HospitalInspections.org
Bringing transparency to federal inspections
LINDSAY MUNICIPAL HOSPITAL
Roles Under a Waiver Declared by Secretary
Tag No.: E0026
Based on record review and interview the hospital failed to ensure the facility had an 1135 wavier as required.
Findings:
Record review of the emergency preparedness policies and procedures revealed the facility did not develop a policy addressing the CMS 1135 wavier as required.
On 04/13/22 at 1:14pm the surveyor asked Staff A for the facility's policy on the 1135 wavier. Staff A stated they thought they had it but did not find it.
EP Training Program
Tag No.: E0037
Based on record review and interview the facility failed to ensure initial emergency preparedness training for 11 of 13 doctors as required.
Findings:
Record review of the facility emergency preparedness training documentation revealed the facility did not train 11 of 13 doctors in intital emergency preparedness training.
On 04/13/22 at 11:17am the surveyor asked staff C for documentation of initial emergency preparedness training for each staff member including all doctors with the facility. Staff C stated that only two of 13 doctors have had the initial emergency preparedness training.
Egress Doors
Tag No.: K0222
Based on observation and interview the facility failed to ensure emergency access corridor doors did not have two locking devices which required a tool or key to unlock.
Findings:
On 04/14/22 at 2:16pm the suveyor observed a barrel latch on the corridor egress door of staff C.
On 04/14/22 at 2:16pm the surveyor asked staff A why was there two latches on staff C's corridor access office door. Staff A stated they had installed the two latches for security for staff C but will remove them to be compliant.
Anesthetizing Locations
Tag No.: K0323
Based on observation and interview the facility failed to ensure CMS ASHRAE 170-2008 ventilatory guidelines were followed as required.
Findings:
On 04/14/22 at 10:33am the surveyor observed a Sterad NX sterilizer in the sterile processing room that is positively ventilated.
On 04/14/22 at 10:33am the surveyor asked staff A why the sterilizer was housed in a positively ventilated area were ASHRAE 170-2008 table 7.1 outlines sterilizers are to be housed in negatively ventilated areas. Staff A stated they will move the Sterad NX sterilizer to a negatively ventilated area to be in compliance with ASHRAE 170-2008.
Corridor - Openings
Tag No.: K0364
Based on observation and interview the facility failed to ensure corridor doors did not have transfer grills as required.
Findings:
On 04/13/22 at 2:32pm the surveyor observed a transfer grill on the men's and women's bathroom corridor door near the cafeteria.
On 04/13/22 at 2:32pm the surveyor asked staff A why there were transfer grills installed on corridor doors which would allow smoke and fire to spread throughout the facility. Staff A stated they did not know it was against code and non-compliant. Staff A stated they will correct the problem with the installed transfer grills in the corridor doors to be compliant.
Electrical Systems - Essential Electric Syste
Tag No.: K0918
Based on record review and interview the facility failed to ensure the emergency generator testing was completed.
Findings:
Record review revealed the facility did not complete monthly load bank testing for 2019, 2020, and 2021.
On 04/13/22 at 10:52am Staff A was asked to provide the emergency generator load bank logs for 2019, 2020 and 2021. Staff A stated the generator load banks were not done for the years 2019, 2020, and 2021. Staff A stated they will start doing monthly load banks to be in compliance.