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Based on the observation, record review and interview the facility was not maintained in a manner safe from fire (C231.) The cumulative effect of these systemic practices resulted in the facility's inability to ensure patient safety. The facility census at the beginning of the survey was 23.

Findings include:

Please refer to C231 for further detail.

The facility failed to ensure doors in smoke barriers resisted the passage of smoke and failed to ensure smoke and fire walls were constructed with at least a one hour fire rated barrier.

The facility failed to ensure doors in fire and smoke barriers were equipped with automatic or self-closing devices.

The facility failed to ensure the hazardous area was constructed with at least a one hour fire rated barrier.

The facility failed to ensure fire drills were conducted at varying times and the manual pull station device was activated with each fire drill.

The facility failed to ensure smoke detectors were not mounted near air flow devices.

The facility failed to ensure the sprinkler system was maintained and in good operating condition at all times.

The facility failed to ensure all portable fire extinguishers were mounted so the top of the fire extinguisher was not greater than five feet from the floor.

The facility failed to ensure medical gas was limited to 300 cubic feet per smoke compartment and all cylinders were secured.

The facility failed to ensure surge protectors were not plugged one into another.

Based on the life safety inspection completed on 09/19/13 it was determined this facility was not maintained in a manner safe from fire. This had potential to affect patients, visitors, and staff members. This facility census at the beginning of the survey was 23.

Findings include:

K-18 Building # 2
Based on facility tour and staff verification the facility failed to ensure all smoke/fire barrier doors were constructed to resist the passage of smoke. Facility tour took place on 09/17/13 and 09/18/13 with staff members A1, B2, C3 and D4. During tour of the basement observation was made of three fire doors which had gaps greater than one eighth inch between the door leafs when in the closed position.
1) One was located in the corridor adjacent to the accounting department identified as C004
2) Another was identified as door C001 next to the business office.
3) The last door was located outside of the vascular lab and identified as C003.
First floor:
4) The double doors leading to the medical office building was observed with a gap greater than one-eighth inch between the door leafs when in the closed position.


K-25 Building # 1
Based on facility tour and staff verification the facility failed to ensure all smoke/fire barriers were constructed with at least a one hour fire resistance rating. Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the first floor two hour fire rated barrier located at the south end of obstetrics department observation was made of penetrations in the following locations:
1) Within room 124, facing the south wall and above the ceiling tiles, observation was made of two insulated lines not sealed around the annular space, one open end silver conduit with blue and orange wires passing through and one silver conduit not sealed around the annular space.
2) Above the ceiling tiles facing the same fire barrier located at the cross-over to the new building by the lab, observation was made of three unsealed girders where it passed through the fire barrier and an unsealed area around two silver conduits.

Building # 2
Basement
1) Within corridor C001 facing the east fire rated wall being across from the business office, observation was made of two insulated lines not sealed around the annular space.
2) Above the ceiling tiles facing the same fire barrier located adjacent south of the stairs and above the double doors, observation was made of two metal sleeves having tape over the ends to cover the openings, two unsealed sleeves with wires passing through, two unsealed black water lines and three unsealed copper lines.
First floor:
3) Beginning at the same fire wall extending from the basement through the first floor and above the double doors adjacent to the stairwell, observation was made of two four inch black unsealed water lines and an open end conduit with blue and white wires passing through.
4) Moving north along the same fire wall in the room just north of the vending area, observation was made of one unsealed pipe and one unsealed conduit.
5) Turning the corner heading west and within the lab waiting area identified as 1103, observation was made of one open end conduit which had tape covering the open end. Just to the west of that, there was one unsealed conduit around the annular space.
6) Within the job care waiting area identified as 1104 observation was made of a one inch open end conduit.
7) Continuing west and now within the x-ray waiting area identified as 1106, observation was made of an approximate two inch open end pipe.
8) Continuing west and now at the north/south fire rated wall being the back wall of the x-ray room identified as 1510, observation was made of two unsealed conduits around the annular space.
9) Continuing south along the north/south fire rated wall and at the double doors located between the a-ray room identified as 1504 and the intake room identified as 1501, observation was made of an unsealed area around the water line feeding the sprinkler system, a small hole drilled through the concrete block and one unsealed flex conduit.

K-27 Building # 2
Based on observation during facility tour and staff verification the facility failed to ensure all doors in smoke/fire barriers were equipped with self-closing or automatic closing devices. Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the east/west two hour fire rated barrier separating the x-ray department from the x-ray waiting area, specifically at the entrance to the x-ray office, observation was made of a one and one-half hour fire rated door which was not equipped with a self-closing or automatic closing device. This door was observed to be left in the open position.

K-29 Building # 2
Based on observation during facility tour and staff verification the facility failed to ensure all hazardous areas were constructed with at least a one hour fire rated enclosure. Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour of the first floor hazardous room identified as 1315, observation was made of seven penetrations around and within conduits located above the ceiling tile.

K-50 Building # 1 and # 2
Based on fire drill record review and staff interview the facility failed to ensure fire drills were held at unexpected times and conducted by activating a manual pull station device in order to sound an audible alarm for hours not between 9:00 PM and 6:00 AM. Fire drill record review took place on 09/16/13. During review observation was made of two second shift drills conducted on 03/26/13 at 3:15 PM and 06/21/13 at 3:05 PM which had notations in the comments section indicating a "silent alarm" was initiated due to patients in surgery and OB. Review was made of four third shift drills conducted with a "silent alarm" during times later than 6:00 AM. These dates and times are as follows: 03/08/13 at 6:50 AM, 07/31/13 at 6:30 AM, 09/28/12 at 6:30 AM and 12/06/12 at 6:45 AM.
Additionally, all six fire drills listed above were observed to be conducted within a 20 minute time frame from each other.

K-54 Building # 2
Based on observation during facility tour and staff verification the facility failed to ensure all smoke detectors were mounted in areas where the normal operation of the detectors would not be affected by any air flow device. Facility tour took place on 09/17/13 through 09/18/13 with staff members A1, B2, C3 and D4. During tour observation was made of smoke detectors mounted or placed near air flow devices in the following locations:
Basement:
1) Within corridor C001
First floor:
2) Within the balcony area identified as corridor C103
3) Within the corridor between rooms 1410 and 1424.
4) Within the ambulance entrance area between rooms 1428 and 1402.
5) Within the emergency department waiting area identified as number 1414.
Second floor:
6) Within the infusing waiting room identified as M2201.
7) Within the coumadin clinic waiting room identified as M2301.
8) Within the respiratory waiting room identified as M2501.

K-62 Building # 1
Based on facility tour and staff verification the facility failed to ensure all components of the sprinkler system were maintained in order to provide complete sprinkler coverage in the event of an emergency requiring discharge of the water source.
Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the first floor obstetrics department observation was made within the closet of room 124 of a sprinkler head which had been displaced from it's original mounting position and was now located above the ceiling and offset from the pendant access opening.

K-64 Building # 1
Based on observation during tour and staff interview the facility failed to ensure all portable fire extinguishers were mounted or placed within a fire extinguisher cabinet and mounted with the mounting bracket no greater than five feet from the floor. Additionally, this facility failed to ensure all fire extinguishers were accessible in the event of an emergency and were checked monthly. Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4.
1) During tour of the generator house and basement area, observation was made of five portable fire extinguishers which were mounted greater than five feet from the floor. These were observed in the following locations: Two were observed in the number one generator house. One was located outside the pump room, one within the boiler room and one within the housekeeping room located east of the medical records room.
2) During tour of the first floor, observation was made of one fire extinguisher located in the lab which was mounted greater than five feet from the floor. Another fire extinguisher in the lab was observed to be mounted behind a large metal framed work station.
3) Within the MRI electrical room, observation was made of a portable fire extinguisher located on the floor.
4) Within the medical surgery department and adjacent to the nurses station observation was made of a hoyer lift placed in front of a mounted portable fire extinguisher. Within a small work room behind the nurse's station observation was made of a portable fire extinguisher sitting on the top of the counter. This fire extinguisher was observed to be "borrowed" and had an inspection tag last dated for September 2009.

K-76 Building # 1
Based on observation during tour and staff verification the facility failed to ensure all medical gas bottles were secured when not in use. Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the MRI control room area observation was made of one E-tank of oxygen unsecured sitting on floor.

Building # 2
Based on facility tour and staff verification the facility failed to ensure medical gas storage did not exceed 300 cubic feet per smoke compartment.
Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the second floor storage room adjacent to the sleep lab observation was made within this room, a quantity of 16 E-tanks of oxygen placed within two holding racks. This amount totaled 400 cubic feet and exceeded the limit per smoke compartment by 100 cubic feet.

K-147 Building # 1
Based on observation during tour and staff verification the facility failed to ensure all electrical wiring and equipment was in accordance with the National Fire Protection Association (NFPA) 70, specifically in regards to the use of surge protectors. Facility tour took place on 09/17/13 with staff members A1, B2, C3 and D4. During tour of the surgery department, specifically operating room number one, observation was made of a surge protector plugged into a wall outlet. The surge protector had three plugs attached to it from surgical equipment and an additional plug which was from another surge protector. In essence, there was one surge protector "piggy backed" into other surge protector.

Based on patient interview, medical record review, staff interview, and policy review the facility failed to follow their written policy regarding providing all patients with information about their rights and responsibilities at patient registration. One of the four patients in the emergency department did not receive notice of rights and all patients seen in the emergency department but not admitted to the facility were affected. (Patient #12) The hospital census at the time of the survey was 23 patients.

Findings included:

An interview was completed with Patient #12 on 09/16/13 at 3:00 PM in the emergency department. Patient #12 and his/her family were present and stated that although a hospital registration person did come in and issue the patient an identification bracelet, they did not provide the patient with any information regarding his/her patient rights and responsibilities. Patient #12 stated that he/she was not aware of the hospital's complaint process or that the State of Ohio had a phone number and/or address for lodging a grievance.

The review of the medical record for Patient #12 was completed on 09/16/13 at 3:30 PM. Patient #12 came into the emergency department on 09/16/13 at 12:40 PM with chest pain. The medical record lacked documentation that Patient #12 received information about his/her rights and responsibilities.

An interview with Staff D was conducted on 09/16/13 at 3:45 PM. Staff D stated if a patient comes in through the emergency department and is not admitted to the hospital, they do not receive anything regarding their patient rights.

The critical access hospital's policy entitled Patient's Bill of Rights and Responsibilities 10-1000-64, effective date 04/06/09 was reviewed on 09/18/13 at 1:00 PM. The policy stated, "Information about the patient's rights and responsibilities will be provided to all patients at patient registration including the mechanism for the initiation, review, and resolution of complaints concerning their care."
In an interview with Staff A, Staff B, and Staff D on 09/16/13 at 1:20 PM, Staff A and Staff C confirmed unless a patient was admitted to the hospital, they did not receive any information about their rights and responsibilities.

Based on observation and staff interview, the critical access hospital failed to ensure expired and/or unlabeled products were not available for patient use in the emergency department and outpatient oncology department. This had the potential to affect all patients treated in the emergency department and outpatient oncology department. The hospital census at the time of the survey was 23 patients.

Findings Included:

On 09/16/13 at 2:25 PM, an observation was made in a cupboard in Treatment Room E in the Emergency Department of an opened 32 ounce bottle of 3% hydrogen peroxide which lacked a label indicating the opened date and/or use by date. This finding was confirmed with Staff B. Staff B stated this should not be in the cupboard and disposed of it upon discovery.
On 09/16/13 at 2:30 PM, an observation was made in a drawer in Treatment Room F in the Emergency Department of six red-topped laboratory blood specimen collection tubes, five of these tubes had an expiration date of 06/13 and one of these tubes had an expiration date of 12/12. This finding was confirmed with Staff B. Staff B stated these should not be in the drawer and disposed of them upon discovery.
On 09/16/13 at 2:35 PM, an observation was made in the storage room in the Emergency Department of an 8 ounce can of nutritional supplement with an expiration date of 09/01/13. This finding was confirmed with Staff B. Staff B stated this should not be in the storage room and disposed of it upon discovery.
On 09/18/13 at 9:30 AM, an observation was made in the storage room in the Outpatient Oncology Department of an opened 32 ounce bottle of 3% hydrogen peroxide which lacked a label indicating the opened date and/or use by date. This finding was confirmed with Staff A and Staff E. Staff E stated this should not be in the storage room and disposed of it upon discovery.
On 09/18/13 at 9:30 AM, an observation was made in the storage room in the Outpatient Oncology Department of an opened 30 milliliter plastic vial of bacteriostatic 0.9% sodium chloride which lacked a label indicating the opened date and/or use by date. This finding was confirmed with Staff A and Staff E. Staff E stated this is a single use vial and should not be in the storage room and disposed of it upon discovery.
In an interview with Staff A on 09/18/13 at 1:30 PM, these findings were summarized and confirmed with Staff A. Staff A stated the hospital did not have a policy to address expired products.

Based on observation and staff interview, the facility failed to protect medical records from potential water damage in the event the sprinkler system was engaged due to fire or smoke. This had the potential to affect all patients receiving services from this facility. The current census was 23.

Findings include:

During tour of the medical records department on 09/17/13 from 10:30 AM until 11:00 AM, the medical records storage room for discharged patient's medical records was observed to have open shelving units for storage. The discharged medical records consisted of manila folders with the paper records fastened with metal stays. The shelving lacked any closure device or covering.

At 11:00 AM on 09/17/13, Staff F verified the metal shelving units were open with no mechanism for covering the medical records or closing up the shelves. Staff F also verified the entire room contained sprinklers that would be activated in the event of a fire.