HospitalInspections.org

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to put in place procedures for tracking of staff and patients.

Findings include:

1. Interview and documentation review on May 30, 2018, at 1:10 p.m., revealed a system for tracking the location of on-duty staff and sheltered patients during an emergency, or those that had been relocated during the emergency, was not included in the EP Plan.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the procedures for tracking staff and patients was not included in the EP Plan.

Based on a review of the facility's Emergency Preparedness (EP) Plan, it was determined the facility failed to put in place policies and procedures for operations during an emergency in accordance with the federal requirements under section 1135 of the National Emergencies Act, and the Stafford Act.

Findings include:

1. Interview and documentation review on May 30, 2018, at 1:25 p.m., revealed the facility did not develop and implement policies and procedures that describe its role in providing care at alternate care sites during emergencies, or what coordination efforts are required during a declared emergency under the Stafford Act.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the EP Plan lacked policy and procedures for operations during an emergency in accordance with the federal requirements under section 1135 of the National Emergencies Act, and the Stafford Act.

Based on observation and interview, it was determined the facility failed to to install protection for the fire alarm system in one instance, affecting the entire facility.

Findings include:

1. Observation on May 30, 2018, at 9:20 a.m., revealed that automatic smoke detection had not been installed at the fire alarm control unit location.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed that an automatic smoke detection device was not present at the fire alarm control unit location.

Based on observation and interview, it was determined the facility failed to maintain corridor walls in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 31, 2018, at 9:42 a.m., revealed the corridor wall above the ceiling near room 114, on the first floor had an unsealed flexible ductwork penetration. This is an area that is not protected by an automatic sprinkler system.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the flex duct penetration in the corridor wall.

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 31, 2018, at 10:22 a.m., revealed the second floor clean linen room corridor door failed to close and latch in its frame when closed by its self closing device.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the corridor door failed to close and latch when tested.

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of six smoke compartments.

Findings include:

1. Observation on May 31, 2018, at 10:20 a.m., revealed the cross corridor smoke barrier door, near room 212 on the second floor, failed to close and latch in its frame when released from the hold open device.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the smoke barrier door failed to close and latch.

Based on observation and interview, it was determined the facility failed to identify and label the door entering the medical gas central supply room, affecting one of six smoke compartments.

Findings include:

1. Observation on May 31, 2018, at 10:50 a.m., revealed the door to the second floor medical gas manifold room containing oxygen and other gases lacked the required labeling: Positive Pressure gases, No Smoking or Open Flame, Room May Have Insufficient Oxygen, Open Door and Allow Room to Ventilate Before Entering.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the medical gas room door lacked the required signage.

Based on observation and interview, it was determined the facility failed to maintain electrical wiring systems and equipment in four instances, on two of three floors.

Findings include:

1. Observation on May 30, 2018, revealed the following misuse of electrical wiring:

a) 9:00 a.m., a surge protector powering deck equipment was connected to an extension cord for power in the basement level kitchen;
b) 9:20 a.m., a refrigerator was connected to an extension cord for power in the basement level receiving office;
c) 9:25 a.m., a coffee maker was connected to a surge protector for power in the basement IT office.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the misuse of electrical wiring.

2. Observation on May 31, 2018, at 10:40 a.m., revealed a microwave oven was connected to a surge protector for power in the OR breakroom, on the second floor.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the misuse of electrical wiring.

Based on observation and interview, it was determined the facility failed to maintain medical gas storage requirements in one instance, affecting one of six smoke compartments.

Findings include:

1. Observation on May 31, 2018, at 9:15 a.m., revealed two unsecured medical gas "H" cylinders, and six unsecured oxygen "E" cylinders stored in the basement medical gas storage room.

Interview with the Administrator and Maintenance Director on May 31, 2018, at 11:30 a.m., confirmed the medical gas cylinders were not properly stored.