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Based on a review of the facility records, interviews with the staff, and observations, the hospital failed to develop a plan to meet the subsistence needs of the patients regarding maintaining safe temperatures to protect patient health and safety in the event of a power failure.
Refer to E015 #1.

The facility failed to have a policy and procedure for sewage and waste disposal in place in the event of a power failure.
Refer to E015 #2.

Unsafe temperatures present possible negative outcomes to patients during a power failure. A lack of planning for sewage and waste disposal during a power failure could result in unsanitary conditions. These cumulative deficits place the patients at risk for not having their needs met in a emergency resulting in the Condition of Participation being out of compliance.

Based on a review of the facility records, interview with the staff, and observations, the hospital failed to develop a plan to meet the subsistence needs of the patients regarding maintaining safe temperatures to protect patient health and safety. The hospital generator is inadequate to power the heating ventilating air conditioning (HVAC) system and the plan to use spot coolers is seriously flawed. The facility also failed to have a policy and procedure for sewage and waste disposal in place.
Unsafe temperatures present the possibility of negative outcomes to patients. A lack of planning for sewage and waste disposal during an interruption in power could result in unsanitary conditions.

The findings included:

1. In an interview on 10/29/20 at 1:00 p.m., the Chief Executive Officer (CEO) said the current plan for keeping patients in safe temperatures during an power failure is to use one spot cooler for each patient room.

In an interview on 10/29/20 at 1:40 p.m., the Facilities Director said the spot coolers are to be plugged into critical outlets. At this time, observations of the spot coolers and an empty patient room revealed there are no operable windows in the patient rooms where the spot coolers could be exhausted. The Facilities Director explained the spot coolers will be exhausted by temporarily attaching the exhaust to the return air duct (a plenum) or into the interstitial space. There were no other methods available to vent the exhaust air to the exterior of the structure.

Review of the Investigative Report by the Senate Committee on Finance, "Sheltering in Danger" (November 2018) revealed in September 2017, following Hurricane Irma, there were 12 deaths in a Florida facility. The improper disposal of exhaust from spot coolers on the first floor was identified as one of the causative factors. The report noted flawed installation of spot coolers can worsen, rather than improve, emergency conditions.

Review of National Fire Protection Association (NFPA) 101 (2012 edition) revealed:
8.4.2(2)(c) "The space above the ceiling is not used as a plenum." and,
8.4.2(3)(c) "Where the space above the ceiling is used as a plenum, return grilles from the hazardous area into the plenums are not permitted."
This shows exhaust into the return air duct or the interstitial space is not permitted.

During the interview on 10/29/20 at 1:40 p.m., the Facilities Director said the hospital is equipped with a 600-kilowatt generator which is currently connected to the critical, and life safety, and equipment branches of the Level 1 system. He acknowledged the HVAC system is not connected to the generator. The current demand load on the generator is 27% of the nameplate rating. The Facilities Director said the demand load was previously calculated during an effort to correct this issue 2 years ago. He said the structure is cooled by 4 air conditioning units on the roof. He said if the units were connected to the current generator, it would only be able to power two of the four units.

The flawed spot cooler plan to patient rooms would be unable to safely cool these rooms. The remainder of the hospital including Critical Care, General Care, Medical-Surgical, Surgery, Therapy, Intensive Care, and the Leased Surgical Wing would also not be cooled in the event of a power failure. The pressure relationships for air balancing would be negated when on generator power.

This plan has been in effect since the Emergency Preparedness rule went in to effect in 2017.

In an interview on 10/29/20 at 4:30 p.m., the CEO said he learned an engineering firm had been retained to find a solution to the issue during a phone conversation with a corporate officer. The CEO acknowledged he had no documentation of this.

2. Review of the remaining requirements in the standard, the hospital is required to have a policy and procedure to address sewage and waste disposal for subsistence needs for staff and patients. The hospital staff could not produce a policy and procedure from the records to meet this requirement.

The surveyor had experience in 2017 immediately following Hurricane Irma when a facility in this field office's service area had a sewage back-up after a local power failure.

In an interview on 10/29/20 at 4:45 p.m., the Facilities Director said he could not locate a policy and procedure addressing sewage and waste disposal during a power failure or system failure.