HospitalInspections.org

Based on document review and interview, the facility failed to ensure a face-to-face assessment of a patient was conducted within 1 hour of an emergency safety intervention (ESI) involving the use of restraint or seclusion for 2 of 10 patient medical records (MR) reviewed (Patients #31 & 32).

Findings include:

1. Review of the policy #4-502 Seclusion Restraint of Inpatient Clients (approved 10-20) indicated the following: "Advanced Practice Nurse (APN) ...[is] privileged at Bowen Center to evaluate client in seclusion/restraint ...[and the] ...Qualified Registered Nurse (QRN) ...is also privileged to evaluate client in seclusion/restraint for the one hour face-to-face evaluation ....the Physician/APN shall evaluate the client based on a face-to-face performed either by the Physician/APN or QRN to determine the need for seclusion or restraint within one (1) hour of the initiation of seclusion/restraint."

2. Review of the MR for Patient #31 indicated a manual restraint/therapeutic hold was ordered and initiated on 2-7-21 at 0820 hours after the Registered Nurse N11 observed the patient during a self-harming behavior and attempts to verbally de-escalate the patient's self-harming behavior by the staff were ineffective. The MR for Patient #31 indicated a new order to initiate 4 point physical restraints was implemented on 2-7-21 at 0830 hours after the patient began attempting to harm the ESI staff and lacked documentation indicating a face-to face evaluation was performed by a Physician, APN or QRN within one hour of initiating the manual restraint.

3. Review of the MR for Patient #32 indicated a manual restraint/therapeutic hold was ordered and initiated on 2-8-21 at 1640 hours after the Registered Nurse N11 observed the patient during a self-harming behavior and attempts to verbally de-escalate the patient's self-harming behavior by the staff were ineffective. The MR for Patient #32 indicated a new order to initiate 4 point physical restraints was implemented on 2-8-21 at 1705 hours after the patient began attempting to harm the ESI staff and lacked documentation indicating a face-to face evaluation was performed by a Physician, APN or QRN within one hour of initiating the manual restraint.

4. On 6-2-21 at 1715 hours, the IPU (inpatient unit) Operations Director A3 and the IPU Quality Assurance Specialist A7 confirmed the ESI restraint documentation for the two patients failed to indicate a face-to-face evaluation was performed within one hour of initiating the intervention.

Based on document review and interview, the facility failed to ensure the attending physician was consulted after a one hour face-to-face evaluation was performed during an emergency safety intervention (ESI) involving the use of restraint or seclusion for 2 of 10 patient medical records (MR) reviewed (Patients #31 & 32).

Findings include:

1. Review of the policy #4-502 Seclusion Restraint of Inpatient Clients (approved 10-20) indicated the following: "Advanced Practice Nurse (APN) ...[is] privileged at Bowen Center to evaluate client in seclusion/restraint ...[and the] ...Qualified Registered Nurse (QRN) ...is also privileged to evaluate client in seclusion/restraint for the one hour face-to-face evaluation ....if the QRN conducts the mandatory one hour evaluation, the QRN must consult with the attending Physician/APN as soon as possible thereafter, to provide an update on the client's status and need for seclusion or restraint."

2. Review of the MR for Patient #31 indicated on 2-7-21 at 0820 hours a manual restraint/therapeutic hold was ordered and initiated after the Registered Nurse N11 observed the patient during a self-harming behavior and attempts to verbally de-escalate the patient's self-harming behavior by staff were ineffective. The MR indicated a new order to initiate 4 point physical restraints was implemented on 2-7-21 at 0830 hours after the patient began attempting to harming the ESI staff and lacked documentation indicating the Psychiatrist MD22 was contacted after a face-to face evaluation was performed.

3. Review of patient #32's MR indicated on 2-8-21 at 1640 hours a manual restraint/therapeutic hold was ordered and initiated after the Registered Nurse N11 observed the patient during a self-harming behavior and attempts to verbally de-escalate the patient's self-harming behavior by staff were ineffective. The MR indicated a new order to initiate 4 point physical restraints was implemented on 2-8-21 at 1705 hours after the patient began attempting to harming the ESI staff and lacked documentation indicating the Psychiatrist MD22 was contacted after a face-to face evaluation was performed.

4. On 6-2-21 at 1715 hours, the IPU (inpatient unit) Operations Director A3 and the IPU Quality Assurance Specialist A7 confirmed the ESI restraint documentation for the two patients failed to indicate the attending Psychiatrist was consulted after the face-to-face evaluation was performed.

Based on observation and interview, the facility failed to ensure the means of egress through 3 of 3 patient emergency exits with special locking arrangements for the clinical security needs of the patients would release upon activation of the smoke detection system or the fire sprinkler system (tag K222), failed to ensure 5 of 5 hazardous areas that contained fuel fire equipment were protected with a self-closing latching door (tag K321), failed to ensure 1 of 1 fire alarm control units, located in an area that was not continuously occupied, was provided with annunciation readily accessible to responding personnel to facilitate an efficient response to the fire situation (tag K341) , failed to ensure 1 of 1 fire damper systems were inspected and provided necessary maintenance after the first year after instillation and at least every six years in accordance with NFPA 90A (tag K521) failed to conduct fire drills on each shift for 2 of 4 quarters (tag K712), failed to maintain proper testing of 1 of 1 rolling fire door/windows in accordance of NFPA 80, Standard for Fire Doors and Other Opening Protectives (tag K761) and failed to ensure 1 of 1 emergency generators was equipped with a properly located remote stop in the event the generator caught fire (tag K918), and failed to provide a written plan that addressed all components in 1 of 1 written fire plans in accordance with 19.7.2.2 (tag K711).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure a safe environment was maintained to provide quality health care for patients.

Based on observation and interview, the facility failed to ensure the means of egress through 3 of 3 patient emergency exits with special locking arrangements for the clinical security needs of the patients would release upon activation of the smoke detection system or the fire sprinkler system, failed to ensure 5 of 5 hazardous areas that contained fuel fire equipment were protected with a self-closing latching door, failed to ensure 1 of 1 fire alarm control units, located in an area that was not continuously occupied, was provided with annunciation readily accessible to responding personnel to facilitate an efficient response to the fire situation. LSC 9.6.1.3 requires a fire alarm system to be installed, tested, and maintained in accordance with NFPA 70, National Electrical Code and NFPA 72, National Fire Alarm and Signaling Code. NFPA 72, 2010 Edition, Section 10.16.3.1 states all required annunciation means shall be readily accessible to responding personnel. Section 10.16.3.2 states all required annunciation means shall be located as required by the authority having jurisdiction to facilitate an efficient response to the fire situation. Section 10.12.5 states the trouble signal(s) shall be located in an area where it is likely to be heard, failed to ensure 1 of 1 fire damper systems were inspected and provided necessary maintenance after the first year after instillation and at least every six years in accordance with NFPA 90A. LSC 9.2.1 requires heating, ventilating and air conditioning (HVAC) ductwork and related equipment shall be in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems. NFPA 90A, 2012 Edition, Section 5.4.8.1 states fire dampers shall be maintained in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. NFPA 80, 2010 Edition, Section 19.4.1 states each damper shall be tested and inspected 1 year after installation. Section 19.4.1.1 states the test and inspection frequency shall be every 4 years except for hospitals where the frequency is every 6 years. If the damper is equipped with a fusible link, the link shall be removed for testing to ensure full closure and lock-in-place if so equipped. The damper shall not be blocked from closure in any way. All inspections and testing shall be documented, indicating the location of the fire damper, date of inspection, name of inspector and deficiencies discovered. The documentation shall have a space to indicate when and how the deficiencies were corrected, failed to conduct fire drills on each shift for 2 of 4 quarters. LSC 19.7.1.6 states 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. QSO-20-31 1135 temporary waiver states in lieu of a physical fire drill, a documented orientation training program related to the current fire plan, which considers current facility conditions, is acceptable. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area, failed to maintain proper testing of 1 of 1 rolling fire door/windows in accordance of NFPA 80, Standard for Fire Doors and Other Opening Protectives, 2010 Edition. LSC 4.5.8 requires any device, equipment, system, condition, arrangement, level of protection, or any other feature is required for compliance with the provision of this Code, such device, equipment, system, condition, arrangement, level of protection, or other feature shall thereafter be maintained unless the Code exempts such maintenance. NFPA 80 5.2.1 requires fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ, and failed to ensure 1 of 1 emergency generators was equipped with a properly located remote stop in the event the generator caught fire. NFPA 110, Standard for Emergency and Standby Power Systems 2010 Edition, Section 5.6.5.6, requires all installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. Section 5.6.5.6.1, requires the remote manual stop station to be labeled. Annex A is not a part of the requirements but is included for informational purposes only.
A.5.6.5.6 states for systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified. This deficient practice could affect all patients, as well as staff and visitors in the facility.

Findings include:

1. Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 1:50 p.m., the inpatient area had special locking arrangements for patients with clinical security needs. The 300, 400, and 500 exit doors in the inpatient area were locked with a latch that hooked into the door frame and could be opened by a key carried by staff, but it could not determine if the doors would unlock from the door frame upon activation of the smoke detection system or sprinkler system. When the fire system was activated by a pull station the doors did not unlock. Based on interview at the time of observation, the Facilities Director stated it is unknown if the doors would unlock from the door frame if the smoke detection system or sprinkler system was activated.

2. Based on observations with the Facilities Director and the Inpatient Director on 06/02/21 between 12:55 p.m. and 2:00 p.m., the corridor doors to the following hazardous areas that contained fuel fire equipment were not self-closing:
a) Housekeeping room 506.
b) Housekeeping room 303.
c) Mechanical room 302.
d) Mechanical room 401.
e) Mechanical room 404.
Based on interview at the time of observations, the Facilities Director agreed all five rooms contained fuel fired equipment and the corridor doors to the rooms were not self-closing.

3. Annex A is not a part of the requirements but is included for informational purposes only
Section A.10.16.3 states the primary purpose of fire alarm system annunciation is to enable responding personnel to identify the location of a fire quickly and accurately and to indicate the status of emergency equipment or fire safety functions that might affect the safety of occupants in a fire situation.
This deficient practice could affect all patients, staff and visitors in the facility.

4. Based on observations with the Facilities Director and the Inpatient Director on 06/03/21 at 1:01 p.m., the main fire alarm control unit was in the I.T. room and a remote annunciator was in the font foyer. Both areas are only occupied during business hours and not continuously occupied. Based on interview at the time of the observations, the Inpatient Director agreed the main panel and remote panel were not in areas continuously occupied and stated there is no remote annunciator in the continuously occupied areas of the building.

5. Based on records review with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., The facility was built and had smoke/fire dampers installed in 2015. No documentation of an inspection for the facility's smoke/fire dampers one year after installation was available for review. Based on interview at the time of records review, the Facilities Director stated the facility does have dampers in the HVAC system and the damper inspection one year after installation could not be found.

6. Based on records review with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., the following shifts were missing documentation of a completed fire drill:
a) A third shift fire drill in the fourth quarter of 2020.
b) A third shift fire drill in the first quarter of 2021.
c) A second shift fire drill in the first quarter of 2021.
Furthermore, no documentation was provided to show staff reviewed fire safety procedures for the fourth quarter of 2020 and first quarter of 2021.
Based on interview at the time of record review, the Facilities Director agreed there were three missing fire drills and staff has not been trained in the fire safety procedures for the last two quarters.

7. Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 12:07 p.m., there were non-rated wall length windows in the fire wall that were protected by a roiling fire door/window. Based on records review at 2:00 p.m., no documentation was provided to show if the roiling fire door/window has ever been inspected. Based on interview at the time of observation, the Facilities Director stated the roiling fire door/window has not been inspected since the building was built in 2015.

8. Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., a remote emergency stop button for the diesel power generator could not be located. Based on interview at the time of observation, the Facilities Director stated the generator was not equipped with a remote emergency stop button.

9. Based on observation and interview, the facility failed to ensure 1 of 1 generators were provided with battery-powered emergency lighting. NFPA 110, 2010 Edition at section 7.3.1 requires the Level 1 or Level 2 EPS equipment location(s) shall be provided with battery-powered emergency lighting. This deficient practice could affect all patients in the facility.

10. Based on observation with the Facilities Director and the Inpatient Director on 06/02/21 at 10:02 a.m., the emergency generator which was enclosed within privacy fencing did not contain battery-powered emergency lighting. Based on an interview at the time of observation, the Facilities Director stated the generator was not provided with battery-powered emergency lighting.

11. The findings were reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on observation, interview, and record review, the facility failed to provide a written plan that addressed all components in 1 of 1 written fire plans in accordance with 19.7.2.2. LSC 19.7.2.2 requires a written health care occupancy fire safety plan that shall provide for the following:
(1) Use of alarms
(2) Transmission of alarm to the 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
This deficient practice could affect all occupants.

Findings include:

Based on records review with the Facilities Director and the Inpatient Director on 06/02/21 at 11:02 a.m., the provided fire emergency plan lacked information on partial or horizontal evacuation from one smoke compartment beyond a smoke or fire barrier to the next smoke compartment. Also, the plan did not identify the locations of smoke/fire door in the barriers. Based on interview during records review, the Facilities Director agreed the fire emergency plan did not contain complete instruction for evacuation of smoke compartment.

The finding was reviewed with the Facilities Director and the Inpatient Director during the exit conference.

Based on document review and interview, the facility's inpatient unit (IPU) failed to maintain documentation of regular fire inspections by the State or local fire control agencies for one occurrence.

Findings include:

1. Review of the policy #3-413 Safety Inspections (approved 2-20) and the Fire Safety Management Plan (approved 10-19) lacked an indication for conducting regular fire safety inspections of the inpatient unit by a State or local fire control agency.

2. On 6-2-21 at 1715 hours, the IPU Operations Director A3 was requested to provide documentation indicating the most recent State and/or local fire inspection of the inpatient unit and none was provided prior to exit.

3. On 6-3-21 at 1235 hours, staff A3 indicated the most recent fire inspection of the IPU was conducted in 2018 and confirmed no documentation of an IPU fire inspection in 2019, 2020 and/or 2021 was available.