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Based on record review and interview, the hospital failed to develop policy for strategies addressing and identifying the patient/client population needs of at risk or vulnerable patient population during an emergency event or disaster.

Findings:

Record review of the emergency preparedness plan showed the facility did not develop or identify the facility's patient client populations that would be at risk; the type of services the facility has the ability to provide during an emergency event.


On 06/25/19 at 10:17 am, the surveyor asked Staff B if the facility identified and addressed the patient/client population needs of at risk population and the types of services the facility would be able to provide in an emergency. Staff B stated the facility is in the process of updating and revising the policies and procedures. The documentation did not exist.

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the sheltering in place of residents, staff and volunteers who remain in the facility during an emergency or disaster. The facility lacked a policy.

Findings:

On 06/25/19 at 2:10 pm, during the review of the Facility's Emergency Preparedness plan showed that they lacked a policy regarding the sheltering in place of residents, staff and volunteers who will remain in the facility during an emergency. Facilities are required to have policies and procedures for sheltering in place which align with the facility's risk assessment and are expected to include the criteria for determining which patients and staff would be sheltered in place.

On 06/25/19 at 2:12 pm, during an interview the surveyor requested Staff B for the shelter in place policy and procedures, Staff B stated that they will update and revise the policies and procedures.

Based on record review and interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with the section 1135 of the act in provision of care and treatment. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness Plan revealed that they lacked a policy regarding the facility's role under a 1135 waiver during a declared disaster providing care and treatment at alternate care sites.

On 06/25/19 at 1:27 pm, the surveyor asked Staff B if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act as been granted by the Secretary. Staff B stated the facility was unaware of the policy and they will update and revise the policies and procedures.

Based on review and interview of the facility's Emergency Plan, it was determined that the procedures failed to include an adequate communications plan.


Findings:


Record review of the emergency preparedness plan showed no communication plan had been updated and reviewed annually for 2017-2018.


On 06/25/19 at 11:17 am, the surveyor requested Staff B for documentation that the communication plan had been reviewed and approved annually. The surveyor requested Staff B for the approved communication plan for 2017-2018, the documentation did not exist.

Based on interview the facility emergency preparedness communication plan did not contain methods for sharing information and medical documentation for patients under the facility's care with other health care providers to maintain continuity of care in the event of an evacuation as required.

Findings:

On 06/25/19 at 4:33 pm, the surveyor asked Staff B for documentation to verify the facility had developed an emergency preparedness communication plan which included how the facility would share information for patients under the facility's care as necessary with other health care providers in the event of an emergency. Staff B stated the facility is in process of writing policies to ensure compliance with all E-tags. The document with required components did not exist. Staff B stated the facility would update and revise a plan to address sharing information in the event of an evacuation as permitted under 45 CFR 164.510(b)(4).

Based on observation and interview the facility failed to ensure the means of egress was continuously maintained free of all obstructions to full use in case of emergency.

Findings:

On 06/24/18 at 4:00 pm the surveyor observed a wooden bookshelf positioned directly in the egress pathway blocking the designated exit near the women's inpatient sleeping rooms.

On 06/24/18 at 4:01 pm the surveyor asked staff E why the wooden bookshelf was positioned in front of the designated exit and blocking it. Staff E stated they did have a resident inpatient that would run into the door and escape but do not know why it is still there. Staff E stated they would move it immediately.

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

Findings:

On 06/24/19 at 3:11 pm the surveyor observed a big red button next to an egress door within the medical records department which had to be activated before the door handle could be used to open the door.

On 06/24/19 at 3:11 pm the surveyor asked staff E why there was a button to push to exit in addition to having to turn the door handle. Staff E stated it had always been there and they did not really know why it was there. Staff E stated that there is a badge reader on the outside of the door but they will remove the button on the inside so it will only take one action to open the door as required.

Based on observation and interview the facility failed to ensure hazardous areas were free from penetrations.

Findings:

On 06/25/19 at 4:06 pm the surveyor observed nine penetrations in the housekeeping closet next to the nurses station.

On 06/25/19 at 4:06 pm the surveyor asked staff E why the penetrations were in the housekeeping closet. Staff E stated contractors are making repairs and having to gain access to piping and wiring in which they did not repair the open areas.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 06/25/19 at 9:40 am one K class fire extinguisher and one ABC class fire extinguisher was observed in the kitchen with no placards posted next to them to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 06/25/19 at 9:40 am Staff E stated he would get with their fire service vendor to get the appropriate placard(s) for each of the fire extinguishers that are installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure fire extinguishers were installed properly as required.

Findings:

On 06/24/19 at 3:28 pm the surveyor observed two fire extinguishers in the kitchen in which the top of the handles were installed over five feet from the floor.

On 06/24/19 at 3:28 pm the surveyor asked staff E what the requirements for installation of fire extinguishers are regarding the height requirement. Staff E stated they look like they are installed too high. The surveyor stated to staff E to be sure and check the American Disability Act for requirements as CMS defaults to the most restrictive.

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 facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 06/24/19 at 3:54 pm the surveyor stated to Staff E the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff E stated they would add that to the fire drill documentation.

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 2018 were not completed and the documentation did not exist.

On 06/24/18 at 2:33 pm the surveyor asked Staff E for the annual fire rated door assembly inspections. Staff E stated the inspection was not completed for 2018 and the documentation does not exist.

Based on obsevation and interview the facility failed to ensure space heaters used within the facility had documentation that the heating elements did not exceed 212 degrees Fahrenheit as required.

Findings:

On 06/25/19 at 4:08 pm the surveyor observed three space heaters in staff offices. The survyeor observed a fourth space heater in a unoccupied doctor's office which was left on.

On 06/25/19 at 4:08 pm the surveyor asked staff E if they have the manufacturers documentation indicating the heating elements to each of the space heaters. Staff E stated they would look to get it. Staff E did not provide the documentation as it 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 facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed. They do not exist.

On 06/24/19 at 2:35 pm the surveyor asked staff E for the EES and Medical Gas building system risk assessments, and staff E stated he would check. Staff E came back a time later and stated they do not have the EES and medical gas building system risk assessments. Staff E stated they will get them completed.