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Based on record review and interview the facility failed to ensure their emergency preparedness plan included a documented, facility-based and community based risk assessment which included strategies for addressing emergency events identified by the risk assessment as required.

Findings:

Record review showed the facility emergency preparedness plan did not include a hazard vulnerability analysis (HVA)/risk assessment which should have included strategies for addressing emergency events that would have been identified by the HVA/risk assessment as required.

On 11/17/20 at 10:30am the surveyor asked staff H to see the HVA that was used for their current emergency preparedness plan. Staff H stated they did not have a HVA and it was not included in their emergency preparedness plan but will be done.

Based on record review and interview the facility failed to ensure the communication plan contained a specific primary and alternative form of communication as required.

Findings:

Record review showed the facility emergency preparedness plan listed several forms of communication but did not delineate which specific ones were the primary or alternate form of emergency communication in the event a disaster occurred.

On 11/16/20 at 2:45 pm the surveyor asked staff H to show them the primary and alternative form of emergency communication in the event a local or facility disaster was to occur. Staff H agreed the plan showed several general forms of emergency communication. Staff H stated they will write in specific primary and alternative forms of emergency communication to be in compliance.

Based on observation and interview the facility failed to ensure corridor doors in a required means of emergency egress were not equipped with a latch/lock that requires two actions to open from the egress side as required.

Findings:

On 11/17/20 at 2:41 pm a thumbturn deadbolt was observed on a surgery area door which would not allow one action to exit from the egress side.

On 11/17/20 at 2:41 pm staff H was asked why there was a corridor door within the main hospital facility with a thumb turn deadbolt which would require two actions to open from the egress side which is not fire code compliant. Staff H stated they will remove the noncompliant deadbolt(s).

Based on observation and interview the facility failed to ensure each exit discharge had emergency generator powered or battery powered backed-up emergency lighting installed as required.

Findings:

On 11/17/20 at 11:37 am each of the seven designated exit discharges from the facility were observed to have lighting fixtures on normal power.

On 11/17/20 at 11:38 am the surveyor asked staff H if each of the seven exits if they were on emergency generator power or had emergency battery power for when the normal power goes off. Staff H stated they did not believe so. The surveyor explained that they could either wire each of the existing lighting fixtures to the generator or install battery powered backed up emergency lighting to be in compliance.

Based on observation and interview the facility failed to maintain a hazardous area free of penetrations as required.

Findings:

On 11/17/20 at 12:01pm the surveyor observed a medication closet with nine penetrations in the wall which would allow fire and/or smoke to spread throughout the facility.

On 11/17/20 at 12:03pm the surveyor asked staff H why the medication closet was not smoke tight. Staff H stated they were not aware and will get the ceiling repaired as soon as possible.