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Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to meet construction types for nonbearing walls for universe of the building. This resulted in the potential for uncontrolled smoke and heat migration into the other parts of the building in the event of a fire, causing the exposure of residents & staff to hazardous products of fire (LSC 19.1.6.4 and 19.1.6.5).

Findings include, but were not limited to:

1. On 1/12/2017, at 3:40 p.m., there were unsealed wall/ceiling penetrations within ICU/Med. Surg. adjacent to "D" door that would allow products of combustion (heat and smoke) into concealed spaces within the building.

2. On 1/13/2017, at 11:15 a.m., there were unsealed wall/ceiling penetrations within the North Basement adjacent to electrical panel BC that measured approximately ½" in diameter and 1"x6" square. These penetrations would allow products of combustion (heat and smoke) into concealed spaces within the building.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that exit egress remained continuously maintained in operable condition in case of an emergency. This resulted in the potential for confusion and panic by patients, visitors & staff during emergency evacuation conditions (LSC 19.2, 7.2.4.3.8).

Findings include, but are not limited to:

On 1/13/2017 at 12:38 p.m., there was an egress door that did not swing in the direction of egress within the Ambulatory Infusion Area of the facility.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interviews during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that exit egress remained clear & unobstructed to the constructed clear width with no projections unless modified by 19.2.2 through 19.2.11 for corridors of the building. This resulted in the potential for impeding full instant use of the exit system in case of fire or other emergency (LSC 19.2.1, 7.1.10.1).

Findings include, but are not limited to:

1. On 1/12/2017, at 3:41 p.m., there were several obstructions within the constructed clear width of the exit egress corridor within/adjacent to the Med. Surgical Unit of the facility.

2. On 1/13/2017, at 11:33 a.m., there were several obstructions within the constructed clear width of the exit egress corridor within/adjacent to the Main Lobby of the facility.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to maintain exit illumination on emergency power for a minimum of 1-1/2 hour duration annually. This resulted in the potential for confusion and panic by residents & staff during emergency evacuation conditions (LSC 19.2.9.1 and 7.9).

Findings include, but are not limited to:

On 1/13/2017, at 11:55 a.m., there was an emergency light within the MRI Room that did not illuminate when tested by the surveyor.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to provide a 1-hour fire separation or an automatic fire extinguishing system between hazardous areas and the corridor. This resulted in the potential for residents/patients & staff to be exposed to hazardous products of fire during a hostile fire event (LSC 19.3.2.1, 8.4, 8.7.1)

Findings include, but are not limited to:

1. On 1/12/2017, at 2:47 p.m., the door leading into and out of the laundry was not closing or latching completely when tested by the surveyor.

2. On 1/12/2017, at 3:22 p.m., there was a latching mechanism that was removed from the soiled lined door within the OR that needs to close and latch completely.

3. On 1/12/2017, at 3:50 p.m., there was hazardous room within the Emergency Department utilizing a sliding glass door that was not self-closing or automatic-closing as required.

4. On 1/13/2017, at 10:58 a.m., there was a storage room door across from Rm. 105 that had door mechanism taped closed to keep the door from closing and latching completely.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that piped-in medical gas complied with NFPA 99 for the facility (NFPA 99, 5.1.4.8.7, 5.1.9.3, 6.4.2.2.4.2 & LSC 8.7, 19.3.2.3, S&C 13-58 and S&C 15-27). This resulted in the potential for injury to patients during medical procedures.

Findings include, but were not limited to:

1. On 1/12/2017, during record review between 9:30 a.m. and 4:30 p.m., the humidity policy that was presented to the surveyor specified the adopted humidity range between 30%-60% relative humidity and the log sheets within the OR showed an adopted humidity range between 20%-60% relative humidity.

2. On 1/12/2017, during record review between 9:30 a.m. and 4:30 p.m., the humidity within OR 1 was measured below 30% on various dates during the month of March and/or April of 2016 and November 2016, December 2016 and January 2017. Humidity within OR 2 was measured below 30% on various dates during the months of March and/or April of 2016 and November 2016, December 2016 and January 2017.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on the observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to install and protect alcohol based hand rub (ABHR) dispensers away from sources of ignition within the building. This resulted in the potential for injury to residents/patients and staff (LSC 19.3.2.6, 8.7.3.1, 42 CFR 403, 418, 460, 482, 483, and 485, NFPA 30).

Findings include, but were not limited to:

On 1/13/2017, at 11:01 a.m., there was an alcohol based hand rub (ABHR) dispenser installed adjacent to an electrical switch in the Pre-OP area.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to install fire alarm system in accordance with NFPA 72 public or private mode systems. This resulted in the potential for system and device failure/delay and panic during fire emergencies for the universe entire building (LSC 19.3.4, 19.3.4.1, 9.6, 9.6.1.8, NFPA 72, NFPA 70).

Findings include, but were not limited to:

1. On 1/10/2017, at 4:45 p.m., there was a missing fire alarm pull station within the ICU Area of the facility.

2. On 1/13/2017, at 12:05 p.m., there was missing smoke protection above the Fire Alarm Control Panel (FACP) within Lincoln County Medical Center.

3. On 1/13/2017, at 12:31 p.m., there was missing smoke protection within the Lobby Skylights within the Samaritan Medical Plaza.

4. On 1/13/2017, at 12:46 p.m., there was missing smoke protection above the Fire Alarm Control Panel (FACP) within the Samaritan Medical Plaza.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to test and maintain fire alarm in accordance with NFPA 72 for the entire building. This resulted in the potential for system and device failure during fire emergencies (LSC 19.3.4, 9.7.5, 9.7.7, 9.7.8, NFPA 70, NFPA 72 and NFPA 25).

Findings include, but were not limited to:

1. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., documentation presented to the surveyor showed that the facility was not conducting the required monthly fire alarm maintenance and testing as outlined in NFPA 72.

2. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., quarterly testing and maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the fire alarm system to the adopted 2010 edition of NFPA 72 standards.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that the emergency preparedness plan had written procedures to be used when the fire alarm system was in an abnormal condition. This potentially prevents early notification of smoke and/or fires that delays evacuation of residents/patients & staff to an area of safe refuge (9.6.1.6, NFPA 72, and NFPA 99).

Findings include, but were not limited to:

1. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., there were no policies or procedures for the notification to OHA, OSFM and local Fire Agency when the fire alarm system for the facility was in an abnormal or inoperable condition.

2. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., fire watch procedures provided to the surveyor showed fire watch patrol at intervals of 60-minutes which was more than the required 30-minute interval.

Survey was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering that the facility failed to test and maintain smoke detectors in accordance with NFPA 72 for the facility. This resulted in the potential for system and device failure during fire emergencies (LSC 4.6.12.1, 9.6.1.3, NFPA 70, NFPA 72).

Findings include, but were not limited to:

On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., documentation presented to the surveyor showed the last fire alarm sensitivity test was conducted on 6/2014 and was past due since 6/2016. Documentation presented to the surveyor for the facilities last sensitivity test was incomplete and was missing information.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA 13 for 1 patient room closet of the building. This resulted in the potential for uncontrolled fire progression in the event of a fire (LSC 19.3.5, 19.3.5.1 - 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1), and NFPA 13).

Findings include, but were not limited to:

1. On 1/12/2017, at 2:30 p.m., there was missing automatic sprinkler coverage for the combustible 4' overhang outside of Cafeteria and Cardio-Pulmonary areas.

2. On 1/12/2017, at 3:04 p.m., there was missing automatic sprinkler coverage within the electrical room adjacent to the Anesthesia Area.

3. On 1/13/2017, at 11:05 a.m., there was missing automatic sprinkler coverage within the Lab Closet.

4. On 1/13/2017, at 11:55 a.m., there was missing automatic sprinkler coverage within the MRI Room and the outside canopy between the MRI Room and Hospital.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure the automatic sprinkler and standpipe systems were continuously maintained, inspected and tested in a reliable operating condition for the building. This resulted in the potential for system failure during fire emergencies (LSC 19.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 25, NFPA 2001).

Findings include, but are not limited to:

1. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., weekly and monthly, testing and maintenance was not being performed by evidence of the lack of documentation for testing and maintenance on the facilities fire sprinkler system as required by NFPA 25 standards.

2. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., quarterly maintenance and testing was being performed by staff and there was no documentation showing technician competence in maintaining the sprinklers and staff did not have access to the adopted 2011 edition of NFPA 25 standards.

3. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., there were deficiencies noted on the annual automatic sprinkler report that were not corrected and facility did not have documentation showing correction of the deficiencies noted.

4. On 1/12/2017, at 2:27 p.m., there was an automatic sprinkler head within the south basement that was installed in the wrong orientation.

5. On 1/12/2017, at 3:10 p.m., there was automatic sprinkler head that appeared to be unbraced or the bracing was loose within the Shower Rm. of the Women's Locker Room.

6. On 1/13/2017, at 11:18 a.m., there were corroded sprinkler heads that shall be replaced outside of the Quiet Room adjacent to the north basement.

7. On 1/13/2017, at 11:42 a.m., there was a damaged sprinkler head that shall be replaced within the PBX Rm.

8. On 1/13/2017, at 11:47 a.m., there was an automatic sprinkler head within the Facility Administrators Office that was installed in the wrong orientation.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on record review and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that the emergency preparedness plan had written procedures to be used when the automatic fire sprinkler system was in an abnormal condition. This potentially prevents early notification of smoke and/or fires that delays evacuation of residents/patients & staff to an area of safe refuge (19.3.5.1, 9.7.6, NFPA 25, and NFPA 99).

Findings include, but were not limited to:

1. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., there were no policies or procedures for the notification to OHA, OSFM and local Fire Agency when the automatic fire sprinkler system for the facility was in an abnormal or inoperable condition.

2. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., fire watch procedures provided to the surveyor showed fire watch patrol at intervals of 60-minutes which was more than the required 30-minute interval.

Survey was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to select, install, inspect and maintain fire extinguishers in accordance with adopted standards for universe all extinguishers of the facility. This resulted in the potential for fires to progress beyond incipient stage (LSC 19.3.5.12, NFPA 10).

Findings include, but were not limited to:

1. On 1/13/2017, at 10:41 a.m., there was a fire extinguisher across from Rm. 109 that was installed to high. Maximum height for fire extinguishers shall be 60" from finish floor.

2. On 1/13/2017, at 11:50 a.m., there was a fire extinguisher within the Server Room that was installed to high. Maximum height for fire extinguishers shall be 60" from finish floor.

3. On 1/13/2017, at 12:00 p.m., there was a fire extinguisher outside of Anti-Coag that was installed to high. Maximum height for fire extinguishers shall be 60" from finish floor.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to maintain/construct at least a 1/2-hour fire resistance rated smoke barrier for 2 of 6 sampled smoke compartments of the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 19.3.7.3, 8.5, and 8.6.7.1(1)).

Findings include, but were not limited to:

On 1/12/2017, during record review between 9:30 a.m. and 4:30 p.m., documentation provided by the facility showed that the Drop-Down Door at the Pharmacy Window and Physical Therapy did not operate properly. Facility could not provide documentation showing that this identified deficiency was addressed/fixed.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on interviews and record review during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to maintain emergency preparedness plan current & readily available to all staff, affecting the entire building. This resulted in the potential for limited staff effectiveness during emergency conditions (LSC 19.7.2.1.2, 19.7.2.2, 19.7.1.1 - 19.7.1.3, 19.7.2.3).

Findings include, but are not limited to:

On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., the Emergency Management Coordinator could not provide written documentation that outlined changes, updates or review dates for the facilities Emergency Preparedness Plan.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing residents to smoke and fire in the facility (LSC 19.7.1.4 - 19.7.1.7).

Findings include, but were not limited to:

1. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., the facility had no documentation on conducting their 1st quarter and 2nd quarter night shift fire drills for 2017.

2. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., the facility documented an actual event as a fire drill. The actual event was used for the required drill during the 2nd quarter day shift drill for 2017.

3. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, and specific location of simulated fire.

4. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., facility documentation presented to the surveyor by the facility showed that fire drills for swing and night shifts for 2015 and 2016 were not completed under varying conditions and random times throughout the shift. Fire drills were conducted between 7:09 p.m. and 8:30 p.m. for swing shift and 9:01 pm and 9:30 p.m. for night shift which demonstrates that fire drills were conducted in a manner that created a pattern, instead of on different days and times and involving different locations and simulated circumstances.

5. On 1/13/2017, at 12:12 p.m., surveyors conducted a fire drill within the Family Labor/Delivery area of the facility. The following deficient items were noted during the drill: Fire Alarm pull station was not activated until staff were coached to pull fire alarm pull station, staff did not conduct a simulated evacuation of patients within the affected smoke compartment to an unaffected smoke compartment, staff did not clear the egress corridors and staff were highly coached on the roles and responsibilities as it pertained to the fire drill.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that no combustibles or decorations of highly flammable characteristics were stored or used, unless in limited quantities or flame retardant for the building. This resulted in the potential for excessive fire spread (LSC 19.7.5.6, 19.7.5.6, and NFPA 701).

Findings include, but were not limited to:

On 1/13/2017, at 12:39 p.m., there were non-fire treated combustible decorations hanging within the Lobby of the Samaritan Medical Plaza. Combustible decorations did not possess a label identifying the flame spread rating.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on record review and interviews during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff the facility failed to maintain or have a documented maintenance program for piped gas and/or vacuum systems (NFPA 99 5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14 and 5.3.13.4.2). This resulted in the potential for injury to patients during medical procedures.

Findings include but are not limited to:

On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., there were deficient items noted on the Medical Gas Report that were not corrected. Corrective actions noted on the report included but were not limited to zone valve within the Radiology Department and O2 Station adjacent to ER Bed #6.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations, record review and interviews it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to properly maintain the generator or other alternate power source and associated equipment affecting the entire facility. This resulted in the potential for the lack of emergency electrical power during an emergency event (LSC 19.2.9, 7.9, NFPA 110, NFPA 99, NFPA 70, and NFPA 111).

Findings include, but were not limited to:

1. On 1/10/2017, during record review between 10:00 a.m. and 5:00 p.m., monthly maintenance was being performed by staff and there was no documentation showing technician competence in maintaining the generator and staff did not have access to the adopted 2010 edition of NFPA 110 standards.

2. On 1/12/2017, at 4:15 p.m., there was not a remote annunciator panel for the generator at a constantly attended location.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to ensure that that electrical wiring & equipment was used/maintained and in accordance with NFPA 70. This resulted in the potential for injury to residents & staff (LSC 9.1.2, NFPA 99 10.2.3.6, 10.2.4, NFPA 70, TIA 12-5).

Findings include, but were not limited to:

1. On 1/12 & 13/2017, during the facility tours between 9:30 a.m. and 4:30 p.m., there were relocatable power taps (RPT's) on the floor within the following rooms but not limited to: Dexa Room, OR2, Med Surg. Rm. 105, Med Surg. Chart Rm., Lab Office, and Volunteer Services Rm.

2. On 1/12/2017, during the facility tour between 9:30 a.m. and 4:30 p.m., there were non-patient power taps (RPT's) that were in use within patient care areas within the following areas but not limited to: Dexa Room, OR1, OR2, and ER Bay #3.

3. On 1/12 & 13/2017, during the facility tours between 9:30 a.m. and 4:30 p.m., there were relocatable power taps (RPT's) that were permanently attached to the building that would require a special tool to be removed within the following rooms but not limited to: Rm. 304, Kitchen, and Radiology Overflow Rm.

4. On 1/12/2017, during the facility tour between 9:30 a.m. and 4:30 p.m., there were extension cords in use as permanent wiring within the following rooms but not limited to: EVS Supply/Electrical Room, OR1 (suction machine), Procedure Room, ER Employee Office, and ER Registers Office.

5. On 1/12/2017, at 3:00 p.m., there was an open electrical junction box in the ceiling within the CT Hallway.

6. On 1/13/2017, at 12:32 p.m., there was a household heat producing appliance (microwave) within the Samaritan Medical Plaza building.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.

Based on observations and interview during the survey, it was determined through on-going dialog with the Director of Engineering and Engineering Staff that the facility failed to provide safe storage (design, construction and/or ventilation) for compressed gas in the universe (oxygen storage room) (1 resident room) of the facility. This resulted in the potential for injury to staff and residents from a damaged compressed gas cylinder releasing unexpectedly. (LSC 19.3.2.4, NFPA 99 5.1.3.3.2, and 5.1.3.3.3).

Findings include, but were not limited to:

1. On 1/12/2017, at 2:07 p.m., there were (8)E-Sized O2 Cylinders being stored within the Cardio Pulmonary Scheduling Rm. that had unprotected electrical outlets within the room.

2. On 1/12/2017, at 3:11 p.m., there were (5)E-Sized O2 Cylinders being stored within the Surgery Vestibule that had unprotected electrical outlets within the room.

3. On 1/13/2017, at 10:53 a.m., there were (10)E-Sized O2 Cylinders being stored within the Med Surge Storage across from Rm. 100 that had unprotected electrical outlets within the room.

4. On 1/13/2017, at 11:21 a.m., there were compressed gas cylinders being stored within the Radiology Overflow Rm. and Nuclear Medicine Rm. that had unprotected electrical outlets within the room.

Surveyor was accompanied by the Director of Engineering and Engineering Staff who acknowledged the existence of these conditions.