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Based on observations, review of policy for disaster procedures, and staff interviews, the facility failed to meet the conditions of Participation of Physical Plant and Environment related to the following life safety from fire and disaster preparedness deficiencies; The facility failed to maintain smoke barriers to provide at least a one half hour fire resistance rating as there were penetrations observed throughout portions of the smoke barrier during the survey. Smoke barrier doors had greater than 1/8 inch gaps when in the closed position. Hazardous areas were not maintained with a one hour fire resistance rating. The facility failed to ensure smoke detector placement was not affected by air flow patterns. The facility failed to ensure surgical staff were knowledgeable of the facility's disaster preparedness policies in regard to tornado warnings. This affected all 12 patients in the facility.

Findings include:

The facility failed to maintain smoke barriers to provide at least a one half hour fire resistance rating as there were penetrations observed throughout portions of the smoke barrier during the survey. Please refer to LSC tag K25 for the findings.

Smoke barrier doors had greater than 1/8 inch gaps when in the closed position. Please refer to LSC tag K27 for the findings.

Hazardous areas were not maintained with a one hour fire resistance rating. Please refer to LSC tag K29 for the findings.

The facility failed to ensure smoke detector placement were not affected by air flow patterns. Please refer to LSC tag K130 for the findings.

The facility failed to ensure surgical staff were knowledgeable of the facility's disaster preparedness policies in regard to tornado warnings. Please refer to C-227 for the findings.

Based on staff interview and review of the surgical and administrative policies for disaster preparedness, it was determined the hospital failed to ensure three surgical staff members (Staff #C, E, and F) were knowledgeable of the disaster procedure in the event of a tornado warning. The hospital census was 12.

Findings include:

On 03/10/10 at 2:40 P.M. interviews were conducted with Staff #C, E, and F. When questioned about what the staff would do in the event of a tornado warning, Staff #C, E, and F were unable to verbalize the steps and procedures that were to be implemented upon notification the disaster preparedness was to be initiated for a tornado warning. Staff #C, E, and F were unable to identity the safe areas, steps to be taken to protect the patient, or the securing of the equipment. Staff #C, E, and F attempted to look up the disaster procedures in their manuals, however, they were unable to find any information on what to do for a tornado warning.

On 03/12/10 at 11:20 A.M. the surgical policy titled, "Emergency Code Call", was reviewed. Under 5. Code Grey: Severe Weather Procedure, the policy directed staff to refer to the Emergency Management Policy in the Administrative Manual.

The Administrative Manual was reviewed on 03/12/10. The policy titled, "Code Grey, High Winds/Thunderstorms/Tornados" was reviewed. The policy directed staff to close doors, assist patient in lying flat or in crouched positions, to keep the patient's head covered (blankets), and secure loose objects.

Based on observations and staff interviews, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association as follows: The facility failed to maintain smoke barriers to provide at least a one half hour fire resistance rating as there were penetrations observed throughout portions of the smoke barrier during the survey. The facility failed to ensure smoke barrier doors did not have greater than 1/8 inch gaps when in the closed position. The facility failed to ensure hazardous areas maintained a one hour fire resistance rating.
The facility failed to ensure smoke detector placement were not affected by air flow patterns. The Director of the Office of the Federal Register has approved the NFPA 101 2000 edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This affected all 12 patients in the facility.

Findings include:

The facility failed to maintain smoke barriers to provide at least a one half hour fire resistance rating as there were penetrations observed throughout portions of the smoke barrier during the survey. Please refer to LSC tag K25 for the findings.

The facility failed to ensure smoke barrier doors did not have greater than 1/8 inch gaps when in the closed position. Please refer to LSC tag K27 for the findings.

The facility failed to ensure hazardous areas maintained a one hour fire resistance rating. Please refer to LSC tag K29 for the findings.

The facility failed to ensure smoke detector placement were not affected by air flow patterns. Please refer to LSC tag K130 for the findings.

Based on medical record review and staff interview, it was determined the hospital failed to ensure the registered nurse evaluated the effectiveness of the medications administered on an as needed basis for five of five patients who received as needed medications (Patients #1, 3, 9, 19, and 20) of a total sample of 21 patients reviewed. The hospital census was 12.

Findings include:

The medical record for Patient #1 was reviewed on 03/09/10. The patient was admitted on 03/07/10 with a diagnosis of chest pain. Review of the medication administration record revealed the patient was given Nitroglycerin orally on 03/07/10 at 23:35 (11:35 P.M.). The record lacked documentation of any follow up documentation of an assessment to determine the effectiveness of the medication administered. The patient was given Xanax (an antianxiety medication) orally on 03/07/10 at 23:50 (11:50 P.M.). The record lacked documentation of a follow-up assessment to evaluate the effectiveness of the medication administered. These findings were verified with Staff #B on 03/07/10 at 4:12 P.M.

The medical record for Patient #3 was reviewed on 03/09/10. The patient was admitted on 03/06/10 with a diagnosis of pneumonia. Review of the medication administration record revealed the patient had been given Tylenol 325 milligrams (ii tablets) on 03/06/10 at 21:30 (9:30 P.M.) and on 03/07/10 at 11:45 A. M. and 20:47 (8:47 P.M.). The record lacked doumentation of a follow up assessment to evaluate the effectiveness of the medication. These findings were verified with Staff #B on 03/09/10 at 2:00 P.M.

The medical record for Patient #9 was reviewed on 03/09/10. The patient was admitted on 03/05/10 with a diagnosis of left knee replacement. The medication administration record documented the patient received Tylenol 325 milligrams (ii tablets) on 03/08/10 at 20:30 (10:30 P.M.) and 03/09/10 at 04:45 (4:45 A.M.). The record lacked documentation of a follow up assessment to evaluate the effectiveness of the medication. On 03/09/10 at 13:03 (1:03 P.M.) the patient was given Tramadol (pain medication). There was no documentation of an evaluation of the effectiveness of the medication. These findings were verified with Staff #B on 03/09/10 at 11:30 A.M.

The closed medical record for Patient #19 was reviewed on 03/11/10. The patient was admitted on 01/29/10 with diagnoses of pneumonia and congestive heart failure. The medication administration record documented the patient was given Tylenol Extra Strength on 01/31/10 at 00:30 (12:30 A.M.), 02/01/10 at 20:20 (10:20 P.M.) and 05:15 (5:15 A.M.), 02/03/10 at 2150 (11:50 P.M.) and 13:50 (1:50 PM.), 02/04/10 at 04:30 (4:35 A.M.), 08:25 (8:25 A.M.), and 15:00 (3:00 P.M.), and 02/05/10 at 21:30 (9:30 P.M.) The record lacked an evaluation of the effectiveness of the medication by a Registered Nurse. These findings were verified with Staff #B on 03/12/10 at 1:05 P.M.



03245

Medical record review was conducted for Patient #20 on 03/12/10. Nursing staff administered four different as needed medications to this patient between 02/07/10 through 02/09/10. The medical record lacked documentation of an assessment to evaluate the effectiveness of these medication in accordance with facility policy. These medications and times were as follows:

Pain medication (Morphine Sulfate) ordered 2 milligrams every hour as needed and given
on 02/07/10 at 7:40 P.M., 11:50 P.M.,
on 02/08/10 at 3:05 AM, 5:40 A.M., 6:50 A.M., 11:45 A.M., and 3:05 P.M., and 11:45 P.M.,
on 02/09/10 at 2:45 A.M., 9:45 P.M., and
on 02/10/10 at 12:15 A.M., and 3:15 A.M.

Pain medication (Dilaudid) 1 milligram was given on 02/10/10 at 9:35 A.M. one time only.

Antihistamine (Benadryl) 25 milligrams was given as needed for itching/rash on 02/11/10 at 1:30 A.M., 8:00 A.M., and 4:00 P.M.

Analgesic (Tylenol) two tablets were given on 02/07/10 at 7:30 P.M., and on 02/08/10 at 7:15 A.M.

Interview with Staff #B on 03/09/10 at 4:12 P.M. revealed the hospital policy directed the registered nurse who administers the as needed medications to evaluate and document the effectiveness in the medication administration record one half hour after intravenous medications were administered and one hour after oral as needed medications were administered.