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Based on record review and interview, the hospital failed to ensure development, maintenance, and annual review of a facility-based community-based risk assessment using an all hazards approach as required.

Findings:

Record review of the emergency preparedness plan showed the facility did not annually maintain and review the facility-based and community-based risk assessments that utilized an all hazards approach for their off site facilities located in Cushing Oklahoma and Jenks, Oklahoma. An annual risk assessment for the facility emergency preparedness plan did not exist for 2017-2018.

On 07/29/19 at 2:17 pm, the surveyor asked Staff F for written documentation of the facility's risk assessments and associated emergency preparedness for the off site facilities located in Jenks, Oklahoma and Cushing, Oklahoma. Both facilities are under the same CCN number as the Bristow location. Staff F stated only one risk assessment was created for all three facilities. The surveyor informed Staff F each facility would need a hazard vulnerability risk assessment created. An annual risk assessment for the facility emergency preparedness plan did not exist for 2017-2018 off site facilities.

Based on record review and staff 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 section 1135 of the act in provision of care and treatment.

Findings:

Record review of the facility's Emergency Preparedness plan showed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster.

On 07/30/19 at 10:50 am, the surveyor asked Staff F 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 has been granted by the Secretary. Staff F stated the facility is in process of updating policies to ensure compliance with the development of the 1135 waiver policy. The document did not exist.

Based on record review, observations and interview the facility failed to ensure the facility emergency generator/prime mover was permanently attached/installed, per NFPA 110. The annual emergency generator fuel quality testing was completed, conducted on the emergency generator as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2017 and 2018 as the documents do not exist.

On 07/29/19 at 1:52 pm, the surveyor asked staff A to provide the following: annual emergency generator fuel quality testing documentation for 2017 and 2018. Staff A stated the tests the surveyor requested were not done so the documents are not available.

On 07/29/19 at 3:38 pm, the surveyor observed a temporary 160 KvA emergency generator on wheels plugged into the facility's automatic transfer switch.

On 07/29/19 at 3:38 pm, the surveyor asked staff A how long they have had the temporary emergency generator and staff A stated they have had it for two years. The surveyor stated they need to get their installed emergency generator fixed or replaced as NFPA 110 requires emergency power supply systems to be permanently attached, therefore portable and mobile generators would not be permitted as an option to provide or supplement emergency power to hospitals, or critical access hospitals.

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

Findings:

On 07/29/19 at 2:32 pm the surveyor observed a deadbolt lock on the IT closet door which had the rectangular area cut out of it with a louver installed. The configuration would cause anyone inside the IT room to to use two actions to egress the closet instead of one action as required. The surveyor also observed deadbolt locks on several corridor doors which would take two actions to gain access to the egress corridor pathway at the Bristow Medical Center, CORE location in Jenks, and Cimarron Healthcare location in Cushing.

On 07/29/19 at 2:32 pm the surveyor asked staff A why there were deadbolts were on the corridor doors. Staff A stated those deadbolts had always been there but they will replace them with appropriate locking devices that will open with one action.

Based on observation and interview the facility failed to protect hazardous areas as required.

Findings:

On 07/29/17 at 3:32 pm a hazardous area room labeled as an IT closet corridor door was observed to have a rectangular portion of the door cut out of it with a louver installed.

On 07/29/17 at 12:06 pm the surveyor asked staff A why there was a hole cut into the corridor door IT closet with a louver installed. Staff A stated the door was there before he started and he will get it replaced or repaired.

Based on record review and interview the facility failed to ensure ventilatory guidelines were maintained per ASHRAE 170-2008 as required.

Findings:

Record review showed Bristow Medical Center, CORE in Jenks, Cimarron Healthcare in Cushing did not have annual test and balance inspections for 2018.

On 07/29/19 at 3:32 pm the surveyor asked staff A for the 2018 annual test and balance inspections for the three locations. Staff A stated they have not completed them but will get them scheduled as soon as possible.

Based on observation and interview the facility failed to ensure corridor doors where held open with approved hold open devices as required.

Findings:

On 07/29/19 at 4:41 pm the surveyor observed several corridor doors with an installed metal hold open device, the men's and women's bathrooms near the front entrance at Bristow Medical Center. A barrel latch was observed on the mechanical room door near dietary.

On 07/19/19 at 4:45 pm the surveyor asked staff A why there are metal and wooden chocks in the facility to hold open corridor doors. Staff A stated he did not know why they were there but will remove them immediately.

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 for Bristow Medical Center, Core in Jenks, and Cimarron Healthcare in Cushing showed their facility fire drills for 2019, and 2018 did not document transmissions of fire alarm signals for every fire drill completed.

On 07/29/19 at 1:07 pm the surveyor stated to staff A each of the facility's fire alarm drills should include documentation of a transmission of a fire alarm signal for each individual fire drill. Staff A stated they would add that to each of the facility's 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 for Bristow Medical Center, Core in Jenks, Cimarron Healthcare in Cushing showed the annual fire rated door assembly inspections for 2018 were not completed and the documentation did not exist.

On 07/29/19 at 10:49 am the surveyor asked staff A for the annual fire rated door assembly inspections for each of their locations. Staff A stated the inspections were not completed for each of the locations and the documentation does not exist.

Based on record review and interview the facility failed to ensure smoke evacuation was tested and maintained as required.

Findings:

Record review showed Bristow Medical Center, CORE in Jenks, Cimarron Healthcare in Cushing did not have 2019 annual inspections for their operating rooms smoke evacuation systems.

On 07/30/19 at 10:21 am the surveyor asked staff A for the annual smoke evacuation inspections for the three locations operating rooms. Staff A stated they have been busy with the details on getting the plans, paperwork for building the new Bristow Medical Center but will get them schedule as soon as possible.

Based on observation and interview the facility failed to ensure manufacturers documentation was available to ensure heating elements of portable space heaters being used in the facility did not exceed 212 degrees Fahrenheit and were not used in sleeping staff areas as required.

Findings:

On 07/30/19 at 2:01 pm the surveyor observed a space heater in the doctor's sleep room #55. There were several other space heaters observed in non-sleeping staff office areas.

On 07/30/19 at 2:02 pm the surveyor asked staff A for the documentation that shows the heating elements in each of the space heaters, other than the one that needs to be removed from the doctor's sleep room, does not exceed 212 degrees Fahrenheit in order to be compliant. Staff A stated they will look for the documentation but it was not provided.

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

Findings:

Record review showed each of the following: Bristow Medical Center, CORE in Jenks, and Cimarron Healthcare in Cushing did not have the EES (Essential Electrical System) and Medical Gas building system risk assessments completed.

On 07/29/19 at 10:35 am the surveyor asked staff A for the EES and Medical Gas building system risk assessments for each of their three facility's. Staff A stated that they were not familiar with the requirement but will get them completed.

Based on record review and interview the facility failed to ensure the facility medical gas systems were inspected annually as required.

Findings:

Record review showed Bristow Medical Center, CORE in Jenks, and Cimarron Healthcare in Cushing did not complete annual medical gas inspections for 2018.

On 07/29/19 at 3:56 pm the medical gas systems annual inspections for each of the three locations were requested for 2018, they were not available as they do not exist.

On 07/29/19 at 3:56 pm the surveyor asked staff A why the medical gas inspections were not completed. Staff A stated that they do not know why but will get it scheduled as soon as possible.

Based on record review, and interview the facility failed to ensure annual impedance testing of patient care related electrical receptacles as required.

Findings:

Record review of Bristow Medical Center, CORE in Jenks, Cimarron Healthcare in Cushing showed the facility did not have the 2019 annual impedance testing of the patient care related electrical receptacles at each location.

On 07/29/19 at 10:43 am the surveyor asked staff A for the 2019 annual impedance testing inspection of patient care related electrical receptacles for patient treatment areas at each of their three locations. Staff A stated they have not completed the testing but will get it scheduled as soon as possible.

Based on observations, record review and interview the facility failed to ensure the facility emergency generator/prime mover was permanetly attached/installed, the annual emergency generator fuel quality testing was completed, the annual two hour load bank testing was completed, and 36 month, four hour load bank testing was conducted on the emergency generator as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2017 and 2018 as the documents do not exist.

Record review showed the facility has not conducted annual two hour load bank testing for 2018, and 2017 as the documents do not exist.

Record review showed the facility has not conducted a 36 month, four hour load bank test on the emergency generator as the document does not exist.

On 07/29/19 at 1:52 pm the surveyor asked staff A to provide the following: annual emergency generator fuel quality testing documentation for 2017 and 2018; Annual load bank testing for 2018, and 2017; and the last 36 month four hour load bank test. Staff A stated the tests the surveyor requested were not done so the documents are not available.

On 07/29/19 at 3:38 pm the surveyor observed a temporary 160 KvA emergency generator on wheels plugged into the facility's automatic transfer switch.

On 07/29/19 at 3:38 pm the surveyor asked staff A how long they have had the temporary emegency generator and staff A stated they have had it for two years. The surveyor stated they need to get their installed emergency generator fixed or replaced as NFPA 110 requires emergency power supply systems to be permanently attached, therefore portable and mobile generators would not be permitted as an option to provide or supplement emergency power to hospitals, or critial access hosptials.

Based on record review and interview the facility failed to ensure features of fire protection/fire loss prevention training for operating room staff including surgeons was completed as required.

Finding:

Record review showed Bristow Medical Center, CORE in Jenks, Cimarron Healthcare in Cushing did not document operating room staff training provided to new staff or continuing education or that procedures were reviewed annually as required per NFPA 99, 2012 Edition, Chapter 15.13.

On 07/29/19 at 4:32 pm the surveyor staff A for the three locations training records for operating staff for fire loss prevention training which includes established procedures for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, extinguishment of drapery, clothing and equipment fires and training is provided to new operating room staff including doctors/surgeons, continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually with the following documentation. Staff A stated the three locations do the training but has not kept documentation of the training. Staff A stated they will implement documentation of the training for the fire loss prevention in operating room training.