HospitalInspections.org

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Based on record review and interview the facility failed to ensure the emergency preparedness plan had been updated annually. This failed practice placed patients and staff at risk for loss in continuity of care. Findings:

Review of the facility's emergency preparedness plan on 7/20/18 revealed the last revision date on the Emergency Preparedness plan was 5/2014.

This finding was confirmed by the Safety Director at the time of discovery.

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Based on record review and interview the facility failed to ensure the emergency preparedness plan included policies and procedures that addressed the role of the facility under an 1135 waiver. This failed practice placed all patients at risk for loss in continuity of care and treatment, as well as, a delay is services. Findings:

Review of the facility's emergency preparedness plan on 7/20/18 revealed no policies and/or procedures pertaining to the facility's role under an 1135 waiver.

This finding was confirmed by the Safety Director at the time of discovery.

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Based on observation and interview the facility failed to ensure manual fire alarm pull stations were continuously attended by staff. Failure to attend the pull stations placed all patients, staff and visitors at risk for delay in warning in the event of a fire. Findings:

Observation during the survey on 7/13-16/18 revealed each of the locked units had a round nurse's desk located in front of the nursing station. The desk was centrally located so the staff sitting at it could visualize the hallways and the common area rooms. The only fire pull station on the unit was located behind the desk.

Observation of Katmai Unit on 7/16/18 at 11:41 am, no staff were seated at the desk for 10 minutes.

Observation on 7/16/18 between 10:05 am and 10:27 am in the Katmai unit revealed the single fire alarm pull station on that unit, located behind a counter was not staffed.

Continuous observation on 7/16/18 from 2:01 pm to 2:07 pm revealed no staff was continuously present at the center nursing station on the Chilkat Unit.

During an interview on 7/17/18 at 6:50 am. PNA #13 stated staff were always supposed to be seated at the desk.

Observation of Kenai Unit on 7/17/18 at 7:22 am no staff were seated at the desk for 3 minutes.

Observation on 7/17/18 at 7:30-8:00, PNA #10, walked back and forth in the nurses station, the PNA then went out to do the every 15 minute checks (locater checks), the PNA then returned to the nurse's station

During an interview on 7/19/18 at 11:30 am the Safety Director confirmed staff were to be behind the counter on the units at all times to activated the fire pull station in the event it was needed.

19.3.4.2.2 Manual fire alarm boxes in patient sleeping areas shall not be required at exits if located at all nurses' control stations or other continuously attended staff location, provided that both of the following criteria are met:
(1) Such manual fire alarm boxes are visible and continuously accessible.
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Based on observation and interview the facility failed to ensure a remote manual shut off was located outside of the generator room. Failure to have a means to shut down the generator in the event of a fire within the generator room would potentially place all residents, staff, and visitors at risk for smoke and or fire injury. Findings:

Observation on 7/20/18, during the Life Safety Code tour, revealed a single remote generator stop located on the generator. A remote generator stop button was not observed outside the generator room.

During an interview on 7/20/18 the Safety Director and Maintenance staff confirmed there was no remote stop for the generator.

NFPA 110 (2010)

110 2010
5.6.5.2 Where a control panel is mounted on the energy onverter,
it shall be mounted by means of antivibration shock mounts, if required, to maximize reliability. An automatic control and safety panel shall be a part of the EPS containing the following equipment or possess the following characteristics, or both:
...(3) Controls to shut down and lock out the prime mover under
any of the following conditions:
(a) Failing to start after specified cranking time
(b) Overspeed
(c) Low lubricating-oil pressure
(d) High engine temperature (An automatic engine shutdown
device for high lubricating-oil temperature shall
not be required.)
(e) Operation of remote manual stop station



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