HospitalInspections.org

Based on record review and interview, the facility failed to include a policy and procedure for tracking of patients and staff during emergencies requiring either evacuation or sheltering in place. Failure to have a tracking policy and procedure for staff and patients under the care and supervision of the facility, has the potential to hinder facility response and continuity of care. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of the provided EOP on 6/15/21 from 9:30 - 11:30 AM, documentation identified a section listed in the Table of Contents for "Client, Staff and Visitor Tracking System", however no content in the plan was provided for this reference. At approximately 1:30 PM, when asked for the section identified in the EOP for tracking, the CNO stated the supporting documentation had not yet been implemented or created into the plan.

Reference:
42 CFR 482.15 (b) (2)

Based on record review and interview, the facility failed to include a policy and procedure for sheltering in place during emergencies or disasters. Failure to have a policy for sheltering in place, has the potential to force evacuation in incidents, increase potential risks to patients unable to transport and limit facility response. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of the provided EOP on 6/15/21 from 9:30 - 11:30 AM, documentation identified a section listed in the Table of Contents for "Staying in Place (SIP) plan", however no content in the plan was provided for this reference. At approximately 1:30 PM, when asked for the section identified in the EOP for tracking, the CNO stated the supporting documentation had not yet been implemented or created into the plan.

Reference:
42 CFR 482.15 (b) (4)

Based on record review, it was determined the facility failed to document their role under an 1135 waiver as declared by the Secretary and the provisions of care as required under this action if identified by emergency management officials. Failure to plan for alternate means of care and the role under an 1135 waiver has the potential to limit facility options during an emergency. This deficient practice potentially affects reimbursement and continuity of care for all patients, staff and visitors housed on the date of the survey along with the available surge needs of the community during a disaster.

Findings include:

During review of provided EOP records conducted on 6/15/21 from 9:30 - 11:30 AM, documentation was not available to demonstrate the role of the facility under the declaration of an 1135 waiver, should that condition be enacted by the Secretary.

Reference:
42 CFR 482.15 (b) (8)

Based on record review and interview, it was determined the facility failed to provide an emergency prep training program conducted on not less than an annual basis. Lack of a training program on the emergency preparedness plan and policies for the facility, has the potential to hinder staff response during a disaster. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided EOP records conducted on 6/15/21 from 9:30 - 11:30 AM, the implementation of a online emergency preparedness training was identified, however only one (1) staff member (the Business Manager) had taken the training.

Interview of the Business Manager at approximately 2:00 PM revealed the facility had not yet implemented the training to all staff and conducted in on an annual basis.

Reference:
42 CFR 482.15 (d) (1)

Based on record review and interview, the facility failed to ensure the emergency power supply system (EPSS) generator was maintained in accordance with NFPA 110. Failure to ensure EPSS generators are maintained in accordance with the standard, has the potential to hinder system performance during an extended power loss. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided EPSS inspection and testing records, conducted on 6/15/21 from 9:30 - 11:30 AM, the following deficiencies were identified:

- No documentation for an annual fuel test for the diesel generator.
- Monthly load testing was conducted during an automatic run time programmed for the generator and not during a manual transfer simulating a power loss.
- Documentation for monthly load testing did not identify manufacturer recommended minimum exhaust gas temperatures, or meet 30 percent of the rated load for the generator. Additionally, no annual load bank testing was documented.
- The documented four-hour load testing conducted in 2018 was performed by the previous Facility Engineer and did not meet or exceed a 30 percent value at any time during the test.

Interview of the Facility Engineer established he was not aware the documentation did not meet the NFPA requirement.

Reference:
42 CFR 482.15 (e) (1)

Based on record review and interview, the facility failed to ensure fire alarm systems were maintained in accordance with NFPA 72. Failure to conduct sensitivity testing on installed fire alarm smoke detection, has the potential to hinder system response during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided inspection and maintenance records conducted on 6/15/21 from 9:30 - 11:30 AM, no documentation was available for a sensitivity testing conducted within the past 5 years. Interview of the Facility Engineer at approximately 11:30 AM, revealed he was not aware a sensitivity test was required for this system.

Actual NFPA standard:

NFPA 72

Chapter 14 Inspection, Testing, and Maintenance

14.4.5.3.1
Sensitivity shall be checked within 1 year after installation.
14.4.5.3.2
Sensitivity shall be checked every alternate year thereafter unless otherwise permitted by compliance with 14.4.5.3.3.
14.4.5.3.3 After the second required calibration test, if sensitivity tests indicate that the device has remained within its listed and marked sensitivity range (or 4 percent obscuration light gray smoke, if not marked), the length of time between calibration tests shall be permitted to be extended to a maximum of 5 years.

Based on observation, the facility failed to ensure fire suppression system sprinkler pendants were maintained free of obstructions such as paint or corrosion. Failure to ensure fire suppression system pendants are free of obstructions, has the potential to hinder system response during a fire event. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 6/15/21 from 1:00 - 3:00 PM, observation of installed fire suppression system pendants in the facility revealed the sprinkler pendant at the door exiting the basement to the main level, was coated with a non-factory applied paint that included the deflector, the fusible link and the pendant support arms.

Actual NFPA standard:

NFPA 25

5.2% Inspection.
5.2.1 Sprinklers.

5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5)%Loading
(6) Painting unless painted by the sprinkler manufacturer

Based on observation, the facility failed to ensure safe electrical installations in accordance with NFPA 70. Use of plug adapters connected in series (daisy-chained) as the substitution for the direct wiring of the facility, has the potential to increase the risk of arc fires and/or electrical shock. This deficient practice affected staff and visitors on the date of the survey.

Findings include:

During the facility tour conducted on 6/15/21, from 1:00 - 2:00 PM, observation of the basement mechanical space revealed a 3 to 1 extension cord adapter was used to supply power to a recirculating pump from the water heater, and a plug adapter for the sump pump.

Actual NFPA standard:

NFPA 70

ARTICLE 100
110.2 Approval. The conductors and equipment required or permitted by this Code shall be acceptable only if approved.
Informational Note: See 90.7, Examination of Equipment for Safety, and 110.3, Examination, Identification, Installation, and Use of Equipment. See definitions of Approved, Identified, Labeled, and Listed.
110.3 Examination, Identification, Installation, and Use of Equipment.
(A) Examination. In judging equipment, considerations such as the following shall be evaluated:
(1) Suitability for installation and use in conformity with the provisions of this Code Informational Note: Suitability of equipment use may be identified by a description marked on or provided with a product to identify the suitability of the product for a specific purpose, environment, or application. Special conditions of use or other limitations and other pertinent information. Suitability of equipment may be evidenced by listing or labeling.
(2) Mechanical strength and durability, including, for parts designed to enclose and protect other eq

Based on record review and interview, the facility failed to ensure annual testing of rated assemblies separating other occupancies. Failure to test doors for fire-rated assemblies separating the facility from another attached occupancy, has the potential to expose patients to those risks associated from that entity. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided maintenance and inspection records conducted on 6/15/21, from 9:30 - 11:30 AM, no documentation was available for the testing of the two (2) doors installed in the fire-rated assembly that separated the hospital from the attached Clinic and associated Physical Therapy.
When asked at approximately 11:30 AM about the missing documentation, the Facility Engineer stated he was aware the annual test had not been completed.

Actual NFPA standard:

NFPA 80
5.2% Inspections.
5.2.1% Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.

5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances do not exceed clearances listed in 4

Based on record review and interview, the facility failed to ensure the piped medical gas system was maintained in accordance with NFPA 99. Failure to ensure valve gauges are provided at outlet zone valves, hinders preventative response during system failure or maintenance emergencies. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided piped medical gas inspection and testing records conducted on 6/15/21 from 9:30 - 11:30 AM, documentation indicated the outlet valve located outside of ED2 was not provided a gauge. Interview of the Facility Engineer at approximately 10:45 AM established he was aware of the noted deficiency from the report.

Actual NFPA standard:

NFPA 99

5.1.8 Pressure and Vacuum Indicators.
5.1.8.2.2 Pressure/vacuum indicators shall be provided at the following locations, as a minimum:
(1) Adjacent to the alarm-initiating device for source main line pressure and vacuum alarms in the master alarm system
(2) At or in area alarm panels to indicate the pressure/ vacuum at the alarm-activating device for each system that is monitored by the panel
(3) On the station outlet/inlet side of zone valves

Based on record review and interview, the facility failed to ensure medical gas system alarms were maintained in accordance with NFPA 99. Failure to provide visual and audible indication of alarms for medical gas systems can hinder staff response during emergency conditions. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of the provided annual inspection for the installed piped medical gas system conducted on 6/15/21 from 9:30 - 11:30 AM, the report listed the following alarm system deficiency:

- No visible indicator on the master alarm during the time the reserve system was in use.

Interview of the Facility Engineer at approximately 10:45 AM, established he was aware of the deficiency as noted in the annual inspection/testing report.

Actual NFPA standard:

NFPA 99

5.1.9.1 General. All master, area, and local alarm systems used for medical gas and vacuum systems shall include the following:
(1) Separate visual indicators for each condition monitored, except as permitted in 5.1.9.5.2 for local alarms that are displayed on master alarm panels
(2) Visual indicators that remain in alarm until the situation that has caused the alarm is resolved
(3) Cancelable audible indication of each alarm condition that produces a sound with a minimum level of 80 dBAat 0.92 m (3 ft)
(4) Means to visually indicate a lamp or LED failure
(5) Visual and audible indication that the communication with an alarm-initiating device is disconnected
(6) Labeling of each indicator, indicating the condition monitored
(7) Labeling of each alarm panel for its area of surveillance
(8) Reinitiation of the audible signal if another alarm condition occurs while the audible alarm is silence

Based on record review and interview, the facility failed to ensure the emergency power supply system (EPSS) generator was maintained in accordance with NFPA 110. Failure to ensure EPSS generators are maintained in accordance with the standard, has the potential to hinder system performance during an extended power loss. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided EPSS inspection and testing records, conducted on 6/15/21 from 9:30 - 11:30 AM, the following deficiencies were identified:

- No documentation for an annual fuel test for the diesel generator.
- Monthly load testing was conducted during an automatic run time programmed for the generator and not during a manual transfer simulating a power loss.
- Documentation for monthly load testing did not identify manufacturer recommended minimum exhaust gas temperatures, or meet 30 percent of the rated load for the generator. Additionally, no annual load bank testing was documented.
- The documented four-hour load testing conducted in 2018 was performed by the previous Facility Engineer and did not meet or exceed a 30 percent value at any time during the test.

Interview of the Facility Engineer established he was not aware the documentation did not meet the NFPA requirement.

Actual NFPA standard:

NFPA 110
Chapter 8 Routine Maintenance and Operational Testing

8.3 Maintenance and Operational Testing.
8.3.8 A fuel quality test shall be performed at least annually using tests approved by ASTM standards.

8.4 Operational Inspection and Testing.
8.4.2% Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the followi

Based on observation and interview, the facility failed to ensure storage of compressed medical gas cylinders were in accordance with NFPA 99. Failure to ensure segregation of stored gas cylinders and installation of electrical sources in accordance to the standard, has the potential for explosions and hinder staff response for patients requiring supplemental oxygen during emergencies.

Findings include:

During the facility tour conducted on 6/15/21 from 1:00 - 3:00 PM, observation of the oxygen storage location on the north side of the facility revealed the following:

- The light switch of the space was positioned at approximately 48 inches when measured from the floor to the bottom of the switch. Overall height was approximately 56 inches to the top when measured from the floor.
- Observation of labeling on the east and west facing walls of the enclosure revealed a sign on the east wall identifying "Empty" and on the west wall identifying "Full". Further observation revealed the rack for "E" size and smaller cylinders on the east side had no cylinders housed. The rack for the "E" size and smaller cylinders on the west side housed six (6) "E" size cylinders; one (1) with a pressure regulator attached; one (1) with a white, plastic valve protective cap; four (4) without the protective cap, one (1) of which had a masking tape label with pen/ink writing on it that read: 'Partial tank "Good"'.

At approximately 1:45 PM, the CNO was asked how the facility trained identification for empty versus full cylinders. She revealed that staff did not have specific training for determining empty versus full cylinders.

Actual NFPA standard:

NFPA 99
5.1.3.3.2% Design and Construction. Locations for central supply systems and the storage of positive-pressure gases shall m

Based on record review and interview, the facility failed to ensure staff training was conducted on the risks associated with oxygen. Failure to conduct continual education for staff on the safe handling, use and storage of compressed medical gases such as oxygen, has the potential to hinder staff response to patients requiring supplemental oxygen during an emergency. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of provided education and training records conducted on 6/15/21 from 9:30 - 11:30 AM, no documentation was available for staff education on the risks associated with oxygen. When asked at approximately 1:30 PM about the missing documentation, the CNO stated she was not aware the facility had not conducted a training on oxygen.

Actual NFPA standard:

NFPA 99
11.5.2 Gases in Cylinders and Liquefied Gases in Containers.
11.5.2.1 Qualification and Training of Personnel.
11.5.2.1.1% Personnel concerned with the application and maintenance of medical gases and others who handle medical gases and the cylinders that contain the medical gases shall be
trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for their personnel.
11.5.2.1.3 Continuing education programs shall include periodic review of safety guidelines and usage requirements for medical gases and their cylinders.