooms still had construction protective plastic on the heads

Item 2 - Fire Alarm System

1. When tested during a fire drill on 7/25/2013, the fire alarm had an excessive delayed reaction from activation to alarm (greater than 10 seconds)

Item 3 - Generator

1. There was no evidence of weekly inspection and monthly testing under full load. This was previously cited during a DOH state licensing and Critical Access Hospital survey in 2011, and there were no logs since that time to demonstrate compliance.

Item 4 - Fire Drills

1. The hospital was cited during the DOH state licensing and Critical Access Hospital survey in 2011 for two quarters not having the required number of fire drills
2. Only 4 of 8 required fire drills were conducted in 2012
3. A fire drill conducted on 7/24/2013 at 9:00 AM revealed staff response that did not follow hospital policy and endangered patients

Item 5 - Fire Doors

1. Fire doors to the nursing administration area did not close and latch when activated on 7/24/2013
2. The exit door to the stairs by the physical therapy unit did not close and latch when activated
3. Doors to patient rooms 13, 14, and 2 did not latch properly when inspected on 7/23/2013. The problem had been reported by work order on 2/20/2013 when discovered during a fire drill but had not been fixed
4. The soiled utility room door did not close and latch when inspected on 7/23/2013
5. Cross-corridor smoke doors adjacent to patient room 10 did not fully close when activated by the fire alarm on 7/24/2013
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Based on observation and interview, the critical access hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2000 edition.

Findings include:

Refer to deficiencies written on the CRITICAL ACCESS HOSPITAL MEDICARE RECERTIFICATION LIFE SAFETY CODE SURVEY
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Based on observation, record review and staff interviews, it was determined that the Critical Access Hospital's Governing Body failed to meet the requirements for the Condition of Participation for Organizational Structure.

Failure to meet established organizational structure requirements resulted in an unsafe healthcare environment.

Reference: 42 CFR 485.627(a) Standard: Governing Body or Responsible Individual
The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH's total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment

Findings:

Due to the scope and severity of deficiencies detailed under the Conditions of Participation for Physical Plant and Environment, and for Periodic Evaluation and Quality Assurance Review, the Condition of Participation for Organizational Structure was NOT MET.

Cross-Reference: Tags C0220, C0231, C0330, and C0337.
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Based on staff interviews and review of the hospital's quality assurance program and quality assurance documentation, it was determined that the facility failed to meet the requirements for the Condition of Participation for Hospital Wide Periodic Evaluation and Quality Assurance Review.

Failure to develop and implement an effective quality assurance program that included monitoring of fire prevention plans, fire suppression systems, and fire response education and drills impaired the facility's ability to provide quality care in a safe environment and resulted in a state of Immediate Jeopardy of the health and safety of patients..

Findings:

Due to the scope and severity of deficiencies detailed under the Conditions of Participation for Physical Plant and Environment, and for Periodic Evaluation and Quality Assurance Review was NOT MET.

Cross Reference: Tag C0337
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Based on interview and review of quality improvement documentation, the Critical Access Hospital failed to develop and implement an effective quality assurance program that included monitoring of fire prevention plans, fire suppression systems, and fire response education and drills

This impaired the facility's ability to provide quality care in a safe environment and resulted in a state of Immediate Jeopardy of the health and safety of patients...

Findings:

Item 1 - Fire Suppression Sprinkler System:

1. There was no evidence that quarterly inspections had been completed
2 An annual report from the contracted sprinkler company included the same deficiencies from 2011 to 2013
3. A 5 year internal pipe inspection had not been done and was noted in the last two annual reports
4. The escutcheon on the sprinklers in the basement Americans with Disabilities Act-compliant (ADA) restrooms had been installed upside down
5. The sprinklers in both ADA-compliant restrooms still had construction protective plastic on the heads

Item 2 - Fire Alarm System

1. When tested during a fire drill on 7/25/2013, the fire alarm had an excessive delayed reaction from activation to alarm (greater than 10 seconds)

Item 3 - Generator

1. There was no evidence of weekly inspection and monthly testing under full load. This was previously cited during a DOH state licensing and Critical Access Hospital survey in 2011, and there were no logs since that time to demonstrate compliance.

Item 4 - Fire Drills

1. The hospital was cited during the DOH state licensing and Critical Access Hospital survey in 2011 for two quarters not having the required number of fire drills
2. Only 4 of 8 required fire drills were conducted in 2012
3. A fire drill conducted on 7/24/2013 at 9:00 AM revealed staff response that did not follow hospital policy and endangered patients

Item 5 - Fire Doors

1. Fire doors to the nursing administration area did not close and latch when activated on 7/24/2013
2. The exit door to the stairs by the physical therapy unit did not close and latch when activated
3. Doors to patient rooms 13, 14, and 2 did not latch properly when inspected on 7/23/2013. The problem had been reported by work order on 2/20/2013 when discovered during a fire drill but had not been fixed
4. The soiled utility room door did not close and latch when inspected on 7/23/2013
5. Cross-corridor smoke doors adjacent to patient room 10 did not fully close when activated by the fire alarm on 7/24/2013
.
Cross-reference: C0220, C0231, K050, K052, K062, K144, K147, K018
.