HospitalInspections.org

Based on documentation review and staff interview, the facility failed to ensure collaboration with tribal, local, state, or federal officials. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Review of the Emergency Operations Plan completed on 06/28/18 revealed no documentation of collaboration with tribal, local, state, or federal officials.

Interview with Staff Y completed on 06/28/18 at 9:00 AM revealed Staff Y was trying to contact others about being involved in a community based drill, but had not yet accomplished this.

Based on documentation review and staff interview, the facility failed to ensure names were listed on the contact information for administrative staff in the Emergency Operations Plan. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Review of the Emergency Operation Plan completed on 06/28/18 revealed a list of contacts for administrative personnel. No names were noted just titles. This findings was verified in an interview with Staff Y on 06/28/18 at 2:12 PM.

Based on documentation review and staff interview, the facility failed to ensure specific contact information was present for emergency services. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Review of the Emergency Operations Plan completed on 06/28/18 revealed emergency contact information for police services ,and fire department was listed as 911 and not specific to the local services. These findings were verified in an interview with Staff Y on 06/28/18 at 2:12 PM.

Based on documentation review and staff interview, the facility failed to ensure all personnel were trained in the Emergency Operations Plan. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

A request was made on 06/29/18 at 2:12 PM for documentation staff were trained on the Emergency Operations Plan.

Interview with Staff Y on 06/28/18 at 2:12 PM revealed all new staff were trained during orientation, but current staff had not been trained.

Based on documentation review and staff interview, the facility failed to ensure a full scale community drill or table top was completed to test the Emergency Operations Plan. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

A request was made on 06/28/18 at 9:00 AM for evidence of a full scale community drill or table top drill.

Interview with Staff Y on 06/28/18 at 9:00 AM revealed the facility had not completed a full scale drill or a table top drill. Staff Y stated that he/she was currently trying to contact others about being involved in a community based drill, but had not yet accomplished this.

Based on observation and staff interview, the facility failed to ensure exit egress doors could be readily unlocked by staff at all times. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

During tour of the facility completed on 06/26/18 between 8:30 AM and 3:30 PM, observation revealed a door marked as an emergency exit located in the "Main Corridor" between the "DDX" and "ADU" units had been locked. There was no obvious way to unlock the doors for exit egress. The door did not release when the bar in the center of the door was pushed. A magnetic lock was noted at the top of the door, but no obvious key pad or card scanner was noted near the door. This finding was verified in an interview by Staff Y and Staff Z at the time of the observation.

During tour of the facility completed on 06/26/18 between 8:30 AM and 3:30 PM, observation revealed a door marked as an emergency exit located in the Geriatric Unit was locked. There was no obvious way to unlock the doors for exit egress. The door did not release when the bar in the center of the door was pushed. A magnetic lock was noted at the top of the door, but no obvious key pad or card scanner was noted near the door. This finding was verified in an interview by Staff Y and Staff Z at the time of the observation.

Interview with Staff Y and Staff Z completed on 06/26/18 at 10:00 AM revealed the only way the door could be opened was with activation of the fire alarm.

A manual pull station was noted beside both doors noted above.

Based on observation and staff interview, the facility failed to ensure exit discharge was provided with a hard level walking service to the public way. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Interview with Staff Y completed on 06/27/18 at 2:10 PM revealed patients were evacuated to the courtyard areas on each unit during a fire drill for patient safety.

On 06/28/18 at 8:15 AM, observation of the courtyard for the Geriatric unit revealed a large grass covered area surrounded by large wood fencing with two gates, one on either side of the courtyard. The West gate was noted to have a pad lock and lead to the courtyard for the ADU unit. The East gate revealed a pad lock was located on the outside of the fencing and could not be unlocked from inside the courtyard. This gate lead to the outside of the fence and the parking lot could be reached from this gate. No hard surface was noted from the gate to the parking lot. Observation of the ADU unit's courtyard revealed the same grass covering two gates on either side but neither lead to the public way, just the other unit's courtyard. Observation of the courtyard for the DDX unit revealed a large grass covered area with two gates. The East gate lead to the ADU unit's courtyard and the North gate lead to the outside of the fence. No hard service was noted to the public way from either the ADU or DDX courtyards. These findings were verified in an interview by Staff Y at the time of the observations.

Interview with Staff Y on 06/28/18 at 9:02 AM revealed he/she had only been at the facility since April 2018 and when he/she arrived, staff would bring patients to the identified exits but would not evacuate due to potential elopement. Staff Y stated that was when he/she started to have the evacuation be into the courtyards.

Based on observation and staff interview, the facility failed to ensure exits were marked as required in Chapter 7 of NFPA 101. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Observation of the exit located in the connection corridor between the old building and new building completed on 06/26/18 revealed the illuminated exit sign had no directional arrow to show the direction of exit. This finding was verified in an interview by Staff Y and Staff Z at the time of the observation.

Interview with Staff Y completed on 06/27/18 at 2:10 PM revealed patients were evacuated to the courtyard areas on each unit during a fire drill for patient safety.

Observation of the exit doors to the courtyard located in the activity rooms on every unit in the 40 bed newer building completed on 06/28/18 at 8:13 AM revealed no signs were noted identifying them as emergency exits. When entering the courtyards from each unit, wood fencing was observed. Two gates were noted on either side of the courtyards, but no signage was noted identifying which gate was the exit. Staff Y was asked which exit was the exit to the public way. Staff Y immediately proceeded to the West gate, but after opening the West gate it was noted to go to the courtyard for the ADU unit and no exit to the public way was noted to have been marked in the courtyard.

Observation of the courtyard for the DDX unit revealed fencing with two gates. Neither gate had signage identifying it as an exit to the public way.

Observation of the courtyard for the ADU and ITU units located in the older building revealed a hard service leading to a gate in the chain-link fencing. No exit signage was noted identifying the gate as the exit to the public way. All findings were verified by Staff Y at the time of the observations.

Based on schematic review, observation, and staff interview, the facility failed to ensure the identified one hour fire rated walls for the hazardous areas were free of penetrations and doors had self closing devices. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

During tour of the facility completed on 06/26/18 between the hours of 8:00 AM and 3:30 PM the following observations of the fire rated hazardous area walls were noted:

1. Observation above the drop ceiling of the soiled utility room of the Geriatric Unit just above the door revealed a 1/2 inch conduit with blue and gray data cables passing through and open on the end.

2. Observation of the soiled utility room door in the ADU unit revealed the door had no self closing device.

3. Observation above the drop ceiling in the DDX units equipment storage revealed a two inch sprinkler pipe penetrating the east wall with open annular space.

4. Observation above the drop ceiling in the DDX units soiled utility room revealed a hanger penetrating the fire rated ceiling with open space around the hanger and a 1 1/2 inch water line with open annular space penetrating the fire rated wall.

5. Observation above the drop ceiling in the DDX unit's linen storage room revealed multiple penetrations varying in size and shape.

6. Observation in the mechanical room by admissions revealed a 1/2 inch conduit with open annular space located penetrating the South wall.

7. Observation in the electrical room by admissions revealed a 3/4 inch conduit with open annular space penetrating the East wall.

All findings were verified in an interview by Staff Y and Staff Z at the time of the observations.

Based on documentation review and staff interview, the facility failed to ensure duct detectors were tested for sensitivity at least bi-annually and smoke detectors were functionally tested annually. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Review of annual fire alarm testing that was completed on 05/30/18 revealed a total of four duct detectors functionally tested. Two smoke detectors were noted to not have been tested due to a lift being needed.

Review of the fire alarm testing documentation that was completed on 01/05/18 revealed only one duct detector had sensitivity testing completed.

Interview with Staff Y on 06/28/18 at 9:45 AM revealed the two smoke detectors that were not tested identified in the annual fire alarm testing that was completed on 05/30/18 had not been tested yet. Staff Y also verified three duct detectors were not sensitivity tested during the fire alarm testing completed 01/05/18.

Based on documentation review, the facility failed to provide documentation the wet sprinkler system gauges had been replaced or calibrated at least every five years. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Review of the Automatic Fire Sprinkler System Inspection Reports revealed no documentation that the wet sprinkler system gauges were replaced or calibrated every five years. A request was made for documentation from Staff Y showing when the gauges were calibrated or replaced for the wet sprinkler system. No documentation was provided before surveyor exit on 06/28/18.

Based on schematic review, observation, and staff interview, the facility failed to ensure the one hour smoke barrier was free of penetrations. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

During tour of the facility completed on 06/26/18 between the hours of 8:00 AM and 3:30 PM the following observations of the fire rated smoke barrier walls were noted:

1. Observation of the smoke barrier between the Geriatric unit and the ADU unit as seen from the ADU unit side above the double doors revealed three half inch flex conduits open on the end and a 1/4 inch flex conduit with open annular space.

2. Observation of the smoke barrier between the Geriatric unit and the ADU unit as seen from the ABU group room 2 revealed a two inch penetration with the fire rated caulking pulled out of the annular space.

3. Observation of the smoke barrier between the DDX unit and the ADU unit as seen from the ADU unit side above the double doors revealed three half inch conduits open on the end and a one inch round penetration with 1/4 inch flex conduit passing through the penetration.

4. Observation of the East wall in the DDX activity room 3 revealed a four inch by four inch hole with a 1/4 inch flex conduit passing through the penetration. Also, the North most point of the fire rated smoke barrier appeared to be open at the end between the two sections of gypsum board measuring approximately four feet by four inches and not sealed at the right side of the steel beam.

All findings were verified in an interview by Staff Y and Staff Z at the time of the observations.

NFPA 80

Chapter 19 Installation, Testing, and Maintenance of
Fire Dampers

19.4.1.1 The test and inspection frequency shall then be every
4 years, except in hospitals, where the frequency shall be every
6 years.

NFPA 105

Chapter 6 Installation, Testing, and Maintenance of
Smoke Dampers

6.5.2* Each damper shall be tested and inspected one year
after installation. The test and inspection frequency shall then
be every 4 years, except in hospitals, where the frequency shall
be every 6 years.


Based on documentation review and staff interview, the facility failed to ensure fire/smoke dampers were tested every six years as per NFPA 80, and NFPA 105 and dampers functioned when tested. This had the potential to affect all patients receiving services from the facility. The facility census was 50.

Findings include:

Review of the documentation for damper testing dated as completed on 04/20/12 revealed two dampers failed during testing. No documentation was noted of these dampers being repaired after the inspection. A request was made on 06/27/18 for any damper testing that was completed after the testing completed in 2012 from Staff Y. No documentation was provided before surveyor exit on 06/28/18.

Interview with Staff Y on 06/27/18 at 2:10 PM revealed the dampers were recently tested, but they had not received the report yet.

Based on observation and staff interview, the facility failed to ensure the remote annunciator panel for the generator of the old building was located in a manned location. This had the potential to affect all patients receiving services from facility. The facility census was 50.

Findings include:

During tour of the facility completed on 06/26/18 revealed the remote annunicator panel for the generator of the old building was located in the basement.

Staff Y verified in an interview at the time of the observation that this was not be a manned location during all operating hours.