HospitalInspections.org

Based on interview and record review, the facility failed to establish an emergency preparedness plan that is maintained, reviewed annually and updated as needed.

The deficiency affects all the staff and the residents who work and/or reside in the facility.

Findings include:

During an interview on 10/10/23 at 2:10 p.m., staff member E stated the emergency preparedness plan had not been updated in the last year. The last full emergency preparedness plan review was 4/12/22. She stated not all the updates to the plan had been completed.

Review of the facility EP plan on 10/10/23, reflected the facility did not have an updated Emergency Preparedness Plan. There was no evidence the plan had been reviewed in the last year. The plan contained information the last review had taken place on 4/12/22.

Based on record review the facility failed to plan and implement a provision of subsistence needs for the residents, maintain emergency lighting, temperatures, and manage sewage and waste disposal in an emergency.

This deficiency affects all occupants in the facility.

Findings include:

1. Review of the EP plan, policies, and procedures on 10/10/23, reflected the facility lacked a complete system for determining subsistence needs for residents, particularly pharmaceutical supplies. The plan lacked information on how the facility will maintain facility temperatures, emergency lighting, and manage sewage and waste disposal in an emergency.

Based on interview and record review, the facility failed to develop a policy and procedure for a means to shelter-in-place in a case of an emergency.

This deficiency affects all staff and patients in the facility.

Findings include:

1. During an interview on 10/10/23 at 2:19 p.m., staff member E stated the facility did not have a written policy and procedure specifically for shelter-in-place.

Review of the EP plan policy and procedures on 10/10/23, showed a lack of written policies regarding shelter-in-place for patients and staff who had the potential to remain in the facility in case of an emergency. The plan lacked specifics regarding food supply, and food sources, in case of a potential emergency if the residents, staff, and volunteers sheltered in the facility, the specifics for the emergency generator support and duration of generator support, including the number of days of sheltering in place before an evacuation is declared.

Based on interview and record review, the facility failed to develop and implement emergency preparedness (EP) policies and procedures, addressing the use of volunteers in an emergency.

This deficiency affects all staff and patients in the facility.

Findings include:

1. During an interview on 10/10/23 at 2:21 p.m., staff member E stated the facility did not have a policy on volunteer use included in the facility's emergency preparedness plan.

Review of the facility's Emergency Preparedness plan on 10/10/23 showed the facility did not include a policy and procedure for the use of volunteers in an emergency.

Based on record review, the facility failed to develop and implement an emergency preparedness (EP) communications plan which includes contact information for the Certification agency.

This deficiency has the potential to affect all staff and patients at the facility.

Findings include:

1. Review of the facility emergency preparedness plan on 10/10/23 showed the facility's communications plan lacked contact information for the State Certification agency.

Based on observation, the facility failed to keep the means of egress open to full and instant use in accordance with NFPA 101, 2012 Edition, Sections 18.2.3.6 (1), 7.1.10.1 and 7.1.10.2.1.

This deficiency affects 1 out of 9 smoke compartments in the facility.

Findings include:

1. During an observation on 10/10/23 at 4:02 p.m., the EVS office was inspected. Multiple boxes of toilet paper, and paper towels were stored in the doorway of the office. This was blocking the means of egress out of the office.

Based on observation the facility failed to maintain an egress door in accordance with NFPA 101-2012, Sections 7.1.10.1, 7.2.1.4.5.1 and 7.2.1.4.1.

This deficiency affects 2 of 9 smoke compartments.

Findings include:

1. During an observation on 10/10/23 at 4:41 p.m., exam room 2 was inspected. There was a table in front of the door, blocking the means of egress.

3. During an observation on 10/10/23 at 4:42 p.m., the supply closet was inspected. The door would not open 90 degrees due to various items being stored behind the door.

Based on observations the facility failed to ensure proper door hold open devices were utilized of corridor doors with self-closure devices per NFPA 101, 2012 Edition, Sections 18.2.2.2.7, 7.2.1.8.1 and 7.2.1.8.2

This deficiency affected 1 of 9 smoke compartments.

Findings include:

1. During an observation on 10/10/23 at 3:01 p.m., the exit corridor door to the medical records door was held open with a rubber wedge (not an automatic release device.) The door had a self-closure device.

2. During an observation on 10/10/23 at 3:12 p.m., the exit corridor door to the HR department was held open with a rubber wedge (not an automatic release device.) The door had a self-closure device.

Based on observation and interview the facility failed to maintain not less than two separate exits from every story of the building in accordance with NFPA 101 2012 Edition, Sections 39.2.4 and 39.2.4.1 (2) (3).

This deficiency affects 1 of 2 smoke compartments at the Wilsall PT facility.

Findings include:

1. During an observation on 10/11/23 at 11:11 a.m., the basement level of the PT facility was inspected. There was one functional exit out of the basement. However, there was another door which led to a window well to the outdoors. There were no stairs leading out of the window well and to the public way making it a non-functioning exit.

Based on observation, the facility failed to mark two paths of egress by approved exit or directional exit signs, in accordance with NFPA 101, 2012 Edition, Sections 7.10.1.2.1, 7.10.1.2.2. and 39.2.10

These deficiencies affect 1 of 1 smoke compartment in the facility.

Findings include:

1. During an observation on 10/11/23 at 9:21 a.m., the Gardner PT facility was inspected. There was no exit signage located in the facility except on the main entrance/exit door.

Based on record review and observation the facility failed to:

Document monthly wet system standpipe gauge readings per NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Sections 13.2.7.1. and 13.2.8

Continuously maintain automatic fire sprinklers in reliable operating condition including examination of the heads per NFPA 25-2011, Sections 5.2.1.1.2. (3)

Maintain sprinkler piping free of external loads in accordance with NFPA 25 Standard for the Inspection, Testing and Maintenance for Water-Based Fire Protection Systems, 2011 Edition, Section 5.2.2.2

Findings include:

1. Review of the facility's sprinkler documentation on 10/10/23, reflected the facility lacked supporting documentation to show the facility's automatic sprinkler systems' gauges were inspected and documented monthly for the wet systems.

2. During an observation on 10/10/23 at 3:34 p.m. the birthing center was inspected. A sprinkler head located near the soiled utility door was bent.

3. During an observation on 10/10/23 at 4:16 p.m., the first-floor supply room was inspected. There were multiple red cords hanging off the sprinkler piping.

Based on observation, interview and record review, the facility failed to:

Maintain appropriate installation and access of a portable fire extinguisher in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 6.1.3.3.1, and 6.1.3.4.

Maintain a placard for a K type extinguisher in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 5.5.5 and 5.5.5.3.

This deficiency affected 2 smoke compartments out of 9 smoke compartments in the facility.

Findings include:

During an observation and interview on 10/10/23 at 3:11 p.m., a portable fire extinguisher was located under a desk in the HR department. Staff member D stated he was unaware that extinguisher was there and it was not in his inventory.

During an observation on 10/10/23 at 4:03 p.m., the kitchen was inspected. The K-type extinguisher did not have a placard present.

Based on observation, interview and record review, the facility failed to:

Maintain monthly inspection records in accordance with NFPA 10 Standard for Portable Fire Extinguishers, 2010 Edition, Sections 7.2.4.3, 7.2.4.4, and 7.2.4.5.

This deficiency affected 1 smoke compartment out of 1 smoke compartment in the facility.

Findings include:

During an observation and interview on 10/11/23 the physical therapy facility located in Gardner was inspected. The portable fire extinguisher in the physical therapy gym did not have any monthly inspections located on the extinguisher. Staff member D stated he was unsure who was in charge of completing the fire extinguisher inspections.

Based on observations, the facility failed to maintain electrical rooms with sufficient working space around electrical panels in accordance with NFPA 70 National Electric Code, 2011 Edition, Article 110-26 (E) (1) (a) through (E) (1) (d).

This deficiency affects 2 of 9 smoke compartments.

Findings include:

1. During an observation on 10/10/23 at 4:05 p.m., the electrical panel in the Kitchen was blocked from easy access by a cart being stored in front of it.

2. During an observation on 10/10/23 at 4:20 p.m., the electrical panel in the Emergency Department storage room was blocked from easy access by various items being stored in front of it.

Based on record review and interview, the facility failed to ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.3.8.

This deficiency affects 9 out of 9 smoke compartments in the facility.

Findings include:

1. Review of the emergency generator inspection records on 10/10/23, revealed there was no documentation of the annual diesel fuel supply quality test was conducted within the last year. In a interview on 10/10/23 at 12:15p.m., staff member D stated the fuel quality test had not been completed.