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Based on record review and interview, this facility did not maintain the diesel emergency generator by maintaining complete monthly, annual, main, and circuit breaker documentation. These deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator would not ensure proper operation and prompt repair which would affect all occupants. The facility has the capacity for 111 beds with a census of 72 on the day of survey.

Findings are:
Record review conducted on 8-22-19, at 12:33 pm of the facility's generator inspection testing and maintenance records from 2017 through 2019 revealed:
1. Facility lacked evidence of inspection of the Main and feeder circuit breakers were inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements.
2. Facility failed to document time to transfer from normal power to generator power.

During an interview on 8-22-19 at 12:33 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 2010
8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kWrating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

4.3 Type. The type defines the maximum time, in seconds, that the EPSS will permit the load terminals of the transfer switch to be without acceptable electrical power. Table 4.1(b) provides the types defined by this standard.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

Based on observation and interview, the facility failed to maintain a 2-hour fire separation between the Business and Hospital. This deficient practice would allow smoke and fire to migrate between the occupancies. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 1:46 pm revealed, the west 90-minute fire door between the Hospital and the OPC failed to latch within the doorframe when closed.

During an interview on 8-21-19 at 1:46 pm, Maintenance Staff A confirmed the 90-minute fire door failed to latch.

Based on observations and interview, the facility failed to assure doors in the means of egress were not capable of locking. This deficient practice would delay egress and cause confusion and panic in the event of an emergency, facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observations on 8-21-19 between 1:00 pm and 2:33 pm revealed:
1. 2 of 2 Emergency Room exit doors were equipped with thumb locks.
2. 1 of 2 Main Entrance doors were equipped with thumb lock.
3. The west exit into Family Medicine was equipped with a magnet, which is engaged after 5:30 pm creating a dead end.

During an interview on 8-21-19 between 1:00 pm and 2:32 pm, Maintenance Staff A confirmed the findings.

Based on observation and interview, the facility failed to provide the required illumination for the means of egress. The deficient practice would delay egress during an emergency. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 12:52 p.m. revealed the area outside of the MRI exit door at the was not equipped with a light fixture.

During an interview on 8-21-19 at 12:52 p.m., Maintenance Staff A revealed the facility was not aware the area outside of the exit did not meet the required arrangement for illumination of the means of egress.

NFPA Standard:
2012 NFPA 101, 19.2.8
Means of egress shall be illuminated in accordance with Section 7.8.
7.8.1.1* Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators, and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way.
7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area.

Based on observation, documentation review and interview, the facility failed to assure that the monthly and yearly emergency light testing was documented and failed to assure that battery backup emergency lights were provided in rooms where sedation or anesthesia was administered. This deficient practice has the potential for emergency lights in the facility to not operate during an emergency. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observations on 8-21-19 at 12:02 pm revealed, the Endoscopy room and OR 2 failed to provide a battery operated emergency light.

During an interview on 8-21-19 at 12:02 pm, Maintenance Staff A failed to verify if battery operated emergency lights were provided.

Documentation review on 8-22-19 at 12:22 pm revealed the facility failed to document monthly and annual inspections of the emergency lights throughout the facility.

During an interview on 8-22-19 at 12:22 pm, Maintenance Staff A confirmed the lack of documentation for the testing of emergency lights.

NFPA Standard:
NFPA 99, 2012 6.3.2.2.11.1
One or more battery-powered lighting units shall be provided within locations where deep sedation and general anesthesia is administered.

Based on observation and interview, the facility failed to provide exit signs. This deficient practice had the potential for delay or to cause confusion during an emergency as occupants would be unable to locate exits. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observations on 8-21-19 between 12:46 pm and 1:34 pm revealed:
1. While standing in the Radiology corridor looking west, no exit sign was visible to direct occupants to the exit.
2. While standing next to the Nurse Station looking west no exit sign was visible to direct occupants to the exit.
3. While standing in the East and West patient wing looking north, no exit sign was visible to direct occupants to the exit.
4. While standing in Respiratory Therapy looking west the facility failed to provide an exit sign with a chevron to indicate direction of egress.

During an interview on 8-21-19 between 12:46 pm and 1:34 pm, Maintenance Staff A confirmed the lack of exit signage.

Based on observation and interview, the facility failed to assure the door to a hazardous area would close and latch within the doorframe. This deficient practice would allow fire, smoke and gasses to migrate into the exit corridor. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 between 1:06 pm and 3:31 pm revealed:
1. Patient Room 222 was used as a storage room, and the facility failed to provide a self-closing device on the door.
2. Double doors to the west wing Storage room failed to be latched within in the doorframe. The door failed to be self-latching and the manual latch was not engaged into the frame.
3. The Operating Room storage room door failed to provide a latching device.
4. Family Medicine Billing office door was propped open with a rubber door stop. The door failed to latch within the doorframe.
5. Storage Room in the medical office building failed to provide a latching device, only a thumb lock was provided.
6. Medication room in the medical office building failed to provide a latching device, only a magnet held the door in place.
7. 2 of 5 Kitchen doors failed to provide latching devices, only deadbolt locks were provided.
8. Double doors to the Mechanical room failed to latch within in the doorframe. The door failed to be self-latching and the manual latch was not engaged into the frame.


During an interview on 8-21-19 between 1:06 pm and 3:31 pm, Maintenance Staff A confirmed the that doors equipped with closures failed to latch within the door frame.

Observation on 8-22-19 at 11:16 am revealed:
9. The housekeeping room in the service hall failed to provide smoke tight construction, the north wall failed to extend to the roof deck.

During an interview on 8-22-19 at 11:16 am, Maintenance Staff A confirmed the wall failed to extend to the roof deck.

Based on observation and interview, the facility failed to ensure that the fire alarm system's circuit breakers were equipped with a lock out device and labeled. This deficient practice could allow the fire alarm panel to be disconnected from its power supply, which would delay the response time to a fire. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 12:39 pm and 2:33 pm revealed:
1. Breakers 11 and 12 in the Electrical Room for fire alarm in panel box labeled LA was not equipped with a lock out device and failed to have a red marking.
2. Fire alarm booster in LB panel in Family medicine was not equipped with a lock out device and failed to have a red marking.

During an interview on 8-21-19 at 12:39 pm and 2:33 pm, Maintenance Staff A confirmed the lack of a lock out on the circuit breaker and the lack of a red marking.

NFPA Standard:
2010 NFPA 72, 10.5.5.2
10.5.5.2.2 For fire alarm systems the circuit disconnecting means shall be identified as "FIRE ALARM CIRCUIT."
10.5.5.2.3 For fire alarm systems the circuit disconnecting means shall have a red marking.
10.5.5.2.4 The circuit disconnecting means shall be accessible only to authorized personnel.

Based on interview and record review, the facility did not provide and maintain complete documentation or provide 100% semi-annual testing of the fire alarm system as required by NFPA 72. The deficient practice of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the fire alarm system does not ensure proper operation and prompt repair affecting all occupants. This facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings are:
Record review on 8-22-19, at 12:53 pm., of the fire alarm inspection forms, documentation did not include sensitivity testing of the smoke detectors.

During an interview on 8-22-19, at 12:53 pm., Maintenance Staff A confirmed the lack of the testing.

Based on observation and interview, the facility failed to maintain a smoke detector in the EMS sleeping room. This deficient would not alert occupants of smoke within the room and would allow smoke to enter the exit corridor. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observations on 8-21-19 at 1:36 pm revealed, the EMS sleeping room failed to provide a smoke detector.

During an interview on 8-21-19 at 1:36 pm, Maintenance Staff A confirmed the lack of a smoke detector.

Based on record review and staff interview, the facility failed to have the fire sprinkler system tested semiannually. This condition created the potential for system failure, which would affect the safety of all occupants. This facility had a capacity of 25 and a census of 6 residents at the time of the survey.

Findings are:
Record review on 8-22-19, at 12:53 pm revealed the 9-27-18 inspection report was the only report provided for review in 2018.

During an interview on 8-22-19, at 12:53 pm, Maintenance Staff A confirmed this was the only report in 2018.

NFPA Standard:
2011, NFPA 25
5.3.3.2* Vane-type and pressure switch-type waterflow alarm devices shall be tested semiannually.

Based on record review and interview, the facility failed to assure that a complete policy was in place regarding the procedures to be taken in the event that the sprinkler system is out of service for more than ten hours in any twenty-four hour period. The lack of a complete written policy and procedure would result in staff failing to implement interim safety measures in the event of an emergency. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Record review on 8-22-19 at 11:42 am, of the fire watch procedures revealed:
1. The policy failed to list insurance carrier, the alarm company, property owner or designated representative, supervisors and other authorities having jurisdiction (SFM, HHSS) have been notified.
2. The policy failed to list emergency impairments would include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping and equipment failure.

During an interview on 8-22-19 at 11:42 am, Maintenance Staff A confirmed the lack of specific items in the fire watch policy.

NFPA Standard:
NFPA 25, 2011
15.5* Preplanned Impairment Programs.
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:
(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:
(a) Evacuation of the building or portion of the building affected by the system out of service
(b)*An approved fire watch
(c)*Establishment of a temporary water supply
(d)*Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire
(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.


15.6 Emergency Impairments.
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.

Based on observation and interview, the facility failed to ensure that the corridor room doors would resist the passage of smoke. This deficient practice would not prevent the spread of fire and smoke within the exit corridors. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 3:08 pm revealed, Therapy Room door failed to provide a latching device; the door was held closed by a magnet only.

During an interview on 8-21-19 at 3:08 pm, Maintenance Staff A confirmed the door failed to provide a latching device. Physical Therapy Staff A confirmed that inpatients used the therapy room.

Based on observation and interview, the facility allowed storage to obstruct access to electrical panel boxes and the Line Isolation Monitors (LIM) in the operating rooms. This deficient practice could cause a delay and injury when turning off the power during an electrical issue emergency. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observations on 8-21-19 at 12:03 pm and 1:16 pm revealed:
1. Obstruction of the LIM in 2 of 2 operating rooms.
2. The electrical panel boxes in the Nutrition Station were obstructed with trash and recycling cans.

During an interview on 8-21-19 at 12:03 pm and 1:16 pm, Maintenance Staff A confirmed the items stored in front of the LIM and panel boxes.

NFPA Standard:
2011 NFPA 70, 110.26
Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment.

Based on interview and documentation review, the facility failed to implement a testing and inspection program to document the integrity and operation of all fire rated doors throughout the facility. This deficient practices failed ensure that the fire doors would operate as designed to prevent the spread of fire and smoke. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Documentation review on 8-21-19 at 10:26 am revealed, that the facility failed to provide written documentation of annual inspections and required testing of all fire rated doors throughout the facility. Document provided from an outside contractor failed to indicate what the doors were inspected for and failed to indicate location of fire rated doors on the form provided.

During an interview on 8-21-19 at 10:26 am, Maintenance Staff A confirmed the lack of a complete document for the fire rated door inspections and testing.

NFPA Standard:
2010 NFPA 80, 5.2*
5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.
5.2.2* Performance-Based Option.
5.2.2.1 As an alternate means of compliance with 5.2.1, subject to the AHJ, fire door assemblies shall be permitted to be inspected, tested, and maintained under a written performance based program.
5.2.2.2 Goals established under a performance-based program shall provide assurance that the fire door assembly will perform its intended function when exposed to fire conditions.
5.2.2.3 Technical justification for inspection, testing, and maintenance intervals shall be documented.
5.2.2.4 The performance-based option shall include historical data acceptable to the AHJ.
5.2.3 Functional Testing.
5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing.
5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting.
5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware.
5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly.
5.2.4.2 As a minimum, the following items shall be verified:
(1) No open holes or breaks exist in surfaces of either the door or frame.
(2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped.
(3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage.
(4) No parts are missing or broken.
(5) Door clearances at the door edge to the frame, on the pull side of the door, do not exceed clearances listed in 4.8.4 and 6.3.1.
(6) The self-closing device is operational, that is, the active door completely closes when operated from the full open position.
(7) If a coordinator is installed, the inactive leaf closes before active leaf.
(8) Latching hardware operates and secures the door when it is in the closed position.
(9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame.
(10) No field modifications to the door assembly have been performed that void the label.
(11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity.

Based on observation and interview, the facility allowed the use of portable electric space heaters and failed to provide documentation the heating element of the device did not exceed 212 degrees Fahrenheit. This deficient practice increased the potential of a fire. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observations on 8-22-19 at 11:27 am revealed a portable heating device in the Clinical Manager Office.

During an interview on 8-22-19 at 11:27 am, Maintenance Staff A stated that the facility did not have the manufactures specification for the heaters and could not confirm the heating element of the device did not exceed 212 degrees Fahrenheit and that the heater was brought into the facility by staff.

NFPA Standard:
2012 NFPA 101, 19.7.8
Portable space heating devices shall be prohibited in all health care occupancies, unless both of the following criteria are met:
(1) Such devices are used only in nonsleeping staff and employee areas.
(2) The heating elements of such devices do not exceed 212°F (100°C).

Based on observation and interview, the facility failed to provide identification for the remote manual stop switch for the emergency generator. This deficient practice could delay shutdown of the generator during a malfunction, which could cause damage to the generator resulting in loss of emergency power that would affect all patients. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 3:15 pm revealed, the facility failed to provide identification for the remote manual shutdown switch.

During an interview on 8-21-19 at 3:15 pm, Maintenance Staff A confirmed the lack of identification for the remote stop for the generator.

NFPA Standard:
2010 NFPA 110, 5.6.5.6*
All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building.

2010 NFPA 110
5.6.5.6.1
The remote manual stop station shall be labeled.

Based on record review and interview, the facility did not document an individualized assessment for receptacles at patient care locations including the continuity of the grounding circuit, polarity and retention force and failed to test the Line Isolation Monitors (LIM). This deficient practice could create electrical injury and fire hazards. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Record review on 8-22-19, at 1:38 p.m., revealed:
1. The facility failed to provide an individualized assessment of patient care receptacles.
2. The facility failed to test the LIM in the operating rooms.

During an interview on 8-22-19 at 1:38 pm, Maintenance Staff A confirmed the lack of receptacle testing.

NFPA Standard:
2012 NFPA 99
6.3.3.2.1
The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2
The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3
Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4
The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz).

6.3.4.1.4
The LIM circuit shall be tested at intervals of not more than 1 month by actuating the LIM test switch (see 6.3.2.6.3.6).
For a LIM circuit with automated self-test and self-calibration capabilities, this test shall be performed at intervals of not more than 12 months. Actuation of the test switch shall activate both visual and audible alarm indicators.

Based on observation, interview and documentation review, the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch and the Critical Branch. This deficient practice had the potential to affect all patients of the facility by affecting the emergency systems of the facility. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 3:44 pm revealed:
1. Electrical panel CA in the Boiler/Electrical room circuits from the life safety branch were intermixed within the critical panel

During an interview on 8-21-19 at 3:44 pm, Maintenance Staff A confirmed the findings.

Based on record review and interview, this facility did not maintain the diesel emergency generator by maintaining complete monthly, annual, main, and circuit breaker documentation. These deficient practices of not providing complete and verifiable documentation on the inspection, testing, and maintenance of the generator would not ensure proper operation and prompt repair which would affect all occupants. The facility has the capacity for 111 beds with a census of 72 on the day of survey.

Findings are:
Record review conducted on 8-22-19, at 12:33 pm of the facility's generator inspection testing and maintenance records from 2017 through 2019 revealed:
1. Facility lacked evidence of inspection of the Main and feeder circuit breakers were inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements.
2. Facility failed to document time to transfer from normal power to generator power.

During an interview on 8-22-19 at 12:33 pm, Maintenance A confirmed that the generator testing documentation failed to be complete.

NFPA Standard:
NFPA 110, 2010
8.4.2* Diesel generator sets in service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(1) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
(2) Under operating temperature conditions and at not less than 30 percent of the EPS nameplate kW rating
8.4.2.1 The date and time of day for required testing shall be decided by the owner, based on facility operations.
8.4.2.2 Equivalent loads used for testing shall be automatically replaced with the emergency loads in case of failure of the primary source.
8.4.2.3 Diesel-powered EPS installations that do not meet the requirements of 8.4.2 shall be exercised monthly with the available EPSS load and shall be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kWrating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

4.3 Type. The type defines the maximum time, in seconds, that the EPSS will permit the load terminals of the transfer switch to be without acceptable electrical power. Table 4.1(b) provides the types defined by this standard.

NFPA Standard:
NFPA 99, 2012, 6.4.4.1.2.1
Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer's recommendations.

Based on observation and interview, the facility failed to assure electrical equipment was installed in a way that would not create a fire or safety hazard. This deficient practice had the potential to cause a fire, or risk electrical shock. The facility has the capacity of 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19, at 12:34 pm revealed, a broken faceplate on the electrical outlet on the north wall in CT behind the door.

During an interview on 8-21-19, at 12:34 pm, Maintenance Staff A confirmed the broken faceplate.

NFPA Standard:
NFPA 70, 2011, 406.6
Receptacle Faceplates (Cover Plates).
Receptacle faceplates shall be installed so as to completely cover the opening and seat against the mounting surface.

Based on observation and interview, the facility failed to prohibit the use of electrical extension cords and power strips as a substitute for adequate wiring. This deficient practice would create electrical injury and increase a fire hazard. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19, between 12:46 pm and 3:02 pm and revealed:
1. A dehumidifier in the MRI equipment room plugged into a power strip.
2. A non hospital grade power strip near Pixis Machine behind the Nurse station to power medical equipment.
3. A non UL listed power strip in the Hospitalist sleeping room.
4. Extension cord in the ITC room in the Housekeeping boiler room.

During an interview on 8-21-19 between 12:46 pm and 3:02 pm, Maintenance Staff A confirmed the use of the power strips and extension cord.

Based on observation and interview, the facility failed to assure that compressed gas cylinders were secured. This deficient practice would allow cylinders to be knocked over, potentially breaking the valves and allowing the escape of oxygen, which would cause an oxygen-enriched atmosphere and increase the potential for a fire, and could cause injury from a projectile. The facility has the capacity for 25 beds with a census of 6 on the day of survey.

Findings are:
Observation on 8-21-19 at 3:21 pm revealed, two cylinders in the Oxygen Storage room were not secured.

During an interview on 3-21-19 at 3:21 pm, Maintenance Staff A confirmed cylinders failed to be secured.

Based on record review and interview the facility failed to have a complete written policy or documentation for staff response for a fire or emergency that could be encountered during surgical procedures. The deficient practice would not provide staff education and training for a fire or other emergency that could occur in the Operating Room (OR) during surgical procedures

Findings are:
Record review on 8-21-19 at 12:40 pm. revealed the facility did not have a complete policy or procedures detailing:
Preoperative "time-out" is conducted prior the initiation of any surgical procedure to verify:
1. Application site is dry prior to draping and use of surgical equipment.
2. Pooling of solution has not occurred or has been corrected.
3. Solution-soaked materials have been removed from the OR prior to draping and use of surgical devices.
4. Policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use.

During the exit interview on 8-21-18 at 12:40 pm, Surgical Nurse Staff A confirmed the findings.