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Based on record review and interview the facility failed to ensure initial testing on emergency preparedness for all staff including contracted staff as required.

Findings:

Record review showed the facility did provide initial emergency preparedness training to doctors and staff under contract as required.

On 04/22/21 at 11:04am the surveyor asked staff A why the doctors and contracted staff were not provided with the emergency preparedness training. Staff A stated they did not know but will provide it to be in compliance.

Based on observation and interview the facility failed to ensure opening doors to access to the emergency egress pathway would only take one action to open as required.

Findings:

On 04/22/21 at 9:54am the surveyor observed one deadbolt lock on each of the procedure room doors in the surgery area which would require two actions to open to gain access to the emergency egress pathway.

On 04/22/21 at 9:54am the surveyor asked staff E why they had deadbolt locks on each of the procedure room doors. Staff E stated they were wanting to control traffic but can install the correct locks which are compliant to code.

Based on observation and interview the facility failed to ensure fire extinguisher(s) located in the kitchen had placard(s) displayed next to each one as required.

Findings:

On 04/22/21 at 12:22pm the surveyor observed one ABC class fire extinguisher in the kitchen with no placard posted next to it as required.

On 04/22/21 at 12:22pm the surveyor asked asked staff E why there was no placard on the ABC fire extinguisher when it was installed. Staff E stated they had staff install it and they probably were not aware of the requirement. Staff E stated they would get the appropriate placard for the fire extinguisher which was installed within the kitchen.


NFPA 96, 2011 Edition
Chapter 10 Fire Extinguishing Equipment
10.2 Types of Equipment
10.2.2* A placard shall be conspicuously placed near each extinguisher that states that the fire protection system shall be activated prior to using the fire extinguisher.

Based on record review and interview the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required.

Findings:

Record review of the facility fire drill documentation showed each fire drill did not include verification of a transmission of a fire alarm signal.

On 04/21/21 at 10:32 am staff E was asked to show the surveyor where they document how they verify the transmission of a fire alarm signal. Staff E stated they did not document it on the fire drill report forms but will add it from this point on.

Based on observation and interview the facility failed to ensure the Type I EES generator had three branch panels and were clearly labeled as required.

Findings:

On 04/21/21 at 2:34pm the surveyor asked staff A if there could ever be a chance the hospital would have a ventilator patient. Staff A stated maybe. The surveyor stated that if that is the case they would be required to have a Type I EES generator with three panels, life safety code branch panel, critical branch panel, and equipment panel.

On 04/22/21 at 11:28am the surveyor observed a large diesel Caterpillar generator being installed.

On 04/22/21 at 11:32am the surveyor asked staff E to show them the three branch panels of their Type I EES emergency generator. Staff E took the surveyor to the room where the main old natural gas Olan generator was housed. Staff E showed the surveyor a panel with a label marked life safety and critical but not the third equipment panel which could not be identified. The surveyor observed the panels and stated to staff E to ensure the two identified (life safety and critical panels) have the proper individual breaker components per NFPA 99.

Based on record review and interview the facility failed to ensure annual impedance was completed as required.

Findings:

Record review showed the facility did not complete annual impedance testing of patient care related electrical receptacles for 2020 as required.

On 04/22/21 at 11:32am the surveyor asked staff E why the annual impedance had not been completed. Staff E stated he was recently placed into the position and will make sure annual impedance inspections get completed.