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Based on interview and review of hospital documents, the hospital failed to develop and implement plans for the emergency provision of water and medical gases. Failure to develop and implement plans for the emergency provision of water and medical gases risks the ability of the hospital to provide services to in patients and other persons who come to the hospital in need of care during emergencies.

Findings:

Emergency/Disaster Coordinators (Staff Member #1, #2) stated during an interview on 9/29/10 at 2:30 PM
"we are not sure about how much water or medical gas may be available or needed during a loss in supply."

The Environment for Care Coordinator (Staff Member #3) stated during an interview on 9/28/10 at 4:00 PM "I don't know how much water would be needed if we lost our supply. I'm not sure if we would have enough water to run the autoclaves. There is an emergency oxygen supply connection, but I am not sure about how much would be needed in an emergency."

A plan for the loss of water and medical gases was not found in the hospital's written Emergency/Disaster Plan.

SEE FIRE AND LIFE SAFETY REPORT

Based on interview and review of hospital policy, the Critical Access Hospital failed to conduct or arrange for a periodic evaluation of it total program at least once a year.

Failure to perform an annual evaluation jeopardizes the ability of the hospital to determine appropriate utilization of services, ensure effective policies and complete an changes needed.

Findings:

During an interview on 9/28/10 at 10:00 AM, the Quality Improvement Coordinator (Staff Member #4) stated "The CAH Annual Evaluation did not get done for 2009."

Hospital policy "CAH Annual Review" (Index Number 10.41, revised 1/1/10) states The Hospital will provide annual review of its CAH Program."