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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 showed the facility did not develop and maintain a 1135 policy and procedure in the emergency preparedness plan as required.

On 08/18/21 at 2:14pm the surveyor asked staff D for the facility's 1135 waiver policy and procedure. Staff D stated the facility had not developed the policy but will to be in complaince.

Based on record review and interview the facility failed to develop and maintain an emergency preparedness communication plan that included the facility's primary and alternative forms of emergency communication as required.

Findings:

Record review showed the facility's emergency preparedness communication plan did not contain their primary and alternative form(s) of communication as required.

On 08/18/21 at 2:26pm the surveyor asked staff D to show them in the facility emergency preparedness communication plan where it outlined the facility's primary/alternative forms of emergency communication. Staff D stated they could not find it in their emergency preparedness communication plan but would add it in order to be in compliance.

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

Findings:

On 08/19/21 at 1:17pm 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 08/19/21 at 1:17pm the surveyor asked staff D why there were deadbolts on the corridor doors which would take two actions to open. Staff D stated the deadbolts were on the doors within the facility since he has started and he did not know they were not allowed. Staff D 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 the operating room was provided with battery-powered lighting units.

Findings:

On 08/18/21 at 12:03pm the surveyor observed the one operating room to not have battery-powered emergency lighting as required.

On 08/18/21 at 12:04pm the surveyor asked staff C why their operating room did not have battery backed up emergency lighting. Staff C stated he will find out but will get it installed in order to be in compliance.


NFPA 99, 2012 Edition
6.3.2.2.11 Battery-Powered Lighting Units.
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 record review, observation and interview the facility failed to ensure maintenance of ASHRAE 170-2008 ventilatory requirements as required.

Findings:

Record review showed the facility did not conduct test and balance annual inspections for 2020, 2019, and 2018 to confirm areas within the surgical area met compliance with the ASHRAE 170-2008 ventilatory requirements for minimum air exchanges per hour/being either positively or negatively ventilated as required.

On 08/18/21 at 11:06 am Staff D was asked for the 2020 through 2018 annual test and balance inspection reports. The surveyor asked staff D why they did not have test and balance inspections for the last three years. Staff D stated they had staff turnover but will get the test/balance inspections scheduled annually to be in compliance.

Based on record review and interview the facility failed to ensure the annual fire rated door assembly annual inspections were completed per NFPA 80 requirements.

Findings:

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

On 08/18/21 at 12:33pm the surveyor asked staff D for the annual fire rated door assembly inspections. Staff D stated they did not have the inspections for 2017, 2018.

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.

On 08/18/21 at 2:15pm the surveyor asked staff D for the EES and Medical Gas building system risk assessment. Staff D stated they were not aware of the requirement but would ensure it would be completed as required.

Based on record review and interview the facility failed to ensure impedance testing/maintenance to patient care related electrical receptacles per NFPA 99 2012 Edition requirements.

Findings:

Record review showed the facility did not complete impedance testing for patient care related electrical receptacles as required in NFPA 99 2012 Edition.

On 08/18/21 at 11:27am the surveyor asked staff D why the impedance testing has not been completed per the requirements outlined in NFPA 99 2012 Edition. Staff D stated they were not fully familiar with the requirements for life safety code but will get the testing scheduled to be done with their contractor to be in compliance.

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 08/19/21 at 12:01pm the surveyor observed the endoscopic machine - Evis Exera III CLV-190 with monitor without a current inspection sticker and a Force FXC cautery machine without a current inspection sticker both in the operating room #1 in service to be used.

On 08/19/21 at 12:01pm the surveyor asked staff D why the endoscopic and cautery machine were not currently inspected. Staff D stated their bio med vendor must have missed them.

Based on observation and interview the facility failed to ensure secure storage of compressed medical gasses contained in cylinders as required.

Findings:

On 08/18/21 at 11:33am the surveyor observed 14 "H" sized medical gas cylinders stored in the doctors dictation room within the surgical area.

On 08/18/21 at 11:33am the surveyor asked staff C why the 14 "H" sized medical air steel cylinders were not properly secured. Staff C stated their medical gas vendor was supposed to have picked them up already but they will get it corrected as soon as possible.