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RURAL WELLNESS STROUD HOSPITAL
Roles Under a Waiver Declared by Secretary
Tag No.: E0026
Based on record review and interview the hospital failed to ensure the emergency preparedness policies and procedures addressed the facility's role in emergencies where the President declares a major disaster.
Findings:
Record review showed the facility did not develop and maintain a 1135 policy and procedure in the emergency preparedness plan as required.
On 10/20/21 at 2:14pm the surveyor asked staff B for the facility's 1135 waiver policy and procedure. Staff B stated the facility had not developed the policy but will to be in compliance.
Corridor - Doors
Tag No.: K0363
Based on obsevation and interview the facility failed to ensure corridor doors did not have unapproved hold open devices that would not allow the doors to close upon activation of the fire alarm system as required.
Findings:
On 10/21/21 at 1:12pm the surveyor observed two corridor doors with plastic chocks and two doors with metal chocks holding them open. The surveyor explained to staff B in the event of a fire the plastic/metal chocks would not allow the door to close to prevent fire and smoke from spreading throughout the facility.
On 10/21/21 at 1:13pm the surveyor asked staff B why the corridor doors had plastic and metal chocks in use to hold them open. Staff B stated they were not aware but will remove the chocks and educate the staff regarding not using the chocks.
Electrical Systems - Maintenance and Testing
Tag No.: K0914
Based on record review and interview the facility failed to ensure impedance testing and maintenance was completed as outlined in NFPA 99 - 2012 Edition requirements.
Findings:
Record review showed the facility did not complete impedance testing for patient care related electrical receptacles for 2020, 2019, or 2018 as required in NFPA 99 - 2012 Edition.
On 10/20/21 at 1:07pm the surveyor asked staff B why the impedance testing has not been completed per the requirements outlined in NFPA 99 2012 Edition. Staff B stated they are in the process of getting bids for replacing existing wiring in many locations due to faulty wiring from a previous contractor and planned on getting it done on completion of the installation of new wiring.