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Based on observations, record review and interview, the facility failed to ensure the minimum requirements for the Physical Plant and Environment were met as follows:
-Failed to maintain an assured source of emergency electrical power to the facility's Life Safety Branch (circuits essential to life safety such as fire alarms, smoke detection, alarm transmission, exhaust hoods) and the Critical Branch (patient ventilators, emergency department, surgery suite, and patient rooms.) (C222, K144)
-Failed to perform and record regular maintenance and testing on two of two alternate power sources and associated equipment in accordance with NFPA 99, (National Fire Protection Association-prescriptive regulations adopted as a standard by the Centers for Medicare & Medicaid Services) and NFPA 110. (C0222, K144). The hospital performs approximately 40 surgeries per month and treats 575 patients monthly in the Emergency Department. This deficient practice affects all staff, visitors and patients.

On 10/24/13 at 10:30 AM, The facility Chief Executive Officer (CEO) and her immediate staff were informed that the cumulative effect of these findings resulted in non-compliance with the Condition of Participation: Physical Plant and Environment and constituted an Immediate Jeopardy (IJ) situation. The facility staff implemented corrective actions and provided an acceptable plan of correction to prevent further risk to patients on 10/24/13 at 6:30 PM. Based on this corrective action, the IJ was considered abated.

Based on observation, record review and interviews, the facility failed to conduct preventive maintenance and repairs to emergency generators and electrical equipment vital to ensuring the safety and well being of patients. The hospital performs approximately 40 surgeries per month and treats 575 patients monthly in the Emergency Department. This deficient practice affects all staff and visitors, and a combined total of 60 patients and residents on the hospital campus. The facility census was 54 Long Term Care (LTC) residents and six medical/surgical patients.

Findings included:

1. Observation on 10/24/13 at 4:00 PM showed batteries in the hospital's central fire alarm control station were installed on 03/11/10. No expiration date or other markings could be found.

2. During an interview at the same date and time, Staff E, Director of Plant Operations, stated that the batteries were at least three years old and should be replaced. He stated that this was basically his first week on the job and he did not know if there was a preventive maintenance procedure to regularly check the power level of batteries in the central alarm control station.

3. During an interview on 10/30/13 at 11:30 AM, Staff D, Director of Human Resources/Safety Officer (DHR/Safety Officer), stated that they did not have a specific procedure that involved checks of the backup batteries, but the fire alarm and fire alarm indicator panels were monitored daily. She stated that if they had trouble signal, the flashing yellow light would be noticed and maintenance would be called to check out the problem. She stated that their recent annual fire alarm inspection had not identified any electrical or battery problems.

4. Observation on 10/24/13 at 10:00 AM showed the hospital campus included a long term care facility, residential care facility and assisted living apartments and two generators for emergency power resources. A visual inspection of the campus' main generator, a Caterpillar diesel, showed the fuel transfer pump (pumps fuel from the bulk holding tank underground to the generator's belly "day" tank) was operating but no fuel flow registered on the flow meter. The batteries used to start the generator had expired in August of 2013, two months ago and were still being depended on to start the generator for monthly exercise and load tests.

5. Record review of maintenance logs for 2013 showed no record of weekly inspections for either the main generator or the second generator (Cummins) which had been added during a 2009 renovation. Records for monthly exercise and facility load tests showed incomplete data on the Caterpillar and no records for the Cummins. The only raw data available showed three monthly tests and one incomplete test in July of 2013 for the Caterpillar. No test data was recorded for April, May, June, August or September of 2013.

6. Record review of a memo dated July 15, 2013, written by Staff H, Plant Engineer stated that the fuel line serving the Caterpillar was bleeding back to the tank and had to be primed often or the generator would "shut down or not start at all." Staff H also wrote that he had problems with the Cummins generator tripping a breaker and not able to successfully carry the facility load for a one hour load test under facility loads.

7. During an interview on 10/24/13 at 10:15 AM, Staff A, CEO stated that the Caterpillar generator was the main generator. She stated that it supported everything in the hospital that was constructed prior to 2009, including the Emergency Department, Surgery Suite, all patient (i.e., Medical-Surgical) beds, Radiology, Lab, Convalescent Center (LTC) Residential Care Facility (RCF), the Independent Living Center (assisted living) Dietary, Central Sterile Processing and Laundry.

8. During a telephone interview on 10/30/13 at 11:30 AM, Staff A, CEO and Staff D DHR/Safety Officer, stated that the regular maintenance man went on medical leave, and due to the Family Medical Leave Act (FMLA) they could not hire a replacement until he abruptly resigned in May with little notice. She stated that they had difficulty finding a qualified person to fill the vacant position. Staff D stated that some of the inspections beyond March had not been completed and the one maintenance person and one groundskeeper that remained did not know how to perform preventive maintenance or monitor tests of the generators. Staff D stated that the only maintenance records that could be located was the one incomplete record on the Caterpillar which showed tests logged for January, February and March of 2013 and one incomplete test in July, with no performance readings recorded.

9. During an interview on 10/24/13 at 11:00 AM, Staff C, Chief Financial Officer (CFO), stated that there were no electrical problems with the Caterpillar. She stated that it automatically started and transferred on 09/02/13, during an extended power failure as a result of a severe storm. She stated that they failed to document the event, however they received no complaints from patients or staff about power being out and no one remembers being left in darkness.

10. During an interview on 10/24/13 at 11:10 AM, Staff E, Director of Plant Operations, stated that he had been hired in late September, but only began working on site a few days ago. He stated that the fuel problem with the Caterpillar had been resolved when the repairman replaced a check valve that was stuck (check valve in fuel line prevents backflow and loss of prime, or fluid in the pump head). He stated that the pump was running and had been pumping fuel but probably had some air in the line that temporarily caused the flow to be suspended. He pointed to a short section of galvanized pipe, and speculated that the former maintenance personnel were possibly using it to prime the pump and keep the fuel flowing into the day tank. He stated he really couldn't be sure if all the problems were fixed until he got rid of the by-pass pipe and could be assured repairs were successful. He noted that the starting batteries were dated that they expired in August, 2013 and stated that they needed to be replaced. He stated that the Caterpillar had been running on 10/23/13 when the valve was repaired and otherwise seemed to be trouble free.

Based on interview and record review, the facility's Governing Body in conjunction with facility Administration, failed to maintain electrical equipment essential to assuring an uninterrupted source of power to the Life Safety Branch (circuits essential to life safety, such as fire alarms, alarm transmission, exhaust hoods) and the Critical Care Branch (patient ventilators, air compressors, emergency department, surgery suite, and patient rooms) in accordance with NFPA 99, 3-4.2.2. (National Fire Protection Association-prescriptive regulations adopted as a standard by the Centers for Medicare & Medicaid Services) as follows:
-Failed to maintain facility to ensure backup batteries in the hospital's central fire alarm control station were in prime serviceable condition and able to sustain a minimum five minute fire alarm in accordance with NFPA 70 and 72, 9.6.1.4. (C222, K052)
-Failed to maintain and document a routine weekly visual inspection, and monthly exercise under facility load of the facility's main emergency generator in accordance with NFPA 99, 3.4.4.1 and NFPA 110, 8.4.2. (C222, K144) The hospital performs approximately 40 surgeries per month and treats 575 patients monthly in the Emergency Department. This deficient practice affects all staff, visitors and patients.

On 10/24/13 at 11:00 AM, The facility Chief Executive Officer (CEO) and her immediate staff were informed that the cumulative effect of these findings resulted in non-compliance with the Condition of Participation: Organizational Structure and an Immediate Jeopardy (IJ) situation. The facility staff implemented corrective actions and provided an acceptable plan of correction to prevent further risk to patients on 10/24/13 at 6:30 PM. Based on this corrective action, the IJ was considered abated.

Based on observation, record review and interview, the facility's governing body and Administration failed to establish policies and implement contingency plans for external maintenance support in a timely manner to address preventive maintenance and repairs needed on essential electrical equipment necessary to assure an uninterrupted source of power to the Life Safety Branch (fire alarms, smoke detectors, alarm transmission, exhaust hoods) and the Critical Branch (patient ventilators, emergency department, surgery suite, and patient rooms) in accordance with NFPA 99, 3-4.2.2. (National Fire Protection Association-prescriptive regulations adopted as a standard by the Centers for Medicare & Medicaid Services). The hospital performs approximately 40 surgeries per month and treats 575 patients monthly in the Emergency Department. This deficient practice affects all staff and visitors. The facility census was 54 Long Term Care residents and six medical/surgical patients.

Findings included:

1. Observation on 10/24/13 at 4:00 PM showed batteries in the hospital's central fire alarm control station were installed on 03/11/10. No expiration date or other markings could be found.

2. During an interview at the same date and time, Staff E, Director of Plant Operations, stated that the batteries were at least three years old and should be replaced. He stated that this was basically his first week on the job and he did not know if there was a preventive maintenance procedure to regularly check the power level of batteries in the central alarm control station.

3. During a telephone interview on 10/30/13 at 11:30 AM, Staff D, Director of Human Resources/Safety Officer, stated that they did not have a specific procedure that involved checks of the backup batteries, but the fire alarm and fire alarm indicator panels are monitored daily. She stated that if they had trouble signal, the flashing yellow light would be noticed and maintenance would be called to check out the problem. She stated that their recent annual fire alarm inspection had not identified any electrical or battery problems.

4. During a telephone interview on 10/28/13 at 5:00 PM, Staff G, Vice Chairman, Board of Directors, stated that since April, the board was generally aware of ongoing problems with the facility's unsuccessful attempts to find qualified people for positions in Maintenance. He stated that the board was aware there were maintenance issues, but they had not been briefed on the details.

5. During a telephone interview on 10/29/13 at 1:48 PM, Staff F, Podiatrist, acknowledged that he was doing a surgical procedure the afternoon of the complaint investigation on 10/24/13. He stated that he was unaware of the problem until after the procedure was completed. He stated that he was unaware that the generators were potentially not a reliable source of emergency electrical power. He stated that, several time during the past year or so the hospital had canceled his surgeries due to problems with the air handlers which directly affected the surgical suite.

6. Record review of maintenance logs for 2013 showed no record of weekly preventive maintenance inspections for either the main Caterpillar generator or the second Cummins generator. Records for monthly exercise and facility load tests showed incomplete data on the Caterpillar and no records for the Cummins. The only raw data available showed three monthly tests and one incomplete test in July of 1013 for the Caterpillar. No test data was recorded for April, May, June, August or September of 2013.

7. Record review of un-addressed memo dated July 15, 2013, written by Staff H, Plant Engineer stated that the fuel line serving the Caterpillar was bleeding back to the tank and had to be primed often or the generator would "shut down or not start at all." Staff H also wrote that he had problems with the Cummins generator tripping a breaker, and it was not able to successfully carry the facility load for a one hour load test under facility loads.