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Based on record review and interview, the hospital failed to develop strategies for addressing and identifying the needs of at risk or vulnerable patient population during an emergency event or disaster.

Findings:

Record review of the emergency preparedness plan showed the facility did not develop or identify the facility's patient populations that would be at risk during an emergency event.


On 08/14/19 at 3:17 pm, the surveyor asked Staff A if the facility identified and addressed the types of services the facility would be able to provide in an emergency. Staff A stated the facility was unaware the emergency plan needed to address the patient populations that would be at risk during an emergency event. The documentation did not exist.

Based on record review and interview, the facility failed to ensure the emergency preparedness policies and procedures identified a system of medical documentation preserving the patient information, protecting confidentiality of patient information.

Findings:

Record review of the emergency disaster plan policies and procedures revealed the facility did not establish and maintain a medical record documentation system in order to preserve patient information, protects the confidentiality and secure patient information.

On 08/14/2019 at 1:05 pm, the surveyor asked Staff A if the facility had a plan in place to address if an disaster would affect the facility and evacuation occurs how the patients medical records would ensure confidentiality was protected and secured. Staff A stated the medical records will be evacuated with the patients. The document did not exist.

Based on record review and interview, the facility failed to ensure the emergency preparedness policies and procedures were developed to address the use of volunteers in an emergency.

Findings:

Record review of the emergency disaster plan policies and procedures revealed the facility did not establish and maintain a policy to address medical or nonmedical volunteers.


On 08/14/19 at 1:38 pm, the surveyor requested documentation to verify an policy was developed for volunteers. Staff A stated the facility did not have a policy in place to address the volunteers roles and responsibilities. The policy did not exist.

Based on record review and interview, the hospital failed to ensure the emergency preparedness policies and procedures addressed the facility's role in emergencies where the President declares a major disaster.

Findings:

Record review of the emergency preparedness policies and procedures showed the facility did not establish and maintain an policy and procedure in the emergency plan describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

On 8/14/2019 at 04:14 pm, the surveyor asked Staff A, for the facility 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 A stated the facility had developed a policy and waiting for the next meeting for approval on 08/28/19.

Based on record review and interview the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least annually.

Findings:

Record review showed the facility's communications equipment or communication systems was not listed in the emergency plan. The documentation did not exist.

On 08/14/19 at 2:26 pm, the surveyor asked Staff A what alternate means of communicating with staff, Federal, State, tribal, regional, and local emergency management agencies. Staff A stated the facility did have alternate means of communicating with staff and the facility was in the process of revising and updating the emergency plan to include the communication plan and means of communicating with both staff, tribal, local, federal and regional agencies.

Based on record review and interview the facility failed to ensure annual and initial in-service training for staff, and individuals providing services under arrangement, on the emergency preparedness plan for 7 of 14 employee files.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and or initial in-service training for existing staff, and individuals providing services under arrangement for the staff:

On 08/14/19 at 11:17 am, the surveyor requested Staff Q for documentation of emergency preparedness training in-service for new, existing staff members, and individuals providing services under arrangement/contract.

On 08/14/19 at 11:43 am, surveyor asked Staff Q if the facility conducted emergency preparedness training for 2018. Staff Q stated he has only been with employed by the facility since 11/18 and unable to conduct training. The 2018 emergency preparedness documentation does not exist for 7 of 14 staff files requested.

Based on record review and interview the facility failed to demonstrate education and instruction to staff, and contractors.

Findings:

Record review of the facility emergency preparedness training documentation did not show documentation of a tabletop exercise, community based exercise, or full-scale exercise to demonstrate staff knowledge of emergency procedures. The documentation did not exist for drills and or exercises to test the emergency plan identifying gaps and areas for improvement.

On 08/14/19 at 10:28 am, surveyor requested Staff Q to verify the facility staff participated in community based training, tabletop or individual based training for 2018. The documentation provided to surveyor was only for 2017. Staff Q stated the facility did not participate or conduct a tabletop or individual based training for 2018 and the facility had a change in staff and the most recent community based or individual based facility training was 2017. Staff Q stated the facility would work on the training requirements.

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

Findings:

On 08/14/19 at 4:17 pm the surveyor observed deadbolt locks on the medical records office door and several other corridor doors in addition to a barrel latch on the second medical records office.

On 08/14/19 at 4:17 pm the surveyor asked the maintenance/safety manager why there were deadbolts on the corridor doors which would take two actions to open. The maintenance/safety manager stated the deadbolts were on the doors within the facility since he has started and he did not know they were not allowed. The maintenance/safety manager stated they would have them changed with a lock that will only take one action to open the door to be in compliance.

Based on observation and interview the facility failed to ensure fire extinguishers located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 08/14/19 at 4:16 pm one ABC class fire extinguisher was observed in the kitchen with no placard posted next to it to indicate the hood fire protection system shall be activated prior to using the fire extinguisher as required.

On 08/14/19 at 4:16 pm the surveyor asked the maintenance/safety manager why there was no placard on the fire extinguisher in the kitchen. The maintenance/safety manger stated he would get the appropriate placard for the fire extinguisher installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on observation and interview the facility failed to ensure alcohol based hand rub (ABHR)dispensers were properly installed as required.

Findings:

On 08/14/19 at 4:38 pm the surveyor observed two ABHR's installed over light switches.

On 08/14/19 at 4:38 pm the surveyor asked the maintenance/safety manager why the ABHR's were installed over ignition sources and he stated that they have a company hired to come reinstall them within the week or so.

Based on observation and interview the facility failed to ensure corridor doors did not have penetrations cut into them which would allow fire and smoke to spread into the protected emergency egress pathway.

Findings:

On 08/14/19 at 3:20 pm the surveyor observed one corridor Information Technology (IT) door with two vent holes cut into the bottom half and top half of the corridor door with a metal louver vent covering the cut out areas.

On 08/14/19 at 3:20 pm the surveyor asked the maintenance/safety manager why the corridor door had penetrations cut into it with metal vents installed and he stated he did not know. The maintenance/safety manager stated they would get the door repaired or replaced.

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 showed the facility fire drills for 2018 and 2017 did not document a transmission of a fire alarm signal for every fire drill completed.

On 08/14/19 at 3:54 pm the surveyor stated to the maintenance/safety manager the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. The maintenance supervisor stated they would add that to the fire drill documentation from this point on.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 and 2018 were not completed and the documentation did not exist.

On 08/14/19 at 2:33 pm the surveyor asked the maintenance/safety manager for the annual fire rated door assembly inspections and he stated the inspections were not completed for 2017, 2018.

Based on observation and interview, the facility failed to ensure that space heaters used in non-sleeping staff areas had heating elements which did not exceed 212 degrees Fahrenheit as required in NFPA 101, 2012 Edition, Chapter 19.7.8.

Findings:

On 08/14/18 at 2:27 pm a space heater was observed in the pharmacy and a second one in a facility staff office under the desk.

On 08/14/18 at 2:30 pm the surveyor asked the maintenance/safety manager for the documentation that the heating elements did not exceed 212 degrees Fahrenheit. The maintenance/safety manager stated they did not have it but will get it to be in compliance.

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

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessment were not completed. They do not exist.

On 08/14/19 at 2:35 pm the surveyor asked the maintenance/safety manager for the EES and Medical Gas building system risk assessments. The maintenance/safety manger stated they were not aware of the requirement but would ensure it would be completed.

Based on observation and interview the facility failed to ensure electrical equipment was protected as required.

Findings:

On 08/14/19 at 4:46 pm the surveyor observed a white residential extension cord daisy chained into a power tap at the nurses station on the second floor and a hydrocollator plugged into a non-GFCI electrical receptacle sitting on top of a combustible plastic sagging cart.

On 08/14/19 at 4:46 pm the surveyor asked staff L why a extension cord is daisy chained into a power tap and the hydrocollator is plugged into a non-GFCI eletrical receptacle. Staff L stated they will remove the extension cord and install a GFCI plug to correct the issues. Staff L stated the staff are trained to know not to use extension cords.

Based on observation and interview the facility failed to ensure electrical equipment was current on inspections before being placed into service as required.

Findings:

On 08/14/19 at 3:28 pm the surveyor observed the medication refrigerator in the pharmacy did not have a current inspection sticker.

On 08/14/19 at 3:28 pm the surveyor asked the maintenance/safety manager why the medication refrigerator was in service without being current on its inspection and he stated their bio med vendor must have missed it.

On 08/14/17 at 4:32 pm a multiplug was observed to be in use at the nurses station.

On 08/14/19 at 4:32 pm the surveyor asked the maintenance/safety manager why there was a multiplug in use and he stated they will remove it.

Based on observation and interview the facility failed to ensure liquid oxygen cylinders were properly secured as required.

Findings:

On 08/14/19 at 5:20 pm the surveyor observed four liquid oxygen cylinders not secured. The four liquid oxygen tanks were observed to be connected to the oxygen manifold at the outdoor location.

On 08/14/19 at 5:20 pm the surveyor asked the maintenance/safety manger L why the liquid oxygen cylinders were not secured and he stated their vendor did not secure them when they were placed there.