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Based on interview and document review, the hospital did not have an effective governing body that carried out the functions required of a governing body to provide a safe and secure environment for patients by the following:

The hospital did not ensure that its performance improvement activities included the evaluation and oversight of their fire safety system. Facilities management had not identified that non-sprinklered patient rooms and corridors did not have the necessary smoke detection system in the corridors of patient sleeping areas for 3 nursing units. A locked door egress in a non-sprinklered nursing unit had limited key access for some nursing staff but not all staff had the ability to open the door. Fire drills were incomplete with no evaluation for all nursing units that participated in the drills. A fire alarm near the outpatient area that was identified on a fire drill dated 8/2016 as not audible by nursing staff, has not been fixed. As a result there was a potential for harm for patients, hospital staff and visitors in the event of a fire. (See A-700)

The Hospital did not develop and maintain an emergency preparedness plan that ensured the special needs of the patient population treated in each psychiatric unit. In addition, the hospital's emergency plan for food and nutrition did not meet the needs of patients and staff. As a result, the safety and well-being of psychiatric patients and staff could not be assured during emergency situations. (See A-701)

The hospital failed to ensure the Fire Watch plan was implemented according to their immediate plan of correction. In addition, the hospital failed to train security staff on the Fire Watch policy and procedure. (Refer to A-710 and A-144)

Findings:

A review of the Governing Body (GB) minutes dated 5/2016 through 3/2017 was conducted on 6/8/17 at 8:15 A.M. There was no documentation in the minutes regarding the lack of smoke detection devices in the non sprinklered patient rooms and corridors. There was no documentation regarding the non-audible fire alarm near the outpatient area. There was no documentation regarding the fire drills lack of evaluation for all nursing units that participated in the drills.

An interview with the CEO was conducted on 6/8/17 at 8:55 A.M. The CEO stated that the expectation is for Facilities management to report any fire safety issues to the Quality Department. The CEO stated regarding the non-audible fire alarm near the outpatient area that it should have been fixed. The CEO stated it is her expectation that fire drills should meet the regulatory requirements. The CEO acknowledged that FM should address any regulatory non-compliance regarding fire safety issues either by fixing the problem or reporting to quality. The CEO stated it is her expectation that the FM manager should have a job description. The CEO acknowledged that the Emergency Management Plan should be specific to the Hospital's psychiatric units and population.

The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Governing Body and failure to provide a safe and secure environment for patients.

Based on observation, interview, and record review, the hospital failed to ensure a Fire Watch Plan was implemented according to their immediate plan of correction to ensure patient safety in the event of a fire. In addition, the hospital failed to train security staff on the Fire Watch policy and procedure.

As a result, the health and safety of patients on Intensive Care Unit (ICU), North Rotunda (NR), and East Wing 2 (EW 2) was at risk in the event of a fire.

Findings:

On 6/7/17 at 5:16 P.M., hospital administration was notified of Immediate Jeopardy to the health and safety of patients on the ICU, NR, and EW 2. The hospital failed to ensure these non sprinklered units of the hospital had the required smoke detection system in the patient rooms or corridors of the patient sleeping areas and failed to ensure all staff had ability to open an egress door in corridor of the ICU.

On 6/7/17 at 7:25 P.M., the hospital provided a written plan to ensure the safety of patients in the event of a fire on the non-sprinklered units. The immediate plan of correction included initiation of the hospital's Fire Watch Plan to ensure patient safety from fire until the hospital secured a permanent fire detection system.

According to the hospital's policy entitled, Establishing a Fire Watch, dated 9/15, "... Fire Watch Personnel- A trained individual assigned to an area for the purpose of protecting the occupants from fire...Fire watch personnel shall be provided 24 hours a day until the system has been verified in proper operational order...Fire watch personnel shall be on constant patrol for signs of fire, keep a log of entries consisting of the date, time, area observed... Engineering is responsible: Explain the purpose of fire watch and duration to the fire watch personnel... Establish the frequency of rounds, locations to be observed, and break procedures..."

On 6/8/17 at 9:46 A.M., SO 71 was observed conducting Fire Watch rounds in the male and female sleeping areas of the ICU. SO 71 was did not enter patient rooms or locked rooms of the corridor to ensure safety from fire.

On 6/8/17 at 11:40 A.M., the Vice President of Campus Planning (VPCP) provided the Fire Watch logs from the time the watch was initiated on the evening of 6/7/17. There was no documentation which indicated Fire Watch had been conducted on the NR unit since 6:30 A.M. on 6/8/17. The VPCP was unaware the log had not been completed and had just reviewed the logs himself.

On 6/8/17 at 11:50 A.M., the Security Officer (SO 71) was observed in the ICU female hallway with a Mental Health Worker (MHW). SO 71 entered a patient room, looked around the room, and walked out. SO 71 did not enter the patient's bathroom. SO 71 then passed the medication room without stopping to open the door and observe the room. SO 71 stated he was unaware he was responsible for Fire Watch on the NR unit.

On 6/8/17 at 12:05 P.M., SO 71 was observed on the NR unit with the VPCP. SO 71 entered a patient room (150), looked around the room, and walked out. At that time, the same patient room was entered with LN 49. The patient room had a private bathroom with a shower and the shower curtain was half open. Behind the door to the patient's room was a built in wardrobe with 2 closed doors. LN 49 stated all patient rooms on the unit had private bathrooms with showers and wardrobes.

On 6/8/17 at 12:10 P.M., the VPCP stated the hospital did not educate SO 71 on the Fire Watch procedure prior to his shift. The VPCP stated, he expected the Security Officers to be competent with the procedure since they were trained upon hire. The VPCP verified Fire Watch not been completed on the NR unit since 6:30 A.M. on 6/8/17. The VPCP stated, he expected the SO to enter every room on the unit including the patient bathrooms. SO 71's Fire Watch competency was requested.

On 6/8/17 at 3 P.M., the VPCP stated the SO fire competency training did not include the process of performing fire watch and did not describe step by step instructions. The VPCP stated the Security Officers were given the log documents at the beginning of their shift and told to "do fire watch" and no other instructions were given. The VPCP confirmed the SOs needed further education on the Fire Watch procedure.

Based on interview and document review, the hospital failed to develop, implement and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program as evidenced by the following:

1)The hospital did not ensure that its performance improvement activities included the evaluation and oversight of their fire safety system. Facilities management had not identified that non-sprinklered patient rooms did not have the necessary smoke detection system in the corridors of patient sleeping areas for 3 nursing units. A locked door egress in a non-sprinklered nursing unit had limited key access for some nursing staff but not all staff had the ability to open the door. Fire drills were incomplete with no evaluation for all nursing units that participated in the drills. A fire alarm near the outpatient area that was identified on a fire drill dated 8/2016 as not audible by nursing staff, has not been fixed. As a result there was a potential for harm for patients, hospital staff and visitors in the event of a fire. (See A-700 and A-710)

2)The Hospital did not develop and maintain an emergency preparedness plan that ensured the special needs of the patient population treated in each psychiatric unit. In addition, the hospital did not ensure the food and nutritional needs were met for patients and staff during an emergency. As a result, the safety and well-being of psychiatric patients and staff could not be assured during emergency situations. (See A-701)

3)The hospital failed to ensure the Fire Watch plan was implemented according to their immediate plan of correction. In addition, the hospital failed to train security staff on the Fire Watch policy and procedure. (See A-144 and A-710)

Findings:

1) A review of the Personnel file for the Facility Manager (FM) and concurrent interview with the Director of Human Resources (DHR) was conducted on 6/7/17 at 11:45 A.M. The file did not contain a job description for the FM. The DHR acknowledged that a job description for the FM could not be produced.

A review of the Environment of Care Tours for FY 2016 was conducted on 6/8/17 at 10:00 A.M. There was no documentation of the lack of smoke detection devices in the non sprinklered patient room corridors or the non-audible smoke alarm near the outpatient area.

A review of the Performance Improvement Patient Safety Infection Control Committee (PIPSIC) meeting minutes dated FY 2016 was conducted on 6/7/17 at 12:45 P.M. A document entitled FY 2016 Departmental Report Card-Plant Operations indicated that for staff knowledge for fire safety and fire drill evaluations was 100% from October 2015 through May 2016. There was no documentation of issues with non sprinklered patient rooms without smoke detection devices, key access in the locked unit or the non-audible fire alarm.

An interview with the Director quality (DQ) was conducted on 6/7/17 at 12:50 A.M. The DQ stated that she was not sure what metric Plant operations used to determine the 100% of staff knowledge for fire safety and fire drill evaluations. The DQ further stated that Plant Operations had not brought any issues regarding fire safety compliance to quality.

2) An interview with the Director of Emergency Preparedness (DOP) was conducted on 6/6/17 at 11:15 A.M. The DOP stated that Hospital A's emergency response plan was system wide to encompass both Hospital A's psychiatric population and the adjacent Hospital B's general acute care population. The DOP acknowledged that Hospital A had not developed an HVA or emergency response plan that was specific to Hospital A's psychiatric units and population.

An interview with the CEO was conducted on 6/8/17 at 8:55 A.M. The CEO stated that the expectation is for Facilities management to report any fire safety issues to the Quality Department. The CEO stated regarding the non-audible fire alarm near the outpatient area that it should have been fixed. The CEO stated it is her expectation that fire drills should meet the regulatory requirements. The CEO acknowledged that FM should address any regulatory non-compliance regarding fire safety issues either by fixing the problem or reporting to quality. The CEO stated it is her expectation that the FM manager should have a job description. The CEO acknowledged that the Emergency Management Plan should be specific to the Hospital's psychiatric units and population.



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3. On 6/7/17 at 7:25 P.M., the hospital provided a written plan to ensure the safety of patients in the event of a fire on the non-sprinklered units without fire detection systems which were ICU, North Rotunda (NR), and East Wing 2 (EW 2). The immediate plan of correction included initiation of the hospital's Fire Watch Plan to ensure patient safety from fire until the hospital secured a permanent fire detection system.

According to the hospital's policy entitled, Establishing a Fire Watch, dated 9/15, "... Fire Watch Personnel- A trained individual assigned to an area for the purpose of protecting the occupants from fire...Fire watch personnel shall be provided 24 hours a day until the system has been verified in proper operational order...Fire watch personnel shall be on constant patrol for signs of fire, keep a log of entries consisting of the date, time, area observed... Engineering is responsible: Explain the purpose of fire watch and duration to the fire watch personnel... Establish the frequency of rounds, locations to be observed, and break procedures..."

On 6/8/17 at 9:46 A.M., SO 71 was observed conducting Fire Watch rounds in the male and female sleeping areas of the ICU. SO 71 was did not enter patient rooms or locked rooms of the corridor to ensure safety from fire.

On 6/8/17 at 11:40 A.M., the Vice President of Campus Planning (VPCP) provided the Fire Watch logs from the time the watch was initiated on the evening of 6/7/17. There was no documentation which indicated Fire Watch had been conducted on the North Rotunda unit since 6:30 A.M. on 6/8/17. The VPCP was unaware the log had not been completed and had just reviewed the logs himself.

On 6/8/17 at 11:50 A.M., SO 71 was observed in the ICU female hallway with a Mental Health Worker (MHW). SO 71 entered a patient room, looked around the room, and walked out. SO 71 did not enter the patient's bathroom. SO 71 then passed the medication room without stopping to open the door and observe the room. SO 71 stated he was unaware he was responsible for Fire Watch on the North Rotunda unit.

On 6/8/17 at 12:05 P.M., SO 71 was observed on the North Rotunda unit with the VPCP. SO 71 entered a patient room, looked around the room, and walked out. At that time, the same patient room was entered with LN 49. The patient room had a private bathroom with a shower and the shower curtain was half open. Behind the door to the patient's room was a built in wardrobe with 2 closed doors. LN 49 stated all patient rooms on the unit had private bathrooms with showers and wardrobes. SO 71 did not enter the patient bathroom or check the wardrobe during the observation.

On 6/8/17 at 12:10 P.M., the VPCP stated the hospital did not educate SO 71 on the Fire Watch procedure prior to his shift. The VPCP stated, he expected the SOs to be competent with the procedure since they were trained upon hire. The VPCP verified Fire Watch not been completed on the North Rotunda unit since 6:30 A.M. on 6/8/17. The VPCP stated, he expected the SO to enter every room on the unit including the patient bathrooms. SO 71's Fire Watch competency was requested.

On 6/8/17 at 3 P.M., the VPCP stated the SO fire competency training did not include the process of performing Fire Watch and did not describe step by step instructions. The VPCP stated the SOs were given the log documents at the beginning of their shift and told to "do fire watch" and no other instructions were given. The VPCP confirmed the SOs needed further education on the Fire Watch procedure.

The cumulative effect of the facility's failure to have a quality assurance system in place to ensure oversight of the hospital's fire safety and lack of smoke detection system in high risk problem prone areas such non sprinklered patient rooms and corridors, locked psychiatric nursing units resulted in the facility's failure to deliver care in compliance with the Condition of Participation for QAPI and failure to provide care to their patients in a safe environment.

Based on interview and record review the facility failed to ensure a licensed nurse documented a reassessment after the administration of pain medication for 1 of 34 sampled patients (Patient 21).

As a result, Patient 21 was at risk for unrelieved pain.

Findings:

Patient 21 was admitted to the facility on 6/5/17, with a diagnosis of alcohol use disorder, per the facility Facesheet.

On 6/6/17 at 10 AM, Patient 21's record was reviewed with LN 1. On 6/5/17 at 9:08 PM, the LN documented Patient 21's pain level was 10 on a scale of 1-10 (1 being the lowest and 10 the highest) and the LN administered pain medication to the patient. There was no documentation which indicated Patient 21 was reassessed for the effectiveness of the pain medication.

During an interview on 6/6/17 at 10:15 AM, the Nurse Manager stated the LN should have reassessed Patient 21's pain level after the pain medication was administered for effectiveness.

The facility policy and procedure entitled, Patient Screening, Assessment and Management of Pain, dated 12/2014, "... Reassess the patient within 60 minutes to evaluate the effectiveness of pain management interventions."

Based on interview and record review, the hospital failed to:
1. Ensure the Licensed Nurses (LNs) assessed and documented a pain assessment for 1 of 34 sampled patients (Patient 11) prior to administering pain medication.

As a result, Patient 11 was at risk for unrelieved pain.

2. Ensure medications were prepared according accepted standards of practice. Sodium chloride flush (a single-dose medication, NS flush, small amount of fluid usually administered directly into the vein before and/or after medication administration) was routinely prepared in advance and stored, and was not discarded immediately as specified by the hospital's policy.

As a result, 1413 Electroconvulsive Therapy (ECT, a procedure where small electric currents are passed through the brain to cause changes in the brain to treat mental illnesses) cases were performed during a three-month sample period, and patients were potentially exposed to infection risks.

Findings:

1. Patient 11 was admitted to the facility on 11/11/16 with diagnoses which included mood disorder, according to the History and Physical.

On 6/6/17 at 2:30 P.M., Patient 11's EMR was reviewed with the CNO.

On 11/14/17 at 9:15 A.M., Patient 11's physician ordered Ibuprofen (pain medication) as needed for pain.

On 11/14/16 at 10:28 A.M. the LN administered ibuprofen to Patient 11. There was no documentation Patient 11 was assessed for pain according to the hospital's policy. At 12:24 P.M., the LN documented the ibuprofen was "effective". There was no documented description of the patient's pain or a pain score documented.

On 11/14/16 at 4:32 P.M., the LN administered ibuprofen to Patient 11. There was no documentation Patient 11 was assessed for pain according to the hospital's policy.

On 6/6/17 at 2:45 P.M. the CNO stated, the LNs should have documented a pain assessment when they administered the ibuprofen to Patient 11. The CNO further stated, the LNs were expected to reassess the patient within 1 hour of pain medication administration for effectiveness, according to hospital policy.

The facility policy and procedure entitled, Patient Screening, Assessment and Management of Pain, dated 12/2014, "... Reassess the patient within 60 minutes to evaluate the effectiveness of pain management interventions."


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2. A tour of the ECT treatment area was conducted with RN 40, who was a nurse in the ECT, Pharmacist (P) 1 and P 2 on 6/5/17 at 3:10 P.M.

Eight (8) NS flushes, each connected to a tubing connection, were in the storage bin. Each NS flush was for single-use, and contained no preservatives, according to the manufacturer's label.

RN 40 stated it was "common practice" for the nurses to connect the tubing to the flush in advance. RN 40 stated she could not determine when these 8 flushes were prepared because they did not contain the preparation date.

RN 40 and P 2 acknowledged the flushes should not have been prepared in advance [and stored].

During an interview on 6/6/17 at 1:20 P.M., P 2 stated the flushes were used to flush the intravenous lines (where medications were administered directly into the veins) for medication administration.

The Infection Preventionist (IP) was interviewed on 6/6/17 at 2:45 P.M. regarding the practice. The IP acknowledged the practice was not acceptable.

According to the document received from the Director of Regulatory Affairs (DRA) on 6/7/17, 1413 ECT cases were performed during a three-month sample period.

According to the hospital's policy, Expiration Dating - Medications, effective date 5/15, "Single-dose vial (SDV): Vials of injectable medication containing the labeling "single-dose." These vials contain no preservative and are not to be used for more than one dose, regardless of their size or capacity... Opened single dose vials should be discarded immediately after use."

Based on interview and record review, the hospital failed to ensure a History and Physical included a treatment plan for 1 of 34 sampled patients (Patient 12).

As a result, Patient 12's History and Physical was incomplete.

Findings:

Patient 12 was admitted to the facility on 5/29/17, with diagnoses which included schizoaffective disorder, according to the History and Physical.

On 6/5/17 at 3 P.M., Patient 12's record was reviewed with LN 12.

On 5/30/17, MD 1 completed a History and Physical for Patient 12. The H&P did not include a plan for the patient's care during the hospitalization. LN 12 stated, the H&P should have included a plan of treatment.

Per Hospital Acreditation medical record standards dated 2017, the H&P's required content should be pertinent, relevant and include sufficient information necessary to provide the care, treatment and services required to address the patient's condition, planned care and assessed needs.

Based on observation, interview, and document review, the hospital failed to ensure medications were stored in sanitary conditions, according to the policy. Medications were in storage bins that were not clean.

As a result, the hospital could not ensure the integrity of its medications.

Findings:

1. A tour of the Pharmacy was conducted on 6/5/17 at 10:15 A.M. with Pharmacist (P) 1 and P 2.

The following medications were stored in containers that were dusty:

Propofol (injectable medication to cause sedation) 100 mg in 10 ml, quantity 2;
Sumatriptan (injectable medication for migraine) 6 mg in 0.5 ml, quantity 2; and
Promethazine (injectable medication for nausea) 25 mg in 1 ml, quantity 8.

Both P 1 and P 2 agreed the storage bins were dusty.

2. A tour of the Electroconvulsive Therapy (ECT, a procedure where small electric currents are passed through the brain to cause changes in the brain to treat mental illnesses) treatment area was conducted with RN 40, Pharmacist (P) 1 and P 2 on 6/5/17 at 3:10 P.M.

Eight (8) sodium chloride flushes (a single-dose medication, small amount of fluid usually administered before and/or after each medication administration) were in the storage bin.

RN 40 acknowledged the storage bin was not clean.

According to the hospital's policy, Drug Storage/Security, effective date 1/17, "Medications... must be stored under proper conditions of sanitation...."

Based on observation, interview, and document review, the hospital failed to ensure medications in the Pharmacy were securely stored to prevent unauthorized access. Four (4) pharmacy technicians had access to the pharmacy 24 hours a day, 7 days a week, and potentially could enter the pharmacy without the pharmacist present.

As a result, the hospital could not ensure medications were securely stored in the Pharmacy.

Findings:

During an interview on 6/5/17 at 10:05 A.M. with Pharmacist (P) 2, the pharmacy manager who was responsible for pharmaceutical services, and P 1, they stated the pharmacy hours were 7 A.M. to 10 P.M., 7 days a week.

A tour of the Pharmacy was conducted with P 1 and P 2 on 6/5/17 at 10:15 A.M. Staff (both pharmacists and pharmacy technicians) scanned the employee badges to access the pharmacy. P 2 acknowledged access to the pharmacy was not restricted for the pharmacy technicians between the hours of 10 P.M. and 7 A.M. when the pharmacist was not present in the pharmacy.

According to the hospital's policy, Drug Storage/Security, effective date 1/17, "Medications... must be stored under proper conditions of... security."

Based on observation, interview, and document review, the hospital failed to ensure medications were protected from light as required by the manufacturers. Medications were exposed to light, contrary to the manufacturer's specifications for storage.

As a result, the hospital could not ensure the potency (strength) and integrity (quality) of its medications.

Findings:

A tour of the Pharmacy was conducted on 6/5/17 at 10:15 A.M. with Pharmacist (P) 1 and P 2. The following medications were exposed to ambient light:

Naloxone (injectable medication to reverse the effect of opioid, or to treat opioid overdose) 0.4 mg in mL, quantity 5;
Labetalol (injectable medication to control heart rate) 200 mg in 40 ml, quantity 1; and
Geodon (injectable medication to treat mental conditions) 20 mg in ml, quantity 7.

The manufacturer's specifications indicated these medications should be protected from light.

P 1 and P 2 agreed these medications were not protected from light.

According to the hospital's policy, Drug Storage/Security, effective date 1/17, "Medications are stored in compliance with manufacturers' recommendations. They must be stored under proper conditions of ... light...."

Based on observation, interview, and record review the facility failed to implement a physician order for a lab specimen for 1 of 34 sampled patients (Patient 22).

As a result, Patient 22 was at risk for inadequate assessment and care planning.

Findings:

Patient 22 was admitted to the facility on 5/31/17, with a diagnosis of alcohol use disorder, per the facility Facesheet.

On 6/6/17 at 9:31 A.M., Patient 22's medical record was reviewed.

On 5/31/17, Patient 22's physician ordered a urine analysis. LN 3 documented she collected Patient 22's urine sample on 5/31/17 at 1 P.M.

On 6/6/17 at 9:31 A.M., LN 1 and LN 2 were interviewed. LN 1 stated she was unable to find results for Patient 22's urine analysis ordered by the physician on 5/31/17. LN 2 stated he called the laboratory and confirmed they never received the urine specimen.

On 6/6/17 at 2:44 P.M., the Director of Laboratory was interviewed. The Director of Laboratory stated, once a specimen was collected by the LN, a courier should have picked up the specimen and delivered it to the laboratory. The Director stated the laboratory technician should have reconciled the specimen with the pending physician order and notified the LN when they did not receive the specimen. The Director of Laboratory was unable to explain what happened to the urine sample. He stated, "The laboratory staff should have verified they received Patient 22's specimens and order. This is an opportunity to fix a systems error."

The facility policy and procedure entitled Pending Test, Review and Resolution, dated 8/2016, "Evaluate each pending test for possible statuses... Specimen collected but not received/logged-in..."

Based on observation, interview and facility document review, the facility failed to provide portion sizes as indicated on the menu. This failure had the potential to not meet or exceed the nutritional needs of patients, as calculated for the approved menus, and lead to nutritional related disease or illness.

Finding:

A review of the spreadsheet menu used for lunch on 6/6/17 titled "Week 3 11/28/106 - 12/4/2016" indicated a number 8 scoop (1/2 Cup) for refried beans, and a number 12 scoop (1/3 Cup) for Mexican Rice.

On 6/6/17 at 11:40 a.m., Diet Aide 3 (DA3) served refried beans with a number 10 scoop (3/8 Cup), which was less than what was indicated on the menu, and Mexican rice with a number 8 scoop (1/2 Cup), which was more than what was indicated on the menu.

On 6/6/17 at 11:50 a.m., in an interview with the General Manager of Food and Nutrition (GMFN), she confirmed the scoops for the rice and beans were incorrect according to the menu.

An interview with GMFN on 6/7/17 at 1:15 p.m. and a review of the untitled, undated, document provided by GMFN read "Why is portion control so important? Too much or too little food can cause unplanned weight loss or weight gain... When ordering diabetic diets all carbohydrates must be fulfilled. Some patients may be overwhelmed by too much food. Serving inaccurate portions can cause trayline to run out of food..." GMFN stated this document is used to train staff. She had signed copies for staff trained on this document but did not have a signed copy that showed DA3 was trained.

Based on interview and record review, the facility failed to ensure that therapeutic supplements provided to patients were ordered by a physician for patient 51 (P 51) and patient 52 (P 52).

Findings:

State of California, Business and Professions Code (B&P Code), Division 2, Chapter 5.65 describes the Scope of Practice of Registered Dietitians (RD) as follows "Notwithstanding any other law, a registered dietitian, or other nutritional professional meeting the qualifications set forth in subdivision (e) of Section 2585 may, upon referral by a health care provider authorized to prescribe dietary treatments, provide nutritional and dietary counseling, conduct nutritional and dietary assessments, and develop and recommend nutritional and dietary treatments, including therapeutic diets, for individuals or groups of patients in licensed institutional facilities." Additionally the B&P Code specifies that the RD, "shall collaborate with a multidisciplinary team, which shall include the treating physician and the registered nurse, in developing the patient's nutrition care plan. The B&P code also specifies that the RD may, "individualize the patients' nutritional treatment, when necessary, by modifying the distribution, type, or quantity of food and nutrients within the parameters of the diet order."

In an interview on 6/7/17 at 10:45 a.m., the Registered Dietitian (RD1) stated the dietitians did assessments on patients and if a supplement was needed for a therapeutic reason, the dietitian ordered a supplement from a list of supplements and then notified the patient's doctor that the supplement was ordered. She said that dietitians had the flexibility to order any supplement on the list for any patient and that diets in the facility's diet manual did not specify which supplements could be given a prescribed diet. When the surveyor asked RD1 if a dietitian had the authority to order a supplement intended for patients with renal (kidney) disease for a patient with diabetes, she said yes.

A review of the approved list of supplement list titled "Oral Supplement Formulary" dated 9/2016 included 14 supplements with indications of use that included poor oral intake, additional protein needs, diabetes, kidney disease, impaired gastro-intestinal function, major surgery and large wounds.

A review of the "Nutrition Assessment/Reassessment" notes dated 6/5/17 written by RD1 for Patient 52 (P 52) indicated the patient's current nutrition status was assessed as severe malnutrition. In the Plan of Care section of the assessment it is written to "Recommend Boost Plus with meals ... (discussed with RN [Registered Nurse] and will send MD [Medical Doctor] communication)."

A review of the Dietary Supplements order for P 52 showed the original order for Boost Plus TID (three times a day) was ordered and electronically signed by RD1 on 6/5/17 at 2:45 p.m. There was no physician signature.

A review of the "Nutrition Assessment/Reassessment" notes dated 6/5/17 written by Registered Dietitian 3 (RD3) for Patient 51 (P 51) indicated the patient's current nutrition status was assessed as moderate malnutrition. This patient also had a history of type 1 insulin dependent diabetes. The Plan of Care section of the assessment read "Pt [patient] with weight loss of 7 lbs [pounds] in the past few months, current weight is 86% of IBW [Ideal Body Weight]... Pt agree to Glucerna with meals since po [by mouth] intake has been very poor since admission."

A review of the Dietary Supplements notes order for P 51 showed the original order for "Glucerna Therapeutic" was entered and electronically signed by RD 3 on 6/5/17 at 9:24 a.m. There was no physician signature.

Based on observation, interview and document review, the hospital did not maintain compliance with fire safety and emergency management requirements, as evidenced by:

1a. The hospital did not develop and maintain an emergency preparedness plan that ensured the special needs of the patient population treated in each psychiatric unit.

1b. The hospital did not ensure the safety and well-being of patients and staff when:

a.) emergency food for staff was not stored on the premises;
b.) the emergency binder did not contain therapeutic diets; and
c.) non-kitchen staff did not know where the emergency binder to implement emergency food service;
d.) there were not air-gaps (a space between the water supply inlet and the flood level rim of the sink) for equipment in the in the kitchen; and
e.) a walk-in freezer had a significant amount of condensation and ice build-up.

As a result, the safety and well-being of psychiatric patients and staff could not be assured during emergency situations. Refer to A-701

2. Based on observation, record review, and interview, the facility failed to meet the provisions under the NFPA (National Fire Protection Association) 101, Life Safety Code 2012 Edition. Refer to A-710

The cumulative effect of these systemic problems resulted in the facility's failure to deliver care in compliance with the Condition of Participation for Physical Environment and failure to provide a safe and secure environment for patients.

Based on observation, interview and document review, Hospital A:
1. Did not develop and maintain an emergency preparedness plan that ensured the special needs of the patient population treated in each psychiatric unit.

2. Did not ensure the safety and well-being of patients and staff when:

a.) emergency food for staff was not stored on the premises;
b.) the emergency binder did not contain therapeutic diets; and
c.) non-kitchen staff did not know where the emergency binder to implement emergency food service;
d.) there were no air-gaps (a space between the water supply inlet and the flood level rim of the sink) for equipment in the in the kitchen; and
e.) a walk-in freezer had a significant amount of condensation and ice build-up.

As a result, the safety and well-being of psychiatric patients and staff could not be assured during emergency situations.

Findings:

A tour and observation of the Hospital A was conducted on 6/5/17 at 10:20 A.M. Hospital A is a psychiatric facility that provides inpatient and outpatient behavioral health services for adults, senior adults, adolescents and children. The Nursing unit layout of the main hospital consisted of 5 locked psychiatric units and 2 open units and a separate building Child and Adolescent Unit (CAP 3) where the children and adolescents are housed. A tour of EW2 and concurrent patient record review indicated that Patient 5 and 6 are receiving Electroconvulsive therapy (ECT) - a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. An interview with the Chief Medical Officer was conducted on 6/8/17 at 3:00 P.M. The CMO stated that the side effects of ECT therapy may include confusion and memory loss.

A review of document entitled [Hospital] Nursing Unit Layout and concurrent interview with the Facilities Manager (FM) was conducted on 6/7/17 at 11:55 A.M. The FM stated that three of the 7 nursing units (East Wing 2-EW2, North Rotunda-NR and Intensive Care Unit-ICU) were partially protected for fire safety which means that EW2 and NR units were non- sprinklered with no smoke detection devices in patient room corridors and nurses station. The ICU central nursing unit was sprinklered and the patient room corridors were not sprinklered and did not have smoke detection devices. The ICU is locked with a key that only staff have access to and patients are not able to leave the unit without staff assistance due to their acute psychological status. The FM acknowledged that emergency response training and drills were very important to ensure the safety of the psychiatric patients in the locked and partially fire protected units.

Per Hospital A's Policy and Procedure entitled "Admission, Transfer and Discharge to Behavioral Health Services" dated 3/2017, the three partially fire protected nursing units admission criteria are descried as:

EW-2 Unit's patient population has a severity of illness that does not require hospitalization on locked (secured) unit, a primary psychiatric diagnosis, 18 years and older, and adolescents under special circumstances . EW2 patients are able and willing to manage self in a less restrictive environment and move safely from unit to cafeteria and other outside areas. EW2's patients must have one of the following: presence of active withdrawal symptoms (unstable vital signs, agitation, withdrawal hallucinations, confusion, disorientation or seizures) or pattern of use of abused substances predicting the potential for clinically significant withdrawal necessitating 24-hour medical intervention to prevent complications. Concurrent interview with the Director of Regulatory Affairs (DRA) indicated that EW2 Patients requiring treatment of active withdrawal symptoms may receive Librium (a benzodiazepine (anti anxiety) medication with the following potential side effects (drowsiness, tiredness, dizziness, blurred vision, confusion, depression, hallucinations and difficulty walking). Patients on EW2 may be treated with Electroconvulsive therapy (ECT) - a procedure, done under general anesthesia, in which small electric currents are passed through the brain, intentionally triggering a brief seizure. Side effects of ECT therapy may include confusion and memory loss.

North Rotunda (NR) unit's patient population has a primary diagnosis of chemical dependence 18 years and older, and adolescents under special circumstances. NR's patients must have presence of active withdrawal symptoms (unstable vital signs, agitation, withdrawal hallucinations, confusion, disorientation or seizures) or pattern of use of abused substances predicting the potential for clinically significant withdrawal necessitating 24-hour medical intervention to prevent complications. Concurrent interview with the Director of Regulatory Affairs (DRA) indicated that NR patients requiring treatment of active withdrawal symptoms may receive Librium (a benzodiazepine medication with the following potential side effects (drowsiness, tiredness, dizziness, blurred vision, confusion, depression, hallucinations and difficulty walking).

The ICU's Patient population has a primary diagnosis of severity of illness requires hospitalization on locked (secured) unit, primary psychiatric diagnosis, 18 years and older, adolescents under special circumstances and emancipated minors who can separately be treated safely on ICU. The ICU's psychiatric inclusion acuity describes patients that are a threat to self or others requiring 24 hour professional observation, acute disordered behavior, psychomotor agitation that can only be addressed in a an acute inpatient setting. ICU criteria also requires constant observation for self harm or disruptive behavior, suicidal precautions, assault risk or temporary seclusion and or restraint. Patients admitted to the ICU may exhibit psychosis (a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality), hallucinations and may be treated with anti-psychotic medication that may have an effect on physical mobility such as difficulty walking.

A review of the Hospital's Hazard Vulnerability Analysis (HVA) - a risk assessment that is a systematic approach to identifying hazards or risks that are most likely to have an impact on a healthcare facility and the surrounding community, was conducted on 6/6/17 at 10:00 A.M. The HVA was a system wide analysis that was not specific to Hospital A's psychiatric units or population. The HVA did not identify the special safety needs that may complicate the evacuation process of the psychiatric patients in the locked ICU, EW2 and NR units that have non sprinklered patient rooms and corridors with no smoke detection devices in the corridors.

The Hospital's Emergency Response Plan (ERP) dated 12/2016 was reviewed on 6/6/17 at 10:00 A.M. The plan was a system wide emergency response plan that included Hospital B (a general acute care hospital that is on the same campus as hospital A). The plan was not specific to Hospital A to describe the emergency response for Hospital A's psychiatric units or population. The ERP did not identify the special safety needs that may complicate the evacuation process of the psychiatric patients in the locked ICU, EW2 and NR units that have non sprinklered patient rooms and corridors with no smoke detection devices in the corridors.

An interview with the Director of Emergency Preparedness (DOP) was conducted on 6/6/17 at 11:15 A.M. The DOP stated that Hospital A's emergency response plan was system wide to encompass both Hospital A's psychiatric population and the adjacent Hospital B's general acute care population. The DOP acknowledged that Hospital A had not developed an HVA or emergency response plan that was specific to Hospital A's psychiatric units and population to identify the special safety needs that may complicate the evacuation process of the psychiatric patients.




34975

2a. On 6/8/17 at 9 a.m., a review of the disaster food binder and concurrent interview with the General Manager of Food and Nutrition (GMFN) showed that the calculation for food needed to implement disaster food service was calculated to include the number of licensed beds and 8 staff. When the surveyor asked GMFN if 8 staff would be able to run the entire hospital in a disaster, she stated that disaster food was calculated for 158 staff and was stored off the premises at another hospital on the campus. When the surveyor asked GMFN if there was a disaster and staff could not leave or enter the building, she stated there would probably be more than 8 staff to feed.

A review of the policy and procedures provided by the facility titled "Food Supply in a Disaster" dated 2/2012 read "The disaster supply will accommodate the 3-days of non-perishable food required to service the total number of licensed beds plus staff/volunteers. Supplies shall be appropriate to meet the requirements of the menu."

b. On 6/8/17 at 9 a.m., a review of the disaster food binder and concurrent interview with RD1, showed there were no menus, including therapeutic diet menus that reflected the diets of the facility's patients. RD 1 stated the nutrient analysis was used as the disaster menu. The nutrient analysis was not signed by a dietitian and did not specify the type of diet. The nutrient analysis was also not descriptive for use as a menu as shown when RD1 stated when the nutrient analysis listed "Nutrient supplement, milk-based, powdered, not reconstituted Portion: 2:0 of 1 tablespoon (25.0g)" for breakfast and dinner on all 3 days of the analysis, she assumed the powdered milk would be reconstituted with water. RD1 confirmed the analysis did not state to reconstitute the powdered milk with water.

In an interview on 6/8/17 at 10:30 a.m., Registered Dietitian 1 (RD1) stated the facility had about 2 patients on a renal (kidney) diet a year.

A review of the document provided by the facility titled "Host/Hostess Worklist by Unit" dated 6/6/17 showed 9 patients received an 1800 calorie diabetic diet, 2 patients received a 2000 calorie diabetic diet, and 3 patients received a mechanical soft diet.

A review of the policy and procedure titled "Food Supply in a Disaster" dated 2/2012 read "Menus: Meals utilizing the designated disaster food should be planned in advance for 3-days. Menus should include guidance for therapeutic diets such as cardiac, renal, etc, mechanically altered diets and tube feedings.

c. In an interview on 6/8/17 at 11:15 a.m. with the District Manager of Food and Nutrition (DMFN), she stated the AL (Administrator Liaison) executed the disaster plan.

In an interview on 6/8/17 at 12 p.m. with Registered Nurse 50 (RN 50), he stated he was the AL that day. When the surveyor asked if there was an emergency where nobody could enter or exit the building and food and nutrition staff were not on the premises, how would meal service be implemented, he stated "he would cater meals in because nursing wouldn't be able to cook a meal." Then RN 50 flipped through pages of the "Fire Safety and Disaster" binder and stated "nobody has ever asked me this before. I don't think there's anything about food in here [the Fire Safety and Disaster binder]."

In an interview on 6/8/17 at 12:10 p.m. with the Senior Safety Manager Specialist (SSMS), DMFN, and GMFN, the surveyor asked who at the facility, with the exception of Food and Nutrition staff, knew where to locate the disaster binder to implement food service and who was trained to implement food service. SSMS, DMFN, and GMFN did not identify anyone on the premises.

d. An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch)." (Federal Food Code 2013).

On 6/6/16, at 9 a.m., an observation showed an ice machine labeled "ice machine [number] 2], a steamer, and the walk-in "salad" refrigerator. All three pieces of equipment had a drain pipe that led to a sink in the floor. The drain pipes for the ice machine and the walk-in refrigerator came into contact the flood level rim of the sink. The drain pipe for the steamer was inside the floor sink, below the flood level of the sink. No air gaps were observed for the three pieces of equipment.

In an interview on 6/7/17 at 12:20 p.m., the Plant Operations Manager (POM) acknowledged that there were inadequate vertical space between the end of the pipe and the top of the floor drain for ice machine number 2, the steamer, and the walk-in salad refrigerator.

e. An observation on 6/6/17, during the initial tour of the kitchen which started at 8:45 a.m., showed a walk-in freezer with significant ice build-up on the floor, on the top of a box of food, an in a large metal pan. There were also icicles hanging from two metal shelves that stored food.

An observation on 6/7/17 at 9 a.m. and concurrent interview with GMFN showed the same amount of significant ice-build up in the walk-in freezer as observed on 6/6/17. GMFN stated a work order was not written for freezer.

In an interview on 6/7/17 at 11:30 a.m., POM stated that the freezer needed maintenance but he was not notified. He said there was an issue with insulation about a year ago and it was fixed and now the insulation probably needed to be replaced.

There was no ongoing preventative maintenance program for the walk-in freezer to ensure the freezer was maintained in working condition.

Based on observation, record review, and interview, the facility failed to substantially comply with 42 CFR (Code of Federal Regulations) 482.41 (B) (1) for General Acute Care Hospitals. This was evidenced by the facility failing to meet the provisions under the NFPA (National Fire Protection Association) 101, Life Safety Code 2012 Edition. As a result, this increased the risk of injury to the patients, staff, and visitors in the event of a fire. This affected the Main Building housing patients potentially not capable of self-preservation.

On 6/7/17 at 5:16 P.M., hospital administration was notified of Immediate Jeopardy (IJ) to the health and safety of patients on the Intensive Care Unit (ICU), North Rotunda (NR), and East Wing 2 (EW 2). The hospital failed to ensure these non sprinklered units of the hospital had the required smoke detection system in the patient rooms or corridors of the patient sleeping areas, and failed to ensure all staff had ability to open an egress door in one patient sleeping corridor of the ICU. The hospital's fire drills were incomplete and there was no evaluation and follow up for all nursing units that participated in the drills. In addition, staff were not knowledgeable of emergency procedures during a fire. A fire alarm near a patient area which was identified as non audible by staff in August 2016 was not fixed and remained non audible at the time of the survey.

On 6/7/17 at 7:25 P.M., the hospital provided a written plan to ensure the safety of patients on the ICU, NR, and EW 2 patient units which included initiation of the hospital fire watch plan, providing all staff with a key to the locked egress door in the ICU, staff education of emergency procedures and fire drills, and contacting a vendor to repair the non audible fire alarm.

On 6/7/17 at 7:33 P.M., hospital administration was notified the IJ was abated.

Findings:

K222

Based on observation and interview, the facility failed to ensure keys were provided to all staff to open a locked egress door in the event of an emergency, and failed to ensure locking of doors were allowed based on patient clinical and security needs to ensure their safety. Only a limited number of nursing staff had access to a key to open one locked egress door on the ICU. The Chemical Dependency Unit smoke barrier doors were locked without clinical or security reasons. This affected 2 of 7 sections of the Main Building and could result in delay in evacuation during fire or other emergencies. The North Section Intensive Care unit was a locked unit. There were no smoke detection system and fire sprinklers in the patient sleeping area. The Chemical Dependency unit was partially locked and had no fire sprinklers. There were battery powered, single station smoke alarms in sleeping rooms not meeting the smoke detection system requirement. This could result in delayed notification of fire and delayed evacuation and possible harm to patients and staff. This affected 2 of 7 sections of the Main Building.

National Fire Prevention Association 101, Life Safety Code, 2000 Edition

19.2.2.2.5.2* Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3)*The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the device.
(5) The locks release by independent activation of each of the following:
(a) Activation of the smoke detection system required by 19.2.2.2.5.2(2)
(b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)

During a tour of the facility with the Plant Operation Manager(POM) and Vice President of Campus Planning (VPCP) from 6/6/17 to 6/8/17, the egress doors and corridors were observed.

Intensive Care Unit (ICU)
1. On 6/7/17 at 8:38 a.m., during facility tour, 2 mental health workers (MHW) were asked if they had keys to unlock the locked exit door by Room 228. The MHW Staff stated they did not have keys to open the exit door. Not all staff had keys to open the locked exit doors.
At 10:22 a.m., the ICU was observed as a locked unit. The East and West Wings sleeping compartments of the ICU were not equipped with smoke detection system and no automatic fire sprinkler system.

2. On 6/8/17 at 10:35 a.m., the North Rotunda Chemical Dependency Unit (CDU) was observed without a complete smoke detection system in the corridors. The sleeping area was not protected with fire sprinklers. On 6/8/17 at 8:30 a.m., during interview with the Vice President of Campus Planning (VPCP), he stated the Chemical Dependency Unit was an open unit and not a locked unit. He said the Facility locked the exit/entrance smoke barrier door by Administrative hallway but the facility staff had keys to open the locked door. The door would not automatically open when the fire alarm was activated. The VPCP stated the locked exit/entrance smoke barrier door was locked due to people using the egress corridor to access other parts of the building. He said there was no clinical or security needs for patient safety to lock the doors.

K345

Based on observation, record review and interview, the facility failed to ensure that the fire alarm notification system was maintained in reliable operating condition. This was evidenced by not hearing the fire alarm in all areas above the ambient sound of the area, and by a fire alarm chime box that failed when tested. This affected 2 of 6 sections of the Main Buildings. This could result in delay in notification of fire to staff and visitors and patients.

NFPA 101 Life Safety Code, 2012 Edition.
19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.
9.6.3.7 Audible alarm notification appliances shall be of such character and so distributed as to be effectively heard above the average ambient sound level that exits under normal conditions of occupancy.
19.3.4.2.2 Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses ' control stations or other continuously attended staff location, provided that both of the following criteria are met:
(1) Such manual fire alarm boxes are visible and continuously accessible

Findings:

During the testing of the fire alarm system with the Plant Operation Manager (POM) and the Vice President of Campus Planning (VPCP) on 6/6/17 to 6/8/17, the strobes and audio alarm boxes were tested and observed.

1. On 6/6/17 at 10:20 a.m., the fire drill records were reviewed. The fire drill conducted on 8/16 indicated the staff in the outpatient area could not hear the fire alarm.

2. On 6/7/17, at 9:39 a.m., the fire alarm chime box located in the corridor outside the Dining Room of Rotunda South failed to emit a sound when the pull station was activated.

3. At 9:43 a.m., when the smoke detector and manual pull station were tested, the alarm could not be heard above the ambient sound in the Dining room/Cafeteria. The Cafeteria and Kitchen areas were not sprinklered. The POM confirmed the alarm could not be heard above the ambient sound in the dining room/cafeteria under normal use.

4. At 9:55 a.m., the manual pull station by outpatient waiting area was blocked from ready access by chairs. A person was seated in one of the chairs next to the manual pull box, blocking the activation of the manual pull box during fire alarm testing.

5. At 10:04 a.m., the smoke detector and manual pull box were tested, and the alarm could not be heard above the ambient sound in the outpatient nurses office. The door to the Nurses office was closed. The Facility Nurse in the room at the time stated that when the door was closed, the staff could not hear the fire alarms.

K346

Based on observation, interview and record review, the facility failed to ensure that fire watch rounds were conducted to ensure fire safety of the occupants. The fire watch was observed not inspecting all areas and rooms to ensure fire safety, and the fire watch was not trained on fire watch procedures. This could result in delay in the facility's response to a fire causing injury to patients, staff and visitors. This affected all areas where the fire watch was assigned.

National Fire Prevention Association (NFPA) 101, Life Safety Code, 2012 Edition

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

19.1.1.3.2 Because the safety of health care occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following:
(1) Design, construction, and compartmentation
(2) Provision for detection, alarm, and extinguishment
(3) Fire prevention procedures and planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building

Findings:

During a tour of the facility with Plant Operation Manager (POM) and Vice President of Campus Planning (VPCP) from 6/6/17 to 6/8/17, the Intensive Care Unit North Rotunda (ICU) and East Wing 2 (EW2) were observed while a fire watch round was being conducted.

1. On 6/7/2017 at 7:10 p.m., it was determined that the facility was not in compliance with the smoke detection system requirement to maintain fire safety. As an interim measure to protect their patients from fire, the CEO stated the security guards will do the fire watch rounds in the areas identified as non-compliant with the smoke detection system requirement. A fire watch was initiated by the facility when it was determined they were not in compliance with the requirement to have smoke detection system in the corridors.

2. On 6/8/17 at 9:46 a.m. the security guard was observed conducting the fire watch rounds in the East and West wing of the ICU. He was observed not going into patient rooms, and locked rooms off the corridors to inspect for a fire or fire hazard.
At 11:45 a.m. the fire watch log was requested. The fire watch log dated 6/7/17 to 6/8/17 indicated that no fire watch rounds were made between 6:30 a.m. to 12 noon on 6/8/17 for the North Rotunda.

3. At 12:15 p.m., a review of the facility fire watch policy dated 9/15 indicated the following: A trained individual assigned to an area for the purpose of protecting the occupants from fire or similar emergencies.
(g) Fire-watch personnel shall be on constant patrol for signs of fire or other unsafe life safety practices, keep a log of entries consisting of the date, time, area observed, observers initials and be assigned no more than 1 floor in affected areas of multistory buildings.
(h) Fire-watch personnel shall be relieved by other qualified standbys as needed for breaks, lunch, etc.
(j) Fire-watch personnel shall be provided with master key and/ or access cards to all areas under the fire watch.

4. At 3 p.m., the VPCP stated the security guard competency file does not address the process of doing a fire watch going and into rooms, opening bathrooms etc. The VPCP stated they do not have a procedure to describe what the expectation is and what to do when conducting a fire watch and the security guard was given the fire watch documents to fill out and does a fire watch rounds with no other instruction and training.

K347

Based on observation, document review and interview, the facility failed to provide a complete smoke detection system in accordance with NFPA 101, 2012 Edition, and failed to maintain their existing smoke alarms to protect their patients from fire. There was no smoke detection system in the corridors of the Intensive Care Unit (ICU), East Wing 2 (EW2) and the North Rotunda. These areas had no automatic fire sprinkler systems in the patient sleeping areas. This affected 71 patients, staff and visitors located in 2 of 3 smoke compartments of the ICU, 3 of 3 smoke compartments in EW2 and the chemical dependency recovery unit. This could result in delay in notification of fire to the fire authorities and cause injury from smoke inhalation and burns.

National Fire Prevention Association (NFPA) 101, Life Safety Code 2012 Edition
19.1.1.1.3 General. The provisions of Chapter 4, General, shall apply.

4.6.1.1 The authority having jurisdiction shall determine whether the provisions of this Code are met.

4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction.

4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction.

19.3.4.1 General. Health care occupancies shall be provided with a fire alarm system in accordance with Section 9.6.

9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use.

19.2.2.2.5.2* Door-locking arrangements shall be permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:
(1) Staff can readily unlock doors at all times in accordance with 19.2.2.2.6.
(2) A total (complete) smoke detection system is provided throughout the locked space in accordance with 9.6.2.9, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.
(3)*The building is protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.1.
(4) The locks are electrical locks that fail safely so as to release upon loss of power to the
device.
(5) The locks release by independent activation of each of the following:
(a) Activation of the smoke detection system required by 19.2.2.2.5.2(2)
b) Waterflow in the automatic sprinkler system required by 19.2.2.2.5.2(3)


19.3.4.5 Detection.
19.3.4.5.1 Corridors. An approved automatic smoke detection system in accordance with Section 9.6 shall be installed in all corridors of limited care facilities, unless otherwise permitted by one of the following:
(1) Where each patient sleeping room is protected by an approved smoke detection system, and a smoke detector is provided at smoke barriers and horizontal exits in accordance with Section 9.6, the corridor smoke detection system shall not be required on the patient sleeping room floors.
(2) Smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7 shall be permitted.

NFPA 72 , National Fire Alarm and Signaling
14.2.1.1.1 Inspection, testing, and maintenance programs shall satisfy the requirements of this Code and conform to the shall satisfy the requirements of this Code and equipment manufacturer's published instructions.

Findings:

During a tour of the facility with the Plant Operation Manager(POM) and Vice President of Campus Planning(VPCP) from 6/6/17 to 6/8/17, the smoke detectors and smoke alarms in patient rooms and corridors were observed and maintenance records were reviewed. The East Wing 2(EW2), Intensive Care Unit (ICU) and the North Rotunda (NR) were not sprinklered in the patient sleeping areas, and were not equipped with smoke detection system in the corridors. The ICU was a locked unit.
Main Building:

1. On 6/6/17 at 10:15 a.m., the maintenance log was reviewed and indicated the battery operated smoke alarms in the patient sleeping rooms of the North Rotunda and the East Wing 2 were inspected and tested quarterly, and not weekly. The smoke alarms were inspected and tested on 6/17, 3/17, 12/16 and 9/16 for 17 smoke alarms in the East Wing 2, and 9 smoke alarms in the North Rotunda. At 10:16 a.m., during an interview with the Plant Operations Manager, he stated they tested the smoke alarms quarterly because they were unable to obtain manufacturer's maintenance instructions for those types of smoke alarms.

2. At 10:30 a.m., during a tour of the facility, the Intensive Care East and West units were observed. There was no smoke detection system observed in the corridors of the Intensive Care unit East and West wings. There were no fire sprinklers in the patient sleeping areas and no smoke detection system in the patient sleeping rooms. This area was a locked unit. The length of the corridor was approximately 80 feet.

3. On 6/7/17 at 9:25 a.m., in the North Rotunda (Chemical Dependency Recovery Unit) of the Main Building, the battery operated smoke alarm in Room 132 failed to activate when tested by the POM. At 9:29 a.m., the battery operated smoke alarm in Room 150 failed to activate when tested by POM.

4. At 9:29 a.m., during an interview with the POM, he stated he was unsure of who the manufacturer was and the age of the battery-powered smoke alarms or the installation dates, and could not determine the information needed because he was unable to remove any of the smoke alarms. The smoke alarms were screwed into the walls of the patient rooms.

5. At 9:30 a.m., in the North Rotunda, chemical dependency unit, there was no smoke detection system observed in the corridors. There were no smoke detection devices at the nurse station and locked rooms off the corridor. This unit was not sprinklered in the patient area corridors and the sleeping rooms.

6. At 12:35 p.m., the gift shop next to the main lobby was not equipped with a smoke detection device. The gift shop was approximately 276 square feet. The gift shop had combustible items for sale and stored boxes of supplies on a top shelf.

7. At 12:40 p.m., in the East Wing 2, the cover for the hard-wired smoke detector by Room 526 was loose from the smoke detector base.

8. At 2:30 p.m., the nurse's station and the corridors on the 2nd floor of the non-sprinklered East Wing 2 were not equipped with a smoke detection system.

9. At 2:39 p.m., in East Wing 2, the open receptionist area with public/patient seating in the corridor was not sprinklered, and was not equipped with a smoke detection system.

K712

Based on record review and interview, the facility failed to ensure that their staff was familiar with their fire safety plan, and failed to conduct their fire drills according to their plan. This was evidenced by records showing that fire drills were conducted at similar times during the overnight and evening shifts, by staff not familiar with their fire response procedures, and by incomplete fire drill records for participating departments/unit. The failure to conduct the fire drills at un-expected times and varying conditions could result in staff not being familiar with how to respond to a fire during meal time, bedtime, shift change and other conditions that arise during a shift. This affected 6 of 6 sections of the Main Building and 3 of 3 floors of the Child & Adolescent Program building (CAP). This could result in a delay in staff response, in the event of a fire.

NFPA 101 Life Safety Code, 2012 Edition

4.7.3 Orderly Evacuation. When conducting drills, emphasis shall be placed on orderly evacuation rather than on speed.

4.7.4* Simulated Conditions. Drills shall be held at expected and unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.

4.8.2.1* Emergency plans shall include the following:
(1) Procedures for reporting of emergencies
(2) Occupant and staff response to emergencies
(3)*Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)
(4) Appropriateness of the use of elevators
(5) Design and conduct of fire drills
(6) Type and coverage of building fire protection systems
(7) Other items required by the authority having jurisdiction

19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.

19.7.1.8 Employees of health care occupancies shall be instructed in life safety procedures devices.

19.7.2.1.1 For health care occupancies, the proper protection of patients shall require the prompt and effective re- response of health care personnel.

19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building occupants and summon
Staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy's fire safety plan

19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:
(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire

Findings:

During document review with the Plant Operation Manager and Vice President of Campus Planning from 6/6/17 to 6/8/17, the fire drills records were reviewed. There was a space in the fire drill report where each department or unit could provide overall response to the fire/drill for comments, suggestion, recommendation improvements.

1. The Facility's fire safety plan and emergency Response plan dated 2/17 was reviewed and indicated the following: Unannounced fire drills will be held quarterly for each shift ... (3) Fire drills will be scheduled to take place on each shift at varying times of shift, days of the week and month throughout the year so as to provide opportunity to evaluate staff actions at varying times.
Alarm:
Activate the nearest fire pull station and yell "Code Red to alert other staff. Dial "50" on any hospital phone- this activates the overhead paging system... Then dial 9-911 to give the 911 dispatcher the specific location type and the extent of the fire.

On 6/6/17 in the Main Building and CAP Building

2. The Vice President of Campus Planning (VPCP) during an interview at 10:10 A.M. stated he does not oversee how the fire drills were conducted.
The VPCP job description dated 7/21/14 was reviewed and indicated the following: Key accountabilities/responsibilities: (4) Ensures organizational compliance with legislation and regulations as they impact assigned area.

2. The Plant Operation Manager stated at 10:20 a.m., that he and his staff conducted the fire drills monthly for the hospital. He stated the fire drill scenarios started in one unit and other unit participates on the basis of that scenario. The employees working hours were: Morning Shift was 7 a.m., to 3 p.m., Afternoon shift was 3:00 p.m., to 11 p.m., and overnight shift was 11 p.m., to 7 a.m.
Upon review of the fire drill records, the following information and comments was read. There was no verification of 911 being notified, no simulated relocation of patients and no documentation of evaluation of the drill for the participating departments. The Fire drills records dated 12/16 for East Wing 2 indicated no simulated call or confirmation of 911 was done. On the 12/16 fire drill, East Wing 1 staff did not respond to drill due to shortage in staffing. On 2/28/17 East Wing 2 staff did not clear the corridor due to "no staff available and drill was over quickly". On 4/12/17, the CAP building participating form was blank. On 1/17 business office participating form was blank. On 8/25/16, the kitchen participating form was blank. On 8/26/16, the outpatient area could not hear the alarms. On 5/19/16 , the East Wing 2 participating form was blank.

3. At 10:20 a.m., the Plant Operation Manager acknowledged that all the unit that participated in the fire drills did not complete or filled out correctly the fire drill forms such as, writing the evaluation of the fire drills and notification of 911.

4. At 10:40 a.m. the four overnight fire drills conducted within the last 12 months indicated the drill was conducted within 1 hour time period. All four afternoon fire drills were conducted within 1/2 hour time period for the last 12 months. The fire drills were not conducted at varying time and conditions.

5. Dietary Aide 62 was interviewed on 6/6/17 at 3:07 p.m. of her role if there was a fire. She stated in the event of a fire she would pull the suppression system and call 911. Dietary Aide 62 stated that was all she would do. Dietary Aide 62 was unfamiliar with the requirements of containment of the fire by closing off doors and evacuating the area.

6. Dietary Aide 63 was interviewed on 6/6/17 at 3:14 p.m. She stated she was unfamiliar with the different type fire extinguisher in the Kitchen and their usage.
They have ABC and K type fire extinguishers in the Kitchen.

On 6/7/17 in Main Building and CAP Building

7. During interview with the Mental Health Worker 64 at 8:38 a.m., she stated she would make an overhead paging call by dialing 50, and let them know the location of the fire and she would get the fire extinguisher. She stated she would aim all over the fire and outside the fire. The State Authority Having Jurisdiction stated the proper way to extinguish a fire using a fire extinguisher was to aim the nozzle at the base of the fire and not all over the fire as stated by Mental health Worker # 64.

8. During interview with Licensed Nurse 67 at 8:40 a.m., he was not familiar with evacuation of a smoke compartment or evacuate to a safe area within the building.
The Facility fire safety plan indicated all occupants were to evacuate from the immediate fire area first; then to the next smoke/fire compartment or designated safe area.

9. During interview with Housekeeping Staff 68 at 8:43 a.m., she stated she would call code 950 if she discovers a fire and she would use the acronym R.A.C.E. When asked to explain what actions are taken for each letter of R.A.C.E, Housekeeper Staff 68 failed to explain facility's fire procedure actions for each letter of R.A.C.E.
Facility fire/emergency procedures indicated to activate the nearest fire pull station and yell "Code Red to alert other staff. Dial "50" on any hospital phone- this activates the overhead paging system

10. During interview with the Private Box Exchange Operator (PBXO) 70 at 10:45 a.m., she stated she is a volunteer and had no training on any of the facility fire/emergency procedures.

11. During interview with PBXO 69 at 10:46 a.m., he stated he would announce on overhead paging the location of the fire from the information passed to him from the staff, and respond to calls from the monitoring company and the fire department. He stated he would not call the fire department because they would call him.

Their Facility fire/ emergency procedures indicated staff to dial 9-911 to give the 911 dispatcher the specific location type and extent of the fire.

Based on observation, interview, and facility document review, the facility failed to develop a system to identify sanitation issues in the kitchen when three outlet covers above a food preparation sink were dirty. This failure had the potential to contaminate food contact surface areas and cause food borne illness in patients.

Findings:

On 6/6/17, during the initial tour of the kitchen which started at 8:45 a.m., an observation and concurrent interview with the General Manager of Food and Nutrition (GMFN) showed three electrical outlets located above a food preparation sink. The wall where the outlets were located was covered with a pegboard and ladles used for food preparation and food service were hung on the pegboard. One ladle hung so it overlapped the outlet cover. The outlets, the metal outlet cover plates, and the wall surrounding the outlet plates, for all three outlets were covered with a significant amount of brown, yellow, and black residue. When the surveyor attempted to wipe the residue off, it was dry and difficult to remove as if the residue was there longer than one day. GMFN acknowledged that the outlets, cover plates, and the wall surrounding the plates were dirty.

A review of the undated "Cleaning schedule" read "clean and sanitize stainless sink and prep working area." The document showed this was done daily. The facility did not provide a policy that included cleaning the outlets, outlet covers, and walls.

According to the Federal Food Code (2013), "Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris."