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Based on record review and interview, it was determined the facility failed to develop an Emergency Preparedness program that included a relevant facility based and community based risk assessment. Failure to provide a risk assessment which includes relevant community hazards, has the potential to focus staff training and resources on hazards that are not site specific. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

1) On 6/25/18 from 2:30 - 3:30 PM, review of the provided emergency plan, policies and procedures, revealed the facility HVA (Hazard Vulnerability Analysis) failed to include geographically relevant information for both Tornadoes and Volcanoes. Further review of the nearest county all-hazard mitigation plan and the state EMS provided hazard analysis, revealed both assessments considered Tornadoes and Volcanoes as a geographically relevant hazards for the area.

2) On 6/26/18 from 2:00 - 2:30 PM, Interview of 3 of 3 staff members identified a potential risk of both Tornadoes and Volcanic activity as relevant to the facility's geographic location and its potential for disasters.

Reference:
42 CFR 482.15 (a) (1) - (2)

Based on record review, it was determined the facility failed to develop policies and procedures based on the Emergency Plan, that aligned with a facility and community based risk assessment. Development of policies and procedures which are not aligned with the HVA, fails to provide identified hazards and confusion of training to identified risks. This deficient practice potentially affected patients, staff and visitors on the date(s) of the survey.

Findings include:

On 6/26/18 from 10:00 AM - 12:00 PM, review of provided policies and procedures revealed procedures contained in the plan for the risk of a Tornado, but the HVA failed to identify this as a potential risk. Further evaluation of the nearest county all-hazard mitigation plan also found consideration of Volcanoes as a risk to the area, but not identified in the HVA or the policies and procedures.

Reference:
42 CFR 482.15 (b)

Additional Reference:
E - 0006

Based on record review, it was determined the facility failed to provide a policy for tracking of staff and sheltered residents during an emergency. Lack of a tracking policy for sheltered staff and patients has the potential to hinder continuity of care and essential services during an emergency. This deficient practice has the potential to affect the patients, staff and visitors in the facility on the date(s) of the survey.

Findings include:

On 6/26/18 from 8:30 - 10:30 AM, review of provided emergency plan, policies and procedures, failed to demonstrate the facility had in place a system to track the location of on-duty staff and patients sheltered in the facility during an emergency.

Reference:
42 CFR 482.15 (b) (2)

Based on record review, it was determined the facility failed to provide a policy, procedure or plan for sheltering in place. Failure to provide a plan for sheltering in place has the potential to leave patients and staff without resources for providing continuity of care during an emergency. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

On 6/26/18 from 8:30 - 10:00 AM, review of provided emergency plan, policies and procedures, failed to reveal information contained in the documentation for sheltering in place.

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 the patients, staff and visitors housed on the date(s) of the survey along with the available surge needs of the community during a disaster.

Findings include:

On 6/26/18 from 8:30 AM - 12:00 PM, review of the provided emergency plan, policies and procedures, did not 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, it was determined the facility failed to provide current emergency prep training and testing program. Lack of an emergency training and testing 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(s) of the survey.

Findings include:

On 6/26/18 from 9:00 - 10:30 AM, review of provided emergency plan, policies and procedures failed to demonstrate any training program in place that included testing of staff's knowledge of the emergency plan and its contents.

Reference:

42 CFR 482.15 (d)

Based on record review and interview, it was determined the facility failed to provide an emergency prep training program. 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 patients, staff and visitors on the date(s) of the survey.

Findings include:

On 6/26/18 from 9:00 AM - 12:00 PM, review of provided emergency plan, policy and procedures, revealed no substantiating documentation demonstrating the facility provided a staff training program on the emergency preparedness plan, policies and procedures for existing and newly hired staff.

Interview of the Education Coordinator revealed the facility had not yet implemented a staff training program on the Emergency Preparedness plan.

Reference:
42 CFR 482.15 (d) (1)

Additional Reference:
E-0036

Based on observation, the facility failed to ensure the heliport on site was provided with appropriate protections in accordance with NFPA 418. Failure to sign heliport landing areas with signs prohibiting smoking as required, has the potential to expose flammable fuels and liquids associated with aircraft to ignition sources. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 6/26/18 from 8:45 - 10:00 AM, observation of the heliport landing area outside of the Emergency Room (ER) entrance, revealed the area was not posted with "NO SMOKING" signs at the access and egress points of the heliport.

Actual NFPA standard:

NFPA 418
Standard for Heliports
2011 Edition

4.6
4.6 No Smoking.
4.6.1 No smoking shall be permitted within 50 ft (15.2 m) of the landing pad edge.
4.6.2 NO SMOKING signs shall be erected at access/egress points to the heliport.

Based on observation and interview, the facility failed to ensure the fire and smoke resistive properties of the structure were maintained. Failure to maintain rated construction assemblies, has the potential to allow fire, smoke and dangerous gases to pass into unprotected concealed spaces and between compartments. This deficient practice potentially affected all patients staff and visitors in on the date(s) of the survey.

Findings include:

During the facility tour conducted on 6/26/18 at the main hospital, from 8:45 AM to 12:00 PM and the off-site Surgery Center from 2:00 - 3:30 PM, the following areas revealed unsealed penetrations:

· Two (2) approximately six inch diameter electrical and data cabling conduits, passing through the 1-hour wall in the Mechanical Room across from the Steiner Conference room.
· An approximately two foot by three foot hole in the interior wall of the Mechanical/Electrical Room, located in the back service corridor on the second floor.
· An above the ceiling inspection at the Surgery Center revealed a three inch unsealed cabling conduit passing through the one-hour wall separating the adjoining doctor's office.

Inquiry of the Engineering Manager revealed he was not aware of these unsealed penetrations prior to the survey date.

Actual NFPA standard:

19.1.6 Minimum Construction Requirements.
19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.)

8.2 Construction and Compartmentation.
8.2.1 Constructio

Based on observation, the facility failed to provide emergency lighting in accordance with NFPA 101. Failure to provide emergency lighting for doors equipped with delayed egress potentially hinders identification of exits affecting patient egress during an emergency. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 6/26/18 from 9:30 AM to 3:30 PM, observation of exit doors revealed exit doors at the stairwells in Med Surg and the exit door at the MBU/NICU were equipped with magnetic locking arrangements, which included a delayed egress component. Further observation established the facility was not providing battery backup emergency lighting for illumination of the means of egress to these exits.

Actual NFPA standard:

19.2.9 Emergency Lighting.
19.2.9.1 Emergency lighting shall be provided in accordance
with Section 7.9.

7.9 Emergency Lighting.
7.9.1 General.
7.9.1.1% Emergency lighting facilities for means of egress shall be provided in accordance with Section 7.9 for the following:
(1) Buildings or structures where required in Chapters 11 through 43
(2) Underground and limited access structures as addressed in Section 11.7
(3) High-rise buildings as required by other sections of this Code
(4) Doors equipped with delayed-egress locks
(5) Stair shafts and vestibules of smokeproof enclosures, for which the following also apply:
(a) The stair shaft and vestibule shall be permitted to include a standby generator that is installed for the smokeproof enclosure mechanical ventilation equipment.
(b) The standby generator shall be permitted to be used for the stair shaft and vestibule emergency lighting power supply.
(6) New ac

Based on observation and operational testing, the facility failed to ensure protections for hazardous area doors were maintained. Failure of hazardous area doors to fully close and latch has the potential to allow fire, smoke and dangerous gases to pass into corridors, hindering the safe egress of patients. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 6/26/18 from 8:45 AM - 12:00 PM, observation and operational testing of the following doors revealed the doors would not fully close and latch when activated:

· Door into the Soiled Linen located in the corridor on the west side of the Surgery department on the 1st floor.
· 1 of 2 doors entering the main Laundry from the corridor.

Actual NFPA standard:

19.3.2 Protection from Hazards.

19.3.2.1 Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in
accordance with 8.7.1.
19.3.2.1.3 The doors shall be self-closing or automatic-closing.
19.3.2.1.5 Hazardous areas shall include, but shall not be restricted to, the following:
(1) Boiler and fuel-fired heater rooms
(2) Central/bulk laundries larger than 100 ft2 (9.3 m2)
(3) Paint shops
(4) Repair shops
(5) Rooms with soiled linen in volume exceeding 64 gal (242 L)
(6) Rooms with collected trash in volume exceeding 64 gal (242 L)
(7) Rooms or spaces larger than 50 ft2 (4.6 m2), including repair shops, used for storage of combustible supplies and equipment in quantities deemed hazardo

Based on observation, the facility failed to ensure cooking exhaust hood suppression systems were maintained in accordance with NFPA 96 and NFPA 17A. Failure to replace the protective caps for suppression system pendants in exhaust hoods, has the potential to allow grease laden vapors to coat system components and impede the operation of the system during a fire. This deficient practice affected staff and vendors of the main Kitchen on the date of the survey.

Findings include:

During the facility tour conducted on 6/26/18 from approximately 1:00 - 3:30 PM, observation of the exhaust hood fire suppression system at the main Kitchen and the Paragon grill, revealed two protective caps for the pendants in each of the respective suppression systems of the two hoods, were not in place.

Actual NFPA standard:

NFPA 96

10.2.6 Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer ' s instructions, and the following standards where applicable:
(1) NFPA 12
(2) NFPA 13
(3) NFPA 17
(4) NFPA 17A

NFPA 17A

4.3.1.5 All discharge nozzles shall be provided with caps or other suitable devices to prevent the entrance of grease vapors, moisture, or other foreign materials into the piping.

Based on record review, observation and interview, the facility failed to ensure automatically activated Alcohol Based Hand Rub Dispensers (ABHR), were maintained in accordance with NFPA 101. Failure to install, test and document operation of ABHR dispensers under manufacturer's recommendations and in accordance with the standard, has the potential of increasing the risk of fires from flammable liquids. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During review of facility maintenance and inspection records conducted on 6/25/18 from approximately 2:30 - 4:00 PM, no records were available for the documentation of inspection and testing performed during the refill of ABHR dispensers.

When interviewed, the Housekeeping supervisor and one (1) housekeeping staff on duty at approximately 3:30 PM revealed Housekeeping was responsible for the refilling of ABHR dispensers and no inspections or testing of the dispensers was being performed or documented.

2) During the facility tour conducted on 6/26/18 from 8:45 AM - 3:30 PM, observation of installed ABHR dispensers revealed automatically activated dispensers had been installed throughout the facility.

3) During the facility tour conducted on 6/26/18 from 8:45 AM - 3:30 PM, observation of installed ABHR dispensers showed the following dispensers were installed within 1 inch of, or above an ignition source:

· Room 2005 the ABHR dispenser was within 1 inch of the light switch.
· The ABHR dispenser in the Endoscopy procedure room of the Surgery Suite was within 1 inch of the light switch.

Based on record review and interview, the facility failed to ensure that fire suppression systems were maintained in accordance with NFPA 25. Failure to maintain the fire suppression system has the potential to hinder performance during a fire event. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of provided facility inspection and testing records conducted on 6/25/18 from 2:30 - 4:00 PM, no records were available for weekly inspection of the dry system gauges.

Interview of the Engineering Manager revealed he was not aware of the requirement for weekly dry system inspections.

Actual NFPA standard:

NFPA 25

5.2.4 Gauges.
5.2.4.2 Gauges on dry, preaction, and deluge systems shall be inspected weekly to ensure that normal air and water pressures are being maintained.

Based on observation, the facility failed to ensure fire extinguishers were installed in accordance with NFPA 10. Failure to install fire extinguishers at the correct height has the potential to hinder staff access during a fire. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

During the facility tour conducted on 6/26/18 from 10:00 AM - 3:30 PM, observation of installed portable fire extinguishers revealed the following:

· Fire Extinguisher resting on the floor in the MRI observation area.
· Fire extinguisher in the corridor on the south side of Physical Therapy was mounted at 68 inches, when measured from the floor to the top of the extinguisher.

Actual NFPA standard:
NFPA 10

6.1.3.8 Installation Height.
6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 l (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.

6.1.3.8.3 In no case shall the clearance between the bottom of the hand portable fire extinguisher and the floor be less than 4 in. (102 mm).

Based on record review, observation and interview, the facility failed to ensure corridor openings were protected in accordance with NFPA 101. Failure to ensure protection of corridor openings are maintained, has the potential to allow fires to pass into corridors, hindering the safe egress of patients during a fire. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During review of the the annual fire alarm inspection report conducted on 6/25/18 from 2:30 - 4:00 PM, records indicated 1 of 2 roll-up doors at the pass thru windows of the Pharmacy, failed to activate and close with the fire alarm and was currently stuck in the open position.

Interview of the Bio Med tech working with the vendor on the remedy, substantiated this door and finding from the report had not been repaired as of the date(s) of the survey.

2) During the facility tour conducted on 6/26/18 from 11:00 AM to 12:00 PM, observation of the Pharmacy area revealed the roll-up doors measured approximately 32 inches by 32 inches. Further observation of the roll-up door on the west side of the Pharmacy, verified the roll up door was stuck open with an approximately 32 inch by 24 inch opening remaining.

Actual NFPA standard:

19.3.6.5 Openings.
19.3.6.5.1% Miscellaneous openings, such as mail slots, pharmacy pass-through windows, laboratory pass-through windows, and cashier pass-through windows, shall be permitted to
be installed in vision panels or doors without special protection, provided that both of the following criteria are met:
(1) The aggregate area of openings per room does not exceed 20 in.2 (0.015 m2).
(2) The openings are installed at or below half the distance from the floor to the room ceiling.

8.3.3 Fire Doors and

Based on observation, the facility failed to ensure electrical installations were provided in accordance with NFPA 70. Failure to maintain electrical panels free of obstructions and utilize power strips in compliance with the applicable standard, has the potential to limit staff capabilities and increase the potential of arc fires in the facility. This deficient practice affected patients, staff and visitors on the date(s) of the survey.

Findings include:

1) During the facility tour conducted on 6/26/18 from 8:45 AM to 3:30 PM, observation of the south corridor outside Radiology revealed two of three electrical panels were blocked by a portable imaging machine.

2) During the facility tour conducted on 6/26/18 from 8:45 AM to 3:30 PM, observation of the passage way from CSP to the main Surgery section, revealed a trash can was placed in front of the electrical panel, inside the designated demarcation area.

3) During the facility tour conducted on 6/26/18 from 8:45 AM to 3:30 PM, observation of the staff break area in the Medical Information office revealed a relocatable power tap (RPT) was being utilized to supply power to a microwave, toaster and coffee machine.

4) During the tour of the facility Surgery Center conducted on 6/26/18 from 8:45 AM to 3:30 PM, observation of the staff break area revealed a RPT was being utilized to supply power to a microwave, toaster oven, toaster and coffee machine.

Actual NFPA standard:

NFPA 70

Finding(s) 1 and 2

110.32 Work Space About Equipment. Sufficient space shall be provided and maintained about electrical equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall be not less than 2.0 m (61.2 ft) high (measured

Based on record review and interview, the facility failed to provide documentation of required fire drills meeting the NFPA 101 standard. Failure to perform audible drills during shift hours conducted prior to 9:00 PM and after to 6:00 AM, has the potential of hindering the safe evacuation of patients during a fire. This deficient practice affected all patients, staff and visitors on the date(s) of the survey.

Findings include:

During review of provided facility fire drills conducted on 6/25/18 from approximately 2:30 - 3:30 PM, fire drill documentation revealed the facility failed to conduct audible fire drills on shifts documented prior to 9 o'clock PM as follows:

· On 3/29/18, fire drill conducted at 6:15 PM was noted as "Verbal".
· On 7/7/17, fire drill conducted at 6:00 PM was noted as "Verbal".
· On 12/20/17, fire drill conducted at 7:00 PM was noted as "Verbal".

Interview of 3 of 3 staff substantiated the "Verbal" fire drill indicated the facility was not activating the alarm and the policy of the facility was to conduct non-audible fire drills from 7 o'clock PM to 7 o'clock AM.

Actual NFPA standard:

NFPA 101

19.7.1.4% Fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions.

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.7 When drills are conducted between 9:00 p.m. and 6:00 a.m. (2100 hours and 0600 hours), a

Based on record review and interview, the facility failed to ensure the EPSS generator was maintained in accordance with NFPA 110. Failure to conduct weekly generator inspections has the potential to miss issues that might result in incipient failures and a lack of emergency power. This deficient practice affected all patients, staff and visitors on the date of the survey.

Findings include:

During review of the facility inspection and maintenance records conducted on 6/25/18 from 2:30 - 3:30 PM, records indicated that weekly inspections of the emergency generator had not been completed prior to June, 2018. When asked about the missing documentation, the Engineering Manager explained the facility had not been conducting weekly inspections prior to that time.

Actual NFPA standard:

NFPA 110

8.4 Operational Inspection and Testing.
8.4.1% EPSSs, including all appurtenant components, shall be inspected weekly and exercised under load at least monthly.

Based on observation and interview, the facility failed to ensure medical gases were stored in accordance with NFPA 99. Failure to segregate medical gases has the potential to result in the improper gas being administered, or using incorrect cylinders during an emergency requiring supplemental oxygen.

Findings include:

During the facility tour conducted on 6/26/18 from 8:30 - 11:45 AM, observation of the oxygen storage area outside the Therapy department revealed the stored cylinders did not have any identifying segregation between empty or full.

Further observation of the Surgery Center from 2:30 - 3:00 PM revealed the cylinders stored in the oxygen storage location on the northwest side of the building, intermixed gases such as oxygen, carbon dioxide, and medical air and did not have segregation of full or empty cylinders in storage.

NFPA 99

11.6.5 Special Precautions - Storage of Cylinders and Containers.
11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier.
11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.
11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.

Based on observation and interview, the facility failed to ensure oxygen transfilling was performed in accordance with NFPA 99. Failure to sign oxygen transfill areas and provide mechanical ventilation to those spaces, has the potential for creating an oxygen rich environment and increase the potential for fires and explosions.

Findings include:

During the facility tour conducted on 6/26/18 from 8:30 AM to 3:30 PM, observation of the storage room in the Med Surge, north of the nurse's station, revealed the space was being used for the storage of combustibles and transfilling of oxygen. Further observation demonstrated the space was not mechanically ventilated, signed for the transfilling process and the cryogenic oxygen cylinder was placed directly on the vinyl composite floor.

In addition, the oxygen storage outside of the Therapy department was also being utilized as a transfilling location and was not signed for that purpose or mechanically ventilated.

When asked about the absence of the signs and mechanical ventilation in these two spaces, the Engineering Manager stated he was not aware of that requirement, but was aware that the transfilling could not take place directly on the vinyl composite flooring.

Actual NFPA standard:

NFPA 99

9.3.7.5.3.2 Mechanical exhaust shall be at a rate of 1 L/sec of airflow for each 300 L (1 cfm per 5 ft3 of fluid) designed to be stored in the space and not less than 24 L/sec (50 cfm) nor more than 235 L/sec (500 cfm).

11.5.2.3 Transfilling Liquid Oxygen. Transfilling of liquid oxygen shall comply with 11.5.2.3.1 or 11.5.2.3.2, as applicable.
11.5.2.3.1 Transfilling to liquid oxygen base reservoir containers or to liquid oxygen portable containers over 344.74 kPa (50 psi) sha