HospitalInspections.org

The critical access hospital (CAH) reported a census of six patients. Based on observation, document review, and staff interview, the CAH failed to provide an onsite fuel source in case of power failure. The fuel source must meet the requirements in accordance with NFPA 99 (National Fire Protection Association), NFPA 70 and NFPA 101. The deficient practice increases the risk if the CAH experiences loss of power, which would affect all patients, staff, and visitors in the CAH. The CAH has a capacity of 13 patients. The hospital's inability to ensure the safety of patients, visitors and staff from loss of power resulted in Immediate Jeopardy, which commenced on 11/8/13 at 9:45am. The immediate jeopardy status abatement determination made on 11/8/13 at 1:35pm. The failure to comply with the standards for safety placed all patients at risk for injury and/or death in the event of a power failure.

Findings include:

- During the tour conducted by the fire marshal on 10/21/13, at 2:30pm, observation made of the CAH generator, with piped in natural gas as the fuel source. The generator starts when there is power failure. The natural gas is on the vein line from the city and the hospital has no other supply source on site available for the Type I ESS system.

On 11/8/13 at 9:45am a determination by the Center for Medicare and Medicaid Services (CMS) that the CAH is in Immediate Jeopardy status for lack of a secondary fuel source on-site of the CAH. The administrator of the CAH notified of the Immediate Jeopardy status by the state agency representative.

The Immediate Jeopardy abatement determination made on 11/8/13 at 1:35pm following a visit and a statement from an electrician confirming the electrical system of the hospital complies with Type I EES NFPA-99, and the hospital ' s electrical system is in complete and proper working order. The chief executive officer and administrator of the hospital provided a written statement on 11/8/13 at 10:00am declaring that no life support or surgeries will be performed until a secondary generator fuel source is available and in working order.

The hospital's failure to meet the Life Safety Code of the NFPA placed patients, visitors and staff at risk.

See the results of the life safety code survey completed on 10/25/13.