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Based on record review and staff interview, the facility's Emergency Preparedness plan failed to address policies and procedures regarding the sheltering in place of residents, staff, and volunteers who remain in the facility during an emergency or disaster event. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the sheltering in place of residents, staff, and volunteers who will remain in the facility during an emergency.


On 08/27/18 at 2:00 pm, the surveyor informed Staff M Facilities are required to have policies and procedures for sheltering in place which align with the facility's risk assessment and are expected to include the criteria for determining which patients and staff would be sheltered in place. Staff M stated, they will update and revise the policies and procedures to include a policy for sheltering in place.

Based on record review and staff interview, the facility failed to ensure the emergency preparedness policies and procedures addressed the role of the facility under the 1135 waiver declared by the president in accordance with section 1135 of the act in provision of care and treatment. The facility lacked a policy.

Findings:

Record review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the facility's roles under a 1135 waiver during a declared disaster providing care and treatment at alternate care sites.


On 08/27/18 at 4:00 pm, the surveyor asked Staff M if the facility established policy and procedures addressing coordination efforts during a declared emergency in which a waiver of federal requirements under section 1135 of the Act has been granted by the Secretary. Staff M stated the facility was unaware of the policy and they will update and revise the policies and procedures.

Based on record review and interview, the facility failed to demonstrate education and instruction to staff, of a community based exercise, tabletop exercise, or full-scale exercise to demonstrate staff knowledge of emergency procedures.

Findings:

Record review of the facility emergency preparedness training documentation did not show the annual and initial in-service training for existing staff, and individuals providing services under arrangement for four (staff S, staff T, staff U, and staff V ) of 28 employees.

Staff V with the date of hire 01/13/15 did not receive annual in-service training in 2016 for the emergency preparedness plan.

Staff U with the date of hire 07/12/07 did not receive initial or annual in-service training in 2007-2015 for the emergency preparedness plan.

Staff S with the date of hire 08/30/76 only received in-service training in 2014, 2017 and 2018 for the emergency preparedness plan.

Staff T with the date of hire 09/24/01 did not receive initial or annual in-service training 2002-2015 for the emergency preparedness plan.

The emergency preparedness training records for initial and or annual in-service do not exist for Staff S, Staff T, Staff U, and Staff V.


On 08/27/18 at 11:38 am Staff M was asked to provide documentation such as a sign-in sheet, meeting minutes, to verify staff received training on drills or exercises dated 05/29/17, 11/14/17, and 04/18/18 completed by the facility. Staff M stated the facility did not have sign-in sheets for the exercises the staff participated in or trained for. The surveyor stated, CMS requires facilities to be able to demonstrate documentation exists for training, drills and exercises in order to verify staff knowledge of emergency procedures, and to identify gaps and areas for improvement. The document did not exist to verify staff received in-service training.

Based on record review and interview the facility failed to implement emergency power system inspection, testing, and maintenance requirements.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016 and 2017, as the documents do not exist. Record review showed the facility has not completed the 36 month, four hour continuous load bank for the facility's emergency generator.


On 08/27/18 at 1:52 pm Staff M was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016 and 2017. Staff M stated annual emergency generator fuel quality tests will be done. Staff M stated the 36 month, four hour load bank is going to be done within the week.

Based on observation and interview the facility failed to ensure the means of egress was continuously maintained free of all obstructions to full instant use in case of emergency.

Findings:

On 08/28/18 at 11:09 am, the left side of the surgical restricted corridor was observed to have ten, five-tiered wheeled steel frame carts and on the right side eight, five-tiered wheeled steel frame carts were stored within the emergency egress pathway. The shelves of each steel framed wheeled cart had sterile supplies stored. The sterile supplies on the cart were observed in sterile packing, peel pouches, and blue non-woven sterile wrapping. Each of the shelves were tightly packed with no open areas.


On 08/30/18 at 10:51 am, a desk was observed to be obstructing an egress access door within the hospitalist's staff room.


On 08/30/18 at 2:18 pm, a patient bed was observed to be stored within the emergency egress corridor pathway located outside the cath lab procedure room obstructing the means of egress pathway.


On 08/30/18 at 2:20 pm, Staff M stated, a doctor had instructed staff to leave the patient bed in the corridor egress pathway. Staff M stated, they would locate an appropriate area to temporarily store the patient bed while patients are in the cath lab procedure room.

Based on observation and interview, the facility failed to ensure each egress access door could be opened with only one action as required.


Findings:

On 08/28/18 at 11:47 am, a thumb knob deadbolt was observed on the door to the endoscopic procedure room within the surgical suite.


On 08/28/18 at 12:07 pm, a deadbolt lock was observed on the surgical suite recovery room door.


On 08/28/18 at 12:08 pm, Staff M was asked why the deadbolt locks were placed on the operating room doors. Staff M stated, it may have been due to security issues but will remove them to meet compliance.

Based on observation and interview, the facility failed to ensure a hazardous area was properly protected/separated from other use spaces.

Findings:

On 08/30/18 at 10:36 am, the surveyor observed penetrations in the ceiling of the wig room.

On 08/30/18 at 10:51 am, in the respiratory therapy department the hazardous area hot water heater closet door was observed to have a gap over one eighth of an inch.

On 08/30/18 at 11:10 am, a plastic wheeled cart exceeding 32 gallons was observed stored open to the egress corridor with combustible corrugated boxes stacked approximately five feet high within the plastic wheeled cart in the shipping and receiving area.

On 08/30/18 at 1:42 pm, the electric closet located in the material unit administrative assistants office was observed to have a ceiling with penetrations and was not smoke tight as required.

On 08/30/18 at 2:09 pm, a fifty gallon plastic drum was observed to be filled halfway with flammable X-ray acetates and was stored open to the egress corridor in the radiology department.

On 08/30/18 at 3:13 pm, the surveyor stated to Staff M there was a gap over one eighth of an inch in the respiratory therapy departments hot water closet, a plastic wheeled cart containing combustible corrugated boxes stacked approximately five feet high stored open to the emergency egress corridor, a electric closet to have non-smoke tight ceiling, and the fifty gallon plastic drum of flammable X-ray acetates stored open to the egress corridor. Staff M stated, he would correct each of the areas to meet code compliance.

Based on observation and interview, the facility failed to ensure biomedical equipment installed met manufacturers recommendations, followed ASHRAE ventilatory standards, and the facility's medical gas piping was properly installed.

Findings:

On 08/28/18 at 11:09 am, two large sterilizers were observed to be installed open within the restricted egress corridor of the surgical suite. The two sterilizers were observed to not be hooded or vented as required by manufacturers recommendations and did not have negative ventilation with the minimum of 10 air exchanges per hour vented directly outside.


On 08/28/18 at 11:11 am, Staff M was asked if the restricted corridor where the two nonhooded sterilizers are located is negatively ventilated. Staff M stated, he does not know how the restricted corridor is ventilated but will have it checked. The surveyor stated the ventilation requirements for the sterilizers are that they are to be hooded, negatively ventilated with a minimum of 10 air exchanges, and vented directly to outside air.


On 08/28/18 at 11:47 am, the endoscope decontamination room located in the surgical suite procedure room was observed to not be negatively ventilated as required with the minimum of 10 air exchanges per hour and exhausted directly to the outside.


Record review of Apex medical gas annual inspection report for 10/17/17 and Airgas medical gas annual inspection report for 07/14/15 both indicated OR 6 (Cysto) with medical gas outlets/inlets being controlled by two separate zone valves, and the nitrous oxide outlets in OR 6 (Cysto) to be controlled by the nitrous oxide zone valve for Operating Room 5 in addition to the oxygen and vacuum outlets/inlets in OR 6 (Cysto) are controlled by the oxygen and vacuum zone valves for the radiology area.


On 08/28/18 at 12:45 pm. Staff M was asked for the medical gas invoice indicating the zone valves for OR 6 (Cysto) and OR 5 were repaired to be operationally independent of each zone valve. Staff M stated, he did not think the valves had a problem and sent a facility maintenance staff person to the surgical suite to check on the zone valves. The facility maintenance staff person returned and advised Staff M the zone valves are not independent of each other as required.

Based on observation and interview, the facility failed to ensure smoke barriers were smoke resistant.


Findings:


On 08/27/18 at 10:01 am, penetrations were observed in the ceiling tiles located throughout the facility which would allow fire and smoke to spread into the plenum space then throughout the facility.


On 08/27/18 at 10:34 am, seven holes were observed in the fire barrier separating the Acute Care Unit unit and the office spaces.


On 08/27/18 at 10:37 am, the surveyor asked Staff M why the penetrations are not filled throughout the facility. Staff M stated, they were just recently advised by the state mental health department they needed to have a preventative maintenance program for penetrations.

Based on observation and interview, the facility failed to ensure barrel latches were not installed within the facility.

Findings:

On 08/27/18 at 10:05 am, Staff M was asked why were there two barrel latches on two of the operating room doors. Staff M stated, he did not know why the barrel latches were installed but will have them removed. The surveyor explained it would take more than one action for a person to gain access to the egress corridor from inside each of the two operating rooms where the barrel latches are located.

Based on observation and interview, the facility failed to ensure facility electrical wiring and equipment was in accordance with the National Electrical Code.

Findings:

On 08/28/18 at 11:38 am, the surveyor observed two power strips in use in the surgery staff lounge.

On 08/28/18 at 12:07 pm, a power strip was observed to be daisy chained into an extension cord in Operating Room #3.

On 08/30/18 at 11:05 am, a residential extension cord was observed to be in use at the ICU nurses station.

On 08/30/18 at 11:09 am, a four prong power tap was observed to be in use powering an X-ray viewer located in the ICU.

On 08/30/18 at 3:04 pm, an extension cord was observed to be plugged into a power tap charging two IV pumps located in materials management.

On 08/30/18 at 3:05 pm Staff M was asked why the extension cord was plugged into a power tap. Staff M stated, he did not know but will address the issue with the facility staff regarding each of the issues with power taps, and extension cords.

Based on record review and interview, the facility failed to ensure elevators were inspected and tested.

Findings:

Record review showed the Department of Labor annual inspection certificates for the main hospital building were not current or completed. Records reviewed for annual inspections for elevators only included the doctor's building and the ambulatory surgical center building. The annual inspections for the elevators for the hospital did not exist.

On 08/28/18 at 1:32 pm, the surveyor asked Staff M again for the elevator annual inspection certificates for the main hospital building and the certificates were not provided.

Based on record review and interview, the facility failed to include the transmission of a fire alarm signal on each fire drill.

Findings:

Record review showed the fire drills for 2016 and 2017 did not document transmission of a fire alarm signal. The documentation of verification of a fire alarm signal for each individual fire drill for the different departments within the facility were not documented.

On 08/27/18 at approximately 11:17 am the surveyor stated to Staff M the facility fire alarm drills should include documentation there was a transmission of a fire alarm signal for each fire drill. Staff M stated, they would add that to the fire drill documentation.

Based on record review and interview, the facility failed to ensure the annual fire rated door assembly annual inspections were completed.

Findings:

Record review showed the annual fire rated door assembly inspections for 2017 were not completed and the documentation did not exist.

On 08/27/18 at 12:35 pm, the surveyor asked Staff M for the annual fire rated door assembly inspections. Staff M stated, the inspection was not completed for 2017.

Based on observation and interview, the facility failed to ensure space heaters were not placed in patient care areas as required.

Findings:

On 08/30/18 at 8:50 am, a space heater was observed in the office of the OB nursing supervisor.


On 08/30/18 at 2:14 pm, a space heater was observed in a patient care area under the CT operator's table while a patient was having a CT scan performed.


On 08/30/18 at 2:16 pm, two space heaters were observed to be in the staff break room located near the cath lab procedure room.


On 08/30/18 at 2:20 pm, Staff M was asked for the manufacturers documentation that the heating element in the space heaters did not exceed 212 degrees Fahrenheit for the space heaters located in the staff break room, and OB nursing supervisors office. Staff M stated, he did not readily have the manufacturers documentation. The surveyor stated the documentation may be obtained from the manufactuers website. Staff M was informed of CMS's standard regarding space heaters in which are prohibited in all health care occupancies within patient care areas, but can only be utilized in nonsleeping staff and employee areas.

Based on observation and interview, the facility failed to ensure any means of egress undergoing construction, repair, or improvements shall be properly separated as required.

Findings:

On 08/28/18 at 12:18 pm, the surveyor observed a large plastic tarp covering a metal garage door located on the 1st Floor decontamination area. The surveyor asked Staff C how long the plastic tarp had been in place and she stated, approximately three years. Staff C was asked if any construction had taken place or if there is a completion date identified. Staff C stated, she has not seen any construction nor knows of any completion date. The surveyor stated the NFPA 101, 2012 Edition regarding Interim Life Safety Measures (ILSM) does not allow the use of plastic sheets/tarps for construction/remodeling.

Based on record review and interview, the facility failed to ensure the building system risk assessments were completed.

Findings:

Record review showed the facility EES (Essential Electrical System) and Medical Gas building system risk assessments were not completed.

On 08/27/18 at 11:23 am, the surveyor asked Staff M for the EES and Medical Gas building system risk assessments, and Staff M stated, he had not completed the medical gas or EES building system risk assessments.

Based on record review and interview, the facility failed to ensure medical gas piping was installed properly as required.

Findings:

Record review of facility documentation showed only two complete annual medical gas inspection reports. Apex on 10/18/17, and Airgas on 07/14/2015. There was no annual medical gas inspection documentation for 2016.


On 08/28/18 at 12:45 pm, Staff M was asked for the 2015, 2016 and 2017 annual medical gas inspection reports. Staff M was asked for the 2016 annual medical gas inspection report and it was not provided as requested.

Based on record review and interview, the facility failed to ensure electrical receptacles in patient care areas were tested annually as required.

Findings:

Record review showed the facility had not tested the operating rooms line isolation monitors (LIM) since 09/28/13 by Hurdle & Associates. No LIM annual inspections were completed for 2014, 2015, 2016, and 2017. Record review showed the facility did not complete annual impedance testing to patient care area electrical receptacles to include ground pole retention testing for 2016, 2017, and 2018

On 08/27/18 at 2:45 pm, Staff M was asked for the LIM annual inspections and impedance (patient care area electrical receptacle) testing for 2016, 2017, and 2018. Staff M failed to provide the impedance testing documentation for the facility. The electrical receptacle impedance testing and LIM annual testing documentation does not exist.

Based on record review and interview, the facility failed to ensure the annual emergency generator fuel quality testing and the 36 month, four hour load bank were completed as required.

Findings:

Record review showed the annual emergency generator fuel quality testing reports were not completed for 2015, 2016, and 2017, as the documents do not exist. Record review showed the facility has not completed the 36 month, four hour continuous load bank for the facility's emergency generator.


On 08/27/18 at 1:52 pm, Staff M was asked to provide the annual emergency generator fuel quality testing documentation for 2015, 2016, and 2017. Staff M stated, annual emergency generator fuel quality tests will be done. Staff M stated, the 36 month, four hour load bank is going to be done within the week.

Based on record review, observation, and interview, the facility failed to ensure adherence to the CMS memo S&C 14-46-LSC requirements for the use of power strips within patient care areas.

Findings:

Record review showed the facility did not have written documentation the facility had elected to use the CMS categorical waiver memo S&C 14-46-LSC for the use of power strips within patient care areas. There was no documentation showing the power strips used within patient care areas met UL 1363A or UL 60601-1 standards.

On 08/27/18 at 10:11 am, at the entrance conference Staff M was asked if the facility is operating under any CMS categorical waivers and Staff M stated, no.

On 08/28/18 at 11:43 am, a power strip was observed to be in use in the endoscopic procedure room patient care area within the surgical suite.

On 08/30/18 at 3:12 pm, Staff M was asked if the board of directors had approved the use of the CMS categorical waiver for the use of power strips within patient care areas. Staff M stated, no. The surveyor explained the facility has to follow the CMS categorical waiver memo S&C 14-46-LSC requirements for the use of power strips within patient care areas if they choose to continue to use power strips in the operating room and have the board of directors approve the use of the CMS categorical waiver for power strips in patient care areas.