HospitalInspections.org

Based on interview, record review and the hospital's own policy review, the hospital Chief Executive Officer (CEO), as a member of the Governing Body, failed to maintain oversight of their Fire Life Safety program to ensure the safety of their patients, visitors and staff as evidenced by failing to follow up on and address a Fire Alarm Report pertaining to deficiencies of the facility wide fire alarm system.

The findings included:
On 11/26/18 and 11/27/18, a Fire Life Safety inspection was conducted by State Agency Fire Life Safety surveyors. During this inspection the Fire Life Safety surveyors discovered a fire alarm system annual certification inspection that was conducted throughout the facility by an outside vendor dated 06/25/18, which was provided to them by the hospital's Regional Manager of Facilities Services, responsible for the safety and maintenance of the hospital's physical plant. Review of this report revealed 12 pages identifying 74 life safety/fire alarm system deficiencies. It was additionally discovered the 74 life safety/fire alarm deficiencies had not been addressed or repairs conducted. On 11/27/18 at 4:30 PM, the hospital Leadership was advised by the State Agency Fire Life Safety surveyors mandating an immediate Fire Watch for two people, 24 hours per day until the fire alarm system was certified and fully functional.

On 12/03/18 an additional onsite State Agency and Federal survey was conducted commencing at 9:30 AM. An entrance conference was held with the Chief Operating Officer (COO), the Associate Administrator, the interim Chief Nursing Officer (CNO) and the Regional Manager of Quality Services at 9:50 AM, who all confirmed the presence of the State Agency Fire Life Safety surveyors on 11/27/18. During the entrance conference on 12/03/18 at 9:50 AM, the COO stated since the State Agency Fire Life Safety inspection on 11/27/18, the hospital has been on a fire watch 24/7. He stated once they, Administration, were apprised of this outside vendor Fire Life Safety inspection report of June 25/18, they, Administration, immediately took action to rectify the identified deficiencies. The COO was asked to clarify what was meant by when they were apprised of the report, to which he stated they, Administration, were not aware of this report until the State Fire Life Safety surveyors brought it to their attention during the survey conducted on 11/26/18 and 11/27/18. The COO stated they are trying to correct these deficiencies in an expedited manner and hope to have them corrected by the end of the week.

Review of the hospital monthly Patient Safety/Quality Council meeting minutes from June 25, 2018 through October 23, 2018 revealed no discussion under the Environment of Care heading related to fire/life safety with the next meeting scheduled for November 27, 2018. Of note, the June 25, 2018 meeting was held on the same day as the fire alarm system annual certification inspection that was conducted throughout the facility by an outside vendor.
Review of the November 27, 2018 meeting minutes documented under the Environment of Care heading 'Fire alarm findings and hourly rounding.' On 12/03/18 at 10:15 AM, an interview was conducted with the Regional Manager of Quality Services inquiring why there was no mention of the fire/life safety report from June to October to which she stated there is nothing documented because they did not know about it.

On 12/03/18 at 10:45 AM, an interview was conducted with the CEO who confirmed he was not aware of the Fire/Life Safety report of June 25, 2018. He stated the bottom line is it did not get to his desk. He stated the State Fire Life Safety surveyors found the report and identified the issues and that is how they found out about it. He stated when they found out, they instantly went on fire watch within 15 minutes of the discovery and it will continue until all the repairs are complete. He stated the facilities director had some confusion about internal systems and it was his understanding a contract was needed however that was not the case. He stated this was an inadvertent error and a significant error and had he known about this back then he would have immediately signed the work order and dealt with corporate later. He stated they took swift immediate action to get the company in to get the work started and completed.

On 12/03/18 at 11:15 AM, the August 2, 2018 Environment of Care Committee Meeting minutes were reviewed to reveal under Fire Protection/Fire Life Safety, the report presented by the Regional Manager of Facilities Services, documents under 'Quarterly Fire Sprinkler/Fire Alarm Testing - There were no deficiencies to report during the quarterly fire sprinkler and fire alarm testing in June 2018.' The Regional Manager of Facilities Services did not report the findings of the 12 page, 74 deficiency Fire Alarm Report of June 25, 2018. Review of the Team Members roster who attend the Environment of Care Meetings include the CEO, COO, Regional Manager of Facilities Services, CNO and Regional Manager of Quality Services.

Review of the hospital policy titled Fire Safety Management Plan, last revised on 01/18 and approved by the CEO states in part, under 'Inspection, Testing and Maintenance - The Facilities Services Manager reports to the Environment of Care Committee on fire alarm maintenance and any impairment to the fire alarm system.'

On 12/03/18 at 11:20 AM, an interview was conducted with the Regional Manager of Quality Services pointing this omission out, to which she stated this was part of the issue and had the Regional Manager of Facilities Services brought the report up at that meeting it would have been addressed right away. She stated it was a failure to communicate.

On 12/03/18 at 11:25 AM, an interview was conducted with the CNO who stated that was part of the breakdown and when we found out about this June report last week, the Assistant Administrator started working on the issues right away. She stated the Environment of Care meetings are held quarterly and they have now changed them to monthly so issues do not fall through the cracks.

On 12/03/18 at 12:00 PM, an interview was conducted with the COO, in the presence of the CNO and the Regional Manager of Quality Services, who stated back in July a purchase order was submitted by the Regional Manager of Facilities Services, however there was no sense of urgency or seriousness of the issues brought forth by the Regional Manager of Facilities Services, and it went to corporate to be approved. He stated at the corporate level it can take some time for approval however if the Regional Manager of Facilities Services told us about the urgency to get these safety issues addressed we would have intervened right away and fast tracked the process and would have requested an emergency approval. An inquiry was made why the Regional Manager of Facilities Services did not say anything to anyone to which the COO, CNO and Regional Manager of Quality Services stated they are in disbelief and cannot understand why he would not have considered this an urgent serious issue.

On 12/03/18 at 12:30 PM, the COO provided the report from the outside fire/life safety vendor dated June 25, 2018 which was 12 pages long. The COO stated the purchase order would have been a one page request with a brief synopsis of the issue requested for repairs, he would not get the 12 page report to review.

On 12/03/18 at 1:45 PM, an interview was conducted with the Regional Manager of Facilities Services, in the presence of the COO, who stated he has been in his role for about a year and a half, stating the COO started working here around the same time too. An inquiry was made how many requests did he submit for approval to get the repairs done to which he stated he submitted a request in July and again in September for a total of 4 requests. He stated you write a 'blurb' why you need the money, present it to the COO who signs off on it and then it goes into a black hole at corporate. The Regional Manager of Facilities Services stated he put in another request in September and had to revise it 2 times changing the wording and then having to put the request on a new form that was implemented and he had his secretary bring it down to administration. An inquiry was made if he at any time followed up or spoke with anyone in an administrative capacity about these requests to which he stated "No." He stated he had his secretary calling once a week and once a week he was told it was on somebody's desk. A second inquiry was made if he ever went down to the administrative office to find out the status of his request to which he again stated "No." The Regional Manager of Facilities Services again stated he had his secretary follow up with the administrative secretary and every time his secretary would call down the administrative secretary would say there are no papers for him yet so he assumed it was caught up in corporate somewhere. He stated that secretary no longer works here so he is not sure what happened to his requests. The Regional Manager of Facilities Services did not acknowledge a 12 page report of fire/life safety deficiencies, identified back on June 25, 2018, was a serious matter and should have been made a priority.

On 12/03/18 at 2:16 PM, an interview was conducted with the secretary of the Regional Manager of Facilities Services, who stated she would make up the requisitions and the Regional Manager of Facilities Services would sign off on it and she would take it to the administrative secretary and she would give it to the COO. She stated the COO signed off on the July request however at that time everything was changing with the system. She stated the September request had to be amended a couple of times due to the wording and then the form changed so she had to rewrite it. She stated when she made the amendments she did not change the date from September 24 so they would not think it was a new request. An inquiry was made when was the last time she submitted the request originating from the September 24 request to which she stated she could not be sure. She stated the administrative secretary that handled all that no longer works here so she was not sure what happened to all the requests.

On 12/03/18 at 2:25 PM, an interview was conducted with the COO and the July 18, 2018 requisition was reviewed to reveal it was signed by the Regional Manager of Facilities Services on July 18, 2018 for the amount of $47,431.73, documenting the request is for 'Fire alarm inspection deficiencies - replace/repair batteries, heat duct and smoke detectors, speakers visual and duct.' This request was signed off by the COO on 08/06/18. The COO on 12/03/18 at 2:25 PM confirmed it was his signature. An inquiry was made if he ever followed up with this request, considering it was a life safety concern to which he stated he gets about 30 requests a day and does not normally follow up, stating had the Regional Manager of Facilities Services expressed the seriousness of the issue he would have made a point to follow up. An inquiry was made to the COO what happened to this July request to which he stated he did not know. An inquiry was made where this request would have gone after he signed it and he stated he did not know. The 3 September 24, 2018 requests were reviewed, now on a form called "One Time Gap & Emergency" Procurement Determination and Approval Justification Memo, all signed by the Regional Manager of Facilities Services, with no other signatures or acknowledgements. An inquiry was made to the COO where did these 3 requests go to, to which he stated he did not know. He stated if his signature is not on them, they did not come to him. The COO further stated he was not aware of the report or any of this and had he been aware, it would have been taken care of right away.

Review of the hospital Procurement Code Policy, last revised 11/2009, documents under 'Purpose - This Procurement Code Policy provides guidance for the (Hospital) procurement of supplies, equipment and services. Requisition Authority - The Board of Commissions sets spending thresholds beyond which it requires its authorization/approval prior to the commitment of funds. The President/CEO sets authorized levels for requests then they do not exceed the $50,000 threshold. The appropriate levels of authorization for the organization for purchase requisitions, requests for checks and contract execution are detailed as follows: The COO is authorized to approve up to $20,000.' Review of the July 18, 2018 requisition reveals the funds for Fire/Life Safety repairs was $47,431.73, which the COO signed, however did not forward to the next authorizing signature which would have been the CEO.

Review of the hospital Organizational Chart documents the COO reports directly to the CEO.

Review of the Job Summary of the CEO-Regional, effective date of 07/01/2015, states in part, 'Direct the overall administration of the Medical Center and related regional operations to assure quality patient care and service within the fiscal and philosophical guidelines set forth by the President/CEO in collaboration with the Executive Team.'

During the interview with the COO on 12/03/18 at 2:25 PM, he stated the Regional Manager of Facilities Services was an experienced technician, however was not an effective leader, stating there have been other instances where there have been issues that needed to be addressed that were not followed up on by the Regional Manager of Facilities Services. The COO did not at any time during the interviews make any indication there was any oversight of, or guidance to the Regional Manager of Facilities in his role. Review of the Chief Operating Officer job description dated effective 08/27/2004 states in part, 'Supervision - Reports to the CEO; Technical Competencies: Interdisciplinary Coordination - Uses advance interpersonal skills in order to mentor and lead manager. Displays ability to build manager capability, ownership, team approach and mentoring/coaching.'

Further, review of the hospital policy titled Fire Safety Management Plan, last revised on 01/18 and approved by the CEO states in part, 'Purpose - The purpose of the Fire Safety Management Plan is to minimize the possibility and risks of a fire and protect all occupants and property from fire, heat and products of combustion. Objectives - Provide an environment that minimizes the risks of fire and related hazards; Report and investigate fire protection deficiencies, failures and user errors; Ensure fire alarm, detection, and suppression systems are designed, installed and maintained to ensure reliable performance. Inspection, Testing and Maintenance - All those responsible for maintaining and responding to the system are properly trained. Interpretation and Administration - The administration and interpretation of this policy is the responsibility of the Senior Vice President/COO.