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Based on record review and interview the facility failed to ensure addressing their patient population within the facility emergency preparedness plan as required at CFR 482.15(a).

Findings:

Record review showed the facility emergency preparedness plan did not address or include the facility's patient/client population. The facility emergency preparedness plan did not contain strategies the facility would or will put in place to address the needs of at-risk or vulnerable patient populations it serves, or the services the facility would be able to provide during an emergency event.

On 09/21/20 at 10:30 pm the surveyor asked staff F to see where in the facility emergency preparedness plan the facility addressed the patient/client population they serve. Staff F stated they could not find where patient population was addressed but will add it.

Based on record review and interview the facility failed to ensure the initial in-service training for emergency preparedness contained the facility emergency preparedness plan as required.

Findings:

Record review of the facility emergency preparedness training documentation did not show the in-service training included the facility emergency preparedness plan as required.

On 09/21/20 at 12:11 pm the surveyor asked staff F why the facility emergency preparedness pan was not included in the emergency preparedness initial employee training. Staff F stated that several portions of the plan are included but will amend the initial training to include all of the facility emergency preparedness plan.

Based on observation and interview the facility failed to ensure corridor doors in a required means of emergency egress were not equipped with a latch/lock that requires two actions to open from the egress side as required.

Findings:

On 09/22/20 at 2:41 pm a total of four latch deadbolt locks were observed in the surgical area. (procedure room door, operating room one, two, and three) A deadbolt latch was observed on the board room conference door to human resources.

On 09/22/20 at 2:41 pm staff E was asked why there were multiple corridor doors within the main hospital facility with latch deadbolts which would require two actions to open from the egress side which is not fire code compliant. Staff E stated they thought the turn latch deadbolts were in compliance but will change them out.

Based on observation and interview the facility failed to enclose a vertical opening in one hour fire resistance rated construction as required.

Findings:

On 9/23/20 at 1:20pm the surveyor observed a vertical opening which had a metal spiral staircase extending from the basement hazardous area mechanical room into the first floor medical records office without the stairway being enclosed with a minimum of one hour fire rated construction as required.

On 9/23/20 at 1:20pm the surveyor asked staff E why they had a vertical opening extending out of a hazardous area mechanical room without the required minimum of one our fire rated enclosure. Staff E started they thought it was a good place in order for the medical records staff to gain access to the medical records stored in the basement but will correct it.

Based on observation and interview the facility failed to maintain a hazardous area free of penetrations and storage of combustible materials as required.

Findings:

On 9/23/20 at 12:01pm the surveyor observed a metal spiral staircase going from the first floor medical records to the basement hazardous area mechanical room. The metal spiral staircase made an three feet circular penetration between the first floor to basement without any fire rated construction protection between floors.

On 9/23/20 at 12:01pm the surveyor observed the mechanical room in the basement had multiple wooden bookshelves with multiple shelves containing a large amount of paper medical records stacked within a foot of the ceiling.

On 9/23/20 at 12:01pm the surveyor asked staff E why they had a penetration between the basement and the first floor. Staff E stated they had not looked at it like that but now see it that way and will fix it. The surveyor asked staff E why they choose to store combustible medical records in a hazardous area mechanical room. Staff E stated they will correct the issue.

On 9/23/20 at 12:13pm the surveyor observed a hazardous area corridor door which did not have a self closer the room contained an electrical transformer.

On 9/23/20 at 12:13pm the surveyor asked why the self closer was taken off the transformer closet door. Staff E stated one of their workers had completed some ceiling work and must have failed to replace it, but will correct it.

Based on record review and interview the facility failed to ensure ASHRAE 170-2008 ventilatory standards were maintained as required.

Findings:

Record review showed the test and balance inspection report did not have the following areas included to be verified for airflow to be in compliance to ASHRAE 170-2008: substerile area room between operating room one and two, sterile storage, surgical soiled utility.

On 9/21/20 at 2:18pm the surveyor asked staff E why the substerile area, sterile storage, soiled utility were not tested on the annual test and balance inspection report. Staff E stated they will correct it and those areas must not have been added as they should have.

Based on record review and interview, the facility failed to ensure fire drills conducted included the transmission of a fire alarm signal as required in NFPA 101, 2012 Edition, Chapter 19.7.1.4 through 19.7.1.7.

Findings:

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

Record review of the third shift showed there was no actual practical fire drill performed as the documentation had "paper drill" written on each third shift fire drill.

On 09/23/20 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. Staff E stated they will have the third shift perform actual fire drills as required.

Based on observation and interview the facility failed to ensure they did not use extension cords in patient care areas as required.

Findings:

On 9/21/20 at 10:19am the surveyor observed extension cords plugged into the ceiling of operating rooms one, two, three and the procedure room.

On 9/21/20 at 10:19am the surveyor asked staff O why they had extension cords in each operating room. Staff O stated the state advised them they could but they will correct it.